Functional Medicine Forms Please complete the below forms prior to your first appointment. Give us a call at 614-839-1044 if you have any questions. First Name Last Name Date Street Address City State/Province -- select an option -- AL AK AA AE AP AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code Cell Phone Work Phone Home Phone Email Height Age Birthday Gender Female male Body Frame Small Medium Large Blood Type if known: Weight: Current Weight: Lowest Weight: Highest Weight: Ideal Marital Status Single Unknown Divorced Widowed Married Other Child Do you have any children? Yes No If so, how many? Live with: Spouse Partner Parents Children Friends Alone Occupation: Hours per week: Retired Emergency contact Relationship Phone How did you hear about us? Why would you like to coach with us? What is your major complaint? Please List when each symptom began and be as descriptive as possible On a Scale of 0-100 (0 being absolutely horrific and 100 being AMAZING), rate the following: Your Health: Your Energy: Your Emotional Health: Your Diet: Your Fitness: Your Brain Health: Your Relationships: Your Finances: Your Sleep: During the past year, how many days did you miss work, or have your regular activities curtailed, due to illness? In the past 12 months, how many days were you in the hospital? Please list all medications you are currently taking INCLUDING the condition for which it is taken, dosage and frequency. Please list all supplements you are currently taking INCLUDING the condition for which it is taken, dosage and frequency. Please describe any current or past usage of recreational drugs. Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.). Is there anything else in your medical history that you consider to be relevant? (Even from childhood) What is your employment history? Please provide brief summary including dates if possible. Please list your past or present Hobbies that could be sources of toxicity or chemical exposure. How often are you involved in these Hobbies currently? Please list past or present allergies, including allergies to medications, food allergies, seasonal and environmental. Please list all past surgeries and the condition each surgery was for, including dates. Explain your sleep. (How many hours do you get, quality, how long does it take you to fall asleep, what is your typical bedtime and wake up time, do you feel rested when you wake up, do you dream?) What type of health equipment have you purchased? (such as sauna, hyperbaric chamber, rife machine, etc.) When was your last dental visit? How often do you go in for cleanings? Have you had you gallbladder removed? Yes No Do you have issues digesting Fats such as avocado, coconut oil, olive oil, cheese, etc? Yes No Do you consume dairy? Yes No Do you have trouble with dairy? Yes No Do you eat pork? Yes No Do you eat gluten or wheat? Yes No Do you have any trouble with gluten or wheat? Yes No Did or do you drink diet soda? Yes No Is there a diet name or type of way you eat and how long have you been eating this way? What are the foods you stay away from? What are the foods you consume a lot of or often? How many servings of alcohol do you consume in an average week? Note: a serving is defined as a 12-ounce beer, 5-ounce glass of wine, or 1.5 ounces of liquor. Do you currently use tobacco products? Yes No Have you previously used