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New Patient Paperwork

Name(Required)

First Last

Email(Required)

Phone(Required)

Date Of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Weight (LB)(Required)

Your weight in pounds

Height (Ft)(Required)

Your height in feet

Who are you seeing?(Required)

Cara Olsen

Haley Surface

Anissa Loseman

Sex(Required)

Male

Female

Main Reason For Visit(Required)

Please describe the main purpose of your visit and list your top 3 objectives.

Body Systems Assessment

List the five main physical complaints you have in order of their importance *(Required)

0 = Not applicable
1 = Mild symptoms (occurs rarely)
2 = MODERATE symptoms (occurs several times a month)
3 = SEVERE symptoms (occurs almost constantly)

Group 1

Acid foods upset(Required)

Get chilled, often(Required)

Lump in throat(Required)

Dry mouth-eyes-nose(Required)

Pulse speeds after meal(Required)

Keyed up - fail to calm(Required)

Cuts heal slowly(Required)

Gag Easily(Required)

Unable to relax, startles easily(Required)

Extremities cold, clammy(Required)

Strong light irritates(Required)

Urine amount reduced(Required)

Heart pounds after retiring(Required)

Nervous stomach(Required)

Appetite reduced(Required)

Cold sweats often(Required)

Fever easily raised(Required)

Neuralgia-like pains(Required)

Staring, blinks little(Required)

Sour stomach frequent(Required)

Group 2

Joint stiffness after arising(Required)

Muscle-leg-toe cramps at night(Required)

Butterfly stomach cramps(Required)

Eyes or nose watery(Required)

Eyes blink often(Required)

Eyelids swollen, puffy(Required)

Indigestion soon after meals(Required)

Always seem hungry; feels 'lightheaded' often(Required)

Digestion rapid(Required)

Vomiting frequent(Required)

Hoarseness frequent(Required)

Breathing irregular(Required)

Pulse slow; feels(Required)

Gagging reflex slow(Required)

Difficulty swallowing(Required)

Constipation, diarrhea alternating(Required)

Slow starter(Required)

Get chilled infrequently(Required)

Perspire easily(Required)

Circulation poor, sensitive to cold(Required)

Subject to colds, asthma, bronchitis(Required)

Group 3

Eat when nervous(Required)

Excessive appetite(Required)

Hungry between meals(Required)

Irritable before meals(Required)

Get shaky if hungry(Required)

Fatigue, eating relieves(Required)

Lightheaded if meals delayed(Required)

Heart palpitates if meals missed or delayed(Required)

Afternoon headaches(Required)

Overeating sweets upsets(Required)

Awaken after few hours sleep - hard to get back to sleep(Required)

Crave candy or coffee in afternoons(Required)

Moods of depression - blues or melancholy(Required)

Abnormal craving for sweets or snacks(Required)

Group 4

Hands and feet go to sleep easily, numbness(Required)

Sigh frequently, air hunger(Required)

Aware of breathing heavily(Required)

High altitude discomfort(Required)

Opens windows in closed room(Required)

Susceptible to colds and fevers(Required)

Afternoon yawner(Required)

Get drowsy often(Required)

Swollen ankles worse at night(Required)

Muscle cramps, worse during exercise; get charlie horses(Required)

Shortness of breath on exertion(Required)

Dull pain in chest or radiating into left arm, worse on exertion(Required)

Bruise easily, black and blue spots(Required)

Tendency to anemia(Required)

Nose bleeds frequent(Required)

Noises in head, or ringing in ears(Required)

Tensions under breastbone, or feeling of tightness(Required)

Group Five

Dizziness(Required)

Dry Skin(Required)

Burning feet(Required)

Blurred Vision(Required)

Itching skin and feet(Required)

Excessive falling hair(Required)

Frequent skin rashes(Required)

Bitter, metallic taste in mouth in mornings(Required)

Bowel movements painful or difficult(Required)

Worrier, feels insecure(Required)

Feeling queasy; headache over eyes(Required)

Greasy foods upset(Required)

Stools light-colored(Required)

Skin peels on foot soles(Required)

Pain between shoulder blades(Required)

