INTEGRATIVE PSYCHOTHERAPY OF OMAHA



INTEGRATIVE PSYCHOTHERAPY OF OMAHA

Joshua H. Friedman, Psy.D., CHHC

6107 Maple Street, Suite B

Omaha, NE 68132

402-709-6161

Fax: 866-615-3670

Email: mind-balance@



Health History Form Date:

What is your chief concern?_________________________________________________

Other Concerns?__________________________________________________________

Occupation:__________________ Hours of work per week:_____________

Relationship status:__________________ Children?:__________________

Do you sleep well?__________Do you wake up at night?_______ What times?_____

To urinate?____________ What time do you generally get up in the AM?___________

Constipation/diarrhea?_________________

Women: Are your periods regular?___________ How many days is your flow?_________

How frequent?__________ Painful or symptomatic?__________

Please explain (if necessary);__________________________________________________

Do you take supplements or medication? If so which?______________________________

________________________________________________________________________

Any therapies or healers you are involved with?

What role does exercise play in your life?______________________________________

Do you drink coffee, smoke cigarettes, or have any major addictions?

________________________________________________________________________

What percentage of your food is home cooked?_______ Where do you get the rest

from?_______________________________________________________________

Please describe your current level of stress:

_____________________________________________________________________

_____________________________________________________________________

How do you relax?____________________________________________________

What do you do for fun?_______________________________________________

Please tell me about the food you eat during a typical day (use a day recently that you remember).

Breakfast Lunch Dinner

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Snacks Liquids

_____________________________________________________________________

_____________________________________________________________________

Mental health Symptoms Chart

1) In Column A, put a number from 1 to 10 by each symptoms experienced, with 1 being slightly felt or hardly ever felt and 10 being strongly felt or felt all the time. 2) Check the substances in Column B that are used to reduce the symptoms in the same section of Column A.

A: Symptoms B: Substances Used

Type 1:Low Serotonin

___afternoon or evening ___sweets

cravings ___starches

___negativity, depression ___tobacco

___winter blues, SAD ___chocolate

___worry, anxiety ___Ecstasy

___low self-esteem ___marijuana

___guilt ___alcohol

___obsessive thought or behaviors ___anti-depressant medication ___perfectionistic

___irritability, rage

___panic attacks; phobias (i.e. fear of heights, small spaces etc.)

___suicidal thoughts, feelings

___hyper-activity

___dislike of hot weather

___fibromyalgia, TMJ

___night-owl, hard to get to sleep

___frequent awakening during night

___waking up too early

typical sleep hours:

____to____

Type 2: Low Catecholemines

___apathetic depression ___sweets

___lack of energy ___starch

___lack of drive, motivation ___chocolate

___lack of focus/concentration ___Aspartame

___Attention Deficit Disorder ___alcohol

___easily bored ___marijuana

___caffeine

___Cocaine

___speed

___tobacco

Section 3: Low GABA

___stiff , tense or painful muscles ___sweets

___over stressed and burned out ___starch

___unable to relax and loosen up ___tobacco

___often fee overwhelmed ___marijuana

___ Xanax, Klonopin

Section 4: Endorphin Deficiency

___very sensitive to emotional ___sweets

or physical pain ___starch

___cry (tear up) easily ___chocolate

___crave comfort, reward, or numbing ___tobacco

from drugs, alcohol, foods or behaviors ___heroin

___marijuana

___alcohol

Section 5: Low Blood Sugar

___craving for sugar, starch ___sweets

or alcohol ___starches

___irritable, shaky, especially ___alcohol

if going too long between meals

Adapted from The Mood Cure by Julia Ross

Did any of the following events occur in the 6 month period prior to 1) the initial onset of mental health symptoms; or 2) the period in which your mental health started to decline?