tobacco products? Yes No General Questions Have you ever had your home tested for radon? Yes No Have you ever had your home tested for radon? Yes No Do you have high blood pressure issues? Yes No Do you have low blood pressure issues? Yes No Do you have sweaty or clammy hands? Yes No Do you have any swollen or tender lymph glands, tissue or skin areas? Yes No Have you ever had a blood transfusion? Yes No If so, when? Do you have a Smart Meter on your home? Yes No Have you ever had mono or suspected having mono? Yes No Do you have bad breath (no relief by brushing)? Yes No Do you have body odor (no relief by washing)? Yes No Do you need to drink caffeine to get going? Yes No Have you had weight loss of more than 10lbs in the last six months? Yes No Have you had weight gain of more than 10lbs in the last six months? Yes No Have you ever lived near, on or by a golf course, freeway or tension wires? Yes No If yes, please explain. Have you ever had any chemical exposures? (i.e. cleaning chemical spills, beauty salon, etc.) Yes No Do you have your house sprayed with pesticides for pest control? Yes No Do you spray herbicide (weed killers) in or around your home? Yes No Do you bug bomb your home? Yes No Do you use conventional insect repellants on yourself or family? Yes No Do you use perfume or cologne? Yes No Do you use aerosol hairspray? Yes No Do you get your nails done? Yes No If so, how often? Do you use air freshener in your house, work or car? Yes No Does your spouse or other family members work around chemicals? Yes No Can you think of any other toxic exposures you may have had? Yes No Do you handle receipt paper often? Such as a cashier. Yes No Does your skin have a yellowish color? (such as hands) Yes No Do you crave sugar or sweets? Yes No Do you crave starches, grains, breads, carbs, etc.? Yes No Do you crave salty foods? Yes No Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities? Yes No Does anyone in your family experience similar symptoms to yours? Yes No What is your birth order (i.e. first born, second, third, etc.)? Do you have any history of kidney dysfunction? Yes No Do you or any immediate family member have a history with cancer? Yes No Do you have any history of heart disease, myocardial infarction (heart attack), etc.? Yes No Are you currently having any thoughts of suicide? Yes No Have you ever been diagnosed with bipolar disorder, schizophrenia or depression? Yes No Do you have rapid mood swings? Yes No Are you impatient, moody, nervous? Yes No Are you in a constant state of anxiety or fear? Yes No Do you excessively worry? Yes No Do you have difficulty making decisions? Yes No Do you have an inability to relax or restlessness? Yes No Do you have a history of strokes? Yes No Have you ever been diagnosed with diabetes, thyroiditis, or heart disease? Yes No Have you ever been in an auto accident, fallen or received a major physical injury? Yes No For Males Only Do you have difficulty maintaining/attaining an erection? Yes No Does ejaculation cause pain? Yes No Is your sexual drive under active? Yes No Is your sexual drive overactive? Yes No Do you have issues with premature ejaculation? Yes No Do you have pain or coldness in genital area? Yes No Do you have infertility issues? Yes No Do you have discharge from Yes No Do you have a lack of early morning erections? Yes No Do you presently or in