Male Patient Intake Form
Functional Health Assessment
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Part I: Chief Health Concerns
Please list your 5 major health concerns in order of importance:
1
2
3
4
5
Part II: Symptom Assessment
Instructions:
Please select the appropriate number for all questions below:
0
= Least/Never |
1
= Occasionally |
2
= Frequently |
3
= Most/Always
Category I: Digestive Function - Lower GI
Feeling that bowels do not empty completely
0
1
2
3
Lower abdominal pain relieved by passing stool or gas
0
1
2
3
Alternating constipation and diarrhea
0
1
2
3
Diarrhea
0
1
2
3
Constipation
0
1
2
3
Hard, dry, or small stool
0
1
2
3
Coated tongue or "fuzzy" debris on tongue
0
1
2
3
Pass large amount of foul-smelling gas
0
1
2
3
More than 3 bowel movements daily
0
1
2
3
Use laxatives frequently
0
1
2
3
Category II: Food Sensitivities & Inflammation
Increasing frequency of food reactions
0
1
2
3
Unpredictable food reactions
0
1
2
3
Aches, pains, and swelling throughout the body
0
1
2
3
Unpredictable abdominal swelling
0
1
2
3
Frequent bloating and distention after eating
0
1
2
3
Abdominal intolerance to sugars and starches
0
1
2
3
Category III: Chemical & Environmental Sensitivities
Intolerance to smells
0
1
2
3
Intolerance to jewelry
0
1
2
3
Intolerance to shampoo, lotion, detergents, etc.
0
1
2
3
Multiple smell and chemical sensitivities
0
1
2
3
Constant skin outbreaks
0
1
2
3
Category IV: Upper Digestive Function
Excessive belching, burping, or bloating
0
1
2
3
Gas immediately following a meal
0
1
2
3
Offensive breath
0
1
2
3
Difficult bowel movement
0
1
2
3
Sense of fullness during and after meals
0
1
2
3
Difficulty digesting fruits and vegetables; undigested food in stools
0
1
2
3
Category V: Stomach Acid & Ulcer Assessment
Stomach pain, burning, or aching 1-4 hours after eating
0
1
2
3
Use antacids
0
1
2
3
Feel hungry an hour or two after eating
0
1
2
3
Heartburn when lying down or bending forward
0
1
2
3
Temporary relief by using antacids, food, milk, or carbonated beverages
0
1
2
3
Digestive problems subside with rest and relaxation
0
1
2
3
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
0
1
2
3
Category VI: Pancreatic Function
Roughage and fiber cause constipation
0
1
2
3
Indigestion and fullness last 2-4 hours after eating
0
1
2
3
Pain, tenderness, soreness on left side under rib cage
0
1
2
3
Excessive passage of gas
0
1
2
3
Nausea and/or vomiting
0
1
2
3
Stool undigested, foul smelling, mucous like, greasy, or poorly formed
0
1
2
3
Frequent urination
0
1
2
3
Increased thirst and appetite
0
1
2
3
Category VII: Liver & Gallbladder Function
Greasy or high-fat foods cause distress
0
1
2
3
Lower bowel gas and/or bloating several hours after eating
0
1
2
3
Bitter metallic taste in mouth, especially in the morning
0
1
2
3
Burpy, fishy taste after consuming fish oils
0
1
2
3
Difficulty losing weight
0
1
2
3
Unexplained itchy skin
0
1
2
3
Yellowish cast to eyes
0
1
2
3
Stool color alternates from clay colored to normal brown
0
1
2
3
Reddened skin, especially palms
0
1
2
3
Dry or flaky skin and/or hair
0
1
2
3
History of gallbladder attacks or stones
0
1
2
3
Have you had your gallbladder removed?
