<p>Adult Medical Questionnaire</p><p>48. Any other family history we should know about? Yes____ No____ If so, please comment: ______</p><p>49. What is the attitude of those close to you about your illness? Supportive Non-supportive</p><p>FOR WOMEN ONLY (questions 50-58):</p><p>50. Have you ever been pregnant? (If no, skip to question 53.) Yes____ No____</p><p>Number of miscarriages _____ Number of abortions _____ Number of preemies _____</p><p>Number of term births _____ Birth weight of largest baby _____ Smallest baby _____</p><p>Did you develop toxemia (high blood pressure)? Yes____ No____</p><p>Have you had other problems with pregnancy? Yes____ No____</p><p>If so, please comment: ______</p><p>51. Age at first period _____ Date of last Pap Smear ______Date of last Mammogram______Pap Smear: ___ Normal ___Abnormal Mammogram: ___ Normal ___ Abnormal</p><p>52. Have you ever used birth control pills? Yes____ No____ If yes, when ______</p><p>53. Are you taking the pill now? Yes____ No____</p><p>54. Did taking the pill agree with you? Yes____ No____ Not applicable _____</p><p>55. Do you currently use contraception? Yes____ No____ If yes, what type of contraception do you use? ______</p><p>56. Are you in menopause? No _____ Yes _____ If yes, age at last period______Do you take: Estrogen?___ Ogen?___ Estrace?___ Premarin?___ Other (specify)______Progesterone?___ Provera? ___ Other (specify) ______</p><p>57. How long have you been on hormone replacement therapy (if applicable)? ______</p><p>58. In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)? Yes____ No____ Not applicable _____</p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use. Adult Medical Questionnaire</p><p>59. Please check if these symptoms occur Back muscle spasm presently or have occurred in the past 6 months. Calf cramps Chest tightness GENERAL: Mild Mod- Severe Foot cramps erate Joint deformity Cold hands & feet Joint pain Cold intolerance Joint redness Daytime sleepiness Joint stiffness Difficulty falling asleep Muscle pain Early waking Muscle spasms Fatigue Muscle stiffness Fever Muscle twitches: Flushing Around eyes Heat intolerance Arms or legs Night waking Muscle weakness Nightmares Neck muscle spasm No dream recall Tendonitis Tension headache HEAD, EYES & EARS: TMJ problems Conjunctivitis MOOD/NERVES: Distorted sense of smell Distorted taste Agoraphobia Ear fullness Anxiety Ear noises Auditory hallucinations Ear pain Black-out Ear ringing/buzzing Depression Eye crusting Difficulty: Eye pain Concentrating Headache With balance Hearing loss With thinking Hearing problems With judgment Lid margin redness With speech Migraine With memory Sensitivity to loud noises Dizziness (spinning) Vision problems Fainting Fearfulness Irritability Light-headedness </p><p>MOOD/NERVES, Mild Mod- Severe MUSCULOSKELETAL: Mild Mod- Severe Cont’d: erate erate</p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use. Adult Medical Questionnaire</p><p>Numbness Foods "repeat" (reflux) Other Phobias Heartburn Panic attacks Hemorrhoids Paranoia Intolerance to: Seizures Lactose All milk products Suicidal thoughts Intolerance to: Tingling Gluten (wheat) Tremor/trembling Corn Visual hallucinations Eggs Fatty foods EATING: Yeast Liver disease/jaundice Binge eating (yellow eyes or skin) Bulimia Lower abdominal pain Can't gain weight Mucus in stools Can't lose weight Nausea Carbohydrate craving Periodontal disease Carbohydrate intolerance Sore tongue Poor appetite Strong stool odor Salt craving Undigested food in stools Upper abdominal pain DIGESTION: Vomiting </p><p>Anal spasms SKIN PROBLEMS: Bad teeth Bleeding gums Acne on back Bloating of: Acne on chest Lower abdomen Acne on face Whole abdomen Acne on shoulders Blood in stools Athlete’s foot Burping Bumps on back of upper Canker sores arms Cold sores Cellulite Constipation Dark circles under eyes Cracking at corner of lips Ears get red Dentures w/poor chewing Easy bruising Diarrhea Difficulty swallowing Dry mouth Farting </p><p>DIGESTION, Cont’d: Mild Mod- Severe erate Fissures </p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use. Adult Medical Questionnaire</p><p>SKIN, DRYNESS OF: Mild Mod- Severe SKIN PROBLEMS, Mild Mod- Severe erate Cont’d: erate Eyes Feet Eczema Any cracking? Herpes - genital Any peeling? Hives Hair Jock itch And unmanageable? Lackluster skin Hands Moles w color/size Any cracking? change Any peeling? Oily skin Mouth/throat Pale skin Scalp Patchy dullness Any dandruff? Psoriasis Skin in general Rash Red face LYMPH NODES: Sensitive to bites Sensitive to poison Enlarged/neck ivy/oak Tender/neck Shingles Other enlarged/tender Skin cancer lymph nodes Skin darkening Strong body odor NAILS: Thick calluses Bitten Vitiligo Brittle SKIN, ITCHING: Curve up Frayed Anus Fungus - fingers Arms Fungus - toes Ear canals Pitting Eyes Ragged cuticles Feet Ridges Hands Soft Legs Thickening of: Nipples Finger nails Nose Toenails Penis White spots/lines Roof of mouth Scalp Skin in general Throat </p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use. Adult Medical Questionnaire</p><p>RESPIRATORY: Mild Mod- Severe URINARY: Mild Mod- Severe erate erate Bad breath Bed wetting Bad odor in nose Hesitancy Cough - dry Infection Cough - productive Kidney disease Hay fever : Spring Kidney stone Summer Leaking/incontinence Fall Pain/burning Change of season Prostate enlargement Hoarseness Prostate infection Nasal stuffiness Urgency Nose bleeds Post nasal drip MALE Sinus fullness REPRODUCTIVE: Sinus infection Discharge from penis Snoring Ejaculation problem Sore throat Genital pain Wheezing Impotence Winter stuffiness Infection Lumps in testicles CARDIOVASCULAR: Poor libido (sex drive) Angina/chest pain FEMALE Breathlessness REPRODUCTIVE: Heart attack Heart murmur Breast cysts High blood pressure Breast lumps Irregular pulse Breast tenderness Mitral valve prolapse Ovarian cyst Palpitations Poor libido (sex drive) Phlebitis Endometriosis Swollen ankles/feet Fibroids Infertility Varicose veins Vaginal discharge Vaginal odor Vaginal itch Vaginal pain</p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use. Adult Medical Questionnaire</p><p>FEMALE Mild Mod- Severe REPRODUCTIVE, erate Cont’d: Premenstrual: Bloating Breast tenderness Carbohydrate craving Chocolate craving Constipation Decreased sleep Diarrhea Fatigue Increased sleep Irritability Menstrual: Cramps Heavy periods Irregular periods No periods Scanty periods Spotting between</p><p>This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own use but cannot be resold or repurposed for commercial use.</p>