General Information Name ____________________________________________ Age _____ Today’s Date ___________________ Date of Birth ________________________ Email _________________________________________________ Address __________________________________ City___________________ State ____ Zip_________ Phone (Home)_____________________ (Cell) ______________________ (Work) _____________________ Genetic Background: o African American o Hispanic o Mediterranean o Asian o Native American o Caucasian o Northern European o Other _________________________________________________________________ When, where and from whom did you last receive medical or health care? ________________________________ ___________________________________________________________________________________________ Emergency Contact: _____________________________________ Relationship ________________________ Phone (Home)_____________________ (Cell) ______________________ (Work) _____________________ How did you hear about our practice? o Clinic website o IFM website o Referral from doctor o Referral from friend/family member o Social media o Other ___________________________________________________________________ Current Health Concerns Please rank current and ongoing health concerns in order of priority Male Intake Questionnaire Describe Problem Severity Prior Treatment/Approach Success Example: Post Nasal Drip X Elimination Diet X 1. 2. 3. 4. 5. 7. 8. 9. 9. 10. Mild Excellent Moderate Good Severe Fair Version 2 Ann Shippy, MD Megan McElroy,MS,PA-C
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Ann Shippy, MD Megan McElroy,MS,PA-C Male Intake Questionnaire
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General Information
Name ____________________________________________ Age _____ Today’s Date ___________________ Date of Birth ________________________ Email _________________________________________________ Address __________________________________ City ___________________ State ____ Zip _________ Phone (Home) _____________________ (Cell) ______________________ (Work) _____________________
Genetic Background: oAfrican American oHispanic oMediterranean oAsianoNative American oCaucasian oNorthern EuropeanoOther _________________________________________________________________
When, where and from whom did you last receive medical or health care? ________________________________
oClinic website oIFM website oReferral from doctor oReferral from friend/family memberoSocial media oOther ___________________________________________________________________
Current Health Concerns
Please rank current and ongoing health concerns in order of priority
Male Intake Questionnaire
Describe Problem Severity Prior Treatment/Approach Success
Activity Type # of Times Per Week Time/Duration (Minutes)
Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (e.g., golf)
Other:
Lifestyle Review
Sleep
How many hours of sleep do you get each night on average? ___________________________________________
Do you have problems falling asleep? oYes oNo Staying asleep? oYes oNoDo you have problems with insomnia? oYes oNo Do you snore? oYes oNoDo you feel rested upon awakening? oYes oNoDo you use sleeping aids? oYes oNo
If yes, explain: ______________________________________________________________________________
Exercise
Current Exercise Program:
Do you feel motivated to exercise? oYes oA little oNo
Are there any problems that limit exercise? oYes oNoIf yes, explain: ______________________________________________________________________________
Do you feel unusually fatigued or sore after exercise? oYes oNoIf yes, explain: ______________________________________________________________________________
Are there any foods that you crave or binge on? oYes oNo If yes, what foods?___________________________________________________________________________
Do you eat 3 meals a day? oYes oNo If no, how many _______________________________________
Does skipping a meal greatly affect you? oYes oNo
How many meals do you eat out per week? o0–1 o1–3 o3–5 o>5 meals per week
Check the factors that apply to your current lifestyle and eating habits:
oFast eateroEat too muchoLate-night eatingoDislike healthy foodsoTime constraintsoTravel frequentlyoEat more than 50% of meals away from homeoHealthy foods not readily availableoPoor snack choicesoSignificant other or family members don’t like
healthy foods
oSignificant other or family membershave special dietary needs
oLove to eatoEat because I have tooHave negative relationship to foodoStruggle with eating issuesoEmotional eater (eat when sad, lonely, bored, etc.)oEat too much under stressoEat too little under stressoDon’t care to cookoConfused about nutrition advice
How many servings do you eat in a typical week of these foods:
Fruits (not juice) _____ Vegetables (not including white potatoes) _____Legumes (beans, peas, etc) _____ Red meat _____ Fish _____Dairy/Alternatives _____ Nuts & Seeds _____ Fats & Oils _____Cans of soda (regular or diet) _____ Sweets (candy, cookies, cake, ice cream, etc.) _____
Do you drink caffeinated beverages? oYes oNo If yes, check amounts:
Coffee (cups per day) o1 o2-4 o>4 Tea (cups per day) o1 o2-4 o>4Caffeinated sodas—regular or diet (cans per day) o1 o2-4 o>4
