Dr. Carucci



Carucci Chiropractic Center&The CT Wellness InstituteIntroductory, Consent, andPatient Information Forms53 New Britain AvenueRocky Hill, CT 06067Phone #860-257-8445Fax #860-257-8084Web site: & Email: caruccichiro@drcarucci.TABLE OF CONTENTSINTRODUCTORY INFORMATIONFrequently Asked Questions_____________________________________Do you think you can help with my problem? ________________Can all the tests I need be done in the clinic? _______________Do you take insurance? ________________________________What credit cards do you take? __________________________11111CONSENT FORMSImportant Patient Information____________________________________Patient Acceptance Form_______________________________Authorization for Release of Medical Information_____________________11-23HEALTH QUESTIONNAIRESGeneral Information____________________________________________Personal Descriptive Information _________________________________Functional Diagnostic Medicine Questionnaire_______________________Health Goals Form____________________________________________Review of systems_____________________________________________Nutrition and Lifestyle Questionnaire_______________________________Social Questionnaire___________________________________________Environmental Influences Questionnaire____________________________Patient Readiness Questionnaire_________________________________Patient Checklist______________________________________________12311142126313643FREQUENTLY ASKED QUESTIONSDo you think you can help me with my health problem? Our clinic uses an innovative approach to assessing and treating your health care concerns. Perhaps you have experienced being examined by your doctor, having blood tests done, x-rays or other diagnostic tests taken, only for your doctor to report back that all your tests are normal yet both you and your doctor know that you are anything but normal!. Unfortunately this experience is all too common. Most physicians are trained to look only in specific places for the answers, using the same familiar labs or diagnostic tests. Yet, many causes of illness cannot be found in these places. The usual tests do not look for food allergies, hidden infections, environmental toxins, mold exposures, nutritional deficiencies and metabolic imbalances. New gene testing can uncover underlying genetic predispositions that can be modified through diet, lifestyle, supplements or medications. We use a variety of innovative testing techniques and procedures to help our patients prevent illness and recover from many chronic and difficult to treat conditions. Our clinicians are highly skilled in evaluating, assessing and treating chronic problems such as fibromyalgia, fatigue syndromes, autoimmune diseases, inflammatory disorders, mood and behavior disorders, memory problems and other chronic, complex conditions. We also focus on the prevention and treatment of many effects of heart disease, diabetes, dementia, hormonal imbalances and digestive disorders. Here at our clinic we focus on the body that has the condition and not the condition itself! Can all the tests I need be done at this clinic?Most of the testing can be performed at this clinic. Some testing can be done through conventional laboratories and others are only available through specialty laboratories. During your consultation, we will determine which tests are needed and then our office assistants can review the testing recommendations, the instructions (e.g. fasting or non-fasting, etc.) and costs. Some testing can be performed at home with test kits to collect urine, saliva or stool. Others may require you to come in to our office to have blood drawn, or go to a local laboratory to draw the blood. In all cases, we will assist you in coordinating initial and follow-up testing.Occasionally, we may recommend certain tests that are not performed at our facility. In those instances, we can provide you with an order that you can take to a facility near your home or we can schedule an appointment to have them done near our office. Do you take insurance?We do not accept insurance or Medicare. On some qualified Insurance Companies, we will file insurance paperwork on your behalf. For the non-qualified Insurance Companies, we will provide a detailed receipt for services performed for you to submit to your insurance carriers. Some insurance carriers may partially cover medical services and laboratory tests performed by the physicians. Payment in full by check, cash or credit card is due at the time services are provided. What credit cards do you accept?We accept the following credit cards: MasterCard, Visa, Discover, and American Express. If you like we can maintain an active credit card on file at the office so we can bill follow-up consultations, laboratory testing, and other services.IMPORTANT PATIENT INFORMATIONPatient Acceptance PolicyIn order to best serve you, the Patient Acceptance Policy should be carefully reviewed. It is Dr. Carucci’s opinion that you should be well informed on our expectations and clinical procedures. To prevent any misunderstandings or confusion on what to expect, Dr. Carucci would appreciate that you read the below steps and provide your signature. This would simply imply that you have read the Patient Acceptance Policy and understand what is expected of pletion of the following forms:The Health QuestionnairesThe Nutritional Assessment Questionnaire This 322 question questionnaire was developed to gather important information about your body. It will help Dr. Carucci assist in helping you. The medical questionnaire will allow Dr. Carucci to quickly “zero” in on the probable causes of your health problems. The Diet DiaryIt is VERY important for you to carefully and thoroughly complete all of these forms and questionnaires prior to your first consultation with Dr. Carucci. Once Dr. Carucci has received your completed forms, our office will schedule your first consultation Medical Records from all physicians since you were first diagnosed with your health condition MUST be obtained prior to scheduling an appointment.Once Dr. Carucci has your completed questionnaires and copies of all your medical records, a one-hour appointment will be scheduled to review your case. The cost for the one-hour appointment as well as Dr. Caruccis’ time for reviewing your medical questionnaire, medical records and written reports is $200.00Based on your scheduled appointment and review of all your medical information, it may be necessary to obtain comprehensive blood chemistry. The blood chemistry test will include:Comprehensive Executive Metabolic Panel, which includes 24 important disease markers such as AST, ALT, GGT, Bilirubin (Liver), BUN, Creatinine, Uric Acid (Kidney), Alkaline Phosphatase (Bone) Cardiovascular Panel: Cholesterol, Triglycerides, LDL, HDL, Cholesterol/HDL Ratio, LDL/HDL Ratio, C Reactive Protein (hs-CRP), Homocysteine, Fibrinogen, FerratinThyroid Panel: Total T3, Total T4, Free T3, Free T4, TSHMagnesium, Vitamin D 3CBC differential: White Blood Cells and Red Blood Cells, PlateletsInflammatory markers: Sedimentation RateBased on your medical history, questionnaire, medical records and initial consultation, it may be necessary to order additional medical laboratory tests. You will be presented with detailed information on the specific tests recommended. The cost for your initial Laboratory tests will be discussed at that time. Payment can be made via check and/or credit card. We accept MasterCard, Visa, Discover and American Express.If you have not had a physical examination within the last two years or since the start of your most recent health problem, it is required to either schedule an appointment with Dr. Carucci or with your primary physician, for that physical examination. The results of your lab tests may take approximately three weeks, at which point, you will be scheduled for an appointment. This appointment usually takes approximately one to one and half hours. You will be presented with a written report detailing the results of your tests, the possible causes of your health