the past have a rash on penis? Yes No Do you have swollen genitals? Yes No Do you have swelling in the groin? Yes No Do you have genital sores? Yes No Do you have a lump or mass in scrotum? Yes No Do you have jock itch? Yes No Have you ever had a sexually transmitted disease? Yes No Do you use any prescriptions for improving sexual function? Yes No Have you ever used HCG, DHEA, or hGH? Yes No For Females Only Are you in or did you go through perimenopause or menopause? Yes No Do you get hot flashes/night sweats? Yes No Do you have a history of missed periods? Yes No Do you have irregular periods? Yes No Do you have pelvic or vaginal soreness or pain? Yes No Do you have menstrual pain? Yes No Do you have heavy menstrual bleeding? Yes No Do you have infertility issues? Yes No Do you have infertility issues? Yes No Do you have an overactive sex drive? Yes No Do you have monthly weight gain? Yes No Do you get bloating and swelling? Yes No Do you have tender breasts? Yes No Do you have vaginal itching? Yes No Do you have vaginal discharge or sores? Yes No Do you have vaginal dryness? Yes No Have you ever had a sexually transmitted disease? Yes No Do you dislike intercourse? Yes No Do you have pain in ovaries? Yes No Do you get water retention? Yes No Do you have a history of miscarriages? Yes No Do you have a history of ovarian cysts? Yes No Do you have a history of uterine cysts or fibroids? Yes No Do you have a history of endometriosis? Yes No Have you had a hysterectomy? Yes No Have you ever taken estrogen, progesterone, testosterone, DHEA, or hGH? Yes No Microbiome & Digestive Health Do you often have gas that has a sulfur or foul smell? Yes No Do you get heartburn or reflux? Yes No Are you sensitive to supplements? Yes No Have you ever been vegan or vegetarian for any length of time? Yes No Can you tolerate Meat? Yes No Do you have a history of using anti-acids, proton pump inhibitors or anything that blocks acid? Yes No Do you currently or have you used birth control? Yes No Do you currently or have you used hormone replacement therapy? Yes No If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving? Yes No Have you been on antibiotics in the last year? Yes No If so, how many rounds? Does your gut temporarily feel better after a round of antibiotics? Yes No Do you have a history of antibiotic use as a child or adult? Yes No Were you caesarian delivered (aka C-section)? Yes No Were you breast fed? Yes No If so, how long? Do you drink filtered water? Yes No If so, what type of filter do you have? Do you have a water filtration system for your entire house? Yes No If so, what type? Do you have a history of cold sores, warts or skin tags? Yes No Have you gotten food poisoning before? Yes No Do you skin issues? Yes No Do you have a history of athlete's foot or foot fungus such as on toenails? Yes No Do you have a history of jock itch or vaginal yeast infections? Yes No How many times a day are you having a bowel movement? Do your bowel movements have a tendency to be more: Yes No Please explain your housing history (type of homes, where and when). Assessment Forms: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Regularly ( Mitochondrial Dysfunction ) History of infections (EBV, Lyme, etc.)