Health History Questionnaire



[Space for Clinic Name][add logo if desired]AddressCity, State, ZipPhone #Fax #Secure e-mailWebsitecenter2103755<INSERT FORM INSTRUCTIONS HERE, i.e.: Welcome to XYZ Chiropractic. Please complete the following form and return to our office before your scheduled appointment.>00<INSERT FORM INSTRUCTIONS HERE, i.e.: Welcome to XYZ Chiropractic. Please complete the following form and return to our office before your scheduled appointment.>Health Questionnaire FormGeneral InformationDate:First Name: MI: Last: Preferred Name:Street Address:City:State: Zip Code:Cell Phone:Work Phone:Email:Age: Date of Birth: Gender: Female Male Non-BinaryOccupation: # of hours per week:Genetic Background: Please check appropriate box(es): African American Native American Hispanic Asian Mediterranean? Caucasian Northern European OtherAre you retired? Yes NoHow did you hear about our office? Friend Family member Website Social Media OtherHave any other family members been to our clinic? If yes, who?Emergency Contact:Relationship:Phone:Who is your primary care physician?personal InformationMarital Status: Married Separated Divorced Widowed Single PartnershipNumber of children: ________Child’s Name______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Age____________________________________________________________Gender____________________________________________________________Number of Siblings: Sisters ______ (# deceased: ______ ) Brothers: ______ (# deceased: ______ )Are you adopted? Yes No What is your birth order? ________Who lives in your home with you? (Include children, parents, relatives, and/or friends.)____________________________________________________________________________________________________________________________________________________________________Do you have any pets or farm animals? Yes NoIf yes, where do they live? Indoors Outdoors Both indoors and outdoorsHave you ever lived or travelled outside the United States? Yes NoIf yes, when and where? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________If yes, did you get sick during your travel or shortly after returning home? Yes NoIf yes, describe your symptoms and experience: _______________________________________________________________________________________________________________________________________________________________________________________________________________Have you or your family recently experienced any major life changes or unexpected trauma? Yes No If yes, please comment: __________________________________________________________________________________________________________________________________Have you experienced any major losses in life? Yes NoIf so, please comment: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you been unable to work or go to school in the past year because of your health issues? Yes NoIf yes, how many days have you missed in the past 12 months? 0-3 days 4-6 days 7-14 days 15 or more daysWhere have you previously worked? ________________________________________________________________________________________________________________________________________________________________________________________________________________________What is your highest level of education? High School College ______________________________________ Major: __________________ Year: _____ Graduate School _______________________________ Field: __________________ Year: _____ Professional School _____________________________ Field: __________________ Year: _____Did you have difficulty learning while in school? Yes NoFunctional Wellness Information-158759531The following information is designed to help us get to know you better. If you are unsure of the answers to any questions, you may need to reach out to other family members for additional insight. Please be as thoughtful and accurate as possible, noting even the smallest symptoms or incidents as these can often provide additional clues as to what might be going on. And be sure to write your answers as clearly as possible.00The following information is designed to help us get to know you better. If you are unsure of the answers to any questions, you may need to reach out to other family members for additional insight. Please be as thoughtful and accurate as possible, noting even the smallest symptoms or incidents as these can often provide additional clues as to what might be going on. And be sure to write your answers as clearly as possible.Please list in order of importance the health problems you are most concerned about. Be sure to note how long each one has been present.Health IssueDate of OnsetFrequency (constant, occasionally, infrequently)Severity (mild, moderate, severe) Have you previously received any formal diagnosis of any of these health issues?