Orlando Functional Health - New Patient Form
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Personal Info
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Contact Info
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Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
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Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Primary Health Goals
What are your top 3 health concerns?
What do you hope to achieve through care?
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When was teh last time you felt well?
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Did anything trigger your decline in health?
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What makes you feel better?
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What makes you feel worse?
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How does your condition affect your life?
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What do you think is happening in your body?
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What would success look like 3 months from now?
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What would success look like 12 months from now?
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Current Diagnoses
Please check any conditions you have been diagnosed with
Autoimmune disease
Thyroid disease
Diabetes / insulin resistance
PCOS
Endometriosis
IBS
IBD
GERD
Chronic fatigue
Fibromyalgia
Lyme / tick-borne illness
Mold illness / CIRS
MCAS / histamine intolerance
Allergies
Asthma
Eczema / psoriasis
Anxiety
Depression
ADHD
Migraine
Hypertension
High cholesterol
Heart disease
Cancer history
Neuropathy
Chronic pain
Other
For each selected provide: Date diagnosed, Current Treatment, Controlled?
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Medical History
Hospitalizations: Please List Below
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Surgeries: Please List Below
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Head Injuries: Please List Below
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Dental history: root canals, implants, amalgams, infections
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Diagnostic studies: MRI, CT, X-ray, ultrasound, colonoscopy, endoscopy, EKG, stress test, bone density
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Major childhood illnesses
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Frequent antibiotic use
Steroid Use
Birth History, if known
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History of Eating Disorder?
History of trauma or major adverse life events?
Medications
Medication
Add Another Medication
Supplements
Supplements: Name Dose, Frequency, Reason, Start date, Helpful?, Side effects?
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Allergies & Sensitivities
Medication Allergies? Please name them below
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Other
Family history: Mother/Father/Sibling/Grandparent
Autoimmune disease
Thyroid disease
Diabetes
Heart disease
Stroke
Cancer
Alzheimer’s/dementia
Parkinson’s
Mental health conditions
Addiction
Obesity
Infertility
PCOS/endometriosis
GI disease
Celiac
Osteoporosis
Sudden cardiac death
Severe Symptom Screening
Have you or are you experiencing any of the following:
Chest pain with exertion?
Unexplained weight loss?
Blood in stool?
Black/tarry stool?
Vomiting blood?
New severe headache?
Fainting?
New neurological symptoms?
Suicidal thoughts?
New lump/mass?
Fever/night sweats?
Severe abdominal pain?
Shortness of breath at rest?
Functional Symptom Review
Fatigue
Low Stamina
Malaise
Fever/Chills
Night Sweats
Weight Gain
Weight Loss
Poor Recovery
Swollen Glands
Brain/Mood/Nervous System
Brain Fog
Poor Memory
Trouble Concentrating
Anxiety
Depression
Panic Attacks
Irritability
Mood Swings
Low Motivation
Insomnia
Restless Sleep
Headaches
Migraines
Dizziness
Numbness/Tingling
Tremors
Eyes/Ears/Nose/Throat
Blurry Vision
Dry Eyes
Itchy/Watery Eyes
Ringing Ears
Sinus Congestion
Postnasal Drip
Sore Throat
Mouth Ulcers
Bad Breath
Bleeding Gums
Jaw Pain/TMJ
Skin/Hair/Nails
Acne
Rashes
Hives
Eczema
Psoriasis
Itching
Easy Bruising
Hair Loss
Brittle Nails
Excess Sweating
Poor Wound Healing
Cardiovascular
Palpitations
0 = never
1 = mild/occasional
2 = moderate/frequent
3 = severe/daily
Chest Tightness
0 = never
1 = mild/occasional
2 = moderate/frequent
3 = severe/daily
High Blood Pressure
Low Blood Pressure
Cold hands/feet
0 = never
1 = mild/occasional
2 = moderate/frequent
3 = severe/daily
Swelling in Ankles
Poor Circulation
Respiratory
Shortness of Breath
Wheezing
Chronic Cough
Exercise Intolerance
Frequent Respiratory Infections
Gastrointestinal
Bloating
Gas
Belching
Reflux
Nausea
Vomiting
Abdominal Pain
Constipation
Diarrhea
Mucus in Stool
Undigested Food
Food Reactions
Cravings - What type of food?
