Functional Medicine Questionnaire

Name

First NameLast Name

Date of appointment

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Birth Date

Date

Place of Birth

Height

Weight

Sex

Occupation

Referred by

Today's date

Date

Please check all that apply

Functional/Naturopathic appointments are considered wellness visits by all insurance companies and therefore insurance does not cover the visits and all visits are out of pocket. We do not bill insurance for Functional/Naturopathic appointments and require a 100 dollar deposit to schedule your visit which can be used toward the balance of your first 90minute appointment.

Late for an appointment: If you arrive at your appointment more than 5 min late for chiro, 5 min late for acute appointments, or 10 for any other appointments including functional, you will have to reschedule for another day.

Canceling an Appointment: Should you need to cancel an appointment, please give our office 24-hour notice (48 hours for Functional Medicine). Any appointment cancelled with less than appropriate notice is subject to a cancellation fee, which will be billed to the card on file. Failure to cancel/no show (you do not come in for your appointment) will result in the cancellation fee. If you do not have a valid card on file, you will be required to pay the cancellation fee prior to any future scheduling at IHW. After three no show appointments, you will be discharged from the practice.

The No Show/Late Cancellation fees are as follows:
Chiro: $50
Mental Health: $80
Naturo/Functional Medicine: $100

This is in place for all patients for all parts of the practice. You have one grace no
show or Late Cancelation with one provider in our clinic. If you no show or are late
for further appointments with same or any other provider past your first, you will
be charged the no show fee/late cancelation fee.

Telephone Calls: Our staff may handle brief questions, but in-depth questions will require an appointment with the Provider or a billable phone consult.

Labs: We use a third-party laboratory for our lab services. You are responsible for ensuring that HealthLabs through Northwestern Medicine out of Winfield, IL is in-network with your insurance. We do not handle the billing for HealthLabs. Should you have an issue with a lab bill, you will have to reach out to HealthLabs directly.

Please rank and identify current and ongoing problems by priority and answer the appropriate questions about each problem. Only fill in the corresponding sections for the number of problems you have. If you only have one problem, leave everything beyond problem 1 blank until you get to the next section.

Problem #1

Severity of problem #1

Treatment approaches tried for problem #1

Success of treatment for problem #1

Problem #2

Severity of problem #2

Treatment approaches tried for problem #2

Success of treatment for problem #2

Problem #3

Severity of problem #3

Treatment approaches tried for problem #3

Success of treatment for problem #3

Problem #4

Severity of problem #4

Treatment approaches tried for problem #4

Success of treatment for problem #4

With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister

Do you have any pets of farm animals? (Please list what kind and whether they live indoors or outdoors)

Have you lived or traveled outside of the United States? If so, when, and where?

Have you or your family recently experienced any major life changes? If yes, pelase comment.

How important is religion (or spirituality) for you and your family's life?

How much time have you lost from work or school in the past year?

Previous jobs:

Past Medical History (mark all that apply)

Comments on medical history:

Injuries (mark all that apply)

Comments on Injuries (please indicate when the injury occurred)

Diagnostic Studies (please mark all that apply)

Comments about studies:

Operations (please mark all that apply)

Comments about operations: (please include dates of operations)

Please list any hospitalizations, including where you were hospitalized, when, for how long, and for what reason:

How often have you taken antibiotics in infancy/childhood?

How often have you taken antibiotics as a teen?

How often have you taken antibiotics as an adult?

How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.) in infancy/childhood?

How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.) as a teen?

How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.) as an adult?

What medications are you currently taking? Please include all prescription, and non-prescription (over the counter) medications. Indicate the medication name, dose, and approximate start date.

Please list any/all allergies, including severity/response:

Were you a full term baby?

Were you a preemie?

Were you breast fed?

Were you bottle fed?

As a child did you eat a lot of sugar and/or candy?

As a child, were there any foods that you had to avoid because they gave you symptoms?

If you answered yes to the question above, please indicate the food and symptom (Example: milk, gas and diarrhea)

Please mark each food/drink that applies to your current diet for breakfast:

Please mark each food/drink that applies to your current diet for lunch:

Please mark each food/drink that applies to your current diet for dinner:

How much candy do you consume each week?

How much cheese do you consume each week?

How much chocolate do you consume each week?

How many cups of coffee containing caffeine do you consume each week?

How many cups of decaffeinated coffee or tea do you consume each week?

How many cups of hot chocolate do you consume each week?

How many cups of tea containing caffeine do you consume each week?

How many diet sodas do you consume each week?

How much ice cream do you consume each week?

How much salty foods do you consume each week?

How many slices of white bread (rolls/bagels, etc) do you consume each week?