________________________________________________________________________________________________________________________________________________________________________Do you have chronic pain? Yes NoIf yes, please describe: _____________________________________________________________________________________________________________________________________________________Do you have chronic inflammation? Yes NoIf yes, please describe: _____________________________________________________________________________________________________________________________________________________When was the last time you really felt well? _____________________________________________________________________________________________________________________________________YOUR HEALTH GOALSWhat do you hope to achieve by working with us? (Please be thoughtful and very honest in your response.)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If you had a magic wand and could erase three problems, what would they be?1. __________________________________________________________________________________2. __________________________________________________________________________________3. __________________________________________________________________________________List up to 5 things that you have been unable to do as a result of your present symptoms. Please be specific. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List up to 5 things that you plan to do once you are feeling better. Please be specific. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are there any other health goals you want to achieve?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Was there a specific trigger or occurrence just prior to the change in your health (i.e., illness, personal loss, travel, etc.)?________________________________________________________________________________________________________________________________________________________________________Are there certain things that make you feel worse? _______________________________________________________________________________________________________________________________What makes you feel better? ________________________________________________________________________________________________________________________________________________When was your last visit to your primary care doctor and what was the reason for the visit? ____________________________________________________________________________________Please list the healthcare practitioners you’ve consulted with for your health concerns and what was done or recommended by each:Name __________________________________Recommendations or Action: ____________________________________________________________Name __________________________________Recommendations or Action: ____________________________________________________________Name __________________________________Recommendations or Action: ____________________________________________________________Name __________________________________Recommendations or Action: ____________________________________________________________Name __________________________________Recommendations or Action: ____________________________________________________________Name __________________________________Recommendations or Action: ____________________________________________________________Place a check mark in the box next to alternative therapies you have already tried:NoneChiropracticAcupunctureIridologyColonicsMassageRolfingReikiHomeopathyBiofeedbackYogaHypnosisAyurveda Light therapyMeditationEnvironmental medicineNutritional therapyBiological DentistryIV (chelation) therapyNaturopathic medicineILLNESSESList any illnesses you’ve had over the course of your life (i.e., chicken pox, tonsillitis, mononucleosis, anemia, bronchitis, food poisoning, digestive issues, kidney stones, sinus infections, gall bladder, thyroid blood pressure, etc.). Try to be as thorough as possible. Nothing is insignificant. Be sure to