BrainGutADHD.

com
Male Intake
Questionnaire
General Information
Name Age Today’s Date
Date of Birth Email
Address City
State Zip
Phone (Home) (Cell) (Work)
Genetic Background: African American Hispanic Mediterranean Asian
Native American Caucasian Northern European
Other
When, where and from whom did you last receive medical or health care?

Emergency Contact: Relationship Phone (Home)

(Cell) (Work)
How did you hear about our practice?
Clinic website IFM website Referral from doctor Referral from friend/family member Social media
Other

Current Health Concerns

Please rank current and ongoing health concerns in order of priority
Describe Problem Severity Prior Treatment/Approach Success

Example: Post Nasal Drip Mild Moderate Elimination Diet Good Excellent
Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

Mild Moderate Good Excellent

Severe Fair

© 2022 The Institute for Functional Medicine Version 4

Allergies

1. Name of Medication/Supplement/Food:
Reaction:
2. Name of Medication/Supplement/Food:
Reaction:
3. Name of Medication/Supplement/Food:
Reaction:
4. Name of Medication/Supplement/Food:
Reaction:
5. Name of Medication/Supplement/Food:
Reaction:

Lifestyle Review

Sleep
How many hours of sleep do you get each night on average?
Do you have problems falling asleep? Yes No Staying asleep? Yes No
Do you have problems with insomnia? Yes No Do you snore? Yes No
Do you feel rested upon awakening? Yes No
Do you use sleeping aids? Yes No
If yes, explain:

Exercise
Current Exercise Program:

Activity Type # of Times Per Week Time/Duration (Minutes)

Cardio/Aerobic
Strength/Resistance
Flexibility/Stretching
Balance
Sports/Leisure (e.g., golf)
Other:

Do you feel motivated to exercise? Yes A little No

Are there any problems that limit exercise? Yes No
If yes, explain:
Do you feel unusually fatigued or sore after exercise? Yes No
If yes, explain:

© 2022 The Institute for Functional Medicine Version 4

Nutrition
Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)
Vegetarian Vegan Allergy Elimination Low Fat Low Carb High Protein
Blood Type Low sodium No Dairy No Wheat Gluten Free
Other:
Do you have sensitivities to certain foods? Yes No
If yes, list food and symptoms:
Do you have an aversion to certain foods? Yes No
If yes, explain:
Do you adversely react to: (Check all that apply)
Monosodium glutamate (MSG) Artificial sweeteners Garlic/onion Cheese Citrus foods
Chocolate Alcohol Red wine Sulfite–containing foods (wine, dried fruit, salad bars)
Preservatives Food colorings Other food substances:
Are there any foods that you crave or binge on? Yes No
If yes, what foods?
Do you eat 3 meals a day? Yes No If no, how many
Does skipping a meal greatly affect you? Yes No
How many meals do you eat out per week? 0-1 1-3 3-5 More than 5 meals per week
Check the factors that apply to your current lifestyle and eating habits:
Fast eater Significant other or family members have special
Eat too much dietary needs
Late-night eating Love to eat
Dislike healthy foods Eat because I have to
Time constraints Have negative relationship to food
Travel frequently Struggle with eating issues
Eat more than 50% of meals away from home Emotional eater (eat when sad, lonely, bored, etc.)
Healthy foods not readily available Eat too much under stress
Poor snack choices Eat too little under stress
Significant other or family members don’t like Don’t care to cook
healthy foods Confused about nutrition advice

© 2022 The Institute for Functional Medicine Version 4

Diet
Please record what you eat in a typical day:
Breakfast
Lunch
Dinner
Snacks
Fluids
How many servings do you eat in a typical week of these foods:
Fruits (not juice) Vegetables (not including white potatoes)
Legumes (beans, peas, etc) Red meat Fish
Dairy/Alternatives Nuts & Seeds Fats & Oils
Cans of soda (regular or diet) Sweets (candy, cookies, cake, ice cream, etc.)
Do you drink caffeinated beverages? Yes No If yes, check amounts:
Coffee (cups per day) 1 2-4 More than 4 Tea (cups per day) 1 2-4 More than 4
Caffeinated sodas—regular or diet (cans per day) 1 2-4 More than 4
Do you have adverse reactions to caffeine? Yes No
If yes, explain:
When you drink caffeine do you feel: Irritable or wired Aches or pains