Do you have adverse reactions to caffeine? oYes oNoIf yes, explain: ______________________________________________________________________________
When you drink caffeine do you feel: oIrritable or wired oAches or pains
Smoking
Do you smoke currently? oYes oNo Packs per day: ______ Number of years _____What type? oCigarettes oSmokeless oPipe oCigar oE-CigHave you attempted to quit? oYes oNo
If yes, using what methods: ____________________________________________________________________
If you smoked previously: Packs per day: _____ Number of years _____Are you regularly exposed to second-hand smoke? oYes oNo
Alcohol
How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)o1–3 o4–6 o7–10 o>10 oNone
Have you ever had a problem with alcohol? oYes oNoIf yes, when? _______________________________________________________________________________Explain the problem: ________________________________________________________________________
Have you ever thought about getting help to control or stop your drinking? oYes oNo
Other Substances
Are you currently using any recreational drugs? oYes oNoIf yes, type: ________________________________________________________________________________
Have you ever used IV or inhaled recreational drugs? oYes oNo
With your boyfriend/girlfriend o 1 2 3 4 5 6 7 8 9 10
With your children o 1 2 3 4 5 6 7 8 9 10
With your parents o 1 2 3 4 5 6 7 8 9 10
With your spouse o 1 2 3 4 5 6 7 8 9 10
Stress
Do you feel you have an excessive amount of stress in your life? oYes oNo
Do you feel you can easily handle the stress in your life? oYes oNo
How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)Work ____ Family ____ Social ____ Finances ____ Health ____ Other ____
Do you use relaxation techniques? oYes oNoIf yes, how often? ___________________________________________________________________________
Which techniques do you use? (Check all that apply)
oMeditation oBreathing oTai Chi oYoga oPrayer oOther: ___________________________
Have you ever sought counseling? oYes oNo
Are you currently in therapy? oYes oNoIf yes, describe: _____________________________________________________________________________
Have you ever been abused, a victim of crime, or experienced a significant trauma? oYes oNo
What are your hobbies or leisure activities? _________________________________________________________
Were there any pregnancy or birth complications? oYes oNoIf yes, explain: ______________________________________________________________________________
You were: oBreast-fed/How long? _______ oBottle-fed/Type of formula: ___________ oDon’t know Age of introduction of: Solid food: ______ Wheat _______ Dairy _______
As a child, were there any foods that were avoided because they gave you symptoms? oYes oNoIf yes, what foods and what symptoms? (Example: milk—gas and diarrhea) _________________________________________________________________________________________
Have you had a significant exposure to any harmful chemicals? oYes oNoIf yes: Chemical name, length of exposure, date: ____________________________________________________
Do you have any pets or farm animals? oYes oNoIf yes, do they live: oInside oOutside oBoth inside and outside
Men’s History
(Check box if applicable)
oTesticular mass oTesticular pain oProstate enlargement oProstate infectionoChange in sex drive oImpotence oPremature ejaculation oDifficulty obtaining an erectionoDifficulty maintaining an erection oLoss of control of urine oUrinary urgency/hesitancy/change in streamoVasectomy oNocturia (urination at night) # of times per night _______________oSexually transmitted diseases (describe) ________________________________________________________
Irritable bowel syndrome o oGERD (reflux) o oCrohn’s disease/ulcerative colitis o oPeptic ulcer disease o oCeliac disease o oGallstones o oOther: o o
Respiratory
Bronchitis o oAsthma o oEmphysema o oPneumonia o oSinusitis o oSleep apnea o oOther: o o
Urinary/Genital
Kidney stones o oGout o oInterstitial cystitis o oFrequent yeast infections o oFrequent urinary tract infections o oSexual dysfunction o oSexually transmitted diseases o oOther: o o
Endocrine/Metabolic
Diabetes o oHypothyroidism (low thyroid) o oHyperthyroidism (overactive thyroid) o oInfertility o oMetabolic syndrome/insulin resistance o oEating disorder o oHypoglycemia o oOther: o o
Inflammatory/Immune
Rheumatoid arthritis o oChronic fatigue syndrome o oFood allergies o oEnvironmental allergies o oMultiple chemical sensitivities o oAutoimmune disease o oImmune deficiency o oMononucleosis o oHepatitis o oOther: o o
Musculoskeletal Yes Past
Fibromyalgia o oOsteoarthritis o oChronic pain o oOther: o o
Skin
Eczema o oPsoriasis o oAcne o oSkin cancer o oOther: o o
Cardiovascular
Angina o oHeart attack o oHeart failure o oHypertension (high blood pressure) o oStroke o oHigh blood fats (cholesterol, triglycerides) o oRheumatic fever o oArrythmia (irregular heart rate) o oMurmur o oMitral valve prolapse o oOther: o o
Neurologic/Emotional
Epilepsy/Seizures o oADD/ADHD o oHeadaches o oMigraines o oDepression o oAnxiety o oAutism o oMultiple sclerosis o oParkinson’s disease o oDementia o oOther: o o
Cancer
Lung o oBreast o oColon o oProstate o oSkin o oOther: o o
Medical History: Illnesses/Conditions
Check YES = a condition you currently have, Check PAST = a condition you’ve had in the past.