problem and the recommended treatment protocol. It is recommended that you have your spouse or a supportive family member attend this appointment. Your treatment may consist of dietary and lifestyle changes as well as prescribed Natural Pharmaceuticals, which must be paid at the time of purchase.Follow-up consultations will be scheduled every 3, 6 or 12 weeks allowing you the opportunity to discuss your progress and any concerns with Dr. Carucci. Dr. Carucci will at this time determine what direction to take to help you continue your progress. Your cooperation in taking “personal responsibility” in your health care will go a long way in YOU getting better. Consultations can be conducted either by phone or in person (at the office). The fee for follow-up consultations is $80.00 for up to 20 minutes. Any examination performed at follow-up appointments are subject to separate charges, i.e. BP monitoring, ABI monitoring, CasPro evaluation, spirometry, UA, etc.Abnormal laboratory tests will need to be re-evaluated. The success of your treatment will not only be measured on the reduction of elimination of your physical symptoms, but on abnormal laboratory tests returning to a normal status. For example: Many physicians will prescribe Lipitor for individuals suffering with high cholesterol. Your physician will also require periodic cholesterol blood tests to monitor the success of the medication. Laboratory fees can vary depending on what needs to be re-tested.I, (Patient’s Name) ___________________________________________ have read and fully understand the Patient Acceptance Policy._______________________________________________ __________________Patient’s Signature DatePatient accepted for evaluation and treatment consideration by:_____________________________________ __________________Dr. Carucci - Signature DateAUTHORIZATION FOR RELEASE OF MEDICAL RECORDSI am Requesting Records of Doctor:Name of Facility or Person: ______________________________________________________________Address: _____________________________________________________________________________Telephone number ( ) ______ - _______________ Fax number ( ) ______ - _______________THE PURPOSE FOR THIS RELEASEYou are hereby authorized to furnish and release to Dr. Gina M. Carucci all information from my medical, psychological, and other health records, with no limitation placed on history of illness or diagnostic or therapeutic information, including the furnishing of photocopies of all written documents pertinent thereto. In addition to the above general authorization to release my protected health information, I further authorize release of the following information if it is contained in those records: Alcohol or Drug Abuse: O Yes O No Communicable disease related information, including AIDS or ARC diagnosis and/or HIT or HTLA-III test results or treatment: O Yes O No Genetic Testing O Yes O No Note: With respect to drug and alcohol abuse treatment information, or records regarding communicable disease information, the information is from confidential records which are protected by State and Federal laws that prohibit disclosure with the specific written consent of the person to who they pertain, or as otherwise permitted by law. A general authorization for the release of the protected health information is not sufficient for this purpose.This authorization can be revoked in writing at any time except to the extent that disclosure made in good faith has already occurred in reliance on this authorization. I hereby release Dr. Gina M. Carucci; any and all of his employees, agents managing members, and any of the attending physician(s) that I am requesting records of and/or from; from any and all legal responsibility or liability for the release of the above information to the extent authorized. A copy of this authorization shall be as valid as the original. I understand that there may be a fee for this service depending on the number of pages photocopied. If such a fee is to be paid, it shall be paid by me, the requestor, and not Dr. Carucci. However; no such fee is usually charged if these records are requested for continuing medical care. Please Print:Patient’s Name: ______________________________________________________________________ Patient Address: ______________________________________________________________________Telephone number ( ) _______ - __________________ Date of Birth: ___________________ Social Security Number: _________________________________Signature: __________________________________________________ Date _____________________*PLEASE INCLUDE A COPY OF YOUR DRIVERS LICENSE ALONG WITH THE COMPLETED AND SIGNED FORM*Please send copy of all records to: Dr. Gina M. Carucci53 New Britain AvenueRocky Hill, CT 06067Phone: 860-257-8445The CT Wellness InstituteGENERAL PATIENT INFORMATIONName _________________________________________________________________ Date ________________Preferred NameAddress _________________________________________ City __________________ State _____ Zip _______Home Phone _____________________________ Work Phone ______________________________________Cell Phone ____________________________ Email ________________________________________________Age ____ Date of Birth _________ Place of birth_____________________________ Gender: female __ male___ Right Handed: ____ Left Handed: ____ Mixed Dominance: _____Number of Sisters: ____ (# deceased: ____) # of Brothers: ____ (# deceased: ____) Birth Order: ______Occupation ____________________________________________ Hours per week _________ Retired ________Nature of job/Business ________________________________________________________________________How did you hear about our clinic? Article____ Book ____ Website ____ Media____ Friend/ family member_____Other ______________________________________________________________________________________Has any other family member already been a patient at the clinic? ______________________________________Next of Kin or other to reach in an emergency ______________________________________________________Relationship __________________________________________ Phone ________________________________Address ____________________________________________________________________________________ Genetic Background: Please check appropriate box(es):African AmericanHispanicMediterraneanAsianNative AmericanCaucasianNorthern EuropeanOther __________________Who is your primary medical physician? ___________________________________________________________Primary Medical Physician: _____________________________________________________________________Address & Phone _______________________________________________________________________________________________________________________________________________________________________PERSONAL DESCRIPTIVE INFORMATIONMarital status:SingleMarriedWidowedSeparatedDivorcedLong Term PartnershipPlease List All Children’s NamesAgeGenderWith whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)Example: Wendy, age 7, sister______________________________________________________________________________________________________________________________________________________________________________________Do you have any pets or farm animals? Yes____ No____If yes, where do they live? Indoors_____ Outdoors _____ Both indoors and outdoors _____Have you ever lived or travelled outside the United States? Yes ____ No ____If so, when and where? _____________________________________________________________________________________________________________________________________________________Have you or your family recently experienced any major life changes? Yes____ No____If yes, please comment: _____________________________________________________________________________________________________________________________________________________Have you experienced any major losses in life?Yes____ No____If so, please comment: ______________________________________________________________________________________________________________________________________________________ How much