Use laxatives(Required)

Stools alternate from soft to watery(Required)

History of gallbladder attacks or gallstones(Required)

Sneezing attacks(Required)

Dreaming, nightmare type bad dreams(Required)

Bad breathe (halitosis)(Required)

Milk products cause distress(Required)

Sensitive to hot weather(Required)

Burning or itching anus(Required)

Crave sweets(Required)

Group Six

Loss of taste for meat(Required)

Lower bowel gas several hours after eating(Required)

Burning stomach sensations, eating relieves(Required)

Coated tongue(Required)

Pass large amounts of foul-smelling gas *(Required)

Indigestion 1/2 - 1 hour after(Required)

Mucous colitis or irritable bowel(Required)

Gas shortly after eating(Required)

Stomach bloat with eating, may be up to 3-4 hours after(Required)

Group Seven (A)

Insomnia(Required)

Nervousness(Required)

Can't gain weight(Required)

Intolerance to heat(Required)

Highly emotional(Required)

Flush easily(Required)

Night sweats(Required)

Thin, moist skin(Required)

Inward trembling(Required)

Heart palpitates(Required)

Increased appetite without weight gain(Required)

Pulse fast at rest(Required)

Eyelids and face twitch(Required)

Irritable and restless(Required)

Can't work under pressure(Required)

Group Seven (B)

Increase in weight(Required)

Decrease in appetite(Required)

Fatigue easily(Required)

Ringing in ears(Required)

Sensitive to cold(Required)

Dry or scaly skin(Required)

Sleepy during day(Required)

Constipation(Required)

Mental sluggishness(Required)

Hair coarse, falls out(Required)

Headaches upon arising wear off during day(Required)

Slow pulse, below 65(Required)

Frequency of urination(Required)

Impaired hearing(Required)

Reduced initiative(Required)

Group Seven (C)

Failing memory(Required)

Low blood pressure(Required)

Increased sex drive(Required)

Headaches, splitting or rendering type(Required)

Decreased sugar tolerance(Required)

Group Seven (D)

Abnormal thirst(Required)

Bloating of abdomen(Required)

Weight gain around hips or waist(Required)

Sex drive reduced or lacking(Required)

Tendency to ulcers, colitis(Required)

Increased sugar tolerance(Required)

Women: menstrual disorders(Required)

Young girls: lack of menstrual function(Required)

Group Seven (E)

Dizziness(Required)

Headaches(Required)

Hot flashes(Required)

Increased blood pressure(Required)

Hair growth on face or body (female)(Required)

Sugar in urine (not diabetes)(Required)

Masculine tendencies (female)(Required)

Group Seven (F)

Weakness, dizziness(Required)

Chronic fatigue(Required)

Low blood pressure(Required)

Nails, weak, ridged(Required)

Tendency to hives(Required)

Arthritic tendencies(Required)

Perspiration increase(Required)

Bowel disorders(Required)

Poor circulation(Required)

Swollen ankles(Required)

Crave salt(Required)

Brown spots or bronzing of skin(Required)

Allergies - tendency to asthma(Required)

Weakness after colds, influenza(Required)

Exhaustion - muscular and nervous(Required)

Respiratory disorders(Required)

Group Eight

Muscle weakness(Required)

Lack of stamina(Required)

Drowsiness after eating(Required)

Muscular soreness(Required)

Rapid heart beat(Required)

Hyper-irritable(Required)

Feeling of a band around your head(Required)

Melancholia (feeling of sadness)(Required)

Swelling of ankles(Required)

Diminished Urination(Required)

Tendency to consume sweets or carbs(Required)

Muscular Spasms(Required)

Blurred vision(Required)

Loss of muscular control(Required)

Numbness(Required)

Night sweats(Required)

Rapid digestion(Required)

Sensitivity to noise(Required)

Redness of palms of hands and bottom of feet(Required)

Visible veins on chest and abdomen(Required)

Hemorrhoids(Required)

Apprehension (feeling that something bad is going to happen)(Required)

Nervousness causing loss of appetite(Required)

Nervousness with indigestion(Required)

Gastritis(Required)

Forgetfulness(Required)

