Allergies

How many servings do you eat in a typical week of these foods:

If you smoked previously:

Alcohol How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits) 1–34–67–10>10None Previous alcohol intake? YesMildModerateHighNone Have you ever had a problem with alcohol? YesNo Have you ever thought about getting help to control or stop your drinking? YesNo

Other Substances Are you currently using any recreational drugs? YesNo Have you ever used IV or inhaled recreational drugs? YesNo

Stress Do you feel you have an excessive amount of stress in your life? YesNo Do you feel you can easily handle the stress in your life? YesNo How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest) Do you use relaxation techniques? YesNo Which techniques do you use? (Check all that apply) MeditationBreathingTai ChiYogaPrayer Have you ever sought counseling? YesNo Are you currently in therapy? YesNo Have you ever been abused, a victim of crime, or experienced a significant trauma? YesNo

Relationships Marital status: SingleMarriedDivorcedGay/LesbianLong-Term PartnerWidow/er Do you have resources for emotional support? YesNo (Check all that apply) Spouse/PartnerFamilyFriendsReligious/SpiritualPets Do you have a religious or spiritual practice? YesNo How well have things been going for you? (Mark on scale of 1–10, or N/A if not applicable)

History

Patient’s Birth/Childhood History: You were born: TermPrematureDon’t know Were there any pregnancy or birth complications? YesNo You were: Age of introduction of: As a child, were there any foods that were avoided because they gave you symptoms? YesNo Did you eat a lot of sugar or candy as a child? YesNo Dental History: Check if you have any of the following, and provide number if applicable: Have you had any mercury fillings removed? YesNo Do you brush regularly? YesNo Do you floss regularly? YesNo Environmental/Detoxification History Do any of these significantly affect you? Cigarette smokePerfume/colognesAuto exhaust fumesOther In your work or home environment are you regularly exposed to: (Check all that apply) MoldWater leaksRenovationsChemicalsElectromagnetic radiationDamp environmentsCarpets or rugsOld paintStagnant or stuffy airSmokersPesticidesHerbicidesHarsh chemicals (solvents, glues, gas, acids, etc)Cleaning chemicalsHeavy metals (lead, mercury, etc.)PaintsAirplane travelOther Have you had a significant exposure to any harmful chemicals? YesNo Do you have any pets or farm animals? YesNo InsideOutsideBoth inside and outside Women’s History Obstetric History: (Check box and provide number if applicable) Did you develop any problems in or after pregnancy, for example, toxemia (high blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.? YesNo Menstrual History Date of last menstrual period Cramping? YesNo Pain? YesNo Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)? YesNo Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)? YesNo Use of hormonal birth control: Birth control pillsPatchNuva ringOther Any problems with hormonal birth control? YesNo Use of other contraception? YesNoCondomsDiaphragmIUDPartner vasectomy Are you in menopause? YesNo Was it surgical menopause? YesNo Do you currently have symptomatic problems with menopause? (Check all that apply) Hot flashesMood swingsConcentration/memory problemsHeadachesJoint painVaginal drynessWeight gainDecreased libidoLoss of control of urinePalpitations Are you on hormone replacement therapy? YesNo Other Gynecological Symptoms: (Check if applicable) EndometriosisInfertilityFibrocystic breastsVaginal infectionFibroidsOvarian cystsPelvic inflammatory diseaseReproductive cancerSexually transmitted disease (describe) Gynecological Screening/Procedures:(If applicable, provide date)

Family History:

Check family members that have/had any of the following Age (if still alive) Age at death (if deceased)

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Medical History: Illnesses/Conditions

Gastrointestinal Respiratory Urinary/Genital Endocrine/Metabolic Inflammatory/Immune Musculoskeletal Skin Cardiovascular Neurologic/Emotional Cancer

Medical History (cont.)