time have you lost from work or school in the past year? a. _____ 0-2 daysb. _____ 3 –14 daysc. _____ > 15 daysPrevious jobs: __________________________________________________________________________________________________________________________________________________________________________ Please list your highest level of education:Some or all of High SchoolCollege ___________________________Major: ____________________ Year: _____________Graduate School ____________________Field: _____________________ Year: ____________Professional School __________________Field: _____________________ Year: ____________Did you have learning problems? _________________________________________________________Functional Diagnostic Medical Health QuestionnairePlease complete the following Functional Medical Health Questionnaire to the best of your ability. You may need family members to help supply information. Your thoroughness and accuracy in answering all appropriate questions will help Dr. Carucci evaluate the root cause of your health concerns and determine an effective treatment program.Note: We are also interested in the so-called minor symptoms as well as the major problems. We know that in many doctor’s offices there is some tendency not to mention too many symptoms for fear that the doctor will take you for a hypochondriac. The rules in our office are different. We are interested in any odd or unusual message you are getting from your body, even though it may be considered irrelevant to “making a diagnosis” or it may seem to you to be of no consequence to your health. Some such symptoms are useful clues in the kind of “medical detective work” we do. Please include as much information as you can on this form. If you need additional space, please use an extra sheet of paper and include it with these forms.Please print or write legibly.CONCERNS / COMPLAINTS Please list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptoms has been present.ProblemOnsetFrequencySeveritye.g. HeadachesJune 20074 times per weekMild / moderate / severeWhat diagnosis or explanations have been given to you? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________When was the last time you felt well? ________________________________________________________________________________________________________________________________________________________Did something trigger your change in health? __________________________________________________________________________________________________________________________________________________What makes you feel worse? ______________________________________________________________________________________________________________________________________________________________What makes you feel better? ______________________________________________________________________________________________________________________________________________________________Please list all physicians you have seen for the above health conditions:1.4.2.5.3.6.Please check all the Alternative Treatments you have tried for your condition(s):NoneChiropracticAcupunctureIridologyColonicsMassageRolfingReikiHomeopathyBiofeedback YogaHypnosisAyurvedic Light therapyMeditationEnvironmental medicineNutritional TherapyBiological DentistryIV (chelation) therapyNaturopathic medicineOther treatments: ____________________________________________________________________PAST MEDICAL & SURGICAL HISTORY ILLNESSESWHEN / ONSETCOMMENTSAnemiaArthritisAsthmaBronchitisCancerChicken PoxChronic Fatigue SyndromeCrohn’s Disease or Ulcerative ColitisDiabetesEmphysemaEpilepsy, convulsions, or seizuresGallstonesGerman MeaslesGoutHeart Attack, AnginaHeart FailureHepatitisHerpes Lesions / ShinglesHigh blood fats (cholesterol, triglycerides)High blood pressure (hypertension)Irritable bowel (or chronic diarrhea)Kidney stonesMeaslesILLNESSESWHEN / ONSETCOMMENTSMononucleosisMumpsPneumoniaRheumatic FeverSinusitisSleep ApneaStrokeThyroid diseaseWhooping CoughOther (describe)Other (describe)INJURIESWHENCOMMENTSBack injuryBroken bones or fractures (describe)Head injuryNeck injuryOther (describe)Other (describe)Other (describe)DIAGNOSTIC STUDIESWHENCOMMENTSBarium Enema Blood TestsBone Density TestBone ScanCarotid Artery UltrasoundCAT Scan (Please indicate type: Brain, Spine, Abdomen, etc.ColonoscopyEKGLiver ScanSigmoidoscopyMammogramMRIUpper GI SeriesX-Ray (Please indicate type: Head, Neck, Back, Pelvis, Chest, Joint, etc.Other (describe)Other (describe)SURGERIESWHENCOMMENTSAppendectomyDental SurgeryGall BladderHerniaHysterectomyTonsillectomyTubes in EarsOther (describe)Other (describe)Other (describe)HOSPITALIZATIONS Where HospitalizedWhenFor What ReasonPATIENT BIRTH HISTORY QuestionYesNoDon’t KnowCommentWere you a full term baby?A Preemie?Forcep delivery?Cesarean section?Epidural used?Breast fed?Bottle fed?When your mother was pregnant with you, did she: Smoke tobacco? Drink alcohol? Take estrogen? Use recreational drugs? On prescription meds?IMMUNIZATION HISTORY Please indicate if you have been vaccinated against any of the following diseases:Smallpox Tetanus DiphtheriaPertussis Polio (oral)Polio (Injection)Mumps Measles Rubella (German measles)TyphoidCholeraCHILDHOOD HEALTH HISTORY QuestionYesNoDon’t KnowCommentDid you live in an area with soft water? Hard water?As a child, did you consume a lot of the following: Sugar? Candy? Sweet foods? Soda? Diet soda? White bread? Cookies? Ice Cream?Meat, vegetable & potato/rice/pasta diet?Vegetarian & grain based diet with little meat?Vegetarian diet with milk & eggs?Vegetarian diet without milk & eggs?As a child, were there any foods that you had to avoid because they gave you symptoms? Yes____ No_____If yes, please name the food and symptom e.g. wheat – gas and bloatingFoodSymptomOther commentsAGE OF ONSET OF ANY ILLNESSES:Please indicate which, if any, of the following problems/conditions developed when you were a child (ages birth to age12) by indicating the approximate age of onset._____ Frequent colds or flu _____Tonsillitis _____ Bronchitis _____ Ear Infections _____ Measles _____ Mumps _____ Chicken Pox _____ Whooping Cough _____ Strep Infections _____ Seasonal allergies _____ Significant dental work _____ Behavior problems _____ ADD _____ Hyperactivity _____ Difficulty learning: _____ Frequent headaches _____ High # of absences from school _____ Upset stomach, indigestion _____ Jaundice_____ Colic_____ Ear infections_____ Congenital abnormalities_____ Premature at birth _____ Pneumonia _____ Fever blisters _____ Parent (s) smoked _____ Abusive or alcoholic parent (s) _____ Skin disorders (eczema) _____ Any major illness(s) that required hospitalization?If yes, please explain your illness:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FEMALE MEDICAL HISTORY (For Women Only)OBSTETRICS HISTORY Check box if yes and provide number of:Pregnancies _____________Caesarean ______________Vaginal deliveries _________Miscarriage _____________Abortion ________________Living Children ___________Post partum depressionToxemiaGestational diabetesBaby over 8 poundsBreast feeding For how long?___________________________GYNECOLOGICAL HISTORYAge at 1st period:______Menses Frequency: ______Length: _________Pain: Yes____ No ____Clotting: Yes _____ No _____Has your period skipped? _______ For how long? _______________Last Menstrual Period: ________Do you currently use contraception? Yes _____ No _____ If yes, what type do you use?CondomDiaphragmIUDPartner vasectomyHave you ever used hormonal contraception? Yes ____ No _____If yes, when __________________________Use of hormonal contraception:Birth control pillsPatchNuva Ring How long?