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Loss of Appetite
Musculoskeletal
Neck Pain
Back Pain
Joint Pain
Muscle Pain
Morning Stiffness
Muscle Weakness
Tendon/Ligament Pain
Poor Flexibility
Exercise Soreness >48 hours
Immune/Inflammatory
Frequent Infections
Slow Recovery From Illness
Autoimmune Flares
Seasonal Allergies
Chemical Sensitivity
Mold Sensitivity
Mold Sensitivity
Histamine Reactions
Random Swelling
Chronic Inflammation
Endocrine/Metabolic
Blood Sugar Crashses
Shakiness Between Meals
Sugar Cravings
Salt Cravings
Heat Intolerance
Cold Intolerance
Excessive Thirst
Frequent Urination
Low Libido
Difficulty Losing Weight
Difficulty Gaining Weight
Nutrition
Please describe your current diet style.
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List any foods you avoid.
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List any foods you do not tolerate well.
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Describe your typical breakfast/lunch/dinner/snacks
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Protein Intake
1. 50g/daily
2. 75g/daily
3. +100g/daily
Describe your vegetable intake
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Describe your fiber intake
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Water Intake
1. 0.5L/daily
2. 1L/daily
3. >1L/daily
Caffeine - How many drinks per day
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Alcohol - How many drinks per week
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Soda/Energy Drinks - How many per week?
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Artificial Sweetners
Gluten Intake - How frequent?
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Daily Intake - How frequent?
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Sugar Intake - How Frequent
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Fast Food - how frequent?
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What time do you finish eating for the day? What time do you beginning eating?
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Digest & Elimintation
Describe your bowel movements per day/week
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Straining?
Urgency?
Incomplete Evacuation?
Blood/Mucus?
Bloating - if yes, timing?
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Reactions after meals?
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Sleep
Bedtime & Wake Time
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Time to fall asleep
Wake during the night?
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Snoring
Mouth Breathing
Sleep Apnea Diagnosis
Wake Rested
Screens Before Bed
Sleep Aids
Stress & Nervous System
Current Stress Level
0
1
2
3
4
5
6
7
8
9
10
No stress
Completely Overwhelmed
Major Current Stressors
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Major Past Stressors
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Trauma History
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Support System
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Coping Tools
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Breathwork/Meditation/Prayer
Therapy/Coaching History
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Work-Life Balance
Movement
Exercise Type
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Exercise Intensity
1
2
3
4
5
6
7
8
9
10
Chill
HIIT/Crossfit
Steps/Day
1. 100
2. 1000
3. 5000
4. <5000
Strength Training
Pain with Exercise?
Environmental Exposure
Mold/Water Damage at Home/Work
Musty Smells
Recent Renovation
Pesticide Exposure/Live on Golf Course
Chemical/Fragrance Exposure
Heavy Metals Exposure/Lived in Rust-Belt Cities or by Factories
Occupational Exposures
Well Water
Water Filtration
Plastics Use
Nonstick Cookware
Sauna Use
Dental Amalgams
Tick Bites
Travel History - 1 year prior to symptom starts - now
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Pets
Smoking/Vaping Exposure
Women's Health
Age at First Period
Last Menstrual Period
Cycle Length
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Bleeding Duration
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Clots
Pain Periods
PMS
Breast Tenderness
Acne Flares
Migraines with Cycle
Irregular Cycles
PCOS Diagnosis
Endometriosis Diagnosis
Fibroids
Ovarian Cysts
Birth Control History
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Pregnancies
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Miscarriages
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Fertility Concerns
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Postpartum Issues
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Perimenopause Symptoms
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Menopause Date
Hot Flashes
Night Sweats
Vaginal Dryness
Low Libido
Hormone Therapy
Last Pap
Last Mammogram
Bone Density Test
Men's Health
Low Libido
Erectile Dysfunction
Morning Erections
Fatigue
Loss of Muscle
Increased Belly Fat
Prostate Issues
Frequent Urination
Nigh Urination
Testosterone Testing
Testosterone Therapy
Fertility Concerns
Vasectomy
Hair Loss
Sleep Apnea/Snoring
Last Prostate Exam
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