Please check if these symptoms occur presently or have occurred in the last 6 months
General Mild Moderate Severe
Cold hands and feet o o oCold intolerance o o oDaytime sleepiness o o oDifficulty falling asleep o o oEarly waking o o oFatigue o o oFever o o oFlushing o o oHeat intolerance o o oNight waking o o oNightmares o o oCan’t remember dreams o o oLow body temperature o o o
Head, Eyes, and Ears
Conjunctivitis o o oDistorted sense of smell o o oDistorted taste o o oEar fullness o o oEar ringing/buzzing o o oEye crusting o o oEye pain o o oEyelid margin redness o o oHeadache o o oHearing loss o o oHearing problems o o oMigraine o o oSensitivity to loud noises o o oVision problems o o o
Musculoskeletal
Back muscle spasm o o oCalf cramps o o oChest tightness o o oFoot cramps o o oJoint deformity o o oJoint pain o o oJoint redness o o oJoint stiffness o o oMuscle pain o o oMuscle spasms o o oMuscle stiffness o o oMuscle twitches: o o o
Around eyes o o oArms or legs o o o
Muscle weakness o o o
Musculoskeletal (cont.) Mild Moderate Severe
Neck muscle spasm o o oTendonitis o o oTension headache o o oTMJ problems o o o
Mood/Nerves
Agoraphobia o o oAnxiety o o oAuditory hallucinations o o oBlackouts o o oDepression o o oDifficulty: o o o
Concentrating o o oWith balance o o oWith thinking o o oWith judgment o o oWith speech o o oWith memory o o o
Dizziness (spinning) o o oFainting o o oFearfulness o o oIrritability o o oLight-headedness o o oNumbness o o oOther phobias o o oPanic attacks o o oParanoia o o oSeizures o o oSuicidal thoughts o o oTingling o o oTremor/trembling o o oVisual hallucinations o o o
Please check if these symptoms occur presently or have occurred in the last 6 months
Urinary Mild Moderate Severe
Bed wetting o o oHesitancy o o oInfection o o oKidney disease o o oKidney stone o o oLeaking/incontinence o o oPain/burning o o oProstate enlargement o o oProstate infection o o oUrgency o o o
Digestion
Anal spasms o o oBad teeth o o oBleeding gums o o oBloating of: o o o
Lower abdomen o o oWhole abdomen o o oBloating after meals o o o
Blood in stools o o oBurping o o oCanker sores o o oCold sores o o oConstipation o o oCracking at corner of lips o o oDentures w/poor chewing o o oDiarrhea o o oDifficulty swallowing o o oDry mouth o o oFarting o o oFissures o o oFoods "repeat" (reflux) o o oHeartburn o o oHemorrhoids o o oIntolerance to: o o o
Lactose o o oAll dairy products o o oGluten (wheat) o o oCorn o o oEggs o o oFatty foods o o oYeast o o o
Liver disease/jaundice o o o(yellow eyes or skin)
Digestion (cont.) Mild Moderate Severe
Lower abdominal pain
Mucus in stools
Nausea o o oPeriodontal disease o o oSore tongue o o oStrong stool odor o o oUndigested food in stools o o oUpper abdominal pain o o oVomiting o o o
Eating
Binge eating o o oBulimia o o oCan't gain weight o o oCan't lose weight o o oCarbohydrate craving o o oCarbohydrate intolerance o o oPoor appetite o o oSalt cravings o o oFrequent dieting o o oSweet cravings o o oCaffeine dependency o o o
Respiratory
Bad breath o o oBad odor in nose o o oCough – dry o o oCough – productive o o oHayfever: o o o
Spring o o oSummer o o oFall o o oChange of season o o o
Hoarseness o o oNasal stuffiness o o oNose bleeds o o oPost nasal drip o o oSinus fullness o o oSinus infection o o oSnoring o o oSore throat o o oWheezing o o o
Please check if these symptoms occur presently or have occurred in the last 6 months
Nails Mild Moderate Severe
Bitten o o oBrittle o o oCurve up o o oFrayed o o oFungus – fingers o o oFungus – toes o o oPitting o o oRagged cuticles o o oRidges o o oSoft o o oThickening of: o o o
Finger nails o o oToenails o o o
White spots/lines o o o
Lymph Nodes
Enlarged/neck o o oTender/neck o o oOther enlarged/tender o o o
lymph nodes
Skin, Dryness of
Eyes o o o
Feet o o o
