Lifestyle Review
Sleep
Do you have problems falling asleep?
Yes No
Do you have problems with insomnia?
Yes No
Do you feel rested upon awakening?
Yes No
Do you use sleeping aids?
Yes No
Staying asleep?
Yes No
Do you snore?
Yes No
Exercise
Current Exercise Program:
Do you feel motivated to exercise?
Yes A little No
Are there any problems that limit exercise?
Yes No
Do you feel unusually fatigued or sore after exercise?
Yes No
Nutrition
Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)
Vegetarian Vegan Allergy Elimination Low Fat Low Carb High Protein Blood Type Low sodium No Dairy No Wheat Gluten Free
Do you have sensitivities to certain foods?
Yes No
Do you have an aversion to certain foods?
Yes No
Do you adversely react to: (Check all that apply)
Monosodium glutamate (MSG) Artificial sweeteners Garlic/onion Cheese Citrus foods Chocolate Alcohol Red wine Sulfite–containing foods (wine, dried fruit, salad bars) Preservatives Food colorings
Are there any foods that you crave or binge on?
Yes No
Do you eat 3 meals a day?
Yes No
Does skipping a meal greatly affect you?
Yes No
How many meals do you eat out per week?
0-1 1-3 3-5 >5 meals per week
Diet
Please record what you eat in a typical day:
How many servings do you eat in a typical week of these foods:
Fruits (not juice)
Legumes (beans, peas, etc)
Dairy/Alternatives
Cans of soda (regular or diet)
Vegetables (not including white potatoes)
Red meat
Fish
Nuts & Seeds
Fats & Oils
Sweets (candy, cookies, cake, ice cream, etc.)
Do you drink caffeinated beverages?
Yes No If yes, check amounts:
Coffee (cups per day)
1 2-4 4<
Tea (cups per day)
1 2-4 4<
Caffeinated sodas—regular or diet (cans per day)
1 2-4 4<
Do you have adverse reactions to caffeine?
Yes No If yes, explain:
When you drink caffeine do you feel:
Irritable or wired Aches or pains
Smoking
Do you smoke currently?
Yes No
What type?
Cigarettes Smokeless Pipe Cigar E-Cig
Have you attempted to quit?
Yes No
If you smoked previously:
Are you regularly exposed to second-hand smoke?
Yes No
Other Substances
Are you currently using any recreational drugs?
Yes No Have you ever used IV or inhaled recreational drugs?
Yes No
Do you use relaxation techniques?
Yes No Which techniques do you use? (Check all that apply)
Meditation Breathing Tai Chi Yoga Prayer Have you ever sought counseling?
Yes No Are you currently in therapy?
Yes No Have you ever been abused, a victim of crime, or experienced a significant trauma?
Yes No
History
Patient’s Birth/Childhood History:
You were born:
Term Premature Don’t know
Were there any pregnancy or birth complications?
Yes No
Dental History:
Check if you have any of the following, and provide number if applicable:
Silver mercury fillings
Gold fillings
Root canals
Implants
Caps/Crowns
Tooth pain
Bleeding gums
Gingivitis
Problems with chewing
Other dental concerns (explain):
Have you had any mercury fillings removed?
Yes No Do you brush regularly?
Yes No Do you floss regularly?
Yes No Environmental/Detoxification History
Do any of these significantly affect you?
Cigarette smoke Perfume/colognes Auto exhaust fumes Other In your work or home environment are you regularly exposed to: (Check all that apply)
Mold Water leaks Renovations Chemicals Electromagnetic radiation Damp environments Carpets or rugs Old paint Stagnant or stuffy air Smokers Pesticides Herbicides Harsh chemicals (solvents, glues, gas, acids, etc) Cleaning chemicals Heavy metals (lead, mercury, etc.) Paints Airplane travel Other Have you had a significant exposure to any harmful chemicals?
Yes No Do you have any pets or farm animals?
Yes No Inside Outside Both inside and outside Men's History
(Check box if applicable)
Testicular mass
Testicular pain
Prostate enlargement
Prostate infection
Change in sex drive
Impotence
Premature ejaculation
Difficulty obtaining an erection
Difficulty maintaining an erection
Loss of control of urine
Urinary urgency/hesitancy/change in stream
Vasectomy
Nocturia (urination at night)
Sexually transmitted diseases (describe)
Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
Symptom Review (cont.)
Please check if these symptoms occur presently or have occurred in the last 6 months
Symptom Review (cont.)
Please check if these symptoms occur presently or have occurred in the last 6 months
Medications/Supplements
Current medications (include prescription and over-the-counter)
Nutritional supplements (vitamins/minerals/herbs etc.)
Have medications or supplements ever caused unusual side effects or problems?
Yes No Have you used any of these regularly or for a long time:
NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin?
Yes No Tylenol (acetaminophen)?
Yes No Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?
Yes No How many times have you taken antibiotics?
Have you ever taken long term antibiotics?
Yes No How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
Health Goals
