Combined Intake Draft 8.4.14amymyersmd.com.s3.amazonaws.com/downloads/Intake-9.29.14.pdf"""""...

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Please submit this form at your earliest convenience so we can schedule your new patient appointment.

Due to sensitivities our office is fragrance free. We ask that you please refrain from wearing scented products to our office. This includes perfumes, colognes, lotions, deodorants, soaps and shampoos.

Austin UltraHealth Westlake Medical Center

5656 Bee Cave Road Suite D-‐203 Austin, Texas 78746

Phone: 512-‐383-‐5343 Fax: 512-‐721-‐0348

GENERAL INFORMATION Name: First Middle Last

www.AmyMyersMD.com [email protected] (512) 383-‐5343 Please Initial: __________

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Preferred Name and Title: Date of Birth: Age: Gender: �Male �Female Genetic Background: O African O European O Native American O Mediterranean O Asian O Ashkenazi O Middle Eastern Highest Education Level: �High School �Under-‐Graduate �Post-‐Graduate Job Title: Nature of Business: Primary Address: Number, Street: Apt. No. City State Zip

Preferred Phone: Secondary Phone: E-‐mail: Emergency Contact: Name Relationship Address Apt. No. Phone Number: City State Zip Referred by: �Google (please list the words you used to find us) �Family Member or Friend (please specify) �Institute of Functional Medicine website �MindBodyGreen website �Facebook � Doctor Oz ________________________________________________________________________________________ �Other (please specify)

PHARMACY INFORMATION Primary Pharmacy: Name Phone Number: Address


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City State Zip Fax

Compounding Pharmacy: Name Phone Number: Address City State Zip Fax

ALLERGIES TO MEDICATIONS/FOODS/SUPPLEMENTS

Medication/Supplement/Food Reaction

AMY MYERS, MD MEDICAL QUESTIONNAIRE

COMPLAINTS/CONCERNS What do you hope to achieve with us? _________


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__________________________________________________________________________________________

What are the top 3 health concerns you would like us to focus on? 1. 2. 3. When was the last time you felt well? ______ ________________________________________________ Did something trigger a change in health? If so, what? ______ ______________________________________________ What makes you feel worse? _________ What makes you feel better? _________ Let us know what you’ve tried in the past:

Describe Problem Prior Treatment/Approach Rank effectiveness (1-‐10)

Example: Post Nasal Drip Example: Elimination Diet

PATIENT BIRTH HISTORY �Term �Premature �Vaginal Delivery �C-‐Section Delivery


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Pregnancy Complications: ___________________________________________________________________________ Birth Complications: _______________________________________________________________________________ Were you breast fed? How long? ____________________________ Bottle fed? ___________________________ CHILDHOOD Age at introduction of: Solid Foods: _________________ Dairy: __________________ Wheat: _________________ Did you eat a lot of candy or sugar as a child? � Yes �No Did you have frequent ear infections? As a child, were you up to date with immunizations? Ο Yes Ο No Does you feel that immunizations have had an impact on health? Ο Yes Ο No If relevant, attach an immunization record or see addendum. � Yes �No GRADE SCHOOL Did you develop any food or seasonal allergies? � Yes �No Did you have any serious infections or experience any trauma? � Yes �No Other health issues:

HIGH SCHOOL Did you have acne that required antibiotics? � Yes �No Did you have mono? � Yes �No Other health issues:

COLLEGE Other health issues:

ADULTHOOD Other health issues: FAMILY HISTORY


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MEDICAL HISTORY Check appropriate box and provide date of onset

Age (if still alive) MOTH

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FATH

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SIBLING 1

Male 0 Fem

ale 0

SIBLING 2

Male 0 Fem

ale 0

SIBLING 3

Male 0 Fem

ale 0

MATERN

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GRANDMOTH

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MATERN

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GRA

NDFA

THER

PATERN

AL

GRA

NDMOTH

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PATERN

AL

GRA

NDFA

THER

AUNTS

UNCLES

OTH

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CHILD

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CHILD

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CHILD

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Age at death (if deceased) Heart Disease Hypertension Obesity Diabetes Type 2 Stroke Arthritis (Osteo) Arthritis (Rheumatoid, Psoriatic, Ankylosing Spondylitis)

Inflammatory Bowel Disease Multiple Sclerosis Lupus Diabetes Type 1 Vitiligo Thyroid Problems Hashimoto’s thyroiditis Graves’ disease Irritable Bowel Syndrome Celiac Disease Asthma Eczema / Psoriasis Food Allergies, Sensitivities or Intolerances

Environmental Sensitivities Dementia Parkinson’s ALS or other Motor Neuron Diseases Genetic Disorders Substance Abuse (such as alcoholism) Psychiatric Disorders Depression Schizophrenia ADHD Autism Bipolar Disease Accidental Death Suicide Cancer: Other:


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GASTROINTESTINAL * Irritable Bowel Syndrome _____________________________ * Inflammatory Bowel Disease __________________________ * Crohn’s ____________________________________________ * Ulcerative Colitis ____________________________________

