Energy level – at what time of day is it……
Energy level – at what time of day is it:
□ High ___________
□ Low ___________ | |
| |
| |
|Stress – my current level is…. |
|Low |
|Moderate |
|High |
|Severe |
| |
| |
|Sweating |
|Rarely sweat |
|Excess sweat |
|Night sweats |
| |
|Circulation – I usually…. |
|Feel hot |
|Feel cold |
|Bleed/bruise easily |
|Have cold limbs |
| |
|Skin |
|Dry |
|Itchy |
|Moist / clammy |
|Burning |
|Changing moles or lumps (cysts / tumors) |
|Boils |
|Frequent skin rashes |
|Acne |
|Hair loss / thinning |
|Dry scalp |
|Puffy or wrinkled skin |
|Hives |
|Other _______________________________ |
| |
|Sleep |
|Trouble falling asleep |
|Trouble staying asleep |
|Usually restful |
|Excess or vivid dreaming |
|Average number of hours per night = ________ |
| |
|Head |
|Dizziness |
|Memory loss |
|Loss of balance |
|Light-headedness |
|Headaches |
|Other _______________________________ |
| |
|Eyes |
|Eye pain |
|Dry eyes |
|Blurred vision |
|Double vision |
|Loss of vision |
|Sensitive to light |
|Other _______________________________ |
|Ears |
|Hearing loss |
|Earaches |
|Discharge / infections |
|Ringing / buzzing |
|Other _______________________________ |
| |
|Nose |
|Frequent nose bleeds |
|Sinus trouble |
|Seasonal allergies |
|Frequent colds |
|Other _______________________________ |
| |
|Throat / Mouth |
|Sore throat |
|Hoarseness |
|Difficulty swallowing |
|Jaw problems |
|Tooth / gum problems |
|Swollen tongue |
|Other _______________________________ |
| |
|Chest |
|Difficulty breathing |
|Wheezing |
|Shortness of breath |
|Mucus rattles when breathing |
|Trouble breathing at night |
|Pain / pressure in chest |
|Palpitations |
|Persistent cough |
|Coughing blood |
|Coughing phlegm |
|Other ______________________________ |
| |
|Bowels |
|# of bowel movements per day ____ |
|Diarrhea |
|Constipation |
|Blood in stools |
|Black stools |
|Mucus in stools |
|Hemorrhoids / anal fissures |
|Lower bowel gas |
|Stools have foul odor |
|Other _______________________________ |
| |
|Urine |
|Frequent urination( □ at night □ during the day |
|Strong smelling |
|Difficulty urinating |
|Pain or burning with urination |
|Blood in urine |
|Frequent infections |
|Incontinence |
|Other _______________________________ |
|Musculoskeletal – pain in….. |
|Neck |
|Shoulder |
|Between shoulders |
|Arms / hands – left, right or both |
|Hip |
|Knee – left, right, or both |
|Fingers |
|Big toe |
|Upper back |
|Mid back |
|Lower back |
|Bones sore / painful |
|Loss of grip |
|Swollen knees / elbows |
|Leg cramps at night |
|Weakness in legs |
|Weak ankles |
|Stiff all over |
|Tingling / burning in feet |
|Muscle spasms / cramps |
|Loss of feeling in hands / feet |
|Painful joints |
|Bursitis |
|Other _______________________________ |
| |
|Neurological/Emotional |
|Nervousness |
|Depression |
|Easily angered |
|Easily irritated |
|Frequent crying |
|Worry / anxiety |
|Mood swings |
|Memory confusion |
|Poor concentration |
|Suicidal thoughts / tendencies |
|Tremors |
|Numbness / tingling in limbs |
|Poor coordination |
|Muscle weakness |
|Feel weak and shaky |
|Seizures |
|Neuralgia (nerve pain) |
|Shingles |
|Other ________________________________ |
| |
|Appetite |
|How many meals a day? ____ |
|Specific food cravings ______________________ |
|Excessive appetite |
|Poor appetite |
|Keeps changing |
|Feel tired or weak if a meal is missed |
|Other _______________________________ |
|Thirst |
|How much water do you drink daily? ___ |
|Excessive thirst |
|Never thirsty |
|Other _______________________________ |
| |
|Digestion |
|Stomach gas |
|Lower bowel gas |
|Heartburn/indigestion |
|Burning / belching / acid reflux |
|Stomach pain/cramps |
|Nausea |
|Vomiting |
|Bad breath |
|Sores in mouth |
|Weight gain |
|Weight loss |
|Bitter / sour taste in mouth |
|Abdominal bloating |
|Other _______________________________ |
| |
|Women only: |
|Are you or do you think you are pregnant? Y / N |
|If using birth control, what kind? ____________ |
|Date of last menstrual period ______________ |
|Average length of cycle __________________ |
|Date of last PAP smear __________________ |
|Menstrual pain ( before, during or after period |
|Cramping |
|Irregular cycle / missed periods |
|Heavy bleeding |
|Light / scanty bleeding |
|Clotting |
|Painful breasts |
|Hot flashes |
|Decreased/increased libido |
|Vaginal discharge |
|Fibroids |
|Endometriosis |
|Ovarian cysts |
|Pelvic inflammatory disease |
|Miscarriages |
|Other ________________________________ |
| |
|Men only: |
|Date of last prostate exam _____________ |
|Prostate pain/swelling |
|Decreased/increased libido |
|Impotence |
|Premature ejaculation |
|Testicular pain/swelling |
|Penile discharge |
|Groin pain |
|Urinary abnormalities/changes |
|Other ________________________________ |
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