_______Are you using the pill now? Yes ____ No _____Did taking the pill agree with you? Yes _____ No _____In the 2nd half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)?YesNoLast Mammogram __________________________Breast Biopsy/Date _________________________Last PAP Test: ___________________________ Normal ______________ Abnormal ______________ Date of last Bone Density: ______________Results:HighLowWithin normal rangeAre you in menopause? Yes _____ No _____ Age at Menopause __________Do you take:EstrogenOgenEstracePremarinOther ____________ProgesteroneProveraOther _____________________________________How long have you been on hormone replacement? __________________________________________FAMILY HISTORYPlace mark any health problem(s) your family has suffered with either now or in the past:Check Family Members that ApplyFatherMotherBrother(s)Sister(s)ChildrenMaternalGrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherAuntsUnclesOtherAge (if still alive)Age at death (if deceased)Heart AttackStrokeUterine CancerColon CancerBreast CancerOvarian CancerProstate CancerSkin CancerADD/ADHDALS or other Motor Neuron DiseasesAlzheimer’sAnemiaAnxietyArthritisAsthmaAutismAutoimmune Diseases (Such as Lupus etc.)Bipolar DiseaseBladder diseaseBlood clotting problemsCeliac diseaseDementiaDepressionDiabetesEczemaEmphysemaEnvironmental SensitivitiesEpilepsyCheck Family Members that ApplyFatherMotherBrother(s)Sister(s)ChildrenMaternalGrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherAuntsUnclesOtherFluFood Allergies, Sensitivities, IntolerancesGenetic disordersGlaucomaHeadacheHeart DiseaseHigh Blood PressureHigh CholesterolInflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing spondylitis)Inflammatory Bowel DiseaseInsomniaIrritable Bowel SyndromeKidney diseaseMultiple SclerosisNervous breakdownObesityOsteoporosisOtherParkinson’sPneumonia/BronchitisPsoriasisPsychiatric disordersSchizophreniaSleep ApneaSmoking addictionStrokeSubstance abuse (such as alcoholism)UlcersIs there any other family history we should know about? Yes ____ No _____If yes, please comment: _________________________________________________________________What is the attitude of those close to you about your illness?SupportiveNon-supportiveAny additional diseases or health concerns:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ESTABLISHING HEALTH GOALSPersonal Message Before we begin our journey together, I would like to discuss something very important that will have a major impact on your ability to recover and achieve maximum improvement. After many years in private practice, I have had the opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms – it’s about living a life of vibrant health.I’ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality; a discussion of how you have lived your life up to this point and how you will live it in the future. Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want you to be honest with yourself and really dig deep inside yourself for the answers.What do you hope to achieve in your visit with us? ____________________________________________________________________________________________________________________________________________If you had a magic wand and could erase three problems, what would they be?1. ________________________________________________________________________________________2. ________________________________________________________________________________________3. ________________________________________________________________________________________Have you made the decision to change? To do what it takes to get well? Yes _____ No _____I have read something interesting: “The definition of insanity is to keep doing the same thing and yet expecting different results”. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination.Most people I ask tell me they’re made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding to do something and having the “reasons” to actually do it.When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness. So now I ask:List up to 5 things that you have been unable to do as a result of your present symptoms. Please be specific. (Use extra pages if necessary)_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List up to 5 things that you plan to do once you are feeling better. Please be specific. (Use extra pages if necessary)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are there any other health goals you want to achieve?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HAVE YOU COMPLETED THE LAST SECTION?IF NOT, PLEASE GO BACK AND ANSWER ALL THE QUESTIONS!PLEASE DO NOT SKIP THIS SECTION!!GIVE CAREFUL THOUGHT TO WHY YOU WANT TO GET BETTER AND HOW IT WOULD AFFECT YOUR LIFE!REVIEW OF SYSTEMSCheck only those items with which you identify, past or present. Ignore anything that does not apply to you.GeneralFeverChills/Cold all overAches/Pains General WeaknessDifficulty sweating Excessive SweatingSwollen Glands Cold hands & FeetFatigueDifficulty falling asleepNight WalkerNightmaresNo dream recallEarly wakingDaytime sleepinessDistorted VisionSKIN:Cuts Heal slowlyBruise EasilyRash Pigmentation Changing Moles Calluses EczemaPsoriasisDrynessOilinessItchingAcneBoilsHivesFungus on NailsPeeling SkinCracking skinShinglesNails Split White Spots/Lines on NailsCrawling Sensation Burning on Bottom of Feet Athletes FootCelluliteBugs love to bite youHave bumps on the back of arms and front of thighsSkin CancerStrong body odorIs you skin sensitive to the:SunFabrics _____________________________Detergents___________________________Lotions/Creams_______________________HEAD:Poor ConcentrationConfusionHeadaches:After MealsSevereMigraineFrontalAfternoonOccipitalAfternoonDaytimeRelieved by:Eating SweetsConcussion/WhiplashMental SluggishnessForgetfulnessIndecisiveFace TwitchPoor MemoryHair LossEYES:Feeling of Sand in the EyesDouble VisionBlurred VisionPoor Night VisionBright FlashesHalo around LightsEye PainsDark Circles under EyesStrong Light IrritatesCataractsFloaters in EyesVisual hallucinationsEARS:AchesDischarge/ConjunctivitisPainsRingingDeafness/Hearing lossItchingPressureWear a hearing aidFrequent infectionsTubes in earsSensitive to loud noisesHearing HallucinationsNOSE/SINUSESStuffyBleedingRunningDischargeWatery NoseCongestedInfectionPolypsAcute smellDrainageSneezing spellsPost nasal dripNo sense of smellDoes the change of seasons tend to make your symptoms worse? Yes/NoIf yes, is it worse in the:SpringSummerFallWinterMOUTH:Coated TongueSore TongueTeeth ProblemsBleeding GumsCanker SoresTMJCracked lips/ cornersChapped lipsFever blistersWear denturesGrind teeth when sleepingBad breathDry mouthTHROAT:MucusDifficulty SwallowingFrequent HoarsenessTonsillitisEnlarged GlandsConstant clearing of throatThroat closes upNECK:StiffnessSwellingLumpsNeck glands swellCIRCULATION/RESPIRATION:Swollen AnklesSensitive to HotSensitive to ColdExtremities Cold or ClammyHands/Feet go to sleep/numbHigh Blood PressureChest PainPain between shouldersDizziness upon standingFainting SpellsHigh CholesterolHigh TriglyceridesWheezingIrregular HeartbeatPalpitationsLow exercise toleranceFrequent coughsBreathing heavilyFrequently SighingShortness of breathNight SweatsVaricose VeinsMitral valve prolapseMurmursSkipped heartbeatHeart enlargementAngina painBronchitis/PneumoniaEmphysemaCroupFrequent coldsHeavy/tight chestPast Heart Attack? When _______PhlebitisSpider VeinsGASTROINTESTINAL/DIGESTIONPeptic/Duodenal UlcerPoor AppetiteExcessive AppetiteGallstonesGallbladder painNervous StomachFull Feeling after mealIndigestionHeartburnAcid RefluxHiatal HerniaNauseaVomitingVomiting BloodAbdominal Pains/CrampsGasDiarrheaConstipationChanges in BowelsRectal BleedingTarry StoolsRectal ItchingUse laxativesBloatingBelch frequentlyAnal itchingAnal fissuresBloody stoolsUndigested food in stoolsKIDNEY/URINARY TRACT:BurningFrequent UrinationBlood in UrineNight time UrinationProblem Passing UrineKidney PainKidney StonesPainful UrinationBladder infectionsKidney infectionsSyphilisBedwettingHave trichomonasWOMEN’S HISTORY (for women only)Fibrocystic BreastsLumps in breastFibroid Tumors/BreastSpottingHeavy PeriodsFibroid Tumors/UterusPainful periodsChange in periodBreast soreness before periodEndometriosisNon-period bleedingBreast soreness during periodVaginal DrynessVaginal dischargeHad partial/total hysterectomyHot FlashesMood SwingsConcentration/Memory ProblemsBreast cancerOvarian cystsPregnantInfertilityDecreased LibidoHeavy BleedingJoint PainsHeadachesWeight GainLoss of Control of