Your SlideShare is downloading. ×
Word File
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
153
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. HOLISTIC HEALTH QUESTIONNAIREName___________________________________ Date__________Please feel free to continue any answer on the back of the page orattach a separate sheet, if needed.What do you want to accomplish in our working together? What are your goals?Be as specific as you can. The more specific you are, the better the chance for oursuccess. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What, if anything, has prevented you from achieving these goals in the past? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________If you are seeing me for particular diagnoses or problems, please give me a chronologicalhistory of their onset, progression, and treatment, if any. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  • 2. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ -2-What other medical problems or diagnoses are you currently under treatment for?Problem/diagnosis Since when? By whom?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any hospitalizations or surgeries you have had at any time in the past.Problem/procedure Approx. year Complications?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any other significant medical problems you have been treated for in the past,including significant injuries or trauma. ______________________________________________________________________________________________________________________________________________________________________________________Have you ever had a blood transfusion? Y N Under what circumstances____________________________________________________________________________________Do you have any history, now or in the past, of frequent infections requiring antibiotictherapy or the need to take them prior to dental procedures? Y N Please describe alongwith name of antibiotic, if you recall: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any prescription medications, including contraceptives, you are now taking.Name Dose/frequency Since when? Side effects?______________________________________________________________________________________________________________________________________________
  • 3. __________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list any allergies/intolerances you have to medication.Medication Reaction________________________________________________________________________________________________________________________________________________________________________________________________________________________ -3-What nutritional supplements are you taking?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family HistoryDo you have a family history of any of the conditions below? Please check and identifywho. Include parents, grandparents, siblings, children, aunts and uncles, if known.___ Diabetes________________________ ___ High blood pressure___________________ Heart disease____________________ ___ Thyroid problems_____________________ Obesity ________________________ ___ Mental illness________________________ Asthma/allergies _________________________________________________________ Alcoholism/drug addiction__________________________________________________ Cancer. Also list what type, if known._________________________________________Other _______________________________________________________________Nutrition and LifestyleHow many glasses of water do you drink a day? ___________________Please describe your typical diet:Meal When What foodsBreakfast_________ _____________________________________________________Lunch____________ ____________________________________________________Dinner___________ ____________________________________________________Snacks____________ _____________________________________________________What foods do you crave?___________________________________________________How often do you use sugar or consume foods with sugar added (this includes anythingwith “high fructose corn syrup”)? ______times a day/week (circle)
  • 4. How many times a week do you eat out?____ Where?____________________________How often do you skip meals? ___times a day/week.What oils do you use for cooking?____________________________________________List any food allergies/intolerances___________________________________________Do you now, or did you ever smoke? Y N Packs per day_____ Since when?______If not now smoking, when did you quit?___________ Why?_______________________Do you drink alcohol? Y N In what form?___________________________________How much and how often?__________________________________________________Have you or anyone close to you ever felt that you had a problem with alcohol or haveyou had an argument with them over how much you drink? Y NDo you drink coffee? Y N Circle: Regular or Decaf How much?______________Do you drink sodas? Y N What kind? _________________How many a day?____ -4-Do you now or have you in the past used any recreational drugs Y NWhat?__________________________________________________________________How much and for how long?________________________________________________Have you ever in your life been exposed or possibly exposed to significant amounts ofpesticides, industrial chemicals, solvents, etc? If so, please give details.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have any mercury amalgam (“silver”) dental fillings? Y N How many?_____Do you have any root canals Y N Which teeth, if known?______________________Any complications? _______________________________________________________What is your occupation?___________________________________________________How many hours a week do you work?________ Level of education________________Any hobbies?____________________________________________________________How else do you relax? ____________________________________________________On a scale of 1-10 (1=not at all, 10=blissfully happy), how satisfied are you with your:____ Relationship with spouse/partner (including sex life)? If not applicable, rate your social life?____ Relationships with other family members?____ Job/career?____ Sense of purpose in life?____ Capacity for fun and play?____ Sense of spiritual fulfillment?
