Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan. 1 One more to go 2 Last one of Part 1 3 4 5 Name* First Last Email* AgeDate Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Birthdate*Sex Male Female HeightWeightOccupationFees for Service: I ask that you pay in full at the time of service. I accept cash, personal checks made payable to Forbes Nutritional Consulting, and PayPal online. There is a $35.00 fee for all returned checks. If you wish to submit an invoice for reimbursment to your insurance company I can provide a record of our appointment for you to do this. Initial Consult Follow-Up Appointments Resting Metabolic Rate Other Please specify other.Main Reason for This Visit Known Diagnoses or Health Problems Personal Health Goals Current/Ongoing ProblemsDescribe ProblemMild/Moderate/SevereTreatment ApproachSuccess Do you have any pets or farm animals? Yes No If yes, where do they live? Indoors Outdoors Both Have you lived or traveled outside of the United States? Yes No If so, 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 yes, please comment...End of Section 1 - Please continueNumber of courses of antibiotics: Less than 5 5-10 More than 10 How often have you taken oral steroids? (Cortisone, Prednisone, etc.) Less than 5 5-10 More than 10 List all medications you are taking (including over the counter meds and birth control pills - past or current)Click "+" to drop down more boxesNameDate StartedDosage Please list any allergies to medications.Click "+" to drop down more boxes List all vitamins, minerals, and other nutritional supplements that you are taking now. indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate)NameDate StartedDosage ChildhoodWere you a full term baby?Preemie?Breast Fed?Bottle Fed? As a child, what foods did you avoid because they gave you symptoms? Please describe (ex. milk- gas and diarrhea)FoodSymptom Soft DrinksYes/NoDrinks Per Day/WeekRegular/Diet Artificial SweetenersYes/NoPacks Per Day/Week Water/FluidGlasses Per DayPlain WaterJuiceOther Health Maintenance (Please mark the year of your last appointment in the box under those that apply)Last check-upCholesterol testBlood testRectal examStool blood test SigmoidoscopyMammogramPap smearBone density test Please list your past illnesses by entering when they occurred as well as any other comments you wish to share.AnemiaArthritis AsthmaBronchitis CancerChronic Fatigue Syndrome Crohn's Disease/Ulcerative ColitisDiabetes EmphysemaEpilepsy/Convulsions/Seizure GallstonesGout Heart AttackHeart Failure HepatitisHigh blood fats (cholesterol/triglycerides) High blood pressure (hypertension)Irritable bowel Kidney StonesMononucleosis PneumoniaRheumatic fever SinusitisSleep apnea StrokeThyroid disease Thyroid diseaseOther Back injuryBroken (describe) Head injuryNeck Injury DIAGNOSTIC STUDIESBarium EnemaBone Scan CAT Scan- AbdomenCAT Scan- Brain CAT Scan- SpineChest X-Ray ColonoscopyEKG Liver ScanNeck X-Ray NMR/MRISigmoidoscopy Upper GI SeriesOther (describe) OPERATIONSAppendectomyDental Surgery GallbladderHernia HysterectomyTonsillectomy Other (describe)Other (describe) Please List and Describe Your HospitalizationsWhereWhenFor What Reason Place an "X" under the food/drink that matches your current diet for BREAKFASTNoneBacon/SausageBagelButterCerealCoffeeDonut EggsFruitJuiceMargarineMilkOat BranSugar Sweet RollSweetenerTeaToastWaterWheat BranYogurt Place an "X" under the food/drink that matches your current diet for LUNCHNoneButterCoffeeEat in CafeteriaEat in RestaurantFish SandwichJuice LeftoversLettuceMargarineMayoMeat SandwichMilkSaladDressing SodaSoupSugarSweetenerTeaTomatoWaterYogurt Place an "X" under the food/drink that matches your current diet for DINNERNoneBeans (legumes)Brown RiceButterCarrotsCoffeeFish Green VeggiesJuiceMargarineMilkPastaPotatoPoultryRed Meat RiceSaladDressingSodaSugarSweetenerTeaWaterYellow Veggies How much of the following do you consume each week?CandyCheeseChocolateCups of Coffee w/ CaffeineCups of decaf coffee or tea Cups of Hot ChocolateCups of tea w/ caffeineDiet Sodasice creamSalty foods Slices of white bread/rolls/bagelsSoda w/ caffeineSoda w/out caffeine Are you on a special diet? Ovo-lacto diabetic dairy-restricted vegetarian vegan blood type diet other Please list "other"...Do you have symptoms immediately after eating such as belching, bloating, sneezing, hives, etc.? Yes No If yes, are these symptoms associated with any particular food or supplement(s)? yes no Please name the food or supplement.Do 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 congestions, etc.? Yes No Do you feel much WORSE when you eat a lot of: High fat foods High protein foods High carbohydrate foods Refined sugar (junk food) Fried foods 1 or 2 alcoholic drinks other List other...Do you feel much BETTER when you eat a lot of: High fat foods High protein foods High carbohydrate foods Refined sugar (junk food) Fried foods 1 or 2 alcoholic drinks other List other...Does skipping a meal greatly affect your symptoms? Yes No Have you ever had a food that you craved or really "binged" on over a period of time? -Food craving may be an indicator that you may be allergic to that food! Yes No If yes, what food(s)?Do you have an aversion to certain foods? Yes No If yes, what food(s)?Please list the frequency of your bowel movements. More than 3x/Day 1-3x/day 4-6x/week 2-3x/week 1 or fewer x/week Consistency Soft and well formed Often float Difficult to pass Diarrhea Thin, long, narrow Small and hard Loose but not watery Alternating between hard and loose/watery Color Medium brown consistently Very dark or black Greenish color Blood is visible Varies a lot Dark brown consistently Yellow, light brown Greasy, shiny appearance Intestinal gas Daily Occasionally Present with pain Excessive Foul smelling Little odor Have you ever used alcohol? Yes No How often do you now drink alcohol? No Longer 1-3 drinks per week 4-6 drinks per week 7-10 drinks per week >10 per week Have you ever had a problem with alcohol? Yes No If yes, please indicate time period month(s)/year(s)Have you ever used recreational drugs? Yes No Have you ever used tobacco? Yes No Fill out applicable boxes.For how long?Amount per dayYear QuitCigarCigaretteSmokelessPipePatch/Gum Are you exposed to second hand smoke regularly? Yes No Do you have mercury amalgam fillings? Yes No Do you feel worse at certain times of the year? Spring Summer Fall Winter Have you, to your knowledge, been exposed to any of the following toxic metals in your job or home? Lead Arsenic Aluminum Cadmium Mercury Do you exercise regularly? If so, how many times a week? 1x 2x 3x 4x or more When you exercise, how long is each session? <15mins 16-30 min 31-45 min > 45 mins Please describe your typical type of exercise routine.Just making sure you're human! What does 4 + Four=?*Enter a value between 8 and 8Please enter a value between 8 and 8.EmailThis field is for validation purposes and should be left unchanged.