note the dates if the illness happened more than once.IllnessDateDateDateCommentsINJURIESList any injuries you’ve had over the course of your life (i.e. auto accident, bicycle fall, head injury, trip and fall, bone break, etc.). Try to be as thorough as possible. Nothing is insignificant. InjuryDateCommentsDIAGNOSTIC TESTINGList any advanced testing you’ve had over the course of your life (i.e., endoscopy, colonoscopy, mammogram, thermogram, chest x-ray, EKG, CAT scan, bone density, MRI, carotid artery ultrasounds, etc.). Try to be as thorough as possible. Type of TestDateCommentsSURGERIESList any surgeries you’ve had over the course of your life (i.e., gall bladder removal, tonsillectomy, tubes in your ears, appendectomy, hernia repair, hysterectomy, dental, cosmetic or reconstructive surgery, joint replacement, etc.). Try to be as thorough as possible. SurgeryDateCommentsHOSPITALIZATIONSNote any overnight or long-term hospitalizations you’ve had over the course of your life. Provide as much information about the reason for the hospitalization as you can. Where HospitalizedDateReasonBIRTH HISTORYYesNoUnsureCommentWere you carried to full-term?Vaginal delivery?Cesarean section?Epidural used?Breast fed? (how long?)Bottle fed? (how long?)Did your mother smoke tobacco while pregnant with you?Did she drink alcohol?Did she take any forms of estrogen?CHILDHOOD DIETARY HISTORYWhich of the following were part of your regular diet?YesNoDon’t KnowCommentSugar/candy/sweetsRegular sodaDiet sodaWhite breadIce creamFruits and vegetablesHigh quality meatsRaw dairyButter or other healthy fatsPotatoes, rice or pastaHigh amount of grainsVegetarian onlyVegetarian with milk and eggsWere there any foods that you avoided because they bothered you?FoodSymptomOther CommentsSPECIFIC CHILDHOOD ILLNESSES OR OTHER HEALTH CONSIDERATIONSAlthough these may have been mentioned previously, please note the approximate age when any of the following occurred (from birth to age 15). Provide additional information as necessary in the space below.Frequent colds or flu (age) _____Tonsillitis (age) _____ Bronchitis or pneumonia (age) _____ Skin disorders (i.e. eczema) (age) _____Measles (age) _____Mumps (age) _____Chicken Pox (age) _____Whooping Cough (age) _____Strep throat infections (age) _____Seasonal allergies (age) _____Significant dental work (age) _____Behavior problems (age) _____ADD or difficulty learning (age) _____Hyperactivity (age) _____Abusive or alcoholic parent(s) (age) _____Frequent headaches (age) _____High # of absences from school (age) _____Upset stomach, indigestion (age) _____Jaundice (age) _____Colic (age) _____Ear infections (age) _____Congenital abnormalities (age) _____Fever blisters (age) _____Exposure to 2nd hand smoke (age) _____Alcoholic parents (age) _____Physical or emotional abuse (age) _____Major illness(es) requiring hospitalization (age) _____ Other: ________________________ (age) _____Additional information: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMMUNIZATION HISTORYPlease indicate which of the following vaccines you had as a child or adult: Smallpox Tetanus DiphtheriaPertussis Polio (oral)Polio (injection)Mumps Measles Rubella (German measles)TyphoidCholeraFAMILY HISTORYComplete the following, noting the age at which your family member experienced any of the following issues.FatherMotherBrother(s)Sister(s)ChildrenMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherAuntsUnclesOtherCurrent age If deceased, age at deathHeart AttackStrokeUterine cancerColon cancerBreast cancerOvarian cancerProstate cancerSkin cancerOther cancerADD/ADHDALS or other Motor Neuron DiseasesAlzheimer’sAnemiaAnxietyArthritisAsthmaAutismAutoimmune Diseases Bipolar diseaseBladder diseaseBlood clotting problemsCeliac diseaseDementiaDepressionDiabetesEczemaEmphysemaEnvironmental sensitivitiesEpilepsyFluFood allergies, sensitivities, or intolerancesGenetic disordersGlaucomaHeadacheHeart diseaseHigh blood pressureElevated cholesterolInflammatory Bowel DiseaseInsomniaIrritable Bowel SyndromeKidney diseaseMacular degenerationMultiple SclerosisNervous breakdownObesityOsteoporosisParkinson’sPneumonia/BronchitisPsoriasisPsychiatric disordersSchizophreniaSleep apneaSmoking addictionStrokeSubstance abuse (such as alcoholism)UlcersAny other illnesses or conditions not listed here that we should know about? If so, please