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Chronic Fatigue/Fibromyalgia Information QuestionnaireName _________________________________ SS# ___________________ Date _____________ Referred by __________________Street Address ________________________________ City _______________________State ________ Zip code _______________Home Phone ____________________________ Work Phone ___________________________ Cell Phone _____________________E-mail Address ___________________________________ What Country do you live in? ____________________________________Allergies/ Sensitivities: _______________________________________________ Height ______________ Weight _______________Please describe briefly (in one sentence) what your main problem(s) are (you will be able to describe things at length later-toward the end of the questionnaire): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please rate each of your symptoms that you have experienced in the past 30 days (average) both by frequency and severity using the scales below:FrequencyScoreSeverityScoreRarely1Mild1Once/ Month222x/ Month333x/ Month44Once a Week5Moderate5Daily/ 2-3 days/ Week66Daily/ 4-6 / Week77Multiple x/ Day 2-3 Days/ Week88Multiple x/ Day 4-6 Days/ Week99Multiple x/ Day 7 days/ Week10Severe10SymptomFrequency ScoreSeverity ScoreMuscle PainStiffnessEnter Score 1-10 1=None 10=SignificantUnrefreshing SleepMy Energy Level ________InsomniaDaytime FatigueEnter Score 1-10 1=Poor 10=ExcellentHeadachesMy Sense of Well Being __________Gastrointestinal DisturbancesNumbnessImpaired ConcentrationSore ThroatOtherList them in order from MOST Important to LEAST Important. ____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________How long have you been fatigued: _________________________________________________________________________What was the approximate date or time of onset: _____________________________________________________________How much has fatigue decreased your ability to function in your daily life: Extreme ____,Significant ____, Mild____, none____How much has your fibromyalgia pain decreased your ability to function in your daily life: Extreme _____, Significant ____,Mild ____, None ____Did symptoms begin: ____Suddenlyor____Gradually5B)Was onset related to:Major StressY NSurgeryYNAccidentYNMedicationYNInfectionYNOther ________YNWhat stresses were occurring in your life when the disease began:___________________________________________________________________________________________________________________________________________________How many children do you have: ______Ages and NamesAGENAME________________________________________________________________________________________________________________________________Are you Married, Single, Separated, Divorced, Widowed. (circle one)How many hours were you working (including commute but not including taking care of your family) weekly at the onset of your illness: _____________; hours spent weekly on your children’s care at onset: __________________9B)How many hours now: Work __________hrs/weekChildren’s care ____________hrs/weekOccupation: __________________________________________________________________________________________Do you have any family members with Fibromyalgia/Chronic Fatigue Syndrome: ____________________________________ If so, who and how old are they: __________________________________________________________________________How old are you: ________Male or Female: _____________How many doctors have you seen for your symptoms: ____________Check all that apply:NUMBER of visitsIn last 6 months____ Rheumatologist-------------------------------------------------------___________________Internist-------------------------------------------------------------------___________________Family Physician (general practitioner) ---------------------------___________________Gastroenterologist------------------------------------------------------___________________Urologist/Proctologist--------------------------------------------------___________________General or Orthopedic Surgeon------------------------------------___________________Podiatrist (foot doctor)-------------------------------------------------___________________Chiropractor-------------------------------------------------------------___________________Physical or Occupational Therapist--------------------------------___________________OTHER--------------------------------------------------------------------_______________Check any of these that you have or have had:Onset At:____ Stroke(s)Approx. year _____________Multiple SclerosisApprox. year _____________Neuropathies- If so, what type ____________________Approx. year _____________GlaucomaApprox. year _____________CataractsApprox. year _____________LupusApprox. year _____________Rheumatoid ArthritisApprox. year _____________Osteo ArthritisApprox. year _____________SclerodermaApprox. year _____________Other Rheumatoid DiseasesList them:___________________Approx. year ____________________________Approx. year ____________________________Approx. year _____________Phlebitis and/ or Pulmonary Embolus (Blood Clots)Approx. year _________If yes, did it go to your lungs ________ (i.e., Pulmonary Embolus)____Angina (chest pain) or heart attack (Myocardial Infarction)Approx. year _____________Angina; ____Heart Attack; ____BothWas this confirmed by-____EKG and/or____exercise stress test and/or____ heart catheterizationDid you have ____Angioplasty and or ____BypassIf so, when ______________Mitral Valve Prolapse____Heart Valve Disease- Which ______________________________________________________________________Are you on blood thinners ____yes____noIf yes, check which one and fill in dose____Coumadin/WarfarinDose _____mg a day____HeparinDose _____mg a day____AspirinDose _____mg a day____Other ________________Dose _____mg a day____ Diagnosis of abnormal heart rhythm(s)____yes____noIf yes, what type __________________________CancerType ________________________________Date of diagnosis ____________________________If yes, Metastatic/Non-metastatic ___________________ to where________________________________Did you have (check all that apply):____Surgery; ____Radiation; ____Chemotherapy; ____Other treatmentwhat type _______________________________________________________Is it active or without recurrence _____________________________________________Emphysema____Hypertension-High Blood Pressure____Asthma____Stomach Ulcers____Spastic Colon or Irritable Bowel Syndrome____Crohns’ Disease or Ulcerative Colitis- If so, which ________________________________________AIDS____Polio____Tuberculosis____Other chronic infectionsType ___________________________________________________Reflex Sympathies Dystrophy (RCPS) - Which extremity ___________________________________Recurrent Prostatitis- Has a bacterial culture ever been positive _____________________________Hepatitis (check all that apply):____Viral____Hepatitis A____Hepatitis B____Hepatitis C____Without infectious Mono____Any toxic chemical exposures: If yes, list what exposures and when:__________________________________________________________________________________________________________________________________________________Lupus____Alcoholic____Other type of Hepatitis: ______________________________________Unknown causeAre you using herbs:________ List: ___________________________________________________________________Do you have Cirrhosis: _____Yes_____No_____Don’t know____Have you had a liver biopsy: _____Yes_____No____Have you had a blood test to check for high iron levels: _____Yes_____No____Prostate enlargement____Kidney Stones____Active Disc Disease (e.g., Sciatica)____Kidney failure____Other kidney problems: Describe: _______________________________________________________________________________Diabetes____Juvenile onsetDate of Diagnosis:__________________________Adult onsetDate of Diagnosis:__________________________PancreatitisIf yes, from____Gallstones____Alcohol____Other known cause (list): ________________________________________________________________Unknown cause16)Have you had any other operations? Please list them:Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________17)Have you had any other hospitalizations? Please list them:Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________Year (approx) ________________Type of surgery _________________________________________________________18)What other diagnosis do you have: _______________________________________________________________________19)Allergic to anything else not listed at the top of page 1: ________________________________________________________20)Details of other Allergies: _______________________________________________________________________________20 B)Does your insurance pay for medications: _____Yes_____No21)Please list any of treatments you are taking or have taken (RX means by prescription only):Please list current medications with dose:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list all medications taken in the past for fibromyalgia and/ or chronic fatigue (no longer taking): If you don’t know remember the exact name just list what you know about it.MedicationDoseWhen was the medication discontinued?Did the medication help?Single main reason it was discontinued:___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive22) Any injectables or intravenous treatments: _____Yes_____NoIf yes, list all below:TreatmentHow many total treatments?Did it help?Reason stopped:___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive23)Please list current nutritional supplements you are taking:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________23B) Please list nutritional supplements taken in the past (not currently):SupplementDoseWhen was the supplement discontinues?Did the supplement help?Single reason it was discontinued?