Yes
No
Category VIII: Detoxification Function
Acne and unhealthy skin
0
1
2
3
Excessive hair loss
0
1
2
3
Overall sense of bloating
0
1
2
3
Bodily swelling for no reason
0
1
2
3
Hormone imbalances
0
1
2
3
Weight gain
0
1
2
3
Poor bowel function
0
1
2
3
Excessively foul-smelling sweat
0
1
2
3
Category IX: Blood Sugar - Hypoglycemia
Crave sweets during the day
0
1
2
3
Irritable if meals are missed
0
1
2
3
Depend on coffee to keep going/get started
0
1
2
3
Get light-headed if meals are missed
0
1
2
3
Eating relieves fatigue
0
1
2
3
Feel shaky, jittery, or have tremors
0
1
2
3
Agitated, easily upset, nervous
0
1
2
3
Poor memory/forgetful
0
1
2
3
Blurred vision
0
1
2
3
Category X: Blood Sugar - Insulin Resistance
Fatigue after meals
0
1
2
3
Crave sweets during the day
0
1
2
3
Eating sweets does not relieve cravings for sugar
0
1
2
3
Must have sweets after meals
0
1
2
3
Waist girth is equal or larger than hip girth
0
1
2
3
Frequent urination
0
1
2
3
Increased thirst and appetite
0
1
2
3
Difficulty losing weight
0
1
2
3
Category XI: Adrenal Stress - Low Cortisol
Cannot stay asleep
0
1
2
3
Crave salt
0
1
2
3
Slow starter in the morning
0
1
2
3
Afternoon fatigue
0
1
2
3
Dizziness when standing up quickly
0
1
2
3
Afternoon headaches
0
1
2
3
Headaches with exertion or stress
0
1
2
3
Weak nails
0
1
2
3
Category XII: Adrenal Stress - High Cortisol
Cannot fall asleep
0
1
2
3
Perspire easily
0
1
2
3
Under high amount of stress
0
1
2
3
Weight gain when under stress
0
1
2
3
Wake up tired even after 6 or more hours of sleep
0
1
2
3
Excessive perspiration or perspiration with little or no activity
0
1
2
3
Category XIII: Mineral Status
Edema and swelling in ankles and 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
Abnormal sweating from minimal activity
0
1
2
3
Alteration in bowel regularity
0
1
2
3
Inability to hold breath for long periods
0
1
2
3
Shallow, rapid breathing
0
1
2
3
Category XIV: Thyroid - Hypothyroid
Tired/sluggish
0
1
2
3
Feel cold—hands, feet, all over
0
1
2
3
Require excessive amounts of sleep to function properly
0
1
2
3
Increase in weight even with low-calorie diet
0
1
2
3
Gain weight easily
0
1
2
3
Difficult, infrequent bowel movements
0
1
2
3
Depression/lack of motivation
0
1
2
3
Morning headaches that wear off as the day progresses
0
1
2
3
Outer third of eyebrow thins
0
1
2
3
Thinning of hair on scalp, face, or genitals, or excessive hair loss
0
1
2
3
Dryness of skin and/or scalp
0
1
2
3
Mental sluggishness
0
1
2
3
Category XV: Thyroid - Hyperthyroid
Heart palpitations
0
1
2
3
Inward trembling
0
1
2
3
Increased pulse even at rest
0
1
2
3
Nervous and emotional
0
1
2
3
Insomnia
0
1
2
3
Night sweats
0
1
2
3
Difficulty gaining weight
0
1
2
3
Category XVI: Sex Hormones - High Estrogen
Increased sex drive
0
1
2
3
Tolerance to sugars reduced
0
1
2
3
"Splitting" type headaches
0
1
2
3
Category XVII: Male - Prostate Function
Urination difficulty or dribbling
0
1
2
3
Frequent urination
0
1
2
3
Pain inside of legs or heels
0
1
2
3
Feeling of incomplete bowel emptying
0
1
2
3
Leg twitching at night
0
1
2
3
Category XVIII: Male - Testosterone Function
Decreased libido
0
1
2
3
Decreased number of spontaneous morning erections
0
1
2
3
Decreased fullness of erections
0
1
2
3
Difficulty maintaining morning erections
0
1
2
3
Spells of mental fatigue
0
1
2
3
Inability to concentrate
0
1
2
3
Episodes of depression
0
1
2
3
Muscle soreness
0
1
2
3
Decreased physical stamina
0
1
2
3
Unexplained weight gain
0
1
2
3
Increase in fat distribution around chest and hips
0
1
2
3
Sweating attacks
0
1
2
3
More emotional than in the past
0
1
2
3
Part III: Lifestyle Assessment
How many alcoholic beverages do you consume per week?
Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds per week?
List the three worst foods you eat during the average week:
List the three healthiest foods you eat during the average week:
Part IV: Current Medications & Supplements
Please list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Part V: Patient Information & Health History
Personal Information
Full Name *
Email Address *
Cell Phone *
Address
City
State
ZIP Code
Date of Birth
Number of Children
Height
Weight (lbs)
Marital Status
Select...
Single
Married
Partnered
Divorced
Widowed
Occupation
Employer/School
Spouse/Partner's Name
Who Referred You?
Emergency Contact
Emergency Contact Name
Relationship
Emergency Contact Phone
Chief Complaint
What is your major complaint? (be as specific as possible)
When did your condition/symptoms/pain first appear?
Is this condition:
Getting progressively worse
Staying the same
Constant
Comes & goes
Medical History - Have you had or do you have any of the following? (check all that apply)
Arthritis
Asthma
Cancer
Diabetes
Heart Disease
High Blood Pressure
Prostate Problems
Depression
Anxiety
Other medical conditions not listed:
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