describe:________________________________________________________________________________________________________________________________________________________________________FEMALE MEDICAL HISTORY(For women only)OBSTETRICS HISTORYSelect all that apply and note number of occurrences.Pregnancies ________Post-partum depression ________ Miscarriages ________Toxemia ________Vaginal deliveries _________Gestational diabetes ________Caesarean sections ________Living children ________Abortions ________Premature deliveries ________GYNECOLOGICAL HISTORYOnset of menses (age): _______ Length of bleeding: _______Date of last menstrual period: _____/_____/_____ N/APainful menstruation: Yes No N/A Clotting: Yes No N/ABreast tenderness: Yes No Water retention around your period: Yes No N/APMS: Yes No Have you had your uterus removed? Yes NoHave you had a complete hysterectomy? Yes NoIf yes, please explain why: ________________________________________________________________________________________________________________________________________________Are you currently using any form of contraception: Yes NoIf yes, which of the following:Hormonal ContraceptionNon-Hormonal ContraceptionBirth control pillsCondom Nuva ringIUDPatchDiaphragmOther _____________________________Partner vasectomyOther _____________________________Have you used hormonal birth control in the past, regardless of whether you are using it right now? If so, please indicate the type and how long you used it:________________________________________________________________________________________________________________________________________________________________________Are you menopausal? Yes No If yes, age of menopause: _______Are you currently on any type of hormone replacement therapy or bioidentical hormones? Yes No Estrogen Estrace Estriol Progesterone Premarin Provera Testosterone DHEA Other ______________________________________________When was your last PAP test? _____/_____/_____ Normal: Yes No Abnormal: Yes NoLast mammogram: _____/_____/_____ Last thermogram: _____/_____/_____Have you had a breast biopsy? Yes No Results: Normal AbnormalLast bone density scan: _____/_____/_____ Results: High Low Within normalDENTAL HISTORYHave you ever had sore gums (gingivitis) in the past? Yes NoHave you experienced ringing in the ears (tinnitus)? Yes NoHave you had TMJ (temporal mandibular joint) problems? Yes NoDo you ever have a 'metallic' taste in your mouth? Yes NoDo you have bad breath (halitosis) or a white tongue (thrush)? Yes NoHave you worn or do you presently wear braces? Yes NoDo you have problems chewing? Yes NoDo you floss regularly? Yes NoHave you had any root canals? Yes No If yes, how many? _______Have you had any dental surgeries? Yes NoIf yes, place the date, description, reason and outcome of the surgery: ___________________________________________________________________________________________________________________________________________________________________________________________________Did your mother have dental fillings prior to giving birth to you? Yes NoDid she have any fillings removed while pregnant with you? Yes NoDid you have mercury dental fillings as a child? Yes No If yes, approximately how many fillings did you have up to 18 years of age? _______Have you had dental fillings as an adult? Yes No If yes, about how many fillings did you have after 18 years of age? _______ If yes, were any of them mercury? Yes NoHow many mercury fillings do you have now? _______Did you play with mercury as a child or adult? Yes NoHave you consumed a significant amount of fish in your life? Yes NoPlease circle the tooth or teeth you have had or still have problems with. Please state what type of problem you have had, for example: root canal, crown, abscessed tooth, partials, etc., and indicate which teeth have fillings. INCLUDEPICTURE "" \* MERGEFORMATINET LEFT SIDE / RIGHT SIDERECORD ANSWERS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ANTIBIOTIC AND STEROID HISTORYAntibiotics: How often have you taken antibiotics?< 5 times> 5 timesInfancy/ChildhoodTeenAdulthoodOral Steroids: How often have you taken oral steroids (e.g., Prednisone, Cortisone, etc.)?