___High levels of stress/anger (e.g. family/relationship related)

___Emotionally traumatic event(s) (e.g. death of a loved one)

___Excessive physical &/or work activity for you

___Sleep deprivation/sleep disruption/night shift work

___New medications (e.g. antibiotics, antacids, hormones, psychiatric)

___Changed dose of medication (e.g. lowered hormones)

___Started supplement containing > 600 mcg (0.6 mg) of copper

___Illicit drug use or started smoking

___Significant change in diet (e.g. crash dieting)

___Increased coffee, diet soft drink or alcohol intake

___New house/job/office/school/class room

___House/work/school renovated or repaired (inc. vinyl wall paper)

___House/work/school freshly painted or sprayed with pesticides

___New mattress, pillow, carpet, furniture or refinished furniture

___Amalgam (silver) filling insertion or removal

___Root canal insertion

___Broke glass thermometer

___Three or more servings of fish per week (1 serving = 150 grams)

___Regularly eating one of the following fish - Swordfish, shark/flake,

marlin, broadbill, orange roughly/sea perch or catfish

___New gas heater, gas stove or other gas appliance

___Water contamination (e.g. leaks/flooding) in house/work/school

___New or increased mold growth in your house/work/school

___Commenced new hobby

___Other chemical exposure (e.g. work or home related)

___Insertion of breast implants, silicon injections, metal crowns, braces,

___Joint/hip replacement, metals screws/pins/nails/slips, etc.

___New cordless phone near bed, started using electric blanket, started

___Sleeping near a meter box or new WiFi system

___Food poisoning / gastroenteritis / parasitic infection

___Household member with parasitic or bacterial infection

___International travel, camping, wilderness activities and/or

travel to parasite prone area

___Viral or bacterial infection (other than typical ‘cold’) / fever

___Tick or spider bite

___Recent Vaccination (e.g. Hepatitis B or Tetanus)

___Blood transfusion or donation

___Hospitalization

___Surgery (e.g. hysterectomy/appendectomy)

___Pregnancy/miscarriage/abortion/menopause onset

___Injury / head injury / stroke

___Unprotected sex with people of unknown STD status

Blood Sugar Issues (Hypoglycemia)- Mark symptoms that apply to you

4. ___Crave a lift from sweets or alcohol, but later experience a drop in energy and mood after ingesting them

4. ___Dizziness, weak, or headachy, especially if meals are delayed

4. ___Family history of diabetes, hypoglycemia, or alcoholism

4. ___Nervous, jittery, inability on and off throughout the day; calmer after meals

4. ___Crying spells, mood swings

4. ___Mental confusion, decreased memory

4. ___Heart palpitations, rapid pulse

4. ___Frequent thirst, night sweats (not menopausal)

Total Score__________ Ideal score under 12

Stress and Adrenal Function- Mark symptoms that apply to you

4. ___Frequently overstressed for more than 3 weeks at a time

3. ___Crave salty foods

4. ___Frequently feel fatigued, overwhelmed

4. ___Dark circles under eyes

4. ___Sensitivity to sound, odors; startle easily

3. ___Edgy, irritable under stress

3. ___Have excessive weight gain in your trunk only

Total Score___________ Ideal score is under 15

Thyroid- Mark the symptoms that apply to you

4 ___Low energy

4 ___Easily Chilled (especially hands and feet)

4 ___Family members with thyroid issues

4 ___Can gain weight without overeating; hard to lose excess weight

3 ___Have to force yourself to do even moderate exercise

4 ___Hard to get going in the morning

3 ___High Cholesterol

3 ___Low blood pressure

4 ___(For women) weight gain began near the start of menses, a pregnancy, or menopause

3 ___Chronic headaches

3 ___Use food, caffeine, tobacco, and/or stimulants to get going

Total Score__________ Ideal score is under 15

Food Allergies- Mark the symptoms that apply to you

3. ___Crave milk, ice cream, yogurt, cheese, doughy foods (pasta, bread, cookies among others and eat them frequently

3. ___Experience bloating after meals

4. ___Gas, frequent belching

3. ___Digestive discomfort of any kind

3. ___Chronic constipation and/or diarrhea

4. ___Respiratory problems, such as asthma, postnasal drip, congestion

3. ___Low energy or drowsiness, especially after meals

4. ___Allergic to milk products or other common foods

3. ___Under eat or often prefer beverages to solid food

3. ___Avoid food or throw up food because bloating after eating makes you feel fat or tired

