Record New Data


First Name
Last Name
English Name
Gender Male Female
Date of Birth (Format is DD/MM/YYYY example 01/01/1990)  /  /
Age
BMI Weight (kg)  Height (cm) 
Religion
Marriage status
Nationality
ID NO. / PASSPORT NO
Occupation
Blood Group
E-mail
Address
Phone Number
Emergency Contact Person
Name
Relation
Phone Number
Address
Chief complain

Current health problem

Yes
No

What is your priority of concerns?

Congenital disease

Yes
No

Drugs / Supplements

Do you take any drugs?

Yes
No

Do you take any supplements?

Yes
No

Allergy

Drug Allergy

Yes
No

Food Allergy

Yes
No

What is your reactions to food?

Yes
No

Smoking / Drinking

Do you smoke? (Number of cigarettes smoked per week)

Yes
No

Do you drink? (Alcohol consumption levels and patterns)

Yes
No

Have you experienced Major stress recently?

Yes
No

Are you a type of Anxious or easy going / relax person?

Yes
No

Do you always feel fatigue, tired, lethargy, or foggy memmory?

Yes
No

How much time have you lost from work or school in the past year?

0-2 days
3-14 days
> 15 days

Past Medical and Surgical History:

Hospitalization (WHERE HOSPITALIZED / WHEN / FOR WHAT REASON)

How often have you have taken antibiotics?

< 5 times > 5 times
Infancy / Childhood
Teen
Adulthood

How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?

< 5 times > 5 times
Infancy / Childhood
Teen
Adulthood

Childhood:

Question Yes No Don't know Comment
1. Were you a full term baby?
a. A preemie?
b. Breast fed?
c. Bottle fed?
2. As a child did you eat a lot of sugar and / or candy?

As a child, were there any foods that you had to avoid because they gave you symptoms?

Yes No

Please describe your current diet and provide your 24 hour diet recall, if possible an average of the three day dietary pattern is the prefer option.

How much of the following do you consume each week?

Fruit
Vegetables
High sugar / carbohydrate food / drink
Dairy product
Egg
Wheat
Gluten
Nut, Bean, Legumes or seed
Seafood, fish
Animal proteins

Do you have symtoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?

Yes No

Do you feel you have delayed symtoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?

Yes No

Do you feel much worse when you eat a lot of :


Do you feel much better when you eat a lot of :


Does skipping a meal greatly affect your symptoms?

Yes No

Have you ever had a food that you craved or really "binged" on over a period of time?

Yes No

Please fill in the chart below with information about your bowel movements

a. Frequency

More than 3x/day
1-3x/day
4-6x/week
2-3x/week
1 or fewer x/week

b. Consistency

Soft and well formed
Often float
Difficult to pass
Diarrhea
Thin, long or narrow
Small and hard
Loose but not watery
Alternating between hard and loose/watery

c. Color

Medium brown consistently
Very dark or black
Greenish color
Blood is visible
Varies a lot
Dark brown consistently
Yellow, light brown
Greasy, shiny appearance

Intestinal gas:


How is your sleep pattern? (feel fresh in the morning?, need any medications/supplement?)

Exercise

a. Frequency

More than 3x/day
1-3x/day
4-6x/week
2-3x/week
1 or fewer x/week

How do you feel after finishing your exercise?

How is your body weight in the past three years?

Do you have mercury amalgam fillings?

Yes
No

Do you have any artificial joints or implants?

Yes No

Do you feel worse at certain times of the year?

Yes No

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

Yes
No

Do you have any reaction to chemicals, odors, perfumes or smoke / cigarette?

Yes No

Have you ever had psychotherapy or counseling?

Yes No

FAMILY HISTORY:

For women only.

1. How is your period?

2. Do you have premenstrual symptoms?

3. Do you have any breast cysts / lumps?

4. Do you have Ovarian cyst, Endometriosis?

5. Do you have Vaginal discharge?