? Yes No Dizziness upon standing up quickly 0 1 2 3 Unable to tolerate much exercise 0 1 2 3 Poor exercise or muscle stamina 0 1 2 3 Low muscle tone? Yes No Brain fog 0 1 2 3 Difficulty focusing 0 1 2 3 Vision or hearing problems 0 1 2 3 General or chronic fatigue Yes No Afternoon headaches 0 1 2 3 Migraines or seizures 0 1 2 3 Mood problems: anxiety, depression, or bipolar 0 1 2 3 Poor brain processing (cognition) 0 1 2 3 Blood sugar issues 0 1 2 3 Breathing problems 0 1 2 3 Overweight? Yes No Low body temperature Yes No Intolerant to heat Yes No Low thyroid lab numbers? Yes No Little or no skin sweating? Yes No Suppressed immune system? Yes No Catch colds or get sick easily? Yes No Chronic inflammation 0 1 2 3 Cannot fall asleep 0 1 2 3 Cannot stay asleep 0 1 2 3 Slow mover in the morning (hard to get going) 0 1 2 3 Wake up tired, even after 6 or more hours of sleep 0 1 2 3 Eyes sensitive to bright or direct light 0 1 2 3 Weight gain when under stress 0 1 2 3 Loss of libido Yes No Mitochondrial Dysfunction Total Drainage Dysfunction Susceptibility Constipation (pooping one or fewer times daily) 0 1 2 3 Feeling that bowels do not empty completely 0 1 2 3 General or chronic fatigue 0 1 2 3 Mood problems: anxiety, depression, or bipolar 0 1 2 3 Poor brain processing (cognition) 0 1 2 3 Chronic inflammation 0 1 2 3 Wake up between 1 a.m. to 4 a.m. 0 1 2 3 Edema, swelling or retain extra fluids 0 1 2 3 Skin problems, rashes, itches, hives, eczema, or acne 0 1 2 3 Yellowish skin, face 0 1 2 3 Suppressed immune system 0 1 2 3 Can't clear infections, despite following pathogen protocols 0 1 2 3 Sore or swollen breast tissue 0 1 2 3 Heart palpitations or irregular heartbeat 0 1 2 3 Light, sound, or EMF sensitivities 0 1 2 3 Morning stiffness 0 1 2 3 Brain fog 0 1 2 3 Swollen glands 0 1 2 3 Cellulite or flabby skin 0 1 2 3 Varicose or spider veins 0 1 2 3 Kidney problems 0 1 2 3 Breathing or lung issues 0 1 2 3 Skin doesn't sweat 0 1 2 3 Puffy Eyes 0 1 2 3 Drainage Dysfunction Total Minerals & Electrolytes Edema (swelling) in ankles or wrists 0 1 2 3 Muscle cramping 0 1 2 3 Poor muscle endurance 0 1 2 3 Frequent urination 0 1 2 3 Frequent thirst 0 1 2 3 Crave salt 0 1 2 3 Unable to hold breath for long periods 0 1 2 3 Shallow, rapid breathing 0 1 2 3 History of carpal tunnel syndrome Yes No History of lower right abdominal pains or ileocecal valve problems Yes No History of stress fracture Yes No Bone loss (reduced density on bone scan) 0 1 2 3 Crave chocolate 0 1 2 3 Feet have a strong odor 0 1 2 3 History of anemia 0 1 2 3 Whites of eyes (sclera) are blue-tinted 0 1 2 3 Hoarse voice 0 1 2 3 White spots on fingernails 0 1 2 3 Minerals & Electrolyte Total Blood Sugar Crave sweets during the day 0 1 2 3 Irritable if meals are missed 0 1 2 3 Eating relieves fatigue 0 1 2 3 Agitated, easily upset, nervous 0 1 2 3 Fatigue after meals 0 1 2 3 Must have sweets after meals 0 1 2 3 Forgetful; poor memory 0 1 2 3 Feel better or calmer after eating 0 1 2 3 Prone to infections and colds 0 1 2 3 History of diabetes in your family Yes No Sugar (glucose) detected in urine test? Yes No Hair loss at ankles/frictional alopecia? Yes No Blood Sugar Total Organs: Stomach Belching or burping 0 1 2 3 Gas quickly following a meal 0 1 2 3 Bad breath 0 1 2 3 Feel full while eating and after meals 0 1 2 3 Difficulty digesting fruits and vegetables; undigested food found in stools 0 1 2 3 Stomach pain, burning, or aching 1 to 4 hours after eating 0 1 2 3 Temporary relief