< 5 times> 5 timesInfancy/ChildhoodTeenAdulthoodMEDICATION HISTORYIndicate any medications you’re currently taking or have taken in the last month:Acid Blocking DrugsAnti-anxiety medications Antibiotics AnticonvulsantsAntidepressantsAntifungalsAspirin/IbuprofenAsthma inhalersBeta blockersBirth control pills/implant contraceptivesChemotherapyCholesterol lowering medicationsCortisone/steroids Diabetic medications/insulinDiureticsEstrogen or progesterone (pharmaceutical, prescription) Estrogen or progesterone (natural) Heart medicationsHigh blood pressure medications LaxativesRelaxants/Sleeping pillsTestosterone (natural or prescription)Thyroid medicationAcetaminophen (Tylenol)Ulcer medicationsSildenafil citrate (Viagra or similar)CURRENT MEDICATION LOGPlease indicate the type of medications you are currently taking, ones you’ve taken in the past and any non-prescription drugs you are currently using.Medication NameDate StartedDated StoppedDosage# per dayCURRENT SUPPLEMENT LOGPlease list all vitamins, minerals, herbs or other nutritional supplements you are currently taking.Supplement Name/BrandDoseFrequencyDated StartedReason for UseAre there any supplement ingredients (animal or otherwise) that you are particularly averse to? Yes NoIf yes, please describe: ___________________________________________________________________________________________________________________________________________________Have your medications or supplements ever caused you unusual side effects or problems? Yes NoIf yes, please describe: _____________________________________________________________________________________________________________________________________________________ALLERGY HISTORYPlease list any allergies, sensitivities or intolerances you currently have or have had in the past.Medication, Supplement or FoodReactionNUTRITION AND LIFESTYLE HISTORYHave you made any changes to your diet because of your health? Yes NoDo you currently follow a special diet or nutritional program? Yes NoIf yes, check all that apply:Low fatMixed food diet (animal and vegetable sources)High proteinVegetarianVeganGluten restrictedLow sodiumFat restrictionLow starch/carbohydrate The Blood Type DietThe Metabolic Typing DietPaleo DietTotal calorie restrictionOvo-lacto dietDiabetic dietary guidelinesNo dairyNo wheatSpecific Program for Weight Loss/Maintenance Type: ____________________________________Other: ___________________________________________________________________________Please check any specific food restrictions or sensitivities you currently have:DairySoyWheatCornEggsAll glutenOther: _______________________Is there anything special about your diet that I should know? ___________________________________________________________________________________________________________________________________________________________________________________________________________Height (feet/inches): _________________________Current weight: _____________________________Usual weight range +/- 5 lbs: __________________Desired weight range +/- 5 lbs: ________________Highest adult weight: ________________________Lowest adult weight: _________________________Do you currently experience weight fluctuations (>10 lbs.)? Yes No How often do you weigh yourself? Daily Weekly Monthly Rarely NeverAre there any foods that you avoid because they cause you digestive discomfort or unpleasant symptoms? Yes NoIf yes, please list the food and the symptom(s) you experience (e.g., wheat—causes gas and bloating).FoodSymptomOther CommentsDo you do your own grocery shopping? Yes NoIf no, who does the shopping? ________________________When you shop do you purchase the following? Organic foods High-quality fats Hormone free and antibiotic free meat Preservative-free foodsDo you read food labels? Yes NoDo you cook? Yes NoIf no, who does the cooking? ________________________________How many meals per week do you eat out? 0–1 1–3 3–5 >5Check all the factors that apply to your current lifestyle and eating habits:Fast eaterErratic eating habitsEat too muchLate night eaterDislike health foodTime constraintsEat more than 50% of meals away from homeTravel frequentlyNon-availability of healthy foodsDo not plan meals or menusReliance on convenience itemsPoor snack choicesSignificant other or family members don’t like healthy foodsSignificant other or family members have special dietary needs of food preferencesLove to eatEat because I have toHave a negative relationship to foodStruggle with eating issuesEmotional eater (eat when sad, lonely, depressed, bored)Eat too much under stressEat too little under stressDon’t care to cookEating in the middle of the nightConfused