___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensive___ Helps____Doesn’t help____Don’t know if it helps____Side effects____Didn’t work____Too expensiveBesides those already discussed:What things or treatments have you found helpful in the past: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What things or treatments have you tried without benefit: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What things or treatments have made you feel worse in the past: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Complete the following as accurately as possible. Do not make any assumptions as to how this information will be evaluated. Each patient is assessed and treated individually with all information and findings utilized to obtain a complete and accurate picture for treatment plan development.SYMPTOM CHECKLISTCIRCLE ONE-I. CFIDS Criteria24) A: YesNoDo you have severe chronic fatigue of six months or longer duration with other known medicalConditions excluded by clinical diagnosis;AND B: YesNoconcurrently have four or more of the following symptoms: substantial impairment in short-term Memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain withoutSwelling or redness; headaches of a new type, pattern or severity; un-refreshing sleep; and postexertional malaise lasting more than 24 hours.The symptoms must have persisted or recurred during six or more consecutive months of illnessand must not have predated the fatigue._____A)Impairment in short-term memory or concentration severe enough to cause substantial reduction inPrevious levels of personal activity?_____B)Sore throat?_____C)Tender neck or auxiliary (armpit) lymph nodes?_____D)Muscle pain?_____E)Multi-joint pain without joint swelling or redness?_____F)Headaches of a new type, pattern, or severity?_____G)Unrefreshing sleep?_____H)Post-exertional fatigue lasting more than 24 hours?Are you sensitive to any chemicals, foods or molds? (circle one)YesNoPlease list all known substances that you are sensitive to:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you allergic to any chemicals, food or molds? (circle one)YesNoPlease list all known substances that you are allergic to:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________CIRCLE ONE-II. FIBROMYALGIA CRITERIA25) YesNoHave you had chronic widespread pain for more than three months in all four quadrants of theBody (i.e., above and below the waist and on both sides of the body) and also axial pain ( i.e., headache or pain around the spine or chest)? (These don’t all have to be at the same time.)26) Please rate the following on a scale: (circle the number that applies):A)How is your energy?123456789101 (near dead) to 10 (excellent)B)How is your sleep?123456789101=no sleep and 10= 8 hours of sleep a night without waking C)How is your mental clarity?123456789101=brain dead and 10= good clarityD)How bad is your achiness?123456789101=very severe pain and 10= pain freeE)How is your overall sense of well being? 123456789101=near dead and 10= excellent27)Give a representative blood pressure: _______________________________28)What are your average temperatures (oral- 11 AM to 7 PM): __________degreesSYMPTOM LISTSome of the symptoms are purposely repeated because different hormone deficiencies may result in similar symptoms.Please put a check mark next to the symptoms you have in each of the following categories:CX Checklist_____ 29.Hypoglycemia_____ 30.Shakiness relieved with eating_____ 31.Moodiness_____ 32.Recurrent infections that take a long time to go away_____ 33.Life was very stressful before symptoms began_____ 34.Low blood pressure_____ 35.Dizziness on first standing_____ 36.Sugar cravings_____37.Food sensitivity (if yes, please list foods): _______________________________________________________ 38.Have you been on Prednisone (Cortisone)?If yes, For how long? __________________Did you feel better when you took it? ___________If yes, did you take it______ after your illness began______before your illness began______bothWhat dose and form of Prednisone/Cortisone did you take? ______________________________Do you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysPoor tolerance to stressAnxiety with stressLow blood pressureTired during the dayFatigue or mood improved w/sugar or sweetsSalt cravingsNauseaInflammatory disease (arthritis, asthma, etc)Allergies to food or medicationsBrown spots or increased pigmentationEczema, psoriasis or dandruffSugar cravingsADL ChecklistDo you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysWeak or tired when standing upUrinate oftenLow blood pressure_____ 39.Weight gain? _________lbs or _________kg – over _________ years_____ 40.Low body temperature (under 98 degrees)_____ 41.Achiness_____ 42.High cholesterol_____ 43.Cold intolerance_____ 44.Dry skin_____ 45,Thin hair_____ 46.Female- Heavy periodsDo