UrinePalpitationsMEN’S HISTORY (for men only)Have you had a PSA done? Yes _____ No _____PSA Level:0 – 2 2 – 4 4 – 10 >10Prostate enlargementProstate infectionChange in libidoImpotenceDiminished libidoPoor libidoInfertilityLumps in testiclesSore on penisGenital painHerniaProstate cancerLow sperm countDifficulty Obtaining ErectionDifficulty Maintaining an ErectionNocturia (urination at night) How many times at night? _________Urgency/Hesitancy/Change in Urinary StreamLoss of Control of Urine?Loss of Bladder Control?JOINT/MUSCLES/TENDONSPain wakes me upWeakness in Legs and armsBalance problemsMuscle crampingHead injuryMuscle Stiffness in MorningDamp weather bothers youEmotional:ConvulsionsDizzinessFainting SpellsBlackoutsAmnesiaHad shock therapyFrequently keyed up and jitteryShakyStartled by sudden noisesOften feel suddenly scaredGo to pieces easilyForgetfulListlessWithdrawn feelingFeel “lost” in timeHad nervous breakdownHad “burnout”Feel groggyUnable to concentrateShort attention spanVision changesUnable to reasonConsidered a nervous personWorried over little thingsAnxietyUnusual tensionFrustrationNumbnessOften break out in cold sweatsProfuse sweatingDepressedBeen admitted for psychiatric careOften awakened by frightening dreamsFamily member had nervous breakdownUse tranquilizersAggressiveMisunderstood by othersIrritableEasily flare in angerFeeling of hostilityFatigueHyperactiveRestless leg syndromeConsidered clumsyUnable to coordinate musclesHave difficulty falling asleepHave difficulty staying asleepDaytime sleepinessAm a workaholicHave had hallucinationsHave considered suicideHave overused alcoholFamily history of overused alcoholCry oftenFeel insecureHave overused drugsBeen addicted to drugsExtremely shyDENTAL HISTORYPlease answer the following questions:Have you had sore gums (gingivitis) often over the years? Yes ____ No _____Have TMJ (temporal mandibular joint) problems been a concern? Yes ____ No _____ Do you often have a 'metallic' taste in your mouth? Yes ____ No _____ Do you have a lot of bad breath (halitosis) or white tongue (thrush)? Yes ____ No _____ Have you worn or do you presently wear braces? Yes ____ No _____Do you have problems chewing? Yes ____ No _____Do you floss regularly? Yes ____ No ____Did your mother have dental fillings prior to giving birth to you? Yes ____ No _____Did you have fillings as a child? Yes ____ No _____If yes, about how many fillings did you have up to 18 yrs? _______Did you have dental fillings as an adult? Yes ____ No _____If yes, about how many fillings did you have after to 18 yrs? _______How many amalgam fillings do you have now? _______Did you play with mercury as a child or adult? Yes ____ No _____Have you eaten a lot of fish in your life? Yes ____ No _____Has ringing in the ears (tinnitus) been present? Yes ____ No _____List the approximate age and the type of dental work done from childhood until present:AgeDescribe Dental WorkHealth Problems following dental work? (describe)BottomTeeth INCLUDEPICTURE "" \* MERGEFORMATINET INCLUDEPICTURE "" \* MERGEFORMATINET LEFT SIDE RIGHT SIDEPlease 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.Please record tooth number and problem:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MEDICATIONS & SUPPLEMENTSAntibiotics: How often have you taken antibiotics?Less than 5 timesMore than 5 timesInfancy/ChildhoodTeenAdulthoodOral Steroids: How often have you taken oral steroids (e.g. Prednisone, Cortisone, etc.)?Less than 5 timesMore than 5 timesInfancy/ChildhoodTeenAdulthoodIndicate any medications you’re currently taking or have taken in the last month:Acid Blocking DrugsAnti-anxiety medications Antibiotics AnticonvulsantsAntidepressantsAnti-fungalsAspirin/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)Other: ___________________________________MEDICATION LOGPlease indicate the type of medications you are taking now. Please include non-prescription drugs.Medication NameDate startedDated StoppedDosage# per daySUPPLEMENT LOGSupplements: List all vitamins, minerals and other nutritional supplementsSupplement Name/BrandDoseFrequencyDated StartedReason for useHave any medications or nutritional supplements ever caused you any unusual side effects or problems? Yes ____ No _____ If yes, please describe: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ALLERGIES Medications You Are Allergic To:Reaction_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Foods You Are Allergic To:Reaction_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supplements You Are Allergic To:Reaction_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Other Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PAIN ASSESSMENTAre you currently in any pain? Yes ___ No___ Is the source of your pain due to an injury? Yes___ No___If yes, please describe your injury and the date in which it occurred: __________________________________________________________________________________________________________________If no, please describe how long you have experienced this pain and what you believe it is attributed to: ___________________________________________________________________________________________Please use the area(s) and illustration below to describe the severity of your pain. (0= no pain, 10= severe pain)Example: Back Pain 1 2 3 4 5 6 7 8 9 10 Area 1:___________________________Area 2:___________________________ 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10Area 3:___________________________Area 4:___________________________ 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10Use the letters provided to mark your area(s) of pain on the illustration.A = acheB= burningN=numbnessS= stiffnessT=tinglingZ=sharp/shootingNUTRITION & LIFESTYLE HISTORYHeight (feet/inches)__________________________Current Weight____________________________Usual weight range +/- 5 lbs___________________Desired Weight range +/- 5 lbs________________Highest adult weight _________________________Lowest adult weight ________________________Weight fluctuations (>10lbs) Yes_____ No _____Body Fat % ______________________________How often do you weigh yourself? Daily_____ Weekly _____ Monthly _____ Rarely _____ Never _____Have you made any changes in your eating habits because of your health? Yes____ No_____Do you currently follow a special diet or nutritional program? Yes____ No_____Check all that apply:Low fatMixed food diet (Animal/vegetable sources)High proteinVegetarianVeganGluten restrictedLow sodiumFat restrictionLow starch/carbohydrate The Blood type DietMetabolic Typing DietThe Zone DietTotal calorie restrictionOvo-lacto dietDiabeticNo dairyNo wheatSpecific Program for Weight Loss/Maintenance Type:_____________________________________ Please check any specific food restrictions you have:DairySoyWheatCornEggsAll glutenOther_____________________________________________________________________________Is there anything special about your diet that I should know?