  • 5. If any of these are less than 5, what needs to be improved? ______________________________________________________________________________________________What spiritual tradition do you follow?________________________________________Primary Systems: Please place a checkmark next to the problems you are currentlyexperiencing unless asked otherwise.Gastrointestinal___ Indigestion/bloating. How soon after meals?___________________________________ Nausea/vomiting. When?______________________________ Any blood? Y N___ Abdominal pains. Where? ______________________________________________ Any relationship to meals or certain foods?____________________________________ Blood or mucous in stool.___ Irritable bowel syndrome/”spastic colitis”___ Heartburn/reflux___ Frequent/excessive gasHow often do you have a bowel movement__________________ Circle as appropriate:Loose Formed Hard Difficult to pass Alternating constipation/diarrhea -5-Adrenal___ Fatigue. During which part of the day is it the worst? ____________________________ Hypoglycemia___ Shakiness, lightheadedness, irritability, or moodiness relieved by eating___ Cold hands and feet___ Low blood pressure___ Sensitivity to light___ Dizziness when first standing___ Frequent sore throats/infections that take a long time to go away___ Tiredness on awakening despite “adequate” sleep___ Feel worse after exercise___ Your mother was under a lot of stress or something very stressful happened to her during her pregnancy with you.___ Difficulty falling or staying asleep. Describe_______________________________On average, how many hours of sleep do you get a night? ________ From when to when? _________________________________Thyroid___ Intolerance to cold___ Hair loss___ Constipation___ Inability to lose weight___ Weight gain unrelated to overeating. _____ pounds over_____ months/years___ Dry skin___ Dry, brittle hair/nails___ High cholesterol___ Carpal tunnel syndrome unrelated to repetitive work stress
  • 6. ___ Low body temperature (less than 98 orally or 97.4 under arm)___ Heavy menstrual flowHormonal – Women onlyIf you are post-menopausal or have had a hysterectomy, check off symptoms you hadbefore then, as well as those you have now.Age when cycles began______ How many days between periods? _________Duration of flow _________days. No. of pads used at highest flow_____________________ Menopause. At what age? ______ Symptoms: _______________________________ Irregular cycles. Please describe_____________________________________________ Menstrual cramps___ Hot flashes/night sweats___ Premenstrual symptoms ___ Breast tenderness/swelling ___ Mood swings/ depression/irritability ___ Bloating ___ Increased appetite/cravings ___ Weight gain ___ Headaches ___ Fluid retention ___ Other______________________________ Uterine fibroids___ Fibrocystic breasts -6-___ Vaginal dryness___ Decreased libido___ Recurrent vaginitis/yeast infectionsHow many times have you been pregnant? ____ How many children do you have? ____Any miscarriages, terminations, stillbirths, or children who died in infancy? Y N Please describe what happened______________________________________________General SystemsConstitutional___ Unexplained weight loss. How much? _______ Over how long? __________________ Excessive perspiration ___ Daytime sleepiness___ Low grade fevers ___ Persistent swollen glands___ History of anemia ___ Slow wound healing___ Easy bruisingSkin___ Rashes ___ Acne___ Eczema/psoriasis ___ Hives___ New or changed mole(s) ___ Itching___ Boils ___ InfectionsHead___ Headaches. Describe when and where_____________________________________ ____________________________________________________________________ What makes them better or worse?________________________________________
  • 7. Any associated symptoms (nausea, visual changes, etc.)?_________________________ Dizziness or lightheadednessEyes___ Need glasses/contacts. For (circle): near or far vision___ Refractive surgery (Lasik,etc) ___ Glaucoma___ Conjunctivitis/blepharitis ___ Cataracts___ Itching/allergies ___ Blurry vision___ Dry eyes/excessive tearing ___ Eye pain___ Double vision ___ Other____________________Ears___ Hearing loss ___Tinnitus (buzzing/ringing)___ Excessive wax ___ Vertigo___ Infection ___ Pain -7-Nose/Sinuses___ Chronic congestion/drainage ___ Frequent colds/sinus infections___ Allergies ___ Loss of smell___ Nose bleeds ___ History of fracture/deviated septum___ Loud snoring/stoppage of breathing noted by partner during sleepMouth and Throat___ Frequent sore throats ___ Bleeding or receding gums/gingivitis___ Canker sores ___ Hoarseness___ Bad breath ___ Metallic taste___ Thrush ___ Cold sores___ Grinding/other teeth problems ___ Jaw clicks/TMJ problemsNeck___ Goiter(enlarged thyroid) ___ Pain/stiffness___ Other lump or mass ___ Other______________________Respiratory___ Shortness of breath ___ Wheezing/asthma___ Bronchitis/colds always go to chest ___ Chest pain with breathing___ Cough. Does it produce phlegm? Y N What color?_____________________ Any blood in sputum/phlegm ___ Other_____________________Cardiovascular
