Before you begin

The following questions are formulated to define your condition and the causes of your difficulties. This series of questions is divided into blocks. When a block repeats a question you already answered, it is not an error; it is so you can learn that this question relates to various functions in the body.

If there is a question you cannot understand, you can resolve your doubts during the consultation with your doctor. Greater authenticity and truthfulness in your answers will result in a more accurate diagnosis and a more effective therapeutic strategy.

When the form asks about symptoms, unless specified, it refers to symptoms present in the last two months.
When the form asks about the history of something, it refers to your entire life.

Medical Questionnaire

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General Information

Personal and contact information

Allergies

Medications, foods or supplements

Chief Complaint

Main symptoms and wellness goals

5
Wellness

Family & Perinatal History

Family diseases and perinatal data

Family disease history
Perinatal Data

Medical History

Physical/emotional traumas and current medications

Traumas and important events (chronological)

Include fractures, surgeries, hospitalizations, emotional traumas, dental treatments, drug/alcohol use, diagnosed diseases, prolonged medication use.

Currently taking medications/supplements?

Gynecological-Obstetric History

For female patients (XX)

If not applicable, you can skip to the next section.

Menstruation
Menopause Symptoms

Nutrition

Body composition, diet and habits

Consumption frequency (1=Frequent, 2=Occasional, 3=Rarely, 4=Never)
Organ meats
Shellfish
Fish
Beef
Lamb/Rabbit/Duck
Pork
Eggs
Free-range Chicken
Industrial Chicken
Processed Meats
Cruciferous vegetables
Spices & Herbs
Nuts & Seeds
Cacao
Butter
Cheese
Olive Oil
Fruits
Nightshades (tomato, potato)
Starchy Vegetables
Legumes (soy, peanut)
Cereals (wheat)
Rice
Soy/Corn/Canola Oil
Coconut Oil
Ghee Butter
Margarine
Sugar/Panela items
Junk/Packaged food
Dietary regimen
Eating habits
Select factors that apply:

Stress

Positive stress, harmful stress and tolerance

Habits & Positive Stress
Stress Tolerance
5
Daily stressors (0-10)
Sympathetic / adrenergic hyperactivation

Sleep

Sleep quality and patterns

Hydration & Electrolytes

Water intake, stimulants and muscular symptoms

Stimulants you consume
Muscular symptoms
Other symptoms

Digestive Process

Gastric, biliary function and bowel movements

Gastric Function
Biliary Function
Bowel Movements
Difficulty digesting these foods?
Do you consume these?

Microorganisms (SIBO/Dysbiosis)

Microbial exposure, infections and biogenic amines

Chronic or recurrent infections
Biogenic amine intolerance symptoms
Ileocecal valve signs

Intestinal Barrier Integrity

Post-meal disorders and food allergies

Do you experience disorders after eating? (describe)
Allergy symptoms after certain foods?

Glycotoxicity & Hypoglycemia

Sugar, neurological and hormonal functions

When do you feel tiredness/drowsiness/dizziness?
Polyneuropathies
Affected neurological functions
Affected senses
For female patients (XX)
For male patients (XY)

Cardiovascular Fatigue

Purine catabolism and cardiovascular symptoms

Vitamins B6, B9 & B12

Diet, estrogens and neurological symptoms

Your diet is low in:
Signs of estrogen imbalances
Neurological symptoms
Others

Iron Deficiency

Sources, medications and anemia symptoms

Foods affecting iron absorption
Medications affecting iron
Anemia and iron deficiency symptoms
Stomach insufficiency symptoms

Chronic Inflammation

Pain, infections and coagulation issues

Chronic or recurrent infections
Neurological problems

Autoimmune Condition

Diagnosis, flare-ups and vaccines

Symptom flare-ups after:
Vaccines Received

Vitamins D3 & K2

Sun exposure, food sources and calcification

Do you consume Vitamin K2 sources?
Have you had calcification / stones?
Current conditions:

Omega 3/6 Ratio

Essential fatty acid consumption

Do you consume Omega 3 rich foods?
Do you consume Omega 6 rich foods?
Omega 3 deficiency symptoms

Cholesterol Elevation & Oxidation

Risk factors for elevated cholesterol

Toxic Load

Environmental exposures, substances and habits

Home or work exposure:
Substance contact:
Are you exposed to these substances?

Cell Energy

Exercise tolerance, weight and symptoms

Which symptoms do you have?

Thyroid

Symptoms, medications and diet

Have you experienced any of these symptoms?
Which medications have you used?
Do you frequently consume?

Social, Emotional & Spiritual

Emotions, relationships and life purpose

How often do you feel these emotions? (0=Never, 1=Weekly, 2=Every 2-3 days, 3=Daily)
Guilt
Pity
Apathy
Hopelessness
Victim mindset
Grief
Numbness
Terror
Fear
Anxiety
Hostility
Resentment
Hate
Frustration
Boredom
Disinterest
How often do you feel these positive emotions?
Moderate Interest
Intense Interest
Joy
Enthusiasm
Aesthetics (Creativity)
Jubilation
Action
Play
Serenity