____________________________________________________________________________________Are there any foods that you avoid because they give you symptoms? Yes____ No_____If yes, please name the food and symptom e.g. wheat – gas and bloatingFoodSymptomOther commentsIf you could only eat a few foods a week, what would they be? ___________________________________________________________________________________________________________________________________________________________________________________________________________Do you grocery Shop? Yes _____ No _____ If no, who does the shopping? ________________________When you shop do you purchase the following?Organic FoodsHormone free and antibiotic free meatDo you read food labels? Yes _____ No _____ Do you Cook? Yes _____ No _____ If no, who does the cooking? ________________________________How many meals do you eat out per week? 0-1_____ 1-3____ 3-5____ >5_____Check 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 controlFOOD DIARYPlace a check mark next to the food/drink that applies to your current diet. (List continues on next page.)Usual BreakfastUsual LunchUsual DinnerNoneBacon/SausageBagelButterCerealCoffeeDonutEggsFruitJuiceMargarineMilk Oat branSugarSweet rollSweetenerTeaToastWaterWheat branYogurtOat mealMilk protein shakeSlim fastCarnation shakeSoy proteinWhey proteinRice proteinOther: (List below)___________________________________________________________________________NoneButterCoffeeEat in a cafeteriaEat in restaurantFish sandwichFried foodsHamburgerHot dogsJuiceLeftoversLettuceMargarineMayoMeat sandwichMilkPizzaPotato chipsSaladSalad dressingSodaSoupSugarSweetenerTeaTomatoVegetablesWaterYogurtSlim fastCarnation shakeProtein shakeNoneBeans (legumes)Brown riceButterCarrotsCoffeeFishGreen vegetablesJuiceMargarineMilkPastaPotatoPoultryRed meatRiceSaladSalad dressingSodaSugarSweetenerTeaVinegarWaterWhite riceYellow vegetablesOther: (List below)_________________________________________________________________________________________________________________________________________________Check foods/drinks 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 freeCoconutCodCoffeeCornCrabCranberryCashewCheeseCucumberDeli MeatsDessertsDeli SandwichEggplantEnsureFlounderFried FoodsFrench FriesFrench ToastGarlicGingerGrapeGritsGreek FoodGrapefruitGrape nutsHaddockHamHalibutHerring Hot Dogs, PorkHot Dogs, BeefHamburgersHardies 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 BrewersYogurtYamZucchiniWhat snacks do you eat or drink between:Breakfast & Lunch: ___________________________________________________________________________Lunch & Dinner: _____________________________________________________________________________After Dinner: ________________________________________________________________________________How much 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-ounce can/bottle)Sodas with caffeine (12-ounce can/bottle)Sodas without caffeine (12-ounce can/bottle)Energy Drinks (12-ounce can/bottle)Ice creamSalty foodsSlices of white bread (rolls/bagels)Water: Glasses/day___ Type: Tap:___ Distilled:___ Spring:___ Well:___ Reverse Osmosis:___Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?Yes _____ No _____ If yes, please explain:_____________________________________________________________________________________________________________________________________If yes, are these symptoms associated with a particular food or supplement(s)? Yes _____ No _____If yes, please name the food and symptom e.g. wheat – gas and bloatingFoodSymptomOther commentsDo you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes _____ No _____ Do you feel worse when you eat a lot of:High fat foodsHigh protein foodsHigh carbohydrate foods (breads, pasta, potatoes)Refined sugar (junk food)Fried foods1 or 2 alcoholic drinksOther________________________Do you feel better when you eat a lot of:High fat foodsHigh protein foodsHigh carbohydrate foods (breads, pasta, potatoes)Refined sugar (junk food)Fried foods1 or 2 alcoholic drinksOther________________________Does skipping meals greatly affect your symptoms? Yes _____ No _____Has there ever been a food that you have craved or really “pigged out” on over a period of time? Yes _____ No _____ If yes, what food(s) __________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have an aversion to certain foods? Yes _____ No _____ If yes, what food(s) ________________________________________________________________________________________________________________________________________________________The most important thing you feel that you should change about your diet and to improve your health is: ________________________________________________________________________________________________________________________________________________________________________TOBACCO HISTORYCurrently using tobacco? Yes _____ No _____ How many years? _______ Packs per day: ________If yes, what type? Cigarette _____ Smokeless/Chew _____ Cigar _____ Pipe _____ Patch/Gum _____Attempts to quit: __________Previous smoking: How many years? _________ Packs per day: __________Are you exposed to 2nd hand smoke? If yes, please explain: ________________________________________________________________________________________________________________________ALCOHOL 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”Any previous alcohol intake? Yes ____ (Mild _____ Moderate _____ High _____)Have you ever been told to cut down your alcohol intake? Yes____ No____Do you get annoyed when people ask you about your drinking? Yes____ No____Do you ever feel guilty about your alcohol consumption? Yes____ No____Do you ever take an eye-opener? Yes____ No____Do you notice a tolerance to alcohol (can you “hold” more than others?) Yes____ No____Have you ever been unable to remember what you did during a drinking episode? Yes____ No____Do you get into arguments or physical fights when you have been drinking? Yes____ No____Have you ever been arrested or hospitalized because of drinking? Yes____ No____Have you ever thought about getting help to control or stop your drinking? Yes____ No____Was your Mother an alcoholic? __________ Father? _________ Other family member? ________________OTHER SUBSTANCESAre you currently using recreational drugs? Yes____ No____ If yes, what types? _____________________________________________________________________Have you ever used IV or inhaled recreational drugs? Yes____ No____ If yes, what types? _____________________________________________________________________EXERCISECurrent Exercise program: Activity (list type, number of sessions/week, and duration of activity)ActivityTypeFrequency per weekDuration in MinutesStretchingWalking/RunningOther Cardio/AerobicsStrength TrainingOther (Pilates, yoga, etc.)Sports or Leisure Activities (golf, tennis, rollerblading etc.)Rate your level of motivation for including exercise in your life?LowMediumHighDo you feel unusually fatigued after exercise? Yes _____ No _____If yes, please describe:______________________________________________________________________________________________________________________________________________________Do you usually sweat when exercising? Yes ___ No ___Please complete the following chart as it relates to your bowel movements:Frequency√Consistency√More than 3x/day?Soft and well formed?1-3x/ day?Often floats?4-6x/week?Difficult to pass?2-3x/week?Diarrhea?1 or fewer x/week?Thin, long or narrow?Color√Small and hard?Medium brown consistently?Loose but not watery?Very dark or black?Alternating between hard and loose/watery?Greenish color?Other (Please describe):Blood is visible?Varies a lot??Dark brown consistently??Yellow, light brown??Greasy, shiny appearance??Intestinal (Bowel) gas:__ Daily __ Occasionally__ Excessive__ Present with pain__ Foul smelling__ Little odorSOCIAL HISTORYPSYCHOSOCIALDo you feel significantly less vital than you did a year ago? Yes _____ No _____Are you happy? Yes ____ No _____Do you feel your life has meaning and purpose? Yes ____ No _____Do you believe stress is presently reducing the quality of your life? Yes ____ No _____Do you like the work you do? Yes ____ No _____Have you experienced major losses in your life? Yes ____ No _____Do you spend the majority of your time and money to fulfill responsibilities and obligations? Yes ___ No ____Would you describe your experience as a child in your family as happy and secure? Yes ____ No _____STRESS/COPINGUnfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immunes system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.Please do your best to answer the following questions:Did you feel safe growing up? Yes _____ No _____Have you ever been involved in abusive relationships in your life? Yes ____ No _____Was alcoholism or substance abuse present in your childhood home? Yes _____ No _____Is alcoholism or substance abuse present in your relationships now? Yes _____ No _____Have you ever sought counseling? Yes ____ No _____Currently? Yes ____ No _____ Previously? Yes ____ No _____If previously from ____ to _____What kind?