Smoking
Do you smoke currently? Yes No Packs per day: Number of years
What type? Cigarettes Smokeless Pipe Cigar E-Cig
Have you attempted to quit? Yes No
If yes, using what methods:
If you smoked previously: Packs per day: Number of years
Are you regularly exposed to second-hand smoke? Yes No

Alcohol
How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)
1-3 4-6 7-10 More than 10 None
Previous alcohol intake? Yes ( Mild Moderate High) None
Have you ever had a problem with alcohol? Yes No
If yes, when?
Explain the problem:
Have you ever thought about getting help to control or stop your drinking? Yes No

Other Substances
Are you currently using any recreational drugs? Yes No
If yes, type:
Have you ever used IV or inhaled recreational drugs? Yes No

© 2022 The Institute for Functional Medicine Version 4

Stress
Do you feel you have an excessive amount of stress in your life? Yes No
Do you feel you can easily handle the stress in your life? Yes No
How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)
Work Family Social Finances Health Other
Do you use relaxation techniques? Yes No
If yes, how often?
Which techniques do you use? (Check all that apply)
Meditation Breathing Tai Chi Yoga Prayer Other:
Have you ever sought counseling? Yes No
Are you currently in therapy? Yes No
If yes, describe:
Have you ever been abused, a victim of crime, or experienced a significant trauma? Yes No
What are your hobbies or leisure activities?

Relationships
Marital status: Single Married Divorced Gay/Lesbian Long-Term Partner Widow/er
With whom do you live? (Include children, parents, relatives, friends, pets)

Current occupation:
Previous occupations:
Do you have resources for emotional support? Yes No (Check all that apply)
Spouse/Partner Family Friends Religious/Spiritual Pets Other:
Do you have a religious or spiritual practice? Yes No
If yes, what kind?

How well have things been going for you?

(Enter score on scale of 1–10, with 1 being poorly, 5 being fine, and 10 being very well; choose N/A if not applicable)

How Well Have Things Been Going for You?

Overall N/A Score
At school N/A Score
In your job N/A Score
In your social life N/A Score
With close friends N/A Score
With sex N/A Score
With your attitude N/A Score
With your boyfriend/girlfriend N/A Score
With your children N/A Score
With your parents N/A Score
With your spouse N/A Score

© 2022 The Institute for Functional Medicine Version 4

History

Patient’s Birth/Childhood History:

You were born: Term Premature Don’t know
Were there any pregnancy or birth complications? Yes No
If yes, explain:
You were: Breast-fed/How long? Bottle-fed/Type of formula: Don’t know
Age of introduction of: Solid food: Wheat Dairy
As a child, were there any foods that were avoided because they gave you symptoms? Yes No
If yes, what foods and what symptoms? (Example: milk—gas and diarrhea)

Did you eat a lot of sugar or candy as a child? Yes No

Dental History:
Check if you have any of the following, and provide number if applicable:
Silver mercury fillings Gold fillings Root canals Implants
Caps/Crowns Tooth pain Bleeding gums Gingivitis
Problems with chewing Other dental concerns (explain):
Have you had any mercury fillings removed? Yes No If yes, when:
How many fillings did you have as a kid?
Do you brush regularly? Yes No Do you floss regularly? Yes No