by using antacids, food, milk, or carbonated beverages 0 1 2 3 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine 0 1 2 3 Indigestion 0 1 2 3 Abdominal bloating 0 1 2 3 Constipation 0 1 2 3 Diminished appetite 0 1 2 3 Stomach Total Small Intestine Increased gut motility, diarrhea 0 1 2 3 Alternating constipation and diarrhea 0 1 2 3 Mucus in stool 0 1 2 3 Poorly formed or loose stools 0 1 2 3 Four or more large stools daily 0 1 2 3 Suspect nutrient malabsorption 0 1 2 3 Stools have foul odor 0 1 2 3 Diagnosed with celiac disease, irritable bowel syndrome (IBS), or diverticulosis/diverticulitis 0 1 2 3 Stomach cramps 0 1 2 3 Flatulence (gas) 0 1 2 3 Fiber-rich diet doesn't help constipation 0 1 2 3 History of pimples or skin eruptions? Yes No Any known food allergies? Yes No Small Intestine Total Colon Feeling that bowels do not empty completely 0 1 2 3 Alternating constipation and diarrhea 0 1 2 3 Lower abdominal pain relieved by passing stool or gas 0 1 2 3 Constipation 0 1 2 3 Hard, dry, or small stool 0 1 2 3 Coated tongue or buildup of debris on tongue 0 1 2 3 Use laxatives 0 1 2 3 History of bladder and/or kidney infection 0 1 2 3 Yeast infection (including vaginal) 0 1 2 3 Fingernail and/or toenail fungus 0 1 2 3 Use of antibiotics in past year? Yes No Colon Total Intestinal Permeability Adverse reactions to foods 0 1 3 4 Unpredictable food reactions 0 2 4 6 Aches, pains, and swelling throughout your body 0 1 2 3 Unpredictable abdominal swelling 0 1 2 3 Food allergies 0 1 2 3 Frequent bloating and distention after eating 0 1 2 3 Leaky Gut Total Hypothyroid Tired or sluggish 0 1 2 3 Feel cold (hands, feet, or your whole body) 0 1 2 3 Require an excessive amount of sleep to function properly 0 1 2 3 Gain weight easily 0 1 2 3 Difficult, infrequent bowel movements 0 1 2 3 Depression or lack of motivation 0 1 2 3 Thinning of outer third of eyebrows 0 1 2 3 Thinning of hair on scalp, face, or genitals, or excessive hair loss 0 1 2 3 Dry skin and/or scalp 0 1 2 3 Slow brain processing 0 1 2 3 Lack of or diminished sex drive 0 1 2 3 Infertility or impotency Yes No Heavy or profuse menstrual bleeding (women only) 0 1 2 3 Hypothyroid Total Hyperthyroid Heart palpitations 0 1 2 3 Inward trembling 0 1 2 3 Increased pulse, even at rest 0 1 2 3 Nervous or emotional 0 1 2 3 Insomnia 0 1 2 3 Night sweats 0 1 2 3 Eyes appear bulging or swollen 0 1 2 3 Difficulty gaining weight 0 1 2 3 Hyperthyroid Total Pathogens: Parasites Restless sleep (toss, turn, or wake up often) 0 1 2 3 Skin issues, rashes, itches, hives, eczema, or acne 0 2 4 6 Frequent diarrhea or loose stools 0 1 2 3 Alternating constipation and diarrhea 0 1 2 3 SIBO (small intestinal bacterial overgrowth), feel bloated or gassy 0 1 2 3 Bowel urgency, occasional accidents 0 1 2 3 Abdominal pains, cramps, or burning 0 1 2 3 Rectal, anal itch 0 2 4 6 Anal fissures (small, painful tears or cracks) 0 2 4 6 Stomach or small intestinal ulcers or lesions 0 1 2 3 Grinding of teeth when asleep 0 2 4 6 Picking at nose, boring nose with finger 0 2 4 6 Excess boogers in nose and scab-like boogers 0 2 4 6 Fingernail biting 0 1 2 3 Headaches/Migraines 0 2 4 6 Irritable (no apparent reason) 0 1 2 3 Mood disorder, depression, anxiety, or suicidal thoughts 0 1 2 3 Hyperactive tendency (nervous) 0 1 2 3 Dark circles under eyes 0 2 4 6 Need for extra sleep, wake unrefreshed 0 1 