How many sodas with caffeine do you consume each week?

How many sodas without caffeine do you consume each week?

Are you on a special diet? Mark all that apply

Is there anything special about your diet that we should know? If yes, please explain:

Do you have symptoms immediately after eating, such as belching, boating, sneezing, hives, etc.?

If yes, are these symptoms associated with any particular food or supplement(s)?

If you answered yes to the question above, please name the food or supplement and symptom(s).

Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?

Please check all that apply--I feel much worse when I eat a lot of:

Please check all that apply--I feel much better when I eat a lot of:

Does skipping a meal greatly affect your symptoms?

Have you ever had a food that you craved or really "binged" on over a period of time?

If you answered yes to the question above, please indicate what food(s):

Do you have an aversion to certain foods?

If you answered yes to the question above, please indicate what food(s):

Check all that apply related to your bowel movements

Internal gas (mark all that apply)

Have you ever used alcohol?

If you answered yes to the question above, how often do you now drink alcohol?

Have you ever used recreational drugs?

Have you ever used tobacco?

If you answered yes to the question above, please indicate the frequency of tobacco use below.

If you currently use, or have used tobacco products in the past, please indicate what types you have used. Mark all that apply.

If you currently use, or have used tobacco products in the past, please indicate how many years you have used. If you quit, please also indicate the year you quit in.

Are you exposed to second hand smoke regularly?

Do you have mercury amalgam fillings?

Do you have artificial joints or implants?

Do you feel worse at certain times of the year?

If you answered yes to the question above, which time(s) of year do you feel worse? Mark all that apply

Have you, to your knowledge, been exposed to toxic metals in your job or at home?

If you answered yes to the question above, which toxic metal(s) have you been exposed to? Please mark all that apply.

Do odors affect you?

How well have things been going for you at school?

How well have things been going for you in your job?

How well have things been going for you in your social life?

How well have things been going for you with close friends?

How well have things been going for you with sex?

How ell have things been going for you with your attitude?

How well have things been going for you with your significant other?

How well have things been going for you with your children?

How well have thigs been going for you with your parents?

Have you ever had psychotherapy or counselling?

If you answered yes to the question above, when did you receive counselling, and what kind? Please share any relevant details.

Are you currently, or have you ever been, married?

If you answered yes to the question above, please indicate all that apply below

Other

If you are currently married, or have been previously, please list when you were married, or when you were separated or divorced.

If you are currently married or in a committed relationship, what is your significant other's occupation?

Please list your hobbies and leisure activities:

Do you exercise regularly?

If you answered yes to the question above, how many times a week, on average, do you exercise?

When you exercise, how long is each session?

What type of exercise do you do? Leave blank if this does not apply.

Please indicate each pertinent familial relationship, the health of said family member (good health, poor health, or deceased), and any present or past illnesses for each. For example: Father, good health, myasthenia gravis, hypothyroid, ADHD. Paternal grandmother, good health, TIAs.

Any additional family history that we should now about? For example, "many family members with autoimmune disease," or "significant family history of colon cancer."

What is the attitude of those close to you about your illness?

Have you ever been pregnant? If no, please mark and then skip the next several questions that do not apply.

If yes, how many miscarriages?

Number of abortions

Number of preemies

Number of term births

Birth weight of largest baby

Birth weight of smallest baby

During your pregnancy(s) did you develop toxemia (high blood pressure)?

Have you had other problems with pregnancy?

If you answered yes to having other problems with pregnancy, please comment below on any further details.

Age at first menstrual cycle

Approximate date of last Pap Smear

Was your last Pap Smear Normal?

Approximate date of last Mammogram

Was your last mammogram normal?

Have you ever used birth control pills?

Are you taking a birth control pill currently?

Did taking a birth control pill agree with you?

Do you currently use some form of contraception?

If you answered yes to the question above, what type of contraception do you currently use?

Are you in menopause?

If yes, what was your age at your last period?

Do you take any of the following for menopause? Please skip if this does not apply to you.

How long have you been on hormone replacement therapy? Skip if this does not apply to you.

In the second half of your cycle, do you have symptoms of breast tenderness, water retention, or irritability (PMS)?

General Symptoms. Please check all that have occurred in the last 6 months.

Have the above general symptoms been mild, moderate, or severe in nature?

Head, Eyes & Ears. Please mark all symptoms that have occurred in the last 6 months.

Have the above problems been mild, moderate, or severe in nature?

Musculoskeletal. Please mark all symptoms that have occurred in the last 6 months.

Have the above problems been mild, moderate, or severe in nature?

Mood/Nerves. Please mark all symptoms that have occurred in the last 6 months.