Functional Medicine Research Center

Document technical information

Format docx
Size 39.5 kB
First found May 22, 2018

Document content analysis

Category Also themed
Language
English
Type
not defined
Concepts
no text concepts found

Persons

Organizations

Places

Transcript

ADULT MEDICAL QUESTIONNAIRE
Our ability to draw effective conclusions about your present state of health and how to improve it depends,
to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and
those posed by the clinician during your consultations. Health issues are usually influenced by many factors.
Accurately assessing all the factors and comprehensively managing them is the best way to deal with these
health challenges. Your careful consideration of each of the following questions will enhance our efficiency and
will provide for more effective use of your scheduled consultation time. These questions will help to identify
underlying causes of illness and will also assist us to formulate a treatment plan.
First Name: _________________Middle Name: _______________Last Name: ____________________
Address:______________________________ City: _________________ State: _______ ZIP: _________
Home Phone: (________) ________-___________
Birth Date: _____/____/____ Age: _________
month
day
year
Work Phone: (________) ________-___________
Place of Birth:_____________________________
Occupation: ______________________________
Referred by: ______________________________
City or town & country if not US
Height: ___′ ____ ″ Weight: _______ Sex: _____
Today’s Date ______________________________
1. Please check appropriate box(es):


African American
Native American


Hispanic
Caucasian
 Mediterranean
 Northern European


Asian
Other
2. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:
DESCRIBE PROBLEM
Example: Post Nasal Drip
a.
b.
c.
d.
e.
f.
MILD/
MODERATE/
SEVERE
Moderate
g.
©Copyright The Institute for Functional Medicine
TREATMENT
APPROACH
Elimination Diet
SUCCESS
Moderate
Adult Medical Questionnaire
3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)
Example: Wendy, age 7, sister
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Do you have any pets or farm animals?
Yes____ No____
If yes, where do they live? 1. _____ indoors 2. _____ outdoors 3. _____ both indoors and outdoors
5. Have you lived or traveled outside of the United States?
Yes____ No____
If so, when and where? __________________________________________________________________
_____________________________________________________________________________________
6. Have you or your family recently experienced any major life changes?
Yes____ No____
If yes, please comment: __________________________________________________________________
_____________________________________________________________________________________
7. Have you experienced any major losses in life?
Yes____ No____
If so, please comment: ____________________________________________________________________
_____________________________________________________________________________________
8. How important is religion (or spirituality) for you and your family’s life?
a. _____ not at all important
b. _____ somewhat important
c. _____ extremely important
9. How much time have you lost from work or school in the past year?
a. _____ 0-2 days
b. _____ 3 –14 days
c. _____ > 15 days
10. Previous jobs:
_______________________________________________________________________________________
_______________________________________________________________________________________
11. Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading
contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can
also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now
an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and