Thinning hair(Required)

FEMALE ONLY

Very easily fatigued

Premenstrual tension

Painful menses

Menstruation excessive and prolonged

Painful breasts

Menstruate too frequently

Vaginal Discharge

Hysterectomy / ovaries removed

Menopausal hot flashes

Menses scanty or missed

Acne, worse at menses

Depression of long standing

MALE ONLY

Prostate trouble

Urination difficult or dribbling

Night urination frequent

Depression

Pain on inside of legs or heels

Feeling of incomplete bowel evacuation

Lack of energy

Migrating aches and pains

Tired too easily

Avoids activity

Leg nervousness at night

Diminished sex drive

Brain Health & Nutrition Assessment

Select the appropriate choice for each question.

0 almost never happens
1 rarely happens
2 sometimes happens
3 almost always happens

Section 1

Low brain endurance for focus and concentration(Required)

Cold hands and feet(Required)

Must exercise or drink coffee to improve brain function(Required)

Poor nail health(Required)

Fungal growth on toenails(Required)

Must wear socks at night(Required)

Nail beds are white instead of pink(Required)

The tip of the nose is cold(Required)

Section 2

Irritable, nervous, shaky, or light-headed between meals(Required)

Feel energized after meals(Required)

Difficulty eating large meals in the morning(Required)

Energy level drops in the afternoon(Required)

Crave sugar and sweets in the afternoon(Required)

Wake up in the middle of the night(Required)

Difficulty concentrating before eating(Required)

Depend on coffee to keep going(Required)

Section 3

Fatigue after meals(Required)

Sugar and sweet cravings after meals(Required)

Need for a stimulant, such as coffee, after meals(Required)

Difficulty losing weight(Required)

Increased frequency of urination(Required)

Difficulty falling asleep(Required)

Increased Appetite(Required)

Section 4

Always have projects and things that need to be done(Required)

Never have time for yourself(Required)

Not getting enough sleep or rest(Required)

Difficulty getting regular exercise(Required)

Feel that you are not accomplishing your life's purpose(Required)

Section 5

Dry and unhealthy skin(Required)

Dandruff or a flaky scalp(Required)

Consumption of processed foods that are bagged or boxed(Required)

Consumption of fried foods(Required)

Difficulty consuming raw nuts or seeds(Required)

Difficulty consuming fish (not fried)(Required)

Difficulty consuming olive oil, avocados, flax seed oil, or natural fats(Required)

Section 6

Difficulty digesting foods(Required)

Constipation or inconsistent bowel movements(Required)

Increased bloating or gas(Required)

Abdominal distention after meals(Required)

Difficulty digesting protein-rich foods(Required)

Difficulty digesting fatty or greasy foods(Required)

Difficulty swallowing supplements or large bites of food(Required)

Abnormal gag reflex(Required)

Yes

Section 7

Brain fog (unclear thoughts or concentration)(Required)

Yes

Pain and inflammation(Required)

Yes

Noticeable variations in mental speed(Required)

Yes

Brain fatigue after meals(Required)

Brain fatigue after exposure to chemicals, scents, or pollutants(Required)

Brain fatigue when the body is inflamed(Required)

Section 8

Grain consumption leads to tiredness(Required)

Grain consumption makes it difficult to focus and concentrate(Required)

Feel better when bread and grains are avoided(Required)

Grain consumption causes the development of any symptoms(Required)

A 100% gluten-free diet(Required)

Yes

Section 9

A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease(Required)

Yes

Family members who have been diagnosed with an autoimmune disease(Required)

Yes

Family members who have been diagnosed with celiac disease or gluten sensitivity(Required)

Yes

Changes in brain function with stress, poor sleep, or immune activation(Required)

Section 10

A loss of pleasure in hobbies and interests(Required)

Feel overwhelmed with ideas to manage(Required)

Feelings of inner rage or unprovoked anger(Required)

Feelings of paranoia(Required)

Feelings of sadness for no reason(Required)

A loss of enjoyment in life(Required)

A lack of artistic appreciation(Required)

Yes

Feelings of sadness in overcast weather(Required)