you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysSensitive to coldCold hands or feetGeneralized fatigueMorning fatigueFatigue unless exercisingSleepy during the dayDistracted easilyPoor motivation for required tasksDepressionHeadachesWater retentionConstant swollen eyelidsSwollen eyes in morningSwollen calves/ feetDifficulty losing weight despite dietingConstipationBedwetting as childSlow heart palpitationsMuscle crampsCarpal tunnel syndromeStiff joints in morningJoint pain worsens with coldHoarse voice in morningDry skin (general/feet or elbows)Slow growing or brittle nailsHoarse voice (constant or in morning)Decreased hearingCoarse skin (rough skin)GXX ChecklistDo you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysThinning hairThinning skinLongitudinal lines on nailsPremature wrinkles on faceLoose or sagging skinThinning lipsOverweightDecreased muscle strength or toneFlabby muscles (triceps of arms or other)Wrinkled handsFlabby drooping bellyOften sickEasily ExhaustedDifficult to do daily required tasksPoor motivation for required tasksConstant tirednessDifficult to stay up lateDifficult to recover after staying up lateNeed for a lot of sleep ( over 10 hours)Low resistance to stressDifficult to recover from stressful situationNot assertiveVery emotionalMood swingsAnxietyLow self esteemDepressionThin muscle as childTendency to isolateTend to give sharp verbal retortsHEX ChecklistDo you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysOlder looking than ageLoss of attention to detailBleeding gums or poor teethFatigue throughout dayPoor recovery from physical exerciseDepressedPoor memoryHot flashesExcessive sweatingDry eyesDry vaginaPain during intercoursePale skinWrinkles around eyes/forehead/mouth or palmsNew body hairDrooping breastsBladder infectionsUrinary incontinenceFirst menstruation before 12 or after 15 yearsDepression before menstruationDay or Night sweats or hot flashesHPX ChecklistFemale Symptoms(Women Only to Complete)Do you have or ever had the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysIrritable before menstruation (PMS)Swollen breast or belly before menstruationBreast cystsFibroids of uterusEndometriosisMenstruation with violent crampsGeneral irritabilityGeneralized AnxietyTEX ChecklistToo emotionalToo rigidPoor strengthLow libido (sex drive)Difficulty achieving orgasmPoor muscle toneExcessive fatCelluliteVaricose veinsHemorrhoidsBruising easilyTEX ChecklistMale Symptoms (Men Only to Complete)Do you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysOlder looking than ageLoss of feeling of well-beingLoss of attention to detailPoorly motivatedExcess fatFatigueLoss of muscle mass or strengthPoor recovery from physical activityPoor endurancePoor motivation for required tasksDepressionPassiveDecreased memoryIrritableToo emotionalRigid demeanorHair lossPoor beard growthScarce body hairBleeding gums or poor teethDry eyesPale skinWrinkles on face or palm of handPoor enduranceVaricose veinsHemorrhoidsEasy bruisingPoor wound healingPoor muscle tone (triceps or others)Joint painIntense sweatingUrination problemsUrinary incontinenceLoss of urine after urinationSwollen prostatePoor libido (sex drive)Difficulty achieving orgasmDecreased erections frequency or firmnessDecreased ability to maintain erectionOTHER HORMONES_____ 47.Any nipple discharge_____One breast_____Both breasts_____ 48. FEMALES ONLY- Have you had:A hysterectomy? _____ if yes, how long ago?__________Ovaries removed?_____ One _____Both; how long ago? _________A tubal ligation? _____ How long ago?_______________ 49.Are you symptoms worse the week before your period? (FEMALE ONLY)_____ 50.Decreased libido?Vasodepressor syncope (NMH)_____ 51.Disequilibrium_____ 52.Did you ever have a Tilt Table Test? If yes, was it ______positive ______negative_____ 53.Do you feel like you’ve been “hit by a truck” the day after exercise?Lyme_____ 54.History of frequent tick bites? If so, how many? _______________ 55.Rash after tick bite?_____56.Rash that looked like a “bull’s eye”?_____57.Have you been treated for Lyme disease?_____58.Numbness or tingling in your fingers or feet?_____58 B.History of a positive Lyme Test?Prostatitis (males only)_____59.Burning on urination_____60.Groin aching_____61.Discharge from your penis (not with ejaculation)_____62.Urine urgency with a small volumeSinusitis/Nasal Congestion and Other Infections_____63.Chronic nasal congestion or post nasal drip_____ 64.Chronic yellow or green nasal discharge_____65.Chronic bad taste in your mouth or bad breath_____66.Headaches under or over eyes_____67.Scratchy or watery eyes_____68.Do you have chronic or intermittent low-grade fevers (over 99 degrees F/______C)If yes, 1) how high does your fever go? _____2) Did your illness begin with a fever?_____3) Do you have lung congestion?_____4) How often do you have the fever?