Name *

First Name

Last Name

Birth date

MM

DD

YYYY

Phone *

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General health:

Difficulty falling asleep or staying asleep

Difficulty waking

Restless sleep

Sleepwalking or night terrors

Nightmares

Teeth grinding

Allergies

Asthma

Fatigue

I am always hungry

I am aware of my appetite increasing

I often find myself suddenly aware that I am starving or shaky due to lack of food.

Sense of taste

Thirst awareness

Heat or cold sensitivity

Thyroid disorder

Sense of smell

Skin problems

Low pain threshold

High pain tolerance

Earaches

Bruxism (teeth grinding)

Visual acuity:

Blurred vision

Eye pain

Visual sensitivity to light

Double vision

Blind spots

Poor night vision

Hearing:

Hearing loss

Ringing in ears

Sensitivity to sound

Cardiovascular / pulmonary:

Breathing problems

Heart problems

Hypertension

Palpitations or tachycardia

Gastrointestinal:

Nausea or vomiting

Stomach pain

Intestinal pain

Chronic constipation

Irritable bowel

Crohn's disease

Pain:

Chronic pain or stiffness

Chronic aching pain

Chronic nerve pain (burning or stabbing)

Muscle cramps

Headaches

Neurological:

Migraines

Fainting

Seizures

Speech problems

Tremor or spasticity

Weakness

Balance

Coordination

Accident prone

Motor or vocal tics

Attention and cognitive:

Difficulty with reading comprehension

Difficulty with math

Learning disability

Developmentally delayed

Dyslexia

Poor sense of direction

Difficulty concentrating

Impulsive

Artistic

Difficulty with reading

Poor short-term memory

Poor long-term memory

Urogenital system:

Incontinence

PMS symptoms

Menopausal symptoms

Erectile Dysfunction

Sexual interest

Habits

Coffee use

Alcohol use

Tobacco use

Diet

Other drug use

Behavior / emotions:

Depressed

Anxious

Panic attacks

Difficulty managing emotions

Angry outbursts / aggression

Mood swings

Extreme fears

Unable to sit still

Excessive worry

Short attention span

Difficulty completing tasks

Easily distracted

Forgetful

Poor time management

Trouble multi-tasking

Engage in risky behaviors

Hyperactive

Have you ever been diagnosed with, taken medication for, or think you may have:

Manic-depression

Panic attacks

Phobias

Obsessive-compulsive behaviors

Eating disorders

Addictions

Schizophrenia

Early childhood development:

Prenatal stress or injury

Prenatal drug exposure

Difficult labor

Difficult birth

Premature or late birth

Medical problems after birth

Adopted

Sleep problems

Eating problems

Emotional development

Delayed movement and motor skills

Delayed language development

Delayed cognitive or learning skills

Chronic ear infections

Allergies

Asthma

Attachment difficulties

Social skills:

Social anxiety

Difficulty making friends

Lack of empathy

Lack of ability to express feelings

Repetitive daily routines

Takes things very literally

Limited interests

Physical traumas:

Head injury

Concussions

Accidents

Serious illness

CNS infection

Drug overdose

Poisoning

Anoxia

Stroke

High fever

Sports:

Football

Soccer

Boxing

Martial arts

Dance

Baseball

Weight lifting

Track / long distance running

Other

History of trauma & stress:

Abuse or neglect

Family stress

School or job stress

School stress

Recent death in family

Illness

Family history:

Check all that apply and note relationship of family member.

Alcoholism or drug abuse

Asthma

Autoimmune disorders: I Diabetes, Rheumatoid Arthritis Lupus, MS, Scleroderma, etc.

Thyroid disorder

Migraine

Sleep problems

Depression

Sleep problems

Phobias

Manic-depression

Panic attacks

Motor or vocal tics

Seizures

Eating disorders or obesity

Addictions

Obsessive compulsive symptoms

Speech problems

Hyperactivity

Learning problems

Conduct problems or criminal behavior

Autism spectrum

Schizophrenia

Diabetes

Anxiety