A loss of enthusiasm for favorite activities(Required)

A loss of enjoyment in favorite foods(Required)

A loss of enjoyment in friendships and relationships(Required)

Inability to fall into deep, restful sleep(Required)

Feelings of dependency on others(Required)

Feelings of susceptibility to pain(Required)

Section 11

Feelings of worthlessness(Required)

Feelings of hopelessness(Required)

Self-destructive thoughts(Required)

Inability to handle stress(Required)

Anger and aggression while under stress(Required)

Feelings of tiredness, even after many hours of sleep(Required)

A desire to isolate yourself from others(Required)

An unexplained lack of concern for family and friends(Required)

An inability to finish tasks(Required)

Feelings of anger from minor reasons(Required)

Section 12

A decrease in visual memory (shapes and images)(Required)

Yes

A decrease in verbal memory(Required)

Occurrence of memory lapses(Required)

A decrease in creativity(Required)

A decrease in comprehension(Required)

Difficulty calculating numbers(Required)

Difficulty recognizing objects and faces(Required)

A change in opinion about yourself(Required)

A decrease in mental alertness(Required)

Section 13

Slow mental recall(Required)

A decrease in mental speed(Required)

A decrease in concentration quality(Required)

Slow cognitive processing(Required)

Impaired mental performance(Required)

An increase in the ability to be distracted(Required)

Need coffee or caffeine sources to improve mental function(Required)

Section 14

Feelings of nervousness or panic for no reason(Required)

Feelings of dread(Required)

Feelings of a knot in your stomach(Required)

Feelings of being overwhelmed for no reason(Required)

Feelings of guilt about everyday decisions(Required)

A restless mind(Required)

An inability to turn off the mind when relaxing(Required)

Disorganized attention(Required)

Worry over things never thought about before(Required)

Feelings of inner tension and inner excitability(Required)

Stress Assessment

List any significant life events or changes in the last 3 months: (illness, injury, job change, new baby, marriage, divorce, extreme training for a sporting event, major project at work, etc)? *(Required)

Hours of sleep each night(Required)

3-4

5-6

7-8

Alcoholic drinks per week:(Required)

1-2

3-5

Meals eaten out per week:(Required)

1-2

3-5

Do you have any downtime or participate in quiet mindfulness activities? (Pilates, yoga, meditation, quiet walks, personal hobbies)(Required)

Yes

Select the appropriate choice for each question based on your experience within the LAST MONTH.

1 Not at all
2 Little bit
3 Somewhat
4 Quite a bit
5 Very Much

How stressful would you say your life is?(Required)

Dealing with daily stresses is negatively affecting my daily tasks(Required)

I have a high intake of sugar and/or processed foods(Required)

I feel worn down and/or burnt out(Required)

I need caffeine or other energy drinks in the morning or afternoon to give me energy(Required)

I seem to have lower than usual energy during the day.(Required)

I experience body aches and pains.(Required)

I have periods of low moods.(Required)

I feel more irritable.(Required)

My weight and metabolism have changed.(Required)

I can't seem to focus or concentrate.(Required)

I have feelings of anxiousness.(Required)

I feel totally exhausted most of the day and only have a few productive hours.(Required)

I find myself pushing through fatigue to get things done.(Required)

I seem to be sleeping alot but never feel quite rested. I wake up feeling tired.(Required)

I have difficulty getting to sleep and/or wake up in the middle of the night.(Required)

I experience strong cravings for sweet or salty foods.(Required)

I feel overwhelmed with daily tasks and all that is on my plate.(Required)

I have a low sex drive.(Required)

I am unable to enjoy socializing with family and/or friends.(Required)

Total Stress

Low Stress (20-40): Stress is fairly well managed in your life. It may be important to support your body to continue its healthy response.

Medium Stress (41-79): Your body's response to stress may be getting in the way of normal activities quite frequently, leaving you feeling depleted. Consult your health care professional for an individualized program to achieve your health goals.

High Stress: (80-100) You may have experienced prolonged stress, and your body's stress response can no longer adapt or successfully cope. Consult your health care professional for targeted support and strategies for improvement.

Functional Medicine Assessment