  • 8. ___ Chest pressure with activity ___ Palpitations/irregular heart beat___ Murmur ___ Cramping in legs with walking___ Blood clots/phlebitis ___ Varicose veinsUrinary___ Frequent urinary infections ___ Kidney stones___ Pain/burning on urination ___ Incomplete emptying___ Incontinence/loss of urine ___ Increased frequency___ Blood in urineReproductive___ History of sexually transmitted disease. When__________________________ What type?______________________ Treatment?_________________________ Infertility, male or female ___ Decrease libido___ Loss of sexual function ___ Other _______________________Women___ History of abnormal Pap smear When?________________________________ Treatment and outcome______________________________________________ When was your last Pap? _______________________________________ -8-___ History of abnormal mammogram When?________________________________ Outcome___________________________________________________________Men___ Urethral discharge ___ Involuntary loss of urine___ Diagnosed prostate problems ___ History of elevated PSA___ Decreased urinary flow ___ Incomplete emptying___ Erectile difficulties ___ Decreased libido___ History of sexually transmitted disease When?_______________________ What type? ______________________ Treatment? ___________________How many times do you need to get up at night to urinate?______________Musculoskeletal___ Joint pain/arthritis Where_________________________________________________ Persistent muscular pain Where_____________________________________________ Diagnosed with fibromyalgia By whom?_____________________________________ Persistent pain from an injury Describe ______________________________________ Tendonitis/bursitis ___ Back pain/sciatica___ Muscle spasms/cramps ___ Osteoporosis/osteopeniaNeurologic___ Numbness/tingling ___ Fainting spells___ Seizures ___ Dizziness___ Memory impairment ___ Tremors
  • 9. ___ Muscular weakness ___ Loss of balance/coordination___ Speech problems ___ Visions/hallucinations___ Poor concentration/”brain fog”PsychologicAnswers here are very helpful to me but do not need to be answered if you are notcomfortable doing so at this time.Are you in counseling? Y N Around what issues____________________________Are you being treated with medication for a mental health problem? Y N Have you been in the past? Y N If yes to either of the above, please give details ____________________________________________________________________________________________________________________________________________________________________________Please check any of the following you are now experiencing;___ Anxiety ___ Depression___ Easily angered or tearful ___ Feeling overwhelmed or hopeless___ Considered or fantasized about suicide -9-Yeast QuestionnaireTotal score gives us the probability of intestinal and/or sinus yeast overgrowth in yourcase.Point score (add up and total below):50 ____ Have you ever been treated for acne with antibiotics for one month or longer?50 ____ Have you ever taken antibiotics for any problem for two consecutive months or been treated with shorter courses 3 or more times in a 12 month period? 6 ____ Have you ever been treated with a “broad-spectrum” antibiotic (something other than a penicillin-related drug), for even a single course?25 ____ Have you ever had chronic prostatitis or recurrent yeast vaginitis?15 ____ Have you been pregnant 2 or more times? 5 ____ Only once?25 ____ Have you ever taken birth control pills for over one year?15 ____ If not, for any length of time?15 ____ Have you ever taken cortisone drugs like prednisone?15 ____ Do perfumes, chemicals, pesticides, etc., REALLY bother you?15 ____ How about cigarette smoke?20 ____ Do you c rave sugar and/or breads?20 ____ Have you had a fungal infection, such as “jock itch,” athlete’s foot, or a skin or
  • 10. nail infection, that was difficult to treat?15 ___ Do you feel worse on damp days or in moldy places?______ Total (a score of 70 or greater indicates a high probability of yeast related problems)

×