about nutritional adviseDiet often for weight controlCHILDHOOD EATING HISTORYWhich of the following foods were regularly consumed during your childhood?Sugary foodsIce creamCandyCookies BreadFast foodProcessed cheese MeatVegetablesStarches (rice, potatoes, etc.)Vegetarian dietBoxed or packaged foods (Top Ramen, macaroni & cheese, etc.)Artificial colors or sweetenersWere there foods you avoided because of the way they made you feel? Yes NoIf so, please explain: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FOOD DIARYPlace a check mark next to the food or drink items that are part of your current diet. BreakfastLunchUsual DinnerNone / don’t eat breakfastBacon/SausageBagelButterCerealCoffeeDonutEggsGranolaFruitJuiceMargarineMilk Oat branSugarSweet rollSweetenerTeaToastWaterWheat branYogurtOatmealMilk protein shakeSlim fastSmoothieSoy proteinWhey proteinRice proteinOther:None / don’t eat lunchButterCoffeeEat in a cafeteriaEat in restaurantFish sandwichFried foodsHamburgerHot dogsJuiceLeftoversLettuceMargarineMayoMeat sandwichMilkPizzaPotato chipsSaladSalad dressingSodaSoupSugarSweetenerTeaTomatoVegetablesQuinoaFish or chickenWaterYogurtProtein shakeOther:None / don’t eat dinnerBeans (legumes)Brown riceButterCarrotsCoffeeFishGreen vegetablesJuiceMargarineMilkPastaPotatoPoultryRed meatRiceSaladSalad dressingSodaSugarSweetenerTeaVinegarWaterWhite riceYellow vegetablesOther:Check items that you consume a minimum of 3 days or more each week.AlmondsAlmond butterAlcoholApplesAvocadoAsparagusBagelsBarleyBananaBurger KingBaconBean, limaBread, whiteBread, wheatBread, ryeBagelsBiscuitsBean, pintoBean, stringBroccoliBrazil nutsBrussels SproutsBlueberriesButterCabbageCereal, Special KCereal, Bran FlakesCereal, cornflakesCereal, _________Cereal, _________CeleryCantaloupeCandy Chinese foodCream cheeseCarrotChickenChili pepperCinnamonClamClovesCocoa-ChocolateCarnation drinkChewing gum, sweetenedChewing gum, sugar free CoconutCodCoffeeCornCrabCranberryCashewCheeseCucumberDeli meatsDessertsDeli sandwichEggplantEnsureFlounderFried foodsFrench friesFrench toastGarlicGingerGrapeGritsGreek foodGrapefruitGrape NutsHaddockHamHalibutHerring Hot dogs, porkHot dogs, beefHamburgersHardee’s foodHoneyItalian foodIce creamIndian foodJack in the Box foodJapanese foodJellyKetchupLambLemonLentilLettuceLimeLobsterMackerelMargarineMcDonalds foodMilletMung beanMushroomMustardMilk, cowMilk, goatMilk, riceMilk, almondMilk, soyMexican foodMaltNutmegNutriSweetOatmeal, regularOatmeal, instantOliveOnionOrange juiceOreganoOysterOrangePapayaParsleyPopTartsPeanutsPeanut butterPeasPeachPecanPepperPepper, greenPerchPineapplePancakesProtein shakes, soyProtein shakes, milkProtein shakes, wheyProtein shakes, ______________Protein shakes, ______________PlumPorkPeanutPotato, sweetPotato, whitePumpkinQuinoaRadishRyeSafflowerSageSaltSalmonScallopsSausageSlim FastSweet & LowSesameShrimpSnapperSoft drinksSoleSour creamSoybeanSpinachStrawberrySucraloseSugarSunflowerSalad barSardinesSquashTaco Bell foodTea, blackTea, decaffeinatedThai foodTomatoTroutTunaTurkeyTangerineVinegarWalnutWafflesWhitefishWheatWendy’s foodYeast, BakersYeast, BrewersYogurtYamZucchiniDo you snack between meals: Yes No If yes, what kinds of snacks do you eat? Between breakfast & lunch: _____________________________________________________________Between lunch & dinner: ________________________________________________________________After dinner: _________________________________________________________________________Which of the following do you consume each day/week?ItemDailyWeeklyFavorite TypeCandyCheeseChocolateCups of caffeine containing coffee Cups of decaffeinated coffee or teaCups of hot chocolateCups of caffeine containing teaDiet sodas (12-oz. can/bottle)Sodas with caffeine (12-oz. can/bottle)Sodas without caffeine (12-oz. can/bottle)Energy drinks (12-oz. can/bottle)Ice creamSalty foodsSlices of white bread (rolls/bagels)How much water do you drink every day (# of 8-oz. glasses)? ____________What type of water do you most often drink?TapDistilledSpringWellReverse osmosisBottled (soft, squishy plastic)Bottled (firm plastic)pH water (above 7.0)Sparkling waterFlavored waterOther _______________Do you experience digestive symptoms immediately after eating or drinking such as belching, bloating, sneezing, etc.? Yes No If yes, please explain: ________________________________________________________________________________________________________________________________________Do