West U Chiropractic / Functional Medicine of Houston

Patient Short Form Questionnaire

Name: ______Date: ______

Address: ______

Date of Birth: ______Height: ______Weight: ______

Phone #: ______Email: ______

Please list any complaints or symptoms IN ORDER OF SEVERITY

Problem / Onset / Frequency / Severity
1 / ie: Headache / Jan-08 / 3 times a week / severe
2
3
4
5
6

Any allergies to food, drugs, supplements? Please list

Allergies / Reactions
1
2
3
4
5
6

Dental History: Do you have any fillings beside porcelain? Y or N

Do your floss? Y or N If yes – do your gums bleed? Y or N

Do you have bad breath? Y or N Do you have losse teeth? Y or N

Do you have Root Canals: Y or N Do you have dry mouth? Y or N

Medications: Please List

Medications / Reason for Taking / Dose
1
2
3
4
5
6

Supplements: Please List

Supplements / Reason for Taking / Dose
1
2
3
4
5
6

Average number of Hours you sleep per night? ______

Do you have trouble falling asleep? Y or N

Do you feel rested upon awakening? Y or N

Do you suffer with insomnia? Y or N

Do you awake in the middle of the night? Y or N If so, do you easily fall back asleep? Y or N

Do you Snore? Y or N

Do you use sleep aids? Y or N If so, what?______

Tobacco: Do you smoke or dip? Y or N If so, what kind? ______

If yes, how many packs a day:______

Alcohol: Do you drink alcohol? Y or N

If yes, how many drinks a week? ______

Sodas: Do you drink sodas? Y or N

If yes, how many a week? ______

Bowel Movements: How many BM’s do you have a day? ______

What is the condition of your stool? Please circle answer

ie: None – constipated Diarrhea Good formed Loose

Intimacy Issues: Please circle level of activity / interest

Active, no issues No interest / mood Vaginal dryness / lack of erection

Is there anything else you would like to tell us about your health that we have forgotten to ask?

______

Females Only

# of Pregnancies______# Caesareans______# Vaginal ______

# of Miscarriages______# Abortions______# Living Children______

Postpartum depression: Y or N Toxemia: Y or N Gestational Diabetes: Y or N

Cycling: Are you currently cycling? Y or N If yes, when was your last cycle? ______

Are you currently on birth control pills or patch? Y or N If yes, which one? ______

If not cycling, are you in menopause: Y or N Are you post-menopause? Y or N

Have you had a hysterectomy? Y or N

Have you had a bone density scan? Y or N If so, results?______

Do you take any HRT’s? If so, please list, if already not listed above______

______

How long on HRT’s? ______

Other Concerns:

Symptoms / Mild / Moderate / Severe / Comments
Anger / Addression
Body / Joint Pain aches
Bone Loss / Osteoporosis
Caffeine cravings
Concentration Issues
Constant Hunger
Craving of sugar, chocolate, etc
Digestive Issues
Dry Skin
Elevated Blood Pressure
Elevated Cholesterol
Fatigue
Foggy Thinking
Hair Loss
Irritability
Low Blood Sugar
Low Mood / Depression
Ringing in Ears
Salt cravings
Weight Gain
Weight Loss

Is there any other information you would like to tell us about? ______

Males Only

Have you had a vasectomy? Y or N If so, when?______

Do you have or have you had any prostate issues? Y or N

If so, please explain:______

Have you had a Digital Rectal Exam – DRG? Y or N If so, results?______

Is there anything else you would like to tell us that we may have forgotten to ask? ______

Please tell us about your typical diet? Not necessarily exactly what you eat, but generally.

Breakfast: Time______

______

Snack: Time______

______

Lunch: Time______

______

Snack: Time______

______

Dinner: Time______

______

Snack: Time______

______

Any other issues / thoughts you would like to share about your diet or foods or drinks?

______

Patient Name: ______Date:______

Spectra Cell: MNT LPP Telomere Apo E Genotype MTHFR

Metametrix: 2100 GI Effects

NeuroScience (Pharmasan Labs): 9606 w/o Melatonin

9608 w Melatonin

7011 – Hormones for Menstruating Women

LRA by Elisa/Act: Food Sensitivity Testing

General Blood Labs: Quest or LabCorp

CMP

CBC w/ diff

Lipid Panel

CRP

Cardio CRP

CEA

Ferritin

Glucose

Iron, IBC % SAT

Iron, Total

Sed Rate (ESR)

Testosterone

THS

TT4

FT4

TT3

FT3

rT3

TPO

TgAB

Vitamin D

Vitamin B 12, FA

Others:

______