Environmental/Detoxification History
Do any of these significantly affect you?
Cigarette smoke Perfume/colognes Auto exhaust fumes Other:
In your work or home environment are you regularly exposed to: (Check all that apply)
Mold Water leaks Renovations Chemicals Electromagnetic radiation
Damp environments Carpets or rugs Old paint Stagnant or stuffy air Smokers
Pesticides Herbicides Harsh chemicals (solvents, glues, gas, acids, etc) Cleaning chemicals
Heavy metals (lead, mercury, etc.) Paints Airplane travel Other
Have you had a significant exposure to any harmful chemicals? Yes No
If yes: Chemical name, length of exposure, date:
Do you have any pets or farm animals? Yes No
If yes, do they live: Inside Outside Both inside and outside

© 2022 The Institute for Functional Medicine Version 4

Men’s History
(Check box if applicable)
Testicular mass Testicular pain Prostate enlargement Prostate infection
Change in sex drive Impotence Premature ejaculation Difficulty obtaining an erection
Difficulty maintaining an erection Loss of control of urine Urinary urgency/hesitancy/change in stream
Vasectomy Nocturia (urination at night) # of times per night
Sexually transmitted diseases (describe)
Screening/Procedures: (If applicable, provide date)
Last PSA test: PSA Level: 0-2 2-4 4-10 More than 10
Other tests/procedures (list type and dates):

© 2022 The Institute for Functional Medicine Version 4

Family History
Check family members that have/had any of the following

Mother

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Father

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Brother

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Sister

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Child

Age (if still alive) Age at death (if deceased)

Cancer Arthritis Asthma Dementia Other:
Heart disease Kidney disease Allergies Substance abuse
Hypertension Thyroid problems Eczema Genetic disorders
Obesity Seizures/epilepsy ADHD
Diabetes Psychiatric disorders Autism
Stroke Anxiety Irritable Bowel
Syndrome
Autoimmune disease Depression

© 2022 The Institute for Functional Medicine Version 4

Family History (continued)

Child

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Child

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Child

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Child

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Maternal Grandmother

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

© 2022 The Institute for Functional Medicine Version 4

Family History (continued)

Maternal Grandfather

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Paternal Grandmother

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Paternal Grandfather

Age (if still alive) Age at death (if deceased)

Cancer Autoimmune disease Anxiety Autism Other:
Heart disease Arthritis Depression Irritable Bowel
Syndrome
Hypertension Kidney disease Asthma
Dementia
Obesity Thyroid problems Allergies
Substance abuse
Diabetes Seizures/epilepsy Eczema
Genetic disorders
Stroke Psychiatric disorders ADHD

Other

Age (if still alive) Age at death (if deceased)

Cancer Arthritis Asthma Dementia Other:
Heart disease Kidney disease Allergies Substance abuse
Hypertension Thyroid problems Eczema Genetic disorders
Obesity Seizures/epilepsy ADHD
Diabetes Psychiatric disorders Autism
Stroke Anxiety Irritable Bowel
Syndrome
Autoimmune disease Depression

© 2022 The Institute for Functional Medicine Version 4

Medical History: Illnesses/Conditions
Check YES = a condition you currently have, Check PAST = a condition you’ve had in the past.