you experience intestinal gas? Never Depends on what I eat Daily Occasionally Excessive Painful Foul smelling Little or no odorBOWEL HABITSFrequencyYesNoVisible SignsYesNoMore than 3x/dayOften floats1-3x per dayContains small pieces of food4-6x per weekBreaks apart easily in the water2-3x per week Light or sandy colored1x per weekFluorescent greenLess than 1x per weekBlack or extremely darkBlood in the waterWhich of the following type(s) best describes your stool?12185655101100 Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7Do 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 NoDo you feel worse when you eat too much of the following? (Check which ones apply)Fatty foodsProtein High carbohydrate foods (breads, pasta, potatoes)Refined sugar (junk food)Fried foods1 or 2 alcoholic drinksOther: ________________________Do you feel better when you eat more of the following? (Check which ones apply)Fatty foodsHigh protein foodsHigh carbohydrate foods (breads, pasta, potatoes)Refined sugar (junk food)Fried foods1 or 2 alcoholic drinksOther: ________________________Do you experience blood sugar lows or feel ‘hangry’ if you skip meals? Yes NoHas there ever been a food that you’ve really craved or “pigged out” on over a period of time? Yes No If yes, what food(s)? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________Are there certain foods that you avoid eating or you know they don’t make your feel well? Yes NoIf yes, what food(s)? _______________________________________________________________________________________________________________________________________________________The worst food I currently eat is: ______________________________________________________________________________________________________________________________________________TOBACCO HISTORYAre you currently using tobacco? Yes NoHow many years? _______ # of packs per day: ________If yes, what type? Cigarette Smokeless Cigar Pipe Patch/Gum VapingHave you attempted to quit? Yes No If so, how many attempts have you made? ________If you smoked previously, how many years? ________ # of packs per day: ________Are you currently exposed to 2nd hand smoke? Yes NoIf yes, please explain: ______________________________________________________________________________________________________________________________________________________Were you exposed to 2nd hand smoke as a child? Yes NoALCOHOL INTAKEHow many drinks currently per week? 1 drink = 5 ounces wine, 12 oz. beer, 1.5 ounces spirits None 1–3 4–6 7–10 >10 If none skip to “Other Substances”Have you previously had high alcohol intake? Yes ( Mild Moderate High) NoHave you ever been told to cut down your alcohol intake? Yes NoDo you ever feel guilty about your alcohol consumption? Yes NoDo you ever have an alcoholic ‘eye-opener?’ Yes NoDo you notice that you can tolerate more alcohol than others? Yes NoHave you ever been unable to remember what you did during a drinking episode? Yes NoHave you ever been arrested or hospitalized because of drinking? Yes NoWas your mother an alcoholic? Father? Other family member? ___________________OTHER SUBSTANCESAre you currently using recreational drugs? Yes NoIf yes, what types? ____________________________________________________________________Are you currently using CBD, THC or other legal marijuana? Yes NoHave you ever used IV or inhaled recreational drugs? Yes NoIf yes, what types? ____________________________________________________________________EXERCISECurrent exercise program: Activity (list type, number of sessions per week, and duration of activity)ActivityTypeFrequency per WeekDuration in MinutesStretchingCardio/AerobicsStrength trainingOther (Pilates, yoga, etc.)Sports or leisure activities (golf, tennis, rollerblading etc.)Rate your level of motivation for including exercise in your life: Low Medium HighList problems that limit activity: _______________________________________________________________________________________________________________________________________________Do you feel unusually fatigued after exercise? Yes NoIf yes, please describe: _____________________________________________________________________________________________________________________________________________________Do you usually sweat when exercising? Yes NoSOCIAL AND PSYCHOSOCIAL HISTORYDo you feel significantly less vital