__________________________________________________________________________Comments:__________________________________________________________________________Do you feel you have an excessive amount of stress in your life? Yes ____ No _____Do you feel you can easily handle the stress in your life? Yes ____ No _____Daily 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:PrayerBreathingMeditationTai ChiYogaImageryOtherHobbies ands leisure activities: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How important is religion (or spirituality) for you and your family’s life? a. _____ not at all importantb. _____ somewhat importantc. _____ extremely importantHave you ever been abused, a victim of a crime, or experienced a significant trauma? Yes ____ No _____How well have things been going for you?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 emotional support? Check all that applySpouseFamilyFriendsReligious/SpiritualPetsOther ____________STRESS EVALUATIONThis section of the questionnaire is an assessment of stressors and related stress symptoms and complaints. The questions have assigned scores/point values. To obtain score, multiply points (column 1) by duration (column 2). Add the scores of each section and make a note at the bottom under total score. SymptomScoreDuration (years)ScoreExcessive Fatigue10?12Dry & Thin Skin10?12Nervous/Irritability?9?12Low body temperature8?12Premenstrual tension?8?12Inability to concentrate?8?12Mental depression?8?12Food allergies & sensitivities?7?12Craving for sweets?7?12Headaches?6?12Alcohol intolerance?6?12Poor memory?5?12Heart palpitations?5?12TOTAL SCOREDo you have chronic pain? Yes ____ No ____.Do you have chronic inflammation? Yes ____ No ____.SOCIAL READJUSTMENT RATING SCALE*Circle YES or NO to each life event in this list that happened in the last twelve months. For every "Yes" that applies, give yourself the points as listed. Upon completion, total the score and enter in box below.Life EventAnswerPointsDeath of spouseYesNo100DivorceYesNo73Marital separationYesNo65Jail termYesNo63Death of close family memberYesNo63Personal injury or illnessYesNo53MarriageYesNo50Fired from workYesNo47Marital reconciliationYesNo45RetirementYesNo45Change in family members healthYesNo44PregnancyYesNo40Sex difficultiesYesNo39Addition to family?YesNo39Business readjustmentYesNo39Change in financial statusYesNo38Death of close friendYesNo37Change in line of workYesNo36Change in # of marital argumentsYesNo35Mortgage or loan over $10,000YesNo31Foreclosure of mortgage or loanYesNo30Change in work responsibilitiesYesNo29Son or daughter leaving homeYesNo29Trouble with in-lawsYesNo29Outstanding personal achievementYesNo28Spouse begins or stops workYesNo26Starting or finishing schoolYesNo26Change in living conditionsYesNo25Revision of personal habitsYesNo24Trouble with bossYesNo23Change in work hours, conditionsYesNo20Change in residenceYesNo20Change in schoolsYesNo20Change in recreational habitsYesNo19Mortgage or loan under $10,000?YesNo18Change in sleeping habitsYesNo16Change in eating habitsYesNo15VacationYesNo13TOTAL SCORE_____________* Holmes, TH and Rahe, RH Booklet for Schedule of Recent Experience (SRE) Seattle, University of Washington, 1967 TOXIC STRESS TRIGGERS(These refer to on-going stress that has accumulated over months or years. Please mark any of the below that you have experienced in your lifetime) Childhood traumasDivorce or change in a relationshipMenopausePerfectionismCare giving: taking care of a sick family memberIllness, either short-term or chronicJob or career challengesDieting: constantly trying a new and improved diet programDo you worry OVER?Home lifeMarriageChildrenJobIncomeIs your life:SatisfactoryBoringDemandingUnsatisfactoryMoney ProblemsSLEEP/RESTAverage number of hours you sleep>108 – 10 6 – 8 <6Do you have trouble falling asleep? Yes ____ No _____Do you feel rested upon awakening? Yes ____ No _____Do you have problems with insomnia? Yes ____ No _____Do you snore? Yes ____ No _____Do you use sleeping aids? Yes ____ No _____ Explain:______________________________________ENVIRONMENTAL INFLUENCESThere are over 70,000 chemicals commercially produced in the United States. The long-term effects of many of these chemicals have never been investigated. But many chemicals are harmful in very low doses. Unless generated by the body (formaldehyde, pentane), the body’s level for chemicals should be non-detectable, and not “low level”. Chemicals are widespread in our environment, and constant exposure to low levels can cause dysfunction in many systems of the body. The purpose in the following questions is to determine if any of your health problems can be a result of chemical toxicity and to measure your TOTAL TOXIN LOAD.Electromagnetic FactorsLive or have you lived within 200 yards from high-voltage wires or transformers? When? _________________________Live or have lived near an electric distribution substationBed is close to the main electrical currentHave a fan directly over your bedHave an alarm clock or radio close to your bed (plugged in)Live or have you lived near a television transmitterSleep with an electric blanket, heating padSleep on a waterbedPosition of your head of your bed is facing:NorthSouthEastWestWork on a computer for longer that six hours/dayUse a screening shield over your computer screenLive or have you lived near a power generating stationLive near a radio towerYou use a cellular phone more than 2 hours per dayUse microwave ovensBed has a wooden backboardHave fluorescent light fixturesWhat is your occupation? _____________________Toxin ExposureTrichloroethylene/TCEWork close to a copy machineWorked in a printing shopDrink decaffeinated coffeeUse typewriter correction fluidUse rug cleanersUse disinfectantsUse carbonless paperUse spot removersUse cleaning suppliesUse metal degreasersDo recreational paintingFormaldehydeWear many dry-cleaned clothes Noticed changes of your health since you moved into your homeWear many polyester clothes and permanent pressYou use Spray Starch Have foam wall insulation Have particleboard, chip board or interior plywoodPut up wallpaper in the last 2 yearsHave foam cushions or foam mattressesLive or lived in a trailerWorked in a laboratoryYour home been insulated since your illnessHad new carpets. When? ________________________________Use waxes and polishes on your floorBeen around resin glues and plasticsHave exterior grade plywood on your homeHome made of stucco, plaster or concreteHave a wood-burning stoveHave draperiesHave used acid-cured resin floor finishesHave fire-proof material in your homeSmoke in your homeHave a photography darkroomUse nail polish removerUse fingernail hardenersPesticides & Herbicides(Organochlorines, Organophosphate, Carbamate, Chlorinated Cyclodiene, Botanical & Microbial)Use pesticidesUse weed killerYou use cleaning fluids, waxesLived or worked at a dry cleaning plantHave been around wood preservativesDrink tap waterWork with electrical equipmentHave mothballs in your closets Gasoline fumes bother you Eat store bought meatUse insecticidesCrop-surface spraysAerosolsFumigantsVolatile Organic Compounds (Paradichlorobenzenes, toluene, ethers, ketones, propane, polymers, tetrachloroethylene)Had home painted in the last 2 yearsUse cleaning solventsHave soft vinyl floorsHandle propane and butaneGet your clothes dry-cleanedStore dry-cleaned clothes in closetsBarbecue more than 2 times per monthWork in a “tightly sealed building” Work close to a laser printerUse moth ballsHave nylon carpetUse air freshenersHave a workshop in the homePhenolsDo you use the following?Household cleanersNasal SpraysStyrofoam cupsCough SyrupDecongestantsHair spraysScented deodorantsScotch tapeNewsprintLysolEpoxyListerineChloraseptic throat spraysNoxemaMildew cleanersPerfumesAir FreshenersDisinfectantsPolishesGluesWaxesMouthwashHard saucepan handlesSmoke in the houseHave you been exposed to chemicals? When?________________________________Have you had your home treated for termites When?