__________69.Has any antibiotic you’ve been on in the past even temporarily improved your Chronic Fatigue/Fibromyalgia symptoms?If yes, which_____________________________________________How long did you take it? __________________________________Disordered SleepSLEEP APNEA_____70.Trouble _____falling; _____and/or staying asleep? If yes, is it a _____mild, _____moderate, or _____ severe problem?_____71.How many hours of uninterrupted sleep do you get in a night? __________________________72.Do you wake up during the night? If so, how often? ___________________________________73.Do you wake at night to urinate?_____74.Do your legs jump a lot or do you kick your spouse or kick your blankets off at night?_____75.Do you snore? If yes,_____ 1) Are you more than 20 lbs overweight?_____ 2) Do you have periods that you stop breathing (ask your bed partner)?_____ 3) Do you have high blood pressure?MEL ChecklistDo you have or feel the following symptoms:No symptomNeverFew orSometimesModerate orRegularlyMuch oroften extremeAlwaysPoor sleepDifficulty falling asleepAwakening at nightExcessive pondering of problems at nightWaking up tired (too little sleep)Yeast overgrowth_____76.Recurrent vaginal yeast infections (FEMALES) if so, how often?________________________________77.Toenail or fingernail fungal changes_____ 78.Skin fungal infections (i.e., athlete’s foot, jock itch, rash under bra)_____79.Do you get in the mouth sores frequently (not on lips)?_____80.Do you get cold sores or Herpes attacks that seem to flare your symptoms? Or during symptom flares?_____81.Been on birth control pills?If yes, how did you feel on them? _____better; _____worse;_____ no change_____82.Small amount of alcohol aggravate symptoms?Parasites_____83.Did your problems begin with a diarrhea attack?_____84.Do you sometimes have diarrhea? If so, is it severe? _____________85.Do you sometimes have constipation?_____86.Do you have well water?Vision/ Dental_____87.Double vision_____88.Constantly changing eyeglass prescriptions_____89.Blurred vision or halos around lights at night?_____90.Have you had temporary vision loss in one eye?Which one? __________How many times? __________How long do they last? __________Is your sedimentation (SED) rate blood test over 30?____________91.Dry eyes_____92.Dry mouth_____93.Any evidence of dental infections?_____93B.Metallic taste in mouth?_____93C.Light sensitivity or trouble focusing at night?Other Problems and Questions_____94.Ringing in ears_____95.Hearing loss_____96.Do you drink non-diet sodas or other sweetened drinks? If so, how much? __________ ounces a day_____97.Do you drink coffee? If so, how many 8 oz (American)/240cc(Metric)cups a day? ____Regular ____Decaf_____98.Do you drink alcohol? If so, how many drinks per day on average? ___________________________99.Do you smoke cigarettes? How many packs a day? _______For how many years?____________Chew tobacco? _____________100.How much do you exercise? ________________________________________________________________101.Besides your illness, what other stresses are going on in your life? ______________________________________________________________________________________________________________________102.Do you have frequent and persistent infections? If yes, what kind? ___________________________________103.A rash? What does it look like? __________________________________________________________How long have you had it? _______________________Does it _______itch, ______burn or _______sting?_____104.Chest painHow long have you had it? ____________________________________Has it been _____getting better, _____getting worse, _____staying the same?With exercise, (e.g. walking steps) the pain _____increases, _____decreases, or _____stays the same?With exercise, do you have:_____Shortness of breath_____Chest tightness_____Pain radiating to your left arm_____SweatingCan you worsen the chest pain by pushing on your chest muscles?______________________Are the chest pains _____sharp, _____dull, _____worse with position change or deep breath?During the chest pains, do you have (check all that apply):_____Feeling of being unable to take a deep enough breath?_____Numbness and/or tingling in hands and toes?_____Numbness and or tingling around the mouth?_____Spacey feelings?_____Feeling of panic or impending death?Did your father, mother, sister(s), brother(s) have angina? _______________________________If yes, did they have it before age 65? ___________Do you have high cholesterol?______ Approximately how high?______________Do you have Diabetes?_______Do you have high blood pressure?_______Recurrent palpitations? _______Palpitations last over 20 seconds? ______Pulse _____regular or ____irregular?Pulse over 120/minute? ________Get dizzy with palpitations? ______Taking Thyroid hormones? ___________105.Shortness of breath?Comes and go suddenly (not with exercise)? _____Wake up short of breath at night? _____ (If yes, answer the following)Do you have ankle swelling? _____Do you get short of breath if you lay flat?