Any cracking? o o o
Any peeling? o o o
Hair o o o
And unmanageable? o o o
Hands o o o
Any cracking? o o o
Any peeling? o o o
Mouth/throat o o o
Scalp o o o
Any dandruff? o o o
Skin in general o o o
Skin Problems
Acne on back o o oAcne on chest o o oAcne on face o o oAcne on shoulders o o oAthlete’s foot o o oBumps on back of upper arms o o oCellulite o o oDark circles under eyes o o oEars get red o o o
Skin Problems (cont.) Mild Moderate Severe
Easy bruising o o oEczema o o oHerpes – genital o o oHives o o oJock itch o o oLackluster skin o o oMoles w color/size change o o oOily skin o o oPale skin o o oPatchy dullness o o oPsoriasis o o oRash o o oRed face o o oSensitive to bites o o oSensitive to poison ivy/oak o o oShingles o o oSkin cancer o o oSkin darkening o o oStrong body odor o o oThick calluses o o oVitiligo o o o
Itching Skin
Anus o o oArms o o oEar canals o o oEyes o o oFeet o o oHands o o oLegs o o oNipples o o oNose o o oGenitals o o oRoof of mouth o o oScalp o o oSkin in general o o oThroat o o o
Male Reproductive
Discharge from penis o o oEjaculation problem o o oGenital pain o o oImpotence o o oInfection o o oLumps in testicles o o oPoor libido (low sex drive) o o o
Name and Brand Dosage Start Date (mo/yr) Reason for Use
Have medications or supplements ever caused unusual side effects or problems? oYes oNoIf yes, describe: _____________________________________________________________________________
Have you used any of these regularly or for a long time:NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin? oYes oNo Tylenol (acetaminophen)? oYes oNoAcid-blocking drugs (Zantac, Prilosec, Nexium, etc.)? oYes oNo
How many times have you taken antibiotics?
< 5 > 5 Reason for Use
Infancy/Childhood
Teen
Adulthood
< 5 > 5 Reason for Use
Infancy/Childhood
Teen
Adulthood
Have you ever taken long term antibiotics? oYes oNoIf yes, explain: ______________________________________________________________________________
How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
Rate 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 o 5 o4 o3 o2 o 1Take several nutritional supplements each day o5 o 4 o3 o2 o 1Keep a record of everything you eat each day o 5 o 4 o3 o2 o1Modify your lifestyle (e.g., work demands, sleep habits) o 5 o 4 o3 o2 o1Practice a relaxation technique o 5 o 4 o3 o2 o 1Engage in regular exercise o5 o4 o3 o2 o 1
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? o 5 o 4 o3 o2 o 1
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to follow through? _____________________________________
Rate on a scale of 5 (very supportive) to 1 (very unsupportive):
At the present time, how supportive do you think the people in your household will be to your implementing the above changes? o5 o4 o3 o2 o1
Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):
How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff would be helpful to you as you implement your personal health program? o5 o4 o3 o2 o1
What do you hope to achieve in your visit with us? __________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
When was the last time you felt well? _____________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Did something trigger your change in health? ______________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
What makes you feel better? ____________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
What makes you feel worse? ____________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
How does your condition affect you? _____________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
What do you think is happening and why? _________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
What do you feel needs to happen for you to get better? ______________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________