and happy than you did a year ago? Yes NoAre you currently happy? Yes NoDo you feel your life has meaning and purpose? Yes NoDo you believe that stress is presently reducing the quality of your life? Yes NoDo you like the work you do? Yes NoHave you experienced major losses in your life? Yes NoDo you spend the majority of your time and money to fulfill responsibilities and obligations? Yes NoWould you describe your experience as a child in your family as happy and secure? Yes NoSTRESS/COPING HISTORYPlease do your best to answer the following questions:Did you feel safe growing up? Yes NoHave you ever been involved in abusive relationships in your life? Yes NoWere alcoholism or substance abuse present in your childhood home? Yes NoIs alcoholism or substance abuse present in your relationships now? Yes NoHave you ever sought counseling? Yes No Currently? Yes No Previously? Yes No What kind? _______________________________________________________________________ Comments: _______________________________________________________________________Do you feel you have an excessive amount of stress in your life? Yes NoDo you feel you can easily handle the stress in your life? Yes NoDaily stressors (Rate on a scale of 1–10; 1=not stressful, 10=very stressful):Work _____Family _____Social _____Finances _____Health _____Other _____Do you practice meditation or relaxation techniques? Yes No How often? _________________Check all that apply: Yoga Meditation Imagery Breathing Tai Chi Prayer Other: ______________Hobbies and leisure activities: _______________________________________________________________________________________________________________________________________________How important is religion (or spirituality) for you and your family’s life? Not at all important Somewhat important Extremely importantHow well are things going in your life in the following areas?Very WellFinePoorlyVery PoorlyDoes Not ApplyAt schoolIn your jobIn your social lifeWith close friendsWith sexWith your attitudeWith your boyfriend/girlfriendWith your childrenWith your parentsWith your spouseWhich of the following provide you with emotional support? (Check all that apply.) Spouse Family Friends Religious/Spiritual Pets Other: ____________________SOCIAL READJUSTMENT RATING SCALEPlace a check mark in the corresponding box for any of the following that have occurred during the last 12 months.Life EventAnswerDeath of spouseYesNoDivorceYesNoMarital separationYesNoJail termYesNoDeath of close family memberYesNoPersonal injury or illnessYesNoGot marriedYesNoFired from workYesNoMarital reconciliationYesNoRetirementYesNoChange in family members healthYesNoPregnancyYesNoSex difficultiesYesNoAddition to family?YesNoBusiness readjustmentYesNoChange in financial statusYesNoDeath of close friendYesNoChange in line of workYesNoChange in # of marital argumentsYesNoMortgage or loan over $10,000YesNoForeclosure of mortgage or loanYesNoChange in work responsibilitiesYesNoSon or daughter leaving homeYesNoTrouble with in-lawsYesNoOutstanding personal achievementYesNoSpouse begins or stops workYesNoStarting or finishing schoolYesNoChange in living conditionsYesNoRevision of personal habitsYesNoTrouble with bossYesNoChange in work hours, conditionsYesNoChange in residenceYesNoChange in schoolsYesNoChange in recreational habitsYesNoMortgage or loan under $10,000?YesNoChange in sleeping habitsYesNoChange in eating habitsYesNoVacationYesNoSTRESS TRIGGERSCheck any of the following that you believe are contributing to your overall stress load over the course of your lifetime.Childhood traumasNeed for perfectionDivorce or change in a relationshipCaregiving or taking care of a sick family memberJob or career challengesIllness, either short-term or chronicDieting or concerns about weightMenopauseDo you worry about any of the following? (Check all that apply)Home lifeMarriageChildrenJobIncomeOther _______________SLEEP/REST HISTORYAverage number of hours you sleep per night: >10 8–10 6–8 <6Do you have trouble falling asleep? Yes NoDo you feel rested upon awakening? Yes NoDo you have problems with insomnia? Yes NoDo you snore? Yes NoDo you use sleeping aids? Yes NoExplain: _________________________________________________________________________________________________________________________________________________________________ ................
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