_____If yes, how many pillows do you sleep on? _____Worse with exertion?______How many flights of steps? _______________106.Transient weakness/paralysis in one arm and /or leg? _______________Is it always on the same side of your body? _______ If yes, which side? ________Does it occur in your arm when you’re sleeping on it and it goes away within 5 minutes of waking?_____If no, how many times has it occurred? _________ How long does it last? ______________________107.Ankle Swelling_____108.Any unusual weight loss? If yes, ________lb/kg, over _____years, ________years agoDescribe what happened: ____________________________________________________________________109.Numbness or tingling around your lips or mouth?_____110.Anxiety or Panic attacks?_____111.Sudden attacks of inability to take a deep enough breath or shortness of breath?_____112.Blood in your stool?Is it only bright red blood on your toilet tissue or on stool (not mixed in)? __________If yes, do you have Hemorrhoids? _____If no, answer the following:Is blood mixed in (not only on) your stool? _______Do you have bloody mucus with stools? ________ How often? ____________________Do you have painful bowel movements? ________Has your doctor done:WhenResults/Diagnoses_____ a) Colonoscopy_____________________________________________________________________ b) Sigmoidoscopy ____________________________________________________________________ c) Barium Enema _____________________________________________________________________ None of theseHave your bowel movements gotten thinner (e.g. pencil like)? _____Have you had a lot of: _____constipation_____diarrhea_____both_____neither_____113.Abdominal pains? Describe___________________________________________________________________114.Cough up blood? How long has it been going on? ___________________________Have you had a chest X-Ray since this began? ________If yes, when? __________________What did it show? _____________________________________________115.Frequent cough up yellow mucus?Have you had a chest X-Ray since this began? _______If yes, when? __________________What did it show? _____________________________________________116.Chronic cough? If yes, for how long? ________________________Have you had a chest X-Ray since it began? __________________When? _______________________What did it show? _____________________________________________117.Chronic burning when you urinate and urinary urgency even with small volumes? Have you had urine cultures checked? _______If no, check urine cultures during symptoms.If yes, do they usually show infection? _______If no,Male- Do you have discharge from your penis when you wake in the morning? _____Female- Is this a severe problems?__________118.Pain in your:______Feet_____Hands_____118B.Chronic anal/rectal pain?_____119.Redness and swelling in one or more joints in hands or feet?_____In one hand_____In one foot_____n both hands_____In both feetIf yes, do you have a history of:_____Gout_____Rheumatoid Arthritis_____Other Arthritis, _________________________________120.Any breast lump that you have had for more than 6 weeks?If yes, which breast?___________Any nipple discharge? ______________Are you breastfeeding? ________If yes, skip to 128B_____120B.Do you have any other lumps or bumps that are new or growing?_________________________________________________________________________________________________________________________121.Have you had problems with infertility? If yes, do you still want to have a (or another) child? ________________122.If female-when was your last period? __________________ over 3 months ago; _________ days ago_____123.Does food often stick in your food pipe?How long has this been going on? ________________________Is it worse for _______solids, ________liquids, _______the same for both?Do you have a history of drinking over 2 alcoholic drinks/day on average? ___________Have you used tobacco for over 12 years? ___________________124.Does your tongue burn?Has your tongue become smooth with cracks/fissures? __________Do you have a white coating throughout your mouth?____________Do you have a white coating on your tongue?__________________Do small taste buds sometimes become inflamed and painful? ____________125.Any history of psychiatric illness? Please describe: ________________________________________________________________________________________________________________________________________________________________________________________________________________________126.Any other symptom(s) or problem(s)?[ Please don’t be bashful, list them all!]