2 3 Allergies and/or food sensitivities 0 2 3 4 Fevers of unknown origin 0 1 2 3 Night sweats (not menopausal) 0 1 2 3 Kiss pets, allow pets to lick your face 0 1 2 3 Increase of symptoms around a full moon 0 1 2 3 Anemia (low iron/hemoglobin on blood test) 0 1 2 3 Anemia (low iron/hemoglobin on blood test) 0 1 2 3 Vitamin B6 deficiency 0 1 2 3 Zinc deficiency and/or white spots on nails 0 1 2 3 Frequent colds, flu, sore throats 0 1 2 3 Travel in developing nations 0 2 4 6 Eat pork products 0 1 2 3 Eat sushi, raw fish 0 2 4 6 Sleep with pets on bed 0 1 2 3 Bed-wetting 0 1 2 3 Frequent vomiting 0 1 2 3 Loss of appetite 0 1 2 3 Hungry all the time, bottomless pit, hungry after meals 0 2 4 6 Strong sugar and processed food cravings 0 1 2 3 Breathing problems, asthma 0 2 4 6 Pain in belly button area (umbilicus) 0 1 2 3 Blurry, unclear vision 0 1 2 3 Eye floaters 0 1 2 3 Lethargy, apathy (disinterest) 0 1 2 3 Menstrual problems 0 1 2 3 Dry lips 0 1 2 3 Drooling while asleep 0 1 2 3 Occult blood in stool (from lab test) 0 1 2 3 Swim in creeks, rivers, lakes 0 2 4 6 History of Giardia, pinworms, or other parasites? Yes No Do you work in childcare? Yes No History of or currently have cancer? Yes No Parasite Infection Total SIBO (Small Intestinal Bacterial Overgrowth) Abdominal distention after consuming fiber, starches, or sugar 0 1 2 3 Abdominal distention after taking certain probiotics or other dietary supplements 0 1 2 3 Abdominal distention, bloating, or a noisy gut after eating healthy vegetables 0 1 2 3 Bloating or feeling full in upper abdominal area (just below rib cage) 0 1 2 3 SIBO Total Lyme Disease Risks Ever diagnosed with Lyme disease? Yes No Dry sockets or infected tooth extractions 1 2 3 Ever bitten by a tick? Yes No Ever had a bullseye rash on any part of your body? Yes No Mother ever diagnosed with Lyme disease? Yes No Spouse/partner/significant other diagnosed with Lyme disease? Yes No Ever diagnosed with chronic fatigue syndrome, fibromyalgia, lupus, rheumatoid arthritis (RA), multiple sclerosis (MS), or an autoimmune condition? Yes No Ever diagnosed with Parkinson's disease, Alzheimer's disease, or Tourette's syndrome? Yes No Frequently go camping, hunting, or engage in outdoor activities? Yes No History of a heart murmur or valve prolapse? Yes No Lyme Disease Risks Total Lyme Arthritis-like joint pain or swelling 0 2 4 6 Pain migrates or moves around to different areas of your body 0 2 4 6 Forgetfulness or poor short-term memory 0 2 4 6 Confusion, difficulty thinking 0 1 2 3 Disorientation (getting lost; going to wrong places) 0 1 2 3 Difficulty with speech or writing 0 4 6 8 Tingling, numbness, burning, or stabbing sensations 0 4 6 8 Disturbed sleep: too much, too little, early awakening 0 2 4 6 Unexplained fevers, sweats, chills, or flushing 0 1 2 3 Unexplained weight change (loss or gain) 0 1 2 3 Difficulty swallowing 0 1 2 3 Fatigue, lack of energy 0 1 2 3 Sore throat or swollen glands 0 1 2 3 Pelvic or testicular pain 0 4 6 8 Crepitus (joint cracking) 0 4 6 8 Crepitus (joint cracking) 0 4 6 8 Stiff neck 0 2 4 6 Twitching of facial or other muscles 0 1 2 3 Muscle pain or cramps 0 1 2 3 Costochondritis (sternum/breastbone and rib junction pain) 0 4 6 8 Right shoulder pain (AC joint) 0 1 2 3 Facial paralysis (Bell's palsy) 0 4 6 8 Unexplained menstrual irregularity 0 4 6 8 Unexplained breast milk