IMPORTANT - PLEASE COMPLETE THE THREE FORMS BELOW AND SUBMIT THEM ONLINE BEFORE YOUR APPOINTMENT.

NEW PATIENT INTAKE FORM
HEALTH QUESTIONNAIRE (NTAF)
METABOLIC ASSESSMENT FORM

NEW PATIENT INTAKE FORM

Name (Last):  (First):  (Middle):   Age:   Date of Birth:

Primary Language Spoken:    Race:    Gender:

Address:    City:   State:    Zip Code:

Mailing Address (if different): 

Home Phone:    Cell Phone:     Work Phone: 

Fax:    Call before faxing?   Email:

Employment Status:  Full-time  Part-time  School  Retired  Unemployed     Other:

Occupation (if retired, state previous occupation): 

Employer:    Employer's Address:

Support activities/pursuits/groups:

Relationship Status:  Single    Married     Partnered     Divorced     Widowed

Living Situation:  Alone    Friend(s)    Spouse    Partner    Parents    Children

Regular physical exercise?   Yes  No     If yes, type:    How often?

Tobacco use (how much):    Previously?    How much?    How long?

Alcohol use (how much):   How often? 

Caffeine use (how much):     

Other mood altering substances (past/present):

Pets:

Names and ages of those living with you:

Name of Partner/Spouse: 

EMERGENCY CONTACT   
In Case of Emergency:    Phone #1:   Phone #2:

MAIN HEALTH ISSUE YOU WISH TO ADDRESS AT THIS TIME:

CANCER INFORMATION

Have you ever been diagnosed with cancer, a mass or tumor?  Yes  No      When?

Location:    Type:

Current Status (eg; post surgery, recurrence, etc.):

Current Stage:

Relevant tumor markers:

CONVENTIONAL TREATMENT HISTORY

Date Surgery/Chemotherapy/Radiation/Other Dose (eg; chemo agents) Duration

If you are in a clinical trial or experimental protocol please provide details:  

CURRENT/RECENT HEALTH CARE PROVIDERS (Surgery, Oncology, Primary Care Providers, etc.)

Name Dates Care Provided

ACCIDENT / INJURIES Briefly describe

MORE than 5 years ago: 

LESS than 5 years ago:   

FAMILY HISTORY
Please include any of the following: alcoholism, high blood pressure, cancer, diabetes, heart disease, osteoporosis, other addiction or illness.

Member Living? Age Important Diseases Cause of Death Age
Mother
Father
Siblings
Siblings
*MGM
*MGF
*PGM
*PGF

* M = Maternal      P = Paternal      GM = Grandmother      GF = Grandfather

If you need more space for family history please list here:

Height:  Weight:   Blood Pressure:

Skin:  Dry     Oily    Normal

Please rate the following on a scale of 1 to 10 (10 being the best), and write in any comments:

Sleep:   Comment:
Energy Level:   Comment:
Appetite:   Comment:
Digestion:   Comment:

Any gas, bloating or other discomfort after eating? Yes   No     Describe:


Stools:  float     sink     daily     bad odor     no odor     blood in stool

Do you rely on any of the following for bowel elimination?  Yes    No     How often?
enemas       laxatives      purgatives       What type/brand?

PERSONAL

How do you feel about the following areas of your life?
Please choose appropriate descriptions and make any comments you would like to.

  GREAT GOOD FAIR POOR COMMENTS
Self
Work
Partner
Sex
Family
Diet
Exercise

PERSONAL STRESS

Please rate your stress level on a scale of 0 to 10 (10 being the most), and write in any comments.
Stress Level:      Comment:

1.  I worry a great deal Yes    No
2.  I feel lonely Yes    No
3.  I am bored with my life Yes    No
4.  I think a lot about dying Yes    No
5.  I have particular concerns relating to my religion Yes    No
6.  I feel fearful or afraid Yes    No
7.  I feel nervous most of the time Yes    No
8.  I often feel depressed Yes    No
9.  I feel anxious often Yes    No
10. I am ill frequently Yes    No
11. I sometimes feel weak or light-headed Yes    No
12. I often have pains in my shoulders, neck or back Yes    No
13. I often feel like crying Yes    No
14. I lose my temper more than I used to Yes    No
15. Other personal concerns Yes    No
      Please describe: 

Please use this space to add any other information about yourself that you think will be of help to us:

DIET AND NUTRITION

Dietary preferences/restrictions:
Favorite food:      Favorite flavor:

Sample of day's menu:

Breakfast:
Lunch:
Dinner: 
Snacks:
Drinks/beverages:

To the best of your knowledge, have you ever been exposed to pesticides, toxic chemicals, heavy metals, radiation, or other toxins
beyond those encountered in daily life? Yes   No
Details:

CURRENT DIETARY SUPPLEMENTS & HERBS

Agent Name Brand/Product Name Potency
(mg or IU, etc.)
Dose Frequency
Additional information:

PRESCRIPTION MEDICATIONS 

Please list all prescriptions and over-the-counter medications you are currently using (except chemo and radiation)

Name What it's for For how long? Strength Dose Frequency

ALLERGIES

Drug allergies (penicillin, etc.):   
Allergies to foods, pollens, etc.:  

MEDICAL HISTORY

Medical history (for example heart disease, diabetes, high blood pressure, high cholesterol, bowel problems, autoimmune disorders such as thyroid and musculoskeletal issues such as arthritis).   Please include those here:

HOSPITALIZATION/SURGERY (NON CANCER)

Date Hospital Diagnosis/Operation Doctor

PAIN

Do you have any pain(s)? Yes    No

Area of pain Description of pain Pain level
(0 to 10)
Frequency

------------------------------------------------------------------------------------------------------------------------------------

FOR WOMEN ONLY!

MENSTRUAL PERIODS
Please complete this section to the best of your ability even if you no longer menstruate. It provides valuable information for an accurate assessment.

Since age:    Regular?    Length of cycle    Flow lasts how many days?
Light   Heavy      Clots?    Color of blood
Date of last menses:   PMS?   Describe symptoms:
Menstrual cramps?   Which days?

HISTORY

Mark the following:  1 - IF CURRENT, 2 - IF PAST

hysterectomy herpes mastectomy
D&C yeast infection lumpectormy
tubular ligation interstitial cystitis breast reconstruction
ablation infertility breast implants
irregular PAP smear pain with intercourse  
fibroids dryness with intercourse osteoporosis
irregular bleeding    

Vaginal discharge?    Color   Frequency   Amount

PREGNANCY/BIRTH CONTROL

Are you pregnant now? Do you think you may be?
Number of pregnancies Number of children
Terminations?     Miscarriages? Tubular pregnancies?

Difficulty in conceiving?

Birth control method(s)

MENOPAUSE

No menses since
Experiences/symptoms you are currently feeling/having?
Experiences/symptoms you have had in the past during menopause?

PLEASE SUBMIT THE NEW PATIENT INTAKE FORM.  YOU WILL BE GIVEN THE OPTION TO RETURN HERE TO FILL OUT THE NEXT FORM.


TOP

 

HEALTH QUESTIONNAIRE (NTAF)

Name:   Date of Birth:     Email address:

Please select the appropriate number "0 - 3" on all questions below. 0 as the least/never to 3 as the most/always.

SECTION A 0    1    2    3
Is your memory noticeably declining?
Are you having a hard time remembering names and phone numbers?
Is your ability to focus noticeably declining?
Has it become harder for you to learn things?
How often do you have a hard time remembering your appointments?
Is your temperament getting worse in general?
Are you losing your attention span endurance?
How often do you find yourself down or sad?
How often do you fatigue when driving compared to the past?
How often do you fatigue when reading compared to the past?
How often do you walk into rooms and forget why?
How often do you pick up your cell phone and forget why?

 

SECTION B 0    1    2    3
How high is your stress level?
How often do you feel that you have something that must be done?
Do you feel you never have time for yourself?
How often do you feel you are not getting enough sleep or rest?
Do you find it difficult to get regular exercise?
Do you feel uncared for by the people in your life?
Do you feel you are not accomplishing your life’s purpose?
Is sharing your problems with someone difficult for you?

 

SECTION C
SECTION C1 0    1    2    3
How often do you get irritable, shaky, or have lightheadedness between meals?
How often do you feel energized after eating?
How often do you have difficulty eating large meals in the morning?
How often does your energy level drop in the afternoon?
How often do you crave sugar and sweets in the afternoon?
How often do you wake up in the middle of the night?
How often do you have difficulty concentrating before eating?
How often do you depend on coffee to keep yourself going?
How often do you feel agitated, easily upset, and nervous between meals?

SECTION C2
0    1    2    3
Do you get fatigued after meals?
Do you crave sugar and sweets after meals?
Do you feel you need stimulants such as coffee after meals?
Do you have difficulty losing weight?
How much larger is your waist girth compared to your hip girth?
How often do you urinate?
Have your thirst and appetite been increased?
Do you have weight gain when under stress?
Do you have difficulty falling asleep?