4. ___Can’t gain weight

3. ___Hyperactive or manic-depressive

3. ___Severe headaches, migraines

4. ___Food allergies in you family

Total Score___________ Ideal is less than 12

Yeast overgrowth or parasites- Mark the symptoms that apply to you

4. ___Often bloated, abdominal distention

3. ___Foggy-headed

a. ___Depressed

4. ___Yeast or sinus infections

4 ___Used antibiotics extensively (at any time in life)

4 ___Used cortisone or birth control pills for more than one year

4 ___Have chronic fungus on nails or feet

3 ___Achy muscles and joints*

3 ___Chronically fatigued*

4 ___Rashes*

3 ___Stool unusual in color, shape, or consistency*

* parasite infection

Total Score__________ Ideal score is under 13

Pyroluria (mark symptoms that apply)

___Little or no dream recall

___White spots on finger nails

___Poor morning appetite and/or tendency to skip breakfast

___Morning nausea

___Pale skin, poor tanning or burn easy in sun

___Sensitivity to bright light

___Hypersensitive to loud noises

___Reading difficulties (e.g. dyslexia)

___Histrionic (dramatic)

___Argumentative/enjoy argument

___Mood swings or temper outbursts

___Much higher capability & alertness in the evening, compared to mornings

___Anxiousness

___Preference for spicy or heavily flavored foods

___Abnormal body fat distribution

___Significant growth after the age of 16

(For Women) Female Sex Hormones- mark the symptoms that apply to you

5. ___Premenstrual mood swings

4 ___Irregular periods

4 ___Premenstrual or menopausal food cravings

3 ___Experienced a miscarriage, an abortion, or infertility

4 ___Use(d) birth control pills or other hormone medication

3 ___Uncomfortable periods-cramps, lengthy or heavy bleeding or sore breasts

4 ___Peri- or postmenopausal discomfort (e.g. ho flashes, sweats, insomnia, or mental dullness

3 ___Excessive hair growth or loss, acne

Total Score___________ Ideal score is under 6

(For Men) Male Sex Hormones (Testosterone) - check the symptoms that apply

___Testosterone deficiency

___Lower sex drive/libido

___Difficulty achieving an erection

___Softer erections

___Takes longer to achieve orgasm

___Decreased ejaculate volume

___Less sexual enjoyment/satisfaction

___Increased abdominal fat

___Loss of muscle mass/strength

___Tendency to feel depressed or irritable

___Decreased memory

___Fatigue / lowered stamina

___Loss of muscle mass/ strength

___Slowed growth or reduction of hair on

face, chest, legs or pubic area

___Reduction or absence of voice deepness

Low Histamine (over-methylation)- mark symptoms that apply

___Do you get canker sores?

___Do you have slow sexual responsiveness or low libido?

___Do you have tension headaches or seldom have headaches?

___Do you have heavy growth of body hair?

___Do you tend to carry an excess fat in your lower extremeties rather than evenly distributed around your body (pear shaped figure)?

___Do you have a lot of dental fillings?

___Do you have a head full of grand plans but are easily frustrated?

___Are you suspicious of people or do you feel paranoid?

___Have you ever heard voices inside your head?

___Are you able to stand pain well?

___Do you have ringing in your ears?

___Do you get few or no colds?

___Do you have low tolerance for medications or drugs?

___Do you tire easily?

___Do you need at least 8 hours of sleep at night and are you a slow riser in the AM?

___Is your mouth usually dry?

___Do you have a tendency to despair, or have bouts of crying?

___Do you experience frequent irritability?

Total Score_________Ideal score is under 10

High Histamine (under-methylation)- mark symptoms that apply

___Do you tend to sneeze in bright sunlight?

___Were you a shy and oversensitive teenager?

___Can you make tears easily, and are you never bothered by a lack of saliva or dry mouth?

___Do you hear your pulse in your head on the pillow at night?

___Do you have frequent muscle cramps?

___Do you have a high sensitivity to pain?

___Do you find it easy to have an orgasm

Please Provide any additional information you think may be contributing to your mental health issues?

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