production 0 4 6 8 Irritable bladder or bladder dysfunction 0 4 6 8 Sexual dysfunction or low libido 0 4 6 8 Blurry or double vision 0 1 2 3 Ear buzzing, ringing, or pain 0 1 2 3 Vertigo or increased motion sickness 0 4 6 8 Light-headedness, poor balance, difficulty walking 0 4 6 8 Woozy (mentally unclear or hazy) 0 2 4 6 Tremors 0 2 4 6 Headaches 0 1 2 3 Impulsivity, aggression, or bipolar 0 1 2 3 Depression 0 1 2 3 Hallucinations, paranoia, or schizophrenia 0 2 4 6 Panic attacks 0 1 2 3 Eating disorder 0 4 6 8 Pulse skips 0 4 6 8 Skin hypersensitivity 0 2 4 6 Gastrointestinal problems 0 2 4 6 Change in bowel function 0 2 4 6 Lyme Disease Current Symptoms Total Babesia Abdominal pain 0 2 4 6 Shortness of breath 0 1 2 3 Air hunger (episodes of breathlessness) 0 4 8 10 Anemia (low iron/hemoglobin on blood test) 0 1 2 3 Low back stiffness or pain 0 1 2 3 Low blood sugar 0 2 4 6 Cough 0 1 2 3 Disturbed sleep: frequent waking 0 4 6 8 Excessive sleepiness 0 1 2 3 Encephalopathy (brain malfunction, brain issues) 0 1 2 3 Fatigue, tiredness, poor stamina 0 1 2 3 Fevers 0 1 2 3 Headaches 0 4 6 8 Hemolysis (destruction of red blood cells) 0 2 4 6 Enlarged liver 0 2 4 6 Imbalance 0 2 4 6 Generalized ill feeling 0 1 2 3 Muscle pains or cramps 0 1 2 3 Nausea, vomiting 0 2 4 6 Neck stiffness, pain 0 1 2 3 Night sweats 0 1 2 3 Poor appetite 0 2 4 6 Shaking chills 0 4 6 8 Enlarged spleen 0 1 2 3 Heart palpitations, pulse skips, Tachycardia 0 4 6 8 Dark urine with or without blood 0 4 6 8 Weakness 0 1 2 3 Weight loss 0 1 2 3 Elevated sedimentation (sed) rate on lab test 0 1 2 3 Dizziness 0 1 2 3 Light headedness 0 1 2 3 Babesia Total Bartonella Abdominal pain 0 2 4 6 Anemia (low iron/hemoglobin on blood test) 0 1 2 3 Anxiety 0 2 4 6 Back stiffness 0 1 2 3 Chills 0 1 2 3 Disturbed sleep: too much, too little, fractionated, early awakening 0 1 2 3 Ear buzzing, ringing, pain, sound sensitivity 0 2 4 6 Brain dysfunction 0 1 2 3 Hemolysis (destruction of red blood cells) 0 2 4 6 Endocarditis 0 2 4 6 Myocarditis 0 2 4 6 Fatigue, tiredness, poor stamina 0 1 2 3 Low-grade fever 0 2 4 6 Headaches 0 1 2 3 Enlarged liver 0 2 4 6 Immune deficiency 0 2 4 6 Feeling of coming down with the flu 0 2 4 6 Insomnia 0 1 2 3 Jaundice (yellowing of skin) 0 4 6 8 Joint pain or swelling 0 1 2 3 Lymph nodes swollen 0 4 6 8 Generalized ill feeling 0 1 2 3 Muscle pains or cramps, especially in calves 0 4 6 8 Foot pain or plantar fasciitis-type pain (heels or soles of the feet) 0 4 6 8 Stretch mark-like rash (not from overweight) 0 6 8 12 Maculopapular rash (small red bumps) 0 4 6 8 Spider veins 0 2 4 6 Seizures 0 4 6 8 Sleepiness or drowsiness 0 2 4 6 Sore throat 0 2 4 6 Enlarged spleen 0 2 4 6 Shinbone pain 0 4 6 8 Tremors 0 2 4 6 Twitching of facial muscles 0 2 4 6 Weight loss 0 1 2 3 Eyes: blurred vision, red eyes, dry eyes, depth perception issue, light sensitivity 0 2 3 6 Anxiety, panic attacks, or excessive worry 0 2 4 6 Obsessive-compulsive disorder (OCD) 0 4 6 8 Bartonella Total Toxicants & Toxins: General Toxicity Live on or near a golf course? Yes No Live near a freeway or high-tension wires? Yes No Wear conventional sunscreen? Yes No Wear perfume or cologne? Yes No Use air fresheners in your house, car, or workplace? Yes No Were you the first-born child? Yes No Receive static shocks (doorknob, car, light switch, other people, etc.) 0 1 2 3 Headaches