_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________127.Are you married? If so, for how long? ________________Is he/she supportive? ____________________What is your spouse’s name? ___________________ Occupation: ___________________________________128.Did you have/need to change jobs or decrease how much you work because of your illness? If so, please describe:_______________________________________________________________________129.Did your symptoms begin soon or immediately after: Pregnancy _________, Accident __________If so, how soon? ______________________________________________________________________If accident, give details: ________________________________________________________________________________________________________________________________________________________130.Since the accident, the symptoms have _____decreased, _____increased, _____stayed the same?_____131.What medical problems do or did your parents or siblings have? If they died, note the cause and approx.age at death.Mother_____________________________________________________________________________Father_____________________________________________________________________________Brothers:___________________________________________________________________________Sisters:_________________________________________________________________________________132.Do you feel depressed (as opposed to frustrated over not being able to function)?________________________________________________________________________________________________________________________________________________________________________________________YEAST QUESTIONAIREThe total score for Section A, B & C may give us the probability of yeast overgrowth being a significant factor in your case.SECTION A: YOUR MEDICAL HISTORYPoint Score_____ Have you been treated for acne with tetracycline, erythromycin, or any other50antibiotic for one month or longer?_____ Have you ever taken antibiotics for any type f infections for more than two consecutivemonths, or shorter courses four or more times in a twelve month period?50_____ Have you ever taken an antibiotic- even for a single course? 6_____ Have you ever had prostatitis, vaginitis, or another infection or problems with yourreproductive organs for more than one month?25 Have you ever been pregnant? _____Two or more times? 5_____Once 3Have you ever taken birth control pills for:_____More than two years?15_____Six months to two years? 8Have you taken corticosteroids such as Prednisone, Cortef, or Medrol by mouthor inhaler for:_____More than two weeks?15_____Two weeks or less? 6When you are exposed to perfumes, insecticides, or other odors or chemicals,Do you develop wheezing, burning eyes, or any other distress?_____Yes, the symptoms keep me from continuing my activities.20_____Yes, but the symptoms are mild and do not change my activities. 5_____Are your symptoms worse on damp or humid days or in moldy places?20Have you ever had a fungal infection, such as jock itch, athlete’s foot, or a nailor skin infection, that was difficult to treat and:_____Lasted for more than two months?20_____Lasted less than two months?10Do you crave:_____Sugar?10_____Breads?10_____Alcoholic beverages?10_____Does tobacco smoke cause you discomfort such as wheezing, burning eyes, or another problem?10Section A Total Score_______________SECTION B: MAJOR SYMPTOMSFor each symptom that is present, enter the appropriate number in the point score column:If a symptom is occasional or mildScore 3 pointsIf a symptom is frequent and/or moderately severeScore 6 pointsIf a symptom is severe and/or disablingScore 9 pointsPoint Score1. Fatigue or lethargy2 .Feeling of being “drained”3. Poor memory4. Feeling “spacey” or “unreal”5. Inability to make decisions6. Numbness, burning, or tingling7. Insomnia8. Muscle aches9. Muscle weakness or paralysis10 . Pain and/or swelling in joints11. Abdominal Pain12. Constipation13. Diarrhea14. Bloating, belching or intestinal gas15. Troublesome vaginal burning, itching, or discharge16. Prostatitis17. Impotence18. Loss of sexual desire or feeling19. Endometriosis or infertility20. Cramps and/or other menstrual irregularities21. Premenstrual tension22. Attacks of anxiety and/or crying23. Cold hands or feet and/or chilling24. Shaking or irritable when hungrySECTION B TOTAL SCORE:SECTION C: OTHER SYMPTOMSFor each symptom that is present, enter the appropriate figure in the point score column:If a symptom is occasional or mildScore 1 pointsIf a symptom is frequent and/or moderately severeScore 2 pointsIf a symptom is severe and/or persistentScore 3 pointsPoint Score1. Drowsiness2. Irritability or jitteriness3. Lack of coordination4. Inability to concentrate5. Frequent mood swings6. Headaches7. Dizziness, loss of balance8. Pressure above ears, feeling of head swelling9. Tendency to bruise easily10. Chronic rashes or itching11. Psoriasis or recurrent hive12. Indigestion or heartburn13. Food sensitivity or intolerance14. Mucus in stool15. Rectal itching16. Dry mouth or throat17. Rash or blisters in mouth18. Bad breath19. Foot, hair or body odor not relieved by washing20. Nasal congestion or postnasal drip21. Nasal itching22. Sore throat23. Laryngitis, loss of voice24. Cough or recurrent bronchitis25. Pain or tightness in chest26. Wheezing or shortness of breath27. Urinary frequency, urgency or incontinence28. Burning on urination29. Spots in front of eyes or erratic vision30. Burning or tearing of eyes31. Recurrent infections or fluid in ears32. Ear pain or deafnessSECTION C TOTAL SCORE:GRAND TOTAL (SECTIONS A & B & C)________________Diet AnalysisPlease check the questions to which you would answer “yes” or fill in the ‘number of times’ you eat the particular food.1._____ Were you breast fed?