 

SECTION 1-S 0    1    2    3
Are you losing your pleasure in hobbies and interests?
How often do you feel overwhelmed with ideas to manage?
How often do you have feelings of inner rage (anger)?
How often do you have feelings of paranoia?
How often do you feel sad or down for no reason?
How often do you feel like you are not enjoying life?
How often do you feel you lack artistic appreciation?
How often do you feel depressed in overcast weather?
How much are you losing your enthusiasm for your favorite activities?
How much are you losing enjoyment for your favorite foods?
How much are you losing your enjoyment of friendships and relationships?
How often do you have difficulty falling into deep restful sleep?
How often do you have feelings of dependency on others?
How often do you feel more susceptible to pain?
How often do you have feelings of unprovoked anger?
How much are you losing interest in life?

 

SECTION 2-D 0    1    2    3
How often do you have feelings of hopelessness?
How often do you have self-destructive thoughts?
How often do you have an inability to handle stress?
How often do you have anger and aggression while under stress?
How often do you feel you are not rested even after long hours of sleep?
How often do you prefer to isolate yourself from others?
How often do you have unexplained lack of concern for family and friends?
How easily are you distracted from your tasks?
How often do you have an inability to finish tasks?
How often do you feel the need to consume caffeine to stay alert?
How often do you feel your libido has been decreased?
How often do you lose your temper for minor reasons?
How often do you have feelings of worthlessness?

 

SECTION 3-G 0    1    2    3
How often do you feel anxious or panic for no reason?
How often do you have feelings of dread or impending doom?
How often do you feel knots in your stomach?
How often do you have feelings of being overwhelmed for no reason?
How often do you have feelings of guilt about everyday decisions?
How often does your mind feel restless?
How difficult is it to turn your mind off when you want to relax?
How often do you have disorganized attention?
How often do you worry about things you were not worried about before?
How often do you have feelings of inner tension and inner excitability?

 

SECTION 4-ACH 0    1    2    3
Do you feel your visual memory (shapes & images) is decreased?
Do you feel your verbal memory is decreased?V
Do you have memory lapses?
Has your creativity been decreased?
Has your comprehension been diminished?
Do you have difficulty calculating numbers?
Do you have difficulty recognizing objects & faces?
Do you feel like your opinion about yourself has changed?
Are you experiencing excessive urination?
Are you experiencing slower mental response?

MEDICATION HISTORY

Please check any of the following medication you have been or are currently taking.

Acetylcholine Receptor Antagonist - Antimuscarinic Agents
Atropine   Ipratopium   Scopolamine   Tiotropium

Acetylcholine Receptor Antagonist - Ganlionic Blockers
Mecamylamine  Hexamethonium   Nicotine (high doses)   Trimethaphan

Acetylcholinesterase Reactivators
Pralidoxime

Acetylcholine Receptor Antagonist - Neuromuscular Blockers
Atracurium   Cisatracurium  Doxacurium   Metocurine   Mivacurium   Pancuronium   Rocuronium   Uccinylcholine
Tubocurarine   Vecuronium   Hemicholine

Agonist Modulator of GABA Receptor (benzodiazpines)
Xanax   Lexotanil   Lexotan   Librium   Klonopin   Valium   ProSon   Rohypnol   Dalmane   Ativan  
Loramet Sedoxil   Dormicum   Megadon   Serax   Restoril   Halcion

Agonist Modulator of GABA Receptors (nonbenzodiazpines)
Ambien   Sonata   Lunesta  Imovane

Cholinesterase Inhibitors (irreversible)
Echotiophate   Isoflurophate   Organophosphate Insecticides   Organophosphate-containing nerve agents

Cholinesterase Inhibitors (reversible)
Donepezil    Galatamine   Rivastigmine   Tacrine   THC   Erophonium   Neostigmine   Phystigimine  
Pyridostigmine Carbamate Insecticides

Dopamine Reuptake Inhibitors
Wellbutrin (Bupropion)

Dopamine Receptor Agonists
Mirapex   Sifrol   Requip

D2 Dopamine Receptor Blockers (antipsychotics)
Thorazine   Prolixin   Trilafon   Compazine   Mellaril   Stelazine   Vesprin   Nozinan   Depixol   Navane
luanxol   Clopixol   Acuphase   Haldol   Orap   Clozaril   Zyprexa   Zydis   Seroquel   Geodon   Solian
Invega   Abilify

GABA Antagonist Competitive binder
Flumazenil

Monoamine Oxidase Inhibitor (MAOI)
Marplan   Aurorix   Maneric   Moclodura   Nardil   Adlegiine   Elepryl   Azilect   Marsilid   Iprozid   Ipronid
Rivivol   Popilniazida   Zyvox   Zyvoxid

Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)
Remeron   Zispin   Avanza   Norset  Remergil   Axit

