Patient Name: Email: Date:
Weight: Height: Eye Color:
Rate each of the following symptoms based upon your typical health profile for the past 30 days.
Point Scale:
0 = Never or almost never have the symptom 1 = Occasionally have it; effect is not severe 2 = Occasionally have it; effect is severe 3 = Frequently have it; effect is not severe 4 = Frequently have it; effect is severe
HEAD:
Headaches: 0 1 2 3 4
Faintness: 0 1 2 3 4
Dizziness: 0 1 2 3 4
Insomnia: 0 1 2 3 4
Total:
EYES:
Watery or itchy eyes: 0 1 2 3 4
Swollen, reddened or sticky eyelids: 0 1 2 3 4
Bags or dark circles under eyes: 0 1 2 3 4
Blurred or tunnel vision (Does not include near- or far-sightedness): 0 1 2 3 4
EARS:
Itchy ears: 0 1 2 3 4
Earaches, ear infections: 0 1 2 3 4
Drainage from ear: 0 1 2 3 4
Ringing in ears, hearing loss: 0 1 2 3 4
NOSE:
Stuffy nose: 0 1 2 3 4
Sinus problems: 0 1 2 3 4
Hay fever: 0 1 2 3 4
Sneezing attacks: 0 1 2 3 4
Excessive mucus formation: 0 1 2 3 4
MOUTH/THROAT:
Chronic coughing: 0 1 2 3 4
Gagging, frequent need to clear throat: 0 1 2 3 4
Sore throat, hoarseness, loss of voice: 0 1 2 3 4
Swollen or discolored tongue, gums, lips: 0 1 2 3 4
Canker sores: 0 1 2 3 4
SKIN:
Acne: 0 1 2 3 4
Hives, rashes, dry skin: 0 1 2 3 4
Hair loss: 0 1 2 3 4
Flushing, hot flashes: 0 1 2 3 4
Excessive sweating: 0 1 2 3 4
HEART:
Irregular or skipped heartbeat: 0 1 2 3 4
Rapid or pounding heartbeat: 0 1 2 3 4
Chest pain: 0 1 2 3 4
LUNGS:
Chest congestion: 0 1 2 3 4
Asthma, bronchitis: 0 1 2 3 4
Shortness of breath: 0 1 2 3 4
Difficulty breathing: 0 1 2 3 4
DIGESTIVE TRACT:
Nausea, vomiting: 0 1 2 3 4
Diarrhea: 0 1 2 3 4
Constipation: 0 1 2 3 4
Bloated feeling: 0 1 2 3 4
Belching, passing gas: 0 1 2 3 4
Heartburn: 0 1 2 3 4
Intestinal/stomach pain: 0 1 2 3 4
JOINTS/MUSCLE:
Pain or aches in joint: 0 1 2 3 4
Arthritis: 0 1 2 3 4
Stiffness or limitation of movement: 0 1 2 3 4
Pain or aches in muscles: 0 1 2 3 4
Feeling of weakness or tiredness: 0 1 2 3 4
WEIGHT:
Binge eating/drinking: 0 1 2 3 4
Craving certain foods: 0 1 2 3 4
Excessive weight: 0 1 2 3 4
Compulsive eating: 0 1 2 3 4
Water retention: 0 1 2 3 4
Underweight: 0 1 2 3 4
ENERGY/ACTIVITY:
Fatigue, sluggishness: 0 1 2 3 4
Apathy, lethargy: 0 1 2 3 4
Hyperactivity: 0 1 2 3 4
Restlessness: 0 1 2 3 4
MIND:
Poor memory: 0 1 2 3 4
Confusion, poor comprehension: 0 1 2 3 4
Poor concentration: 0 1 2 3 4
Poor physical coordination: 0 1 2 3 4
Difficulty in making decisions: 0 1 2 3 4
Stuttering or stammering: 0 1 2 3 4
Slurred speech: 0 1 2 3 4
Learning disabilities: 0 1 2 3 4
EMOTIONS:
Mood swings: 0 1 2 3 4
Anxiety, fear, nervousness: 0 1 2 3 4
Anger, irritability, aggressiveness: 0 1 2 3 4
Depression: 0 1 2 3 4
OTHER:
Frequent illness: 0 1 2 3 4
Frequent or urgent urination: 0 1 2 3 4
Genital itch or discharge: 0 1 2 3 4
Are you sensitive/allergic to fragrances (perfume, air fresheners, fabric softeners, candles, etc.)? If so, list:
Do you use a self-cleaning oven? Yes No
Do you color your hair? Yes No Do you permanent wave your hair? Yes No Do you wear acrylic nails? Yes No
Do you use clothes dryer fabric softener sheets? Yes No
Do you use conventional window/glass cleaners? Yes No
Are you sensitive/allergic to refueling your car? Yes No
How old is your car? How old is your home?