____________________________2._____Was a significant percentage of your diet as a child high in fatty foods and sugar?____________________________3._____ Do you go out of your way to avoid foods containing preservatives or additives?____________________________4._____Do you avoid foods which contain sugar?____________________________5._____How many teaspoons of sugar do you add to food/drinks each day?____________________________6._____Do you use salt in your cooking?____________________________7._____Do you add salt to your food?____________________________8._____How many coffees do you drink each day?____________________________9._____How many cups of tea do you drink each day?____________________________10._____How many times a week do you have meals containing fried foods?____________________________11._____How many packet of ‘instant’ or fast foods do you eat each week?____________________________12._____How many times a week do you eat chocolate or confectionary sugar?____________________________13. _____What percentage of your diet is RAW fruit and RAW vegetables?____________________________14._____Do you normally eat white rice or flour?____________________________15._____How many cans of food do you eat per week?____________________________16. _____How many slices of bread or rolls do you eat each week?____________________________17._____How many pints of milk do you drink in a week?____________________________18._____How many times a week do you eat red meat? (beef, pork, lamb, game)____________________________19._____How many times a week do you eat white meat? (poultry, fish)____________________________20._____What is your usual alcoholic drink?____________________________21._____How many glasses do you drink a week?____________________________22._____How many times a week do you eat live yogurt?____________________________23._____DO you use a water filter or drink bottled water instead of tap water?____________________________24. _____Do you frequently eat under stressful conditions or on the move?____________________________25. _____Does your job involve eating out a lot?____________________________26._____How would you describe your appetite?1. Poor2. Average3. Good___________________________________________________________________________________________________________SAMPLE 48 HOUR DIETWrite down all the foods and drinks consumed over the next two days, starting today.Please add as much information as possible including quantities eaten, brand names,and whether the food is fresh, packaged, refined or natural.Day 1_________________________________________________________________________________________________Breakfast_________________________________________________________________________________________________Lunch_________________________________________________________________________________________________Dinner_________________________________________________________________________________________________Snacks/Drinks_________________________________________________________________________________________________Day 2_________________________________________________________________________________________________Breakfast_________________________________________________________________________________________________Lunch_________________________________________________________________________________________________Dinner_________________________________________________________________________________________________Snacks/Drinks________________________________________________________________________________________________Are these two days representative of your usual eating habits? If not, what is a more usual day?_________________________________________________________________________________________________Breakfast_________________________________________________________________________________________________Lunch_________________________________________________________________________________________________Dinner_________________________________________________________________________________________________Snacks/Drinks_________________________________________________________________________________________________ ................
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