optimize your treatment outcomes.
Please do your best to answer the following questions:
a. Did you feel safe growing up?
 Yes
 No
b. Have you been involved in abusive relationships in your life?
 Yes
 No
c. Was alcoholism or substance abuse present in your childhood home, or is it present now in your
relationships?
 Yes
 No
©Copyright The Institute for Functional Medicine
Adult Medical Questionnaire
d. Do you currently feel safe in your home?
 Yes
 No
e. Do you feel safe, respected and valued in your current relationship?
 Yes
 No
f.
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any
violence or abuse?
 Yes
 No
g. Would you feel safer discussing any of these issues privately?
 Yes
 No
12. Past Medical and Surgical History:
ILLNESSES
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Anemia
Arthritis
Asthma
Bronchitis
Cancer
Chronic Fatigue Syndrome
Crohn’s Disease or Ulcerative Colitis
Diabetes
Emphysema
Epilepsy, convulsions, or seizures
k.
l.
Gallstones
Gout
ILLNESSES
m.
n.
o.
Heart attack/Angina
Heart failure
Hepatitis
p.
High blood fats (cholesterol, triglycerides)
q.
High blood pressure (hypertension)
r.
Irritable bowel
s.
Kidney stones
t.
Mononucleosis
u.
Pneumonia
v.
Rheumatic fever
w.
Sinusitis
x.
Sleep apnea
y.
Stroke
z.
Thyroid disease
aa.
Other (describe)
©Copyright The Institute for Functional Medicine
WHEN
COMMENTS
WHEN
COMMENTS
Adult Medical Questionnaire
INJURIES
ab.
Back injury
ac.
Broken (describe)
ad.
Head injury
ae.
Neck injury
af.
Other (describe)
DIAGNOSTIC STUDIES
ag.
ah.
ai.
Barium Enema
Bone Scan
CAT Scan of Abdomen
aj.
ak.
al.
am.
an.
ao.
ap.
aq.
ar.
as.
at.
CAT Scan of Brain
CAT Scan of Spine
Chest X-ray
Colonoscopy
EKG
Liver scan
Neck X-ray
NMR/MRI
Sigmoidoscopy
Upper GI Series
Other (describe)
OPERATIONS
au.
av.
aw.
ax.
ay.
az.
ba.
bb.
WHEN
COMMENTS
WHEN
COMMENTS
WHEN
COMMENTS
Appendectomy
Dental Surgery
Gall Bladder
Hernia
Hysterectomy
Tonsillectomy
Other (describe)
Other (describe)
13. Hospitalizations:
WHERE HOSPITALIZED
a.
b.
c.
d.
e.
©Copyright The Institute for Functional Medicine
WHEN
FOR WHAT REASON
Adult Medical Questionnaire
14. How often have you have taken antibiotics?
< 5 times
> 5 times
Infancy/ Childhood
Teen
Adulthood
15. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
< 5 times
> 5 times
Infancy/ Childhood
Teen
Adulthood
16. What medications are you taking now? Include non-prescription drugs.
Medication Name
Date started
Dosage
1.
2.
3.
4.
5.
6.
7.
8.
Are you allergic to any medications?
Yes____ No____
If yes, please list: ________________________________________________________________________
_____________________________________________________________________________________
17. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg
or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.
Vitamin/Mineral/Supplement Name
1.
2.
3.
4.
5.
6.
7.
8.
Date started
Dosage
18. Childhood:
Question
1. Were you a full term baby?
a. A preemie?
b. Breast fed?
©Copyright The Institute for Functional Medicine
Yes
No
Don’t
Know
Comment
Adult Medical Questionnaire
c. Bottle fed?
2. As a child did you eat a lot of sugar and/or candy?
19. As a child, were there any foods that you had to avoid because they gave you symptoms?
Yes____ No____
If yes, please: name the food and symptom (Example: milk – gas and diarrhea)
________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
20. Place a check mark next to the food/drink that applies to your current diet. (List continues on next page.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
Usual Breakfast
None
Bacon/Sausage
Bagel
Butter
Cereal
Coffee
Donut
Eggs
Fruit
Juice
Margarine
Milk
Oat bran
Sugar
Usual Breakfast
Sweet roll
Sweetener
Tea
Toast
Water
Wheat bran
Yogurt
Other: (List below)