Gastrointestinal Musculoskeletal
Irritable bowel syndrome Yes Past Fibromyalgia Yes Past
GERD (reflux) Yes Past Osteoarthritis Yes Past
Crohn’s disease/ulcerative colitis Yes Past Chronic pain Yes Past
Peptic ulcer disease Yes Past Other: Yes Past
Celiac disease Yes Past Skin
Gallstones Yes Past Eczema Yes Past
Other: Yes Past Psoriasis Yes Past
Respiratory Acne Yes Past
Bronchitis Yes Past Skin cancer Yes Past
Asthma Yes Past Other: Yes Past
Emphysema Yes Past Cardiovascular
Pneumonia Yes Past Angina Yes Past
Sinusitis Yes Past Heart attack Yes Past
Sleep apnea Yes Past Heart failure Yes Past
Other: Yes Past Hypertension (high blood pressure) Yes Past
Urinary/Genital Stroke Yes Past
Kidney stones Yes Past High blood fats (cholesterol, triglycerides) Yes Past
Gout Yes Past Rheumatic fever Yes Past
Interstitial cystitis Yes Past Arrythmia (irregular heart rate) Yes Past
Frequent yeast infections Yes Past Murmur Yes Past
Frequent urinary tract infections Yes Past Mitral valve prolapse Yes Past
Sexual dysfunction Yes Past Other: Yes Past
Sexually transmitted diseases Yes Past Neurologic/Emotional
Other: Yes Past Epilepsy/Seizures Yes Past
Endocrine/Metabolic ADD/ADHD Yes Past
Diabetes Yes Past Headaches Yes Past
Hypothyroidism (low thyroid) Yes Past Migraines Yes Past
Hyperthyroidism (overactive thyroid) Yes Past Depression Yes Past
Infertility Yes Past Anxiety Yes Past
Metabolic syndrome/insulin resistance Yes Past Autism Yes Past
Eating disorder Yes Past Multiple sclerosis Yes Past
Hypoglycemia Yes Past Parkinson’s disease Yes Past
Other: Yes Past Dementia Yes Past
Inflammatory/Immune Other: Yes Past
Rheumatoid arthritis Yes Past Cancer
Chronic fatigue syndrome Yes Past Lung Yes Past
Food allergies Yes Past Breast Yes Past
Environmental allergies Yes Past Colon Yes Past
Multiple chemical sensitivities Yes Past Prostate Yes Past
Autoimmune disease Yes Past Skin Yes Past
Immune deficiency Yes Past Other: Yes Past
Mononucleosis Yes Past
Hepatitis Yes Past
Other: Yes Past

© 2022 The Institute for Functional Medicine Version 4

Medical History (continued)

Diagnostic Studies
Bone Density Date: Comments:

CT scan Date: Comments:

Colonoscopy Date: Comments:

Cardiac stress test Date: Comments:

EKG Date: Comments:

MRI Date: Comments:

Upper endoscopy Date: Comments:

Upper GI series Date: Comments:

Chest X-ray Date: Comments:

Other X-rays Date: Comments:

Barium enema Date: Comments:

Other: Date: Comments:

Injuries
Broken bone(s) Date: Comments:

Back injury Date: Comments:

Neck injury Date: Comments:

Head injury Date: Comments:

Other: Date: Comments:

Surgeries
Appendectomy Date: Comments:

Dental Date: Comments:

Gallbladder Date: Comments:

Hernia Date: Comments:

Tonsillectomy Date: Comments:

Joint Replacement Date: Comments:

Heart surgery Date: Comments:

Other: Date: Comments:

Hospitalizations
Date: Reason:

Date: Reason:

Date: Reason:

Date: Reason:

Date: Reason:

© 2022 The Institute for Functional Medicine Version 4

Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months

General Musculoskeletal (continued)