or migraines 0 1 2 3 Word reversal or trouble finding words 0 1 2 3 Sensitivity to skin or touch 0 1 2 3 Poor short-term memory 0 1 2 3 Chronic sinus issues or congestion 0 1 2 3 Difficulty losing weight regardless of diet or exercise 0 1 2 3 Excessive perspiring during day or night 0 1 2 3 Cold extremities (hands and feet) 0 1 2 3 Issues processing new information 0 1 2 3 Chronic fungal or viral infection, including Candida, foot fungus, warts, or jock itch 0 1 2 3 Get sick often 0 1 2 3 Weakness or numbness in extremities 0 1 2 3 Joint pain 0 1 2 3 Muscle cramps, aches, sharp pains 0 1 2 3 Muscle twitching 0 1 2 3 Stomach pain 0 1 2 3 Appetite swings 0 1 2 3 Rashes or rosacea 0 1 2 3 General Toxicity Total Radioactive Elements History of or currently have cancer? Yes No Suppressed immune system? Yes No Osteoporosis or osteopenia diagnosis? Yes No Can't clear infections, despite following pathogen protocols? Yes No Chronic Candida infection 0 2 4 6 Fatigue 0 2 4 6 Anemia 0 2 4 6 Skin (red, dry, itchy, color changes) 0 1 2 3 Hair loss 0 2 4 6 Loss of appetite 0 1 2 3 Nausea and vomiting 0 1 2 3 Low blood cell count 0 1 2 3 Seizures 0 1 2 3 Earaches or difficulty hearing 0 1 2 3 Hormone problems 0 1 2 3 Sore or dry mouth 0 1 2 3 Taste changes 0 1 2 3 Difficulty swallowing 0 2 4 6 Voice changes, hoarseness 0 1 2 3 Dry eyes 0 1 2 3 Stiff jaw 0 1 2 3 Tooth decay 0 1 2 3 Soreness or swelling of the breast 0 1 2 3 Heart palpitations 0 2 4 6 Irregular heartbeat 0 1 2 3 Stomach ulcers 0 2 4 6 Kidney problems 0 1 2 3 Burning or pain during urination 0 1 2 3 Bladder infection (cystitis) 0 2 4 6 Loss of bladder control 0 1 2 3 Fertility problems 0 1 2 3 Sexual problems (male & female) 0 1 2 3 Radioactive Elements Total Mercury Toxicity Do you have amalgam (silver) fillings in your teeth? Yes No Have you ever had an amalgam removed? Yes No If you had amalgams removed, was it done by a biological dentist using a safe protocol? Yes No Were there amalgam fillings in your mother's mouth while she was pregnant with you? Yes No Worked in a dental office? 0 1 2 3 Wore contact lenses during the 1980s or early 1990s 0 1 2 3 Took oral contraceptives during the 1980s or early 1990s 0 1 2 3 Have had allergy shots 0 1 2 3 Eat tuna, shark, swordfish or Atlantic salmon more than twice per week 0 1 2 3 Eat tuna, shark, swordfish or Atlantic salmon more than twice per week 0 1 2 3 Urinate frequently (during the day, night, or both) 0 1 2 3 Do you have compact fluorescent (CFL) bulbs in your home? 0 1 2 3 Do you have compact fluorescent (CFL) bulbs in your home? 0 1 2 3 Have you broken any CFL bulbs? Yes No Anxiety Yes No Mood swings 0 1 2 3 Anger for no apparent reason 0 1 2 3 Excessive shyness, timidity, social phobia (not typical to your personality) 0 1 2 3 Irritability (not typical to your personality) 0 1 2 3 Dizzy or balance issues 0 1 2 3 Insomnia (can't get to sleep or return to sleep) 0 1 2 3 Low body temperature (below 97.5 degrees Fahrenheit or 36.4 degrees Celsius) 0 1 2 3 Sound in ears (ringing or hearing your heart beat) 0 1 2 3 Psychological symptoms, even thoughts of suicide 0 1 2 3 Sound sensitivities 0 1 2 3 Mercury Toxicity Total Lead Toxicity Have lived in a home built before 1978 using lead-based paint 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Took oral contraceptives during the 1980s or early 1990s 0 2 4 6 Send