Selective Serotonin Reuptake Inhibitor
Paxil   Zoloft   Prozac  Celexa   Lexapro   Luvox   Cipramil   Emocal   Serpam   Seropram   Cipralex
Esteria   Fontex   Seromex   Seronil   Sarafem   Fluctin   Faverin   Seroxat   Aropax   Deroxat   Rexetin
Xentor   Paroxat Lustral   Serlain   Dapoxetine

Selective Serotonin Reuptake Enhancers
Stablon   Coaxil   Tatinol

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Effexor   Pristiq   Meridia   Serzone   Dalcipran   Despramine   Duloxetine

Tricylic Antidepresseants (TCAs)
Elavil   Endep   Tryptanol   Trepiline   Asendin   Asendis   Defanyl   Demolox   Moxadil   Anafranil
Norpramin   Pertofrane   Prothiadin   Thanden   Adapin   Sinequan   Trofranil   Janamine   Gamanil   Aventyl
Pamelor   Opipramol   Vivactil   Rhotrimine   Surmontil

PLEASE SUBMIT THE HEALTH QUESTIONNAIRE.  YOU WILL BE GIVEN THE OPTION TO RETURN HERE TO FILL OUT THE NEXT FORM.


TOP

 

METABOLIC ASSESSMENT FORM

Name:   Date of Birth:     Email address: 

PART I

Please list the 5 major health concerns in order of importance:
1.
2.
3.
4.
5.

PART II

Please select the appropriate number "0 - 3" on all questions below. 0 as the least/never to 3 as the most/always.

Category I 0    1    2    3
Feeling that bowels do not empty completely
Lower abdominal pain relief by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard dry or small stool
Coated tongue of “fuzzy” debris on tongue
Pass large amount of foul smelling gas
More than 3 bowel movements daily
Do you use laxatives frequently

Category II 0    1    2    3
Excessive belching burping or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested foods found in stools

Category III 0    1    2    3
Stomach pain, burning or aching 1- 4 hours after eating
Do you frequently use antacids
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk, carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine

Category IV 0    1    2    3
Roughage and fiber cause constipation
Indigestion and fullness lasts 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage bloated
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucouslike, greasy or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight

Category V 0    1    2    3
Greasy or high fat foods cause distress
Lower bowel gas and or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates for clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed? Yes       No

Category VI 0    1    2    3
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded and if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision

Category VII 0    1    2    3
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst & appetite
Difficulty losing weight

Category VIII 0    1    2    3
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails

Category IX 0    1    2    3
Cannot fall asleep
Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity

Category X 0    1    2    3
Tired, sluggish
Feel cold - hands, feet, all over.
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals or excessive falling hair
Dryness of skin and/or scalp
Mental sluggishness

Category XI 0    1    2    3
Heart palpations
Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night sweats
Difficulty gaining weight

Category XII 0    1    2    3
Diminished sex drive
Menstrual disorders of lack of menstruation
Increased ability to eat sugars without symptoms

Category XIII 0    1    2    3
Increased sex drive
Tolerance to sugars reduced
“Splitting” type headaches

Category XIV (Male Only) 0    1    2    3
Urination difficulty or dribbling
Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night

Category XV (Male Only) 0    1    2    3
Decrease in libido
Decrease in spontaneous morning erections
Decrease in fullness of erections
Difficulty in maintain morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional then in the past

Category XVI (Menstruating Females Only) 0    1    2    3
Are you a menopausal Yes     No
Alternating menstrual cycle lengths Yes     No
Extended menstrual cycle, greater than 32 days Yes     No
Shortened menses, less than every 24 days Yes     No
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne break outs
Facial hair growth
Hair loss/thinning

Category XVII (Menopausal Females Only) 0    1    2    3
How many years have you been menopausal?
Do you ever have uterine bleeding since menopause? Yes     No
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breast
Facial hair growth
Acne
Increased vaginal, pain, dryness or itching

PART III

How many alcohol beverages do you consume per week? 
How many caffeinated beverages do you consume per day?
How many times do you eat out per week?
How many times a week do you eat raw nuts or seeds?
How many times a week do you eat fish?
How many times a week do you workout?
List the three worst foods you eat during the average week?  1.   2.   3.
List the three healthiest foods you eat during the average week?  1.   2.   3.
Do you smoke? Yes   No    If yes, how many times a day , a week .
Rate your stress levels on a scale of 1-10 during the average week.

Please list any medications you currently take and for what conditions:


Please list any natural supplements you currently take and for what conditions:

PLEASE SUBMIT THE METABOLIC ASSESSMENT FORM.