Cold hands and feet Mild Moderate Severe Muscle weakness Mild Moderate Severe
Cold intolerance Mild Moderate Severe Neck muscle spasm Mild Moderate Severe
Daytime sleepiness Mild Moderate Severe Tendonitis Mild Moderate Severe
Difficulty falling asleep Mild Moderate Severe Tension headache Mild Moderate Severe
Early waking Mild Moderate Severe TMJ problems Mild Moderate Severe
Fatigue Mild Moderate Severe Mood/Nerves
Fever Mild Moderate Severe Agoraphobia Mild Moderate Severe
Flushing Mild Moderate Severe Anxiety Mild Moderate Severe
Heat intolerance Mild Moderate Severe Auditory hallucinations Mild Moderate Severe
Night waking Mild Moderate Severe Blackouts Mild Moderate Severe
Nightmares Mild Moderate Severe Depression Mild Moderate Severe
Can’t remember dreams Mild Moderate Severe Difficulty:
Low body temperature Mild Moderate Severe Concentrating Mild Moderate Severe
Head, Eyes, and Ears With balance Mild Moderate Severe
Conjunctivitis Mild Moderate Severe With thinking Mild Moderate Severe
Distorted sense of smell Mild Moderate Severe With judgment Mild Moderate Severe
Distorted taste Mild Moderate Severe With speech Mild Moderate Severe
Ear fullness Mild Moderate Severe With memory Mild Moderate Severe
Ear ringing/buzzing Mild Moderate Severe Dizziness (spinning) Mild Moderate Severe
Eye crusting Mild Moderate Severe Fainting Mild Moderate Severe
Eye pain Mild Moderate Severe Fearfulness Mild Moderate Severe
Eyelid margin redness Mild Moderate Severe Irritability Mild Moderate Severe
Headache Mild Moderate Severe Light-headedness Mild Moderate Severe
Hearing loss Mild Moderate Severe Numbness Mild Moderate Severe
Hearing problems Mild Moderate Severe Other phobias Mild Moderate Severe
Migraine Mild Moderate Severe Panic attacks Mild Moderate Severe
Sensitivity to loud noises Mild Moderate Severe Paranoia Mild Moderate Severe
Vision problems Mild Moderate Severe Seizures Mild Moderate Severe
Musculoskeletal Suicidal thoughts Mild Moderate Severe
Back muscle spasm Mild Moderate Severe Tremor/trembling Mild Moderate Severe
Calf cramps Mild Moderate Severe Visual Hallucinations Mild Moderate Severe
Chest tightness Mild Moderate Severe Cardiovascular
Foot cramps Mild Moderate Severe Angina/chest pain Mild Moderate Severe
Joint deformity Mild Moderate Severe Breathlessness Mild Moderate Severe
Joint pain Mild Moderate Severe Heart attack Mild Moderate Severe
Joint redness Mild Moderate Severe Heart murmur Mild Moderate Severe
Joint stiffness Mild Moderate Severe High blood pressure Mild Moderate Severe
Muscle pain Mild Moderate Severe Irregular pulse Mild Moderate Severe
Muscle spasms Mild Moderate Severe Mitral valve prolapse Mild Moderate Severe
Muscle stiffness Mild Moderate Severe Palpitations Mild Moderate Severe
Muscle twitches Mild Moderate Severe Phlebitis Mild Moderate Severe
Around eyes Mild Moderate Severe Swollen ankles/feet Mild Moderate Severe
Arms or legs Mild Moderate Severe Varicose veins Mild Moderate Severe

© 2022 The Institute for Functional Medicine Version 4

Symptom Review (continued)
Please check if these symptoms occur presently or have occurred in the last 6 months

Urinary Digestion (continued)