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
Usual Lunch
None
Butter
Coffee
Eat in a cafeteria
Eat in restaurant
Fish sandwich
Juice
Leftovers
Lettuce
Margarine
Mayo
Meat sandwich
Milk
Salad
Usual Lunch
Salad dressing
Soda
Soup
Sugar
Sweetener
Tea
Tomato
Water
Yogurt
Other: (List below)
21. How much of the following do you consume each week?
a.
b.
c.
d.
Candy
Cheese
Chocolate
Cups of coffee containing caffeine
©Copyright The Institute for Functional Medicine

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
Usual Dinner
None
Beans (legumes)
Brown rice
Butter
Carrots
Coffee
Fish
Green vegetables
Juice
Margarine
Milk
Pasta
Potato
Poultry
Usual Dinner
Red meat
Rice
Salad
Salad dressing
Soda
Sugar
Sweetener
Tea
Water
Yellow vegetables
Other: (List below)


Adult Medical Questionnaire
e.
f.
g.
h.
i.
j.
k.
l.
m.
Cups of decaffeinated coffee or tea
Cups of hot chocolate
Cups of tea containing caffeine
Diet sodas
Ice cream
Salty foods
Slices of white bread (rolls/bagels)
Sodas with caffeine
Sodas without caffeine
22. Are you on a special diet?
_____ ovo-lacto
_____ diabetic
_____ dairy restricted
_____ vegetarian
_____ vegan
_____ blood type diet
Yes____ No____
_____ other (describe):
__________________________
__________________________
23. Is there anything special about your diet that we should know?
Yes____ No____
If yes, please explain:
__________________________________________________________________________________
24. a. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?
Yes____ No____
b. If yes, are these symptoms associated with any particular food or supplement(s)?
Yes____ No____
c. Please name the food or supplement and symptom(s). Example: Milk – gas and diarrhea.
___________________________________________________________________________________
___________________________________________________________________________________
25. Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident
for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes____ No____
26. Do you feel much worse when you eat a lot of :
high fat foods
high protein foods
high carbohydrate foods
(breads, pastas, potatoes)
refined sugar (junk food)
fried foods
1 or 2 alcoholic drinks
other ____________________________
27. Do you feel much better when you eat a lot of :
high fat foods
high protein foods
high carbohydrate foods
(breads, pastas, potatoes)
refined sugar (junk food)
fried foods
1 or 2 alcoholic drinks
other ____________________________
28. Does skipping a meal greatly affect your symptoms?
Yes____ No____
29. Have you ever had a food that you craved or really "binged" on over a period of time?
Food craving may be an indicator that you may be allergic to that food.
Yes____ No____
If yes, what food(s)? _______________________________________________________________
________________________________________________________________________________
30. Do you have an aversion to certain foods?
©Copyright The Institute for Functional Medicine
Yes____ No____
Adult Medical Questionnaire
If yes, what foods? ___________________________________________________________________
31. 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
32. Intestinal gas:
b. 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
Daily
Occasionally
Excessive
_____ Present with pain
_____ Foul smelling
_____ Little odor
33. a. Have you ever used alcohol?
b. If yes, how often do you now drink alcohol?
Yes____ No____
___ No longer drinking alcohol
___ Average 1-3 drinks per week
___ Average 4-6 drinks per week
___ Average 7-10 drinks per week
___ Average >10 drinks per week
c. Have you ever had a problem with alcohol?
Yes____ No____
If yes, please indicate time period (month/year): from ________ to ___________.
34. Have you ever used recreational drugs?
Yes____ No____
35. Have you ever used tobacco?
Yes____ No____
If yes, number of years as a nicotine user _____. Amount per day _____. Year quit _____.
If yes, what type of nicotine have you used? _____Cigarette
_____ Smokeless
_____Cigar
_____Pipe
_____Patch/Gum
36. Are you exposed to second hand smoke regularly?
Yes____ No____
37. Do you have mercury amalgam fillings?
Yes____ No____
38. Do you have any artificial joints or implants?
Yes____ No____
39. Do you feel worse at certain times of the year?
If yes, when?
spring
summer
Yes____ No____
©Copyright The Institute for Functional Medicine
fall
winter
Adult Medical Questionnaire
40. Have you, to your knowledge, been exposed to toxic metals in your job or at home? Yes____ No____
If yes, which one(s)?
lead
cadmium
arsenic
mercury
aluminum
41. Do odors affect you?
Yes____ No____
42. How well have things been going for you?
Very Well
Fair
Poorly
Very
Poorly
Does not
apply
a. At school
b. In your job
c. In your social life
d. With close friends
e.
f.
g.
h.
i.
j.
With sex
With your attitude
With your boyfriend/girlfriend
With your children
With your parents
With your spouse
43. Have you ever had psychotherapy or counseling?
Yes____ No____
Currently? _____ Previously? _____ If previously, from ______ to _______.
What kind? ____________________________________________________________________________
Comments: ____________________________________________________________________________
44. Are you currently, or have you ever been, married?
Yes____ No____
If so, when were you married?
__________
Spouse's occupation __________________
When were you separated? __________
Never _____
When were you divorced?
__________
Never _____
When were you remarried? __________
Never _____
Spouse’s occupation ________________
Comments: ___________________________________________________________________________
45. Hobbies and leisure activities: _____________________________________________________________
________________________________________________________________________________________
46. Do you exercise regularly?
If so, how many times a week?
1.
1x
2.
2x
3.
3x
4.
4x or more
What type of exercise is it?
jogging/walking
basketball
home aerobics
©Copyright The Institute for Functional Medicine
Yes____ No____
When you exercise, how long is each session?
1.
<15 min
2.
16-30 min
3.
31-45 min
4.
> 45 min
tennis
water sports
other ______________________________________
×

Report this document