________________________________Wash own vehicle by hand. What type of cleaners do you use? __________Carbon Monoxide/Nitrogen Oxide/Sulfur DioxideHave oil or gas stoveHave water heatersChimney is damagedLive near a busy streetGarage attached to your homeSmoke at homeHave an open fireplaceOzoneUse an electrical sewing machineUse power toolsUse ion generatorsWork close to a photocopierCarbon DioxideWork in a crowded work placeHave poor ventilation at workAsbestosLive in an old homeHave old ceiling tiles, plaster, insulation board and heating duct tapeLived in a large city with many trucks, buses etc.Lived near a building which was torn downMother exposed to any unusual chemicals or drugs during pregnancy (DES)Do you have your nails treated? Acrylic AdhesivesPlease note the “brand” of product you useFor example: Toothpaste: CrestShampoo: _________________________________Toothpaste: ________________________________Hair Conditioner: ____________________________Makeup: __________________________________Lipstick: ___________________________________Make-up Foundation: ________________________Deodorant: ________________________________Perfume: __________________________________Hairspray: _________________________________Shaving Cream: ____________________________Cologne: __________________________________Facial Creams: _____________________________Body Creams: ______________________________Do you have hair permanents? O Yes O No If yes, how often? _____Do you have hair colorings? O Yes O No If yes, was it permanent or temporary?Do you use Latex products?Baby bottle nipplesBalloonsBandagesDiaphragmsHot water bottlesLatex glovesDishwashing gloves Rubber dams for dental workTiresWorked in a rubber industry General MiscellaneousHave basement MoldsHome is dampUse a humidifier? If yes, when the last time you cleaned it? _____________________________Use black hair dye (Nitrosamines)Worked in beauty shop. When? ________________________________Take any illicit drugs as an adolescent/young adult? What type?________________________Open your windows at homeWork in a machine shopWork in a garden?Work or have you worked on a farm When? ________________________________Have mercury fillingsHad mercury fillings removed? When?_________________________________Been exposed to radiation When?_________________________________Have a hot tubUse chlorine or bromineHave a wellWork around PVC pipe (Vinyl chloride)Home well ventilatedMoved to a new office in the last two yearsLive in an apartment? How old? _______________________________Eat at salad barsEat raw fish (Sushi)Buy food from street vendorsFor Women: Have breast implants. The implant was made of saline ___ silicone___Has any type of metal been used in implants or joint replacements in your body?What type?_____________________________Where_________________________________Notice more symptoms at work than at home or vice versa?Symptoms worse going into a mallHave you ever worked in a mall? When?_________________________________Have live plants in your homeHave pets in your homeOwned a new vehicle since your symptoms beganFurniture been put in storage or possibly fumigatedStained furniture in the last 2 yearsHave a tool shop in your garageLive on or near a golf courseLive in or near an industrial areaLived or traveled outside the US. Where? ________________________________Bought new furniture? What type of material? ____________________Installed drop ceilingsPainted indoorsSided your homeChanged your heating system, stove, clothes dryer or water heaterLived in a brand new homeLived in a new officeNoticed changes of your health since you moved into your home?Have a water purification system? Live near a landfill?Have a water filter on your shower? Describe the contents of your bedroomWhat type of mattress? ___________________Have hardwood floorsHave carpetingHave blindsHave draperiesUse a foam pillowUse a feather pillowUse a Dacron pillowUse wool blanketsUse cotton blanketsUse quiltsUse synthetic blanketsUse an electric blanketHave a ceiling fanHave material under your bedHave real plants in your bedroomHave artificial plants in your bedroomUse aromatherapy in your bedroomBurn scented candles in your bedroomHave central heatHave a fireplace in your roomHave an electric baseboardUse gas heatUse an air filter in your bedroom?What type? _____________________________When was the last time you changed your filter in your room? ___________________________Have central air conditioningSleep with your windows openLive close to a high traffic roadSmoke in bedAllow any pets in your roomWhat type?_____________________________Have plugged in air freshenersArt and Leisure ActivitiesSilk-screeningMake stained glassMake pottery & ceramic productsMake jewelryBuy art and craft suppliesUse airbrush and spray paintsDo quilting and weavingGardeningMake soapstone carvingsUse acrylic paintWhat hobbies do you have? Please list:1.________________________________________2.________________________________________3.________________________________________Please indicate the occupation of your parents during your childhood:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________READINESS ASSESSMENTRate on a scale of:5 (very willing) to 1 (not willing).In order to improve your health, how willing are you to:Significantly modify your diet: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Take several nutritional supplements each day: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Keep a record of everything you eat each day: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Modify your lifestyle (e.g. work demands, sleep habits): 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Practice relaxation techniques: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Engage in regular exercise: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Have periodic lab tests to assess progress: 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rate on a scale of: 5 (very confident) to 1 (not confident at all).How confident are you of your ability to organize and follow through on the above health related activities? 5 _____ 4 _____ 3 _____ 2 _____ 1 _____If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in the above activities? ______________________________________________________________________________________________________________________________________________________________________________________________________________________Rate on a scale of: 5 (very supportive) to 1 (not supportive at all).At the present time, how supportive do you think the people in your household will be to your implementing the above changes? 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact).How much ongoing support and contact (e.g. telephone consults, e-mail correspondence) from your professional staff would be helpful to you as you implement your personal health program? 5 _____ 4 _____ 3 _____ 2 _____ 1 _____Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thank you for taking the time to complete this health history medical questionnaire.The information derived from all of these medical forms will provide invaluable data.Each section builds upon the other, allowing me and other physicians the opportunity to discover the “missing key” that will solve your health problem. Once all the sections of this form and the questionnaires have been filled out please return them to our office and we’ll make an appointment for our initial consultation.I thank you once again and look forward to helping you achieve a “return to health and well being.”Please see the next page and go over the Patient Checklist.Sincerely,Gina M. Carucci, DC, MS, DICCP, DABCIPATIENT CHECKLISTDID YOU REMEMBER TO?Read all of our documentsObtain your medical records and/or test results from previously seen physicians and have them sent to: Dr. Gina M. Carucci, 53 New Britain Avenue, Rocky Hill, CT 06067FILL OUT AND/OR SIGN THE FOLLOWING FORMSImportant Patient InformationAuthorization for Release of Medical InformationGeneral InformationHealth Goals FormFunctional Diagnostic Medicine QuestionnaireNutrition and Lifestyle QuestionnaireReview of systemsEnvironmental Influences QuestionnairePatient Readiness FormNutritional Assessment Questionnaire Diet DiaryThank you ................
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