Bed wetting Mild Moderate Severe Lower abdominal pain Mild Moderate Severe
Hesitancy Mild Moderate Severe Mucus in stools Mild Moderate Severe
Infection Mild Moderate Severe Nausea Mild Moderate Severe
Kidney disease Mild Moderate Severe Periodontal disease Mild Moderate Severe
Kidney stone Mild Moderate Severe Sore tongue Mild Moderate Severe
Leaking/incontinence Mild Moderate Severe Strong stool odor Mild Moderate Severe
Pain/burning Mild Moderate Severe Undigested food in stools Mild Moderate Severe
Prostate enlargement Mild Moderate Severe Upper abdominal pain Mild Moderate Severe
Prostate infection Mild Moderate Severe Vomiting Mild Moderate Severe
Urgency Mild Moderate Severe Eating
Digestion Binge eating Mild Moderate Severe
Anal spasms Mild Moderate Severe Bulimia Mild Moderate Severe
Bad teeth Mild Moderate Severe Can’t gain weight Mild Moderate Severe
Bleeding gums Mild Moderate Severe Can’t lose weight Mild Moderate Severe
Bloating of: Carbohydrate craving Mild Moderate Severe
Lower abdomen Mild Moderate Severe Carbohydrate intolerance Mild Moderate Severe
Whole abdomen Mild Moderate Severe Poor appetite Mild Moderate Severe
Bloating after meals Mild Moderate Severe Salt cravings Mild Moderate Severe
Blood in stools Mild Moderate Severe Frequent dieting Mild Moderate Severe
Burping Mild Moderate Severe Sweet cravings Mild Moderate Severe
Canker sores Mild Moderate Severe Caffeine dependency Mild Moderate Severe
Cold sores Mild Moderate Severe Respiratory
Constipation Mild Moderate Severe Bad breath Mild Moderate Severe
Cracking at corner of lips Mild Moderate Severe Bad odor in nose Mild Moderate Severe
Dentures w/poor chewing Mild Moderate Severe Cough – dry Mild Moderate Severe
Diarrhea Mild Moderate Severe Cough – productive Mild Moderate Severe
Difficulty swallowing Mild Moderate Severe Hayfever: Mild Moderate Severe
Dry mouth Mild Moderate Severe Spring Mild Moderate Severe
Farting Mild Moderate Severe Summer Mild Moderate Severe
Fissures Mild Moderate Severe Fall Mild Moderate Severe
Foods “repeat” (reflux) Mild Moderate Severe Change of season Mild Moderate Severe
Heartburn Mild Moderate Severe Hoarseness Mild Moderate Severe
Hemorrhoids Mild Moderate Severe Nasal stuffiness Mild Moderate Severe
Intolerance to: Nose bleeds Mild Moderate Severe
Lactose Mild Moderate Severe Post nasal drip Mild Moderate Severe
All dairy products Mild Moderate Severe Sinus fullness Mild Moderate Severe
Gluten (wheat) Mild Moderate Severe Sinus infection Mild Moderate Severe
Corn Mild Moderate Severe Snoring Mild Moderate Severe
Eggs Mild Moderate Severe Sore throat Mild Moderate Severe
Fatty foods Mild Moderate Severe Wheezing Mild Moderate Severe
Yeast Mild Moderate Severe Winter stuffiness Mild Moderate Severe
Liver disease/jaundice Mild Moderate Severe
(yellow eyes or skin)

© 2022 The Institute for Functional Medicine Version 4

Symptom Review (continued)
Please check if these symptoms occur presently or have occurred in the last 6 months

Nails Skin problems (continued)

