Name*
First
Last
Email*
Date*
Date Format: MM slash DD slash YYYY
What positive changes have you noticed since your last appointment?*
What are your main concerns at this time?*
Any changes with weight and/or waist size?*
How is your sleep?*
Constipation or diarrhea? Gas or bloating? Which?*
How is your mood?*
Is your energy level higher or lower lately?*
To what do you attribute this energy level?*
Are you in any pain on a regular basis? Please describe.*
If this is ongoing pain, is it better, same, or worse than before?*
Are you receiving good support from those around you for the changes you are making?*
Are you taking all supplements consistently? Any concerns?*
What do you see as a significant barrier to you making more/faster progress toward your health goals?*
Are you cooking more?*
What do you crave? What are you doing or feeling when you crave?*
What's your food like these days? Breakfast*
Lunch*
Dinner*
Snacks*
Liquids*
Any other comments you wish to share?
Do you have any particular questions or topics you would like to cover in our next session?
Symptom Questionnaire Please rate the frequency and severity of symptoms you have experienced over the past two weeks.
HEAD Headache 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Faintness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Dizziness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Insomnia 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
NOSE Stuffy nose 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Sinus problems 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Hay fever 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Sneezing attacks 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Excessive mucus formation 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
MOUTH Chronic coughing 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Gagging or frequent need to clear throat 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Sore throat, hoarseness, or loss of voice 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Swollen or discolored tongue, gums, or lips 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Tooth ache or gum pain or new dental work 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Canker sores 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
SKIN Acne 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Hives or other allergic breakout 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Rash or persistently dry skin 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Hair loss 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Flushing or hot flashes 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Frequently feel cold 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Excessive sweating 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Part of body frequently feeling numb (Which part? Please describe below.) 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
HEART Irregular or skipped heartbeat 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Rapid or pounding heartbeat 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Chest pain 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
LUNGS Chest congestion 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Asthma, bronchitis 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Shortness of breath 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Difficulty breathing 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
DIGESTION Nausea or vomiting 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Diarrhea 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Constipation 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Bloated feeling 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Belching, burping 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Passing gas, flatulence 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Heartburn 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Intestinal or stomach pain (Which? Please describe below.) 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Other pain in GI tract (Where? Please describe below.) 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
JOINTS AND MUSCLES Pain or aches in joints 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Arthritis 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Stiffness or limitation of movement 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Pain or aches in muscles 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Tremor or restless leg 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Feeling of weakness or tiredness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
WEIGHT Binge eating/drinking 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Craving certain foods 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Excessive weight 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Compulsive eating 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Water retention 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Underweight 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
ENERGY Fatigue, sluggishness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Apathy, lethargy 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Hyperactivity 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Restlessness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
MIND Poor memory 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Confusion, poor comprehension 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Poor concentration or focus 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Poor physical coordination 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Difficulty in making decisions 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Stuttering or stammering 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Learning disabilities 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
MOOD Mood swings 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Anxiety, fear, nervousness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Anger, irritability, aggressiveness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Depression 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Other mood challenges (Please describe below.) 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
OTHER Frequent illness 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Frequent or urgent urination 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Inability to urinate or low urine flow 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Low libido or other sexual dysfunction 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Genital itch or discharge 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Women: breast fibroids 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Women: painful or tender breasts 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Women: Uterine/ovarian fibroids 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Other (Please describe below.) 0 - Never have symptom 1 - Occasionally have symptom and the effect is Mild 2 - Occasionally have symptom and the effect is Severe 3 - Frequently or Consistently have symptom and the effect is Mild 4 - Frequently or Consistently have symptom and the effect is Severe
Comments or Details?
Comments
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