Does your home have standing water or visible mold? Yes No
Have you recently painted any room in your home or office? Yes No
Is the carpet in your home or office newer than 2 years? Yes No
What type of cook stove do you have? (check which one) Natural gas, electric, wood, propane, solar power
What type of heat do you have in your home? (check which one) Natural gas, electric, radiant, wood, propane, solar power, hot water, baseboard heat
Do you use a microwave oven at home or office? Yes No
Are your mattresses newer than 4 years? Yes No If so, when were they purchased?
Do you use fragranced spray room fresheners or plug-in fresheners? Yes No
Do you use carpet sprays for cleaning or deodorizing? Yes No
How many times per year do you travel by air?
Have you traveled outside the U.S.? Yes No If so, when was last trip:
Do you get symptoms of any of the following when exposed to any environmental factors? Yes No (If yes, check those that apply): Headaches Stuffy nose Sinus pain Muscle aches Blurred vision Trouble concentrating Loss of balance Sore throat Cough Sneezing
Headaches
Stuffy nose
Sinus pain
Muscle aches
Blurred vision
Trouble concentrating
Loss of balance
Sore throat
Cough
Sneezing
Are you exposed to chemicals in your work/profession? Yes No If so, what type?
Has your home or office been remodeled within the past 4 years? Yes No If so, when:
If you use a computer, how many hours average per day do you use it?
If you commute to your office or place of business, how long is your commute in time? in miles round trip per day or total miles per week.
DENTAL HEALTH: How often do you regularly get your teeth cleaned by either a dentist or hygienist? When was the last time you had a professional teeth cleaning? Month: Year: Do you have any root canals? Yes No If so where: Do you have any silver (amalgam) fillings? Yes No If you’ve had silver (amalgam) fillings replaced, give Month: Year: Do you wear, or have you ever worn a night-guard? Yes No Are you allergic to epinephrine in local anesthetic? Yes No If so, what type of anesthetic can you tolerate? Does your tongue have a definite white coating? Yes No Have you had any extractions? Yes No If so, describe location of teeth and approximate year of extraction: Do you wear a partial or dentures? Yes No If so, which: Partial Dentures Have you been diagnosed with TMJ syndrome? Yes No Are you overly apprehensive about going to the dentist? Yes No Do you experience headaches, depression, anxiety or emotionally fragile systems after local anesthetic? Yes No (If yes, check those that apply): Headaches Depression Anxiety Emotionally Fragile
Have you had any dental implants? Yes No Have you ever had an allergic reaction either in the dental office or as a result of a dental procedure? Yes No If so, explain: Does your biological father have dentures? Yes No If so, at what age approximately did they receive them? Does your biological mother have dentures? Yes No If so, at what age approximately did they receive them? Did you have a lot of cavities as a child and adolescent? Yes No What type of product do you use to brush your teeth? Describe: Do you floss daily? Yes No Do you use toothpicks? Yes No Have you been told you have any form of gum (periodontal) disease? Yes No If so, describe: Have you ever had I.V. sedation? Yes No Was your experience positive? Yes No If not, explain: Does heart disease run in your family? Yes No Do inflammatory disorders fun in your family (Arthritis, Fibromyalgia, Gout, Lupus etc.) Yes No If so, describe condition and relationship: When was your last dental visit for restorative work? Month: Year: Do you have difficulty swallowing pills? Yes No Do you gag easily? Yes No Do you get nausea easily? Yes No Do you experience sinus infections? Yes No How Often? Do you experience migraine-type headaches? Yes No How Often? Who is your dentist? Dr.: City: State: Country:
Click the button below to print this form, as you need to mail us a signed copy. You should also print this as a backup and for your own personal records.
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