Bitten Mild Moderate Severe Eczema Mild Moderate Severe
Brittle Mild Moderate Severe Herpes – genital Mild Moderate Severe
Curve Up Mild Moderate Severe Hives Mild Moderate Severe
Frayed Mild Moderate Severe Jock itch Mild Moderate Severe
Fungus – fingers Mild Moderate Severe Lackluster skin Mild Moderate Severe
Fungus – toes Mild Moderate Severe Moles w color/size change Mild Moderate Severe
Pitting Mild Moderate Severe Oily skin Mild Moderate Severe
Ragged cuticles Mild Moderate Severe Pale skin Mild Moderate Severe
Ridges Mild Moderate Severe Patchy dullness Mild Moderate Severe
Soft Mild Moderate Severe Psoriasis Mild Moderate Severe
Thickening of: Rash Mild Moderate Severe
Fingernails Mild Moderate Severe Red face Mild Moderate Severe
Toenails Mild Moderate Severe Sensitive to bites Mild Moderate Severe
White spots/lines Mild Moderate Severe Sensitive to poison ivy/oak Mild Moderate Severe
Lymph Nodes Shingles Mild Moderate Severe
Enlarged/neck Mild Moderate Severe Skin cancer Mild Moderate Severe
Tender/neck Mild Moderate Severe Skin darkening Mild Moderate Severe
Other enlarged/tender lymph nodes Mild Moderate Severe Strong body odor Mild Moderate Severe
Skin, Dryness of Thick calluses Mild Moderate Severe
Eyes Mild Moderate Severe Vitiligo Mild Moderate Severe
Feet Mild Moderate Severe Itching Skin
Any cracking? Mild Moderate Severe Anus Mild Moderate Severe
Any peeling? Mild Moderate Severe Arms Mild Moderate Severe
Hair Mild Moderate Severe Ear canals Mild Moderate Severe
And unmanageable? Mild Moderate Severe Eyes Mild Moderate Severe
Hands Mild Moderate Severe Feet Mild Moderate Severe
Any cracking? Mild Moderate Severe Hands Mild Moderate Severe
Any peeling? Mild Moderate Severe Legs Mild Moderate Severe
Mouth/throat Mild Moderate Severe Nipples Mild Moderate Severe
Scalp Mild Moderate Severe Nose Mild Moderate Severe
Any dandruff Mild Moderate Severe Genitals Mild Moderate Severe
Skin in general Mild Moderate Severe Roof of mouth Mild Moderate Severe
Skin Problems Scalp Mild Moderate Severe
Acne on back Mild Moderate Severe Skin in general Mild Moderate Severe
Acne on chest Mild Moderate Severe Throat Mild Moderate Severe
Acne on face Mild Moderate Severe Male Reproductive
Acne on shoulders Mild Moderate Severe Discharge from penis Mild Moderate Severe
Athlete’s foot Mild Moderate Severe Ejaculation problem Mild Moderate Severe
Bumps on back of upper arms Mild Moderate Severe Genital pain Mild Moderate Severe
Cellulite Mild Moderate Severe Impotence Mild Moderate Severe
Dark circles under eyes Mild Moderate Severe Infections Mild Moderate Severe
Ears get red Mild Moderate Severe Lumps in testicles Mild Moderate Severe
Easy bruising Mild Moderate Severe Poor libido (low sex drive) Mild Moderate Severe

© 2022 The Institute for Functional Medicine Version 4

Medications/Supplements

Current medications (include prescription and over-the-counter)

Medication Dosage Start Date (mo/yr) Reason for Use

Nutritional supplements (vitamins/minerals/herbs etc.)

Name and Brand Dosage Start Date (mo/yr) Reason for Use

Have medications or supplements ever caused unusual side effects or problems? Yes No
If yes, describe:
Have you used any of these regularly or for a long time:
NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin? Yes No Tylenol (acetaminophen)? Yes No
Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)? Yes No
How many times have you taken antibiotics?
Infancy/childhood Less than 5 5 or more Reason for use
Teen Less than 5 5 or more Reason for use
Adulthood Less than 5 5 or more Reason for use
Have you ever taken long term antibiotics? Yes No
If yes, explain:
How often have you taken oral steroids (e.g., cortisone, prednisone, etc.)?
Infancy/childhood Less than 5 5 or more Reason for use
Teen Less than 5 5 or more Reason for use
Adulthood Less than 5 5 or more Reason for use

© 2022 The Institute for Functional Medicine Version 4

Readiness Assessment and Health Goals

Readiness Assessment
Rate on a scale of 5 (very willing) to 1 (not willing):
In order to improve your health, how willing are you to:
Significantly modify your diet
Take several nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (e.g., work demands, sleep habits)
Practice a relaxation technique
Engage in regular exercise
Rate on a scale of 5 (very confident) to 1 (not confident at all):
How confident are you of your ability to organize and follow through on the above health-related activities?
If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to
follow through?

Rate on a scale of 5 (very supportive) to 1 (very unsupportive):

At the present time, how supportive do you think the people in your household will be to your
implementing the above changes?
Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):
How much ongoing support (e.g., telephone consults, email correspondence) from our professional staff
would be helpful to you as you implement your personal health program?
Comments:

© 2022 The Institute for Functional Medicine Version 4

Health Goals

What do you hope to achieve in your visit with us?

When was the last time you felt well?

Did something trigger your change in health?

What makes you feel better?

What makes you feel worse?

How does your condition affect you?

What do you think is happening and why?

What do you feel needs to happen for you to get better?

© 2022 The Institute for Functional Medicine Version 4