* Gastritis or Peptic Ulcer Disease ________________________ * GERD (reflux) ________________________________________ * Celiac Disease ________________________________________ * Other _______________________________________________

CARDIOVASCULAR * Heart Attack _________________________________________ * Other Heart Disease ___________________________________ * Stroke _______________________________________________ * Elevated Cholesterol ___________________________________ * Arrythmia (irregular heart rate) _________________________

* Hypertension (high blood pressure) _____________________ * Rheumatic Fever _____________________________________ * Mitral Valve Prolapse _________________________________ * Other _______________________________________________

METABOLIC/ENDOCRINE * Type 1 Diabetes ______________________________________ * Type 2 Diabetes ______________________________________ * Hypoglycemia _______________________________________ * Metabolic Syndrome __________________________________ * (Insulin Resistance or Pre-‐Diabetes) * Hypothyroidism (low thyroid) __________________________ * Hyperthyroidism (overactive thyroid)____________________ * Endocrine Problems___________________________________ * Polycystic Ovarian Syndrome (PCOS) ___________________ * Infertility ____________________________________________

* Weight Gain _________________________________________ * Weight Loss _________________________________________ * Frequent Weight Fluctuations __________________________ * Bulimia _____________________________________________ * Anorexia ____________________________________________ * Binge Eating Disorder_________________________________ * Night Eating Syndrome ________________________________ * Eating Disorder (non-‐specific) __________________________ * Other _______________________________________________

INFLAMMATORY/AUTOIMMUNE * Chronic Fatigue Syndrome _____________________________ * Autoimmune Disease List: ___________________________________________________ ___________________________________________________ ___________________________________________________ * Immune Deficiency Disease ___________________________

* Herpes-‐Genital _______________________________________ * Immune Dysfunction _________________________________ * Multiple Chemical Sensitivities _________________________ * Latex Allergy ________________________________________ * Other ______________________________________________

CANCER * Cancer ______________________________________________ Specify type: ____________________________________________

________________________________________________________ ________________________________________________________

GENITAL AND URINARY SYSTEMS * Kidney Stones ________________________________________ * Gout ________________________________________________


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* Interstitial Cystitis ____________________________________ * Frequent Urinary Tract Infections _______________________ * Frequent Yeast Infections ______________________________

* Erectile Dysfunction or Sexual Dysfunction _______________ * Other _______________________________________________

MUSCULOSKELETAL/PAIN * Osteoarthritis ________________________________________ * Fibromyalgia _________________________________________

* Chronic Pain _________________________________________ * Other _______________________________________________

RESPIRATORY DISEASES* Asthma______________________________________________ * Chronic Sinusitis _____________________________________ * Bronchitis ___________________________________________ * Emphysema__________________________________________

* Pneumonia __________________________________________ * Tuberculosis _________________________________________ * Sleep Apnea _________________________________________ * Other _______________________________________________

SKIN DISEASES * Eczema _____________________________________________ * Psoriasis ____________________________________________

* Acne ________________________________________________ * Other _______________________________________________

NEUROLOGIC/MOOD * Depression _________________________________________ * Anxiety ____________________________________________ * Bipolar Disorder _____________________________________ * Schizophrenia _______________________________________ * Headaches/Migraines _________________________________

* ADD/ADHD_________________________________________ * Autism _____________________________________________ * Parkinson’s Disease __________________________________ * Seizures_____________________________________________ * Other Neurological Problems __________________________

PREVENTIVE TESTS AND DATE OF LAST TEST Check box if yes and provide date * Full Physical Exam ____________________________________ * Bone Density ________________________________________ * Colonoscopy _________________________________________ * Cardiac Stress Test ____________________________________ * EBT Heart Scan ______________________________________ * EKG ________________________________________________

* Hemoccult Test-‐stool test for blood ______________________ * MRI ________________________________________________ * CT Scan ____________________________________________ * Upper Endoscopy ____________________________________ * Upper GI Series ______________________________________ * Ultrasound __________________________________________

INJURIES List injuries: ________________________________________________________________________________________________ ___________________________________________________________________________________________________________ SURGERIES Check box if yes and provide date of surgery * Appendectomy ______________________________________ * Hysterectomy +/-‐ Ovaries _____________________________ * Gall Bladder _________________________________________ * Hernia _____________________________________________ * Tonsillectomy ________________________________________ * Dental Surgery _______________________________________ * Joint Replacement –Knee/Hip __________________________

* Heart Surgery–Bypass Valve ___________________________ * Angioplasty or Stent __________________________________ * Pacemaker __________________________________________ * GI Surgery __________________________________________ * Caesarean section ____________________________________ * Other _______________________________________________ * None ______________________________________________

BLOOD TYPE: *A * B * AB * O * Rh+ * Unknown HOSPITALIZATIONS


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*None Date: Reason:

TRAVEL HISTORY Foreign travel? �Yes �No Where? __________________________________________ Wilderness camping? �Yes �No Where? _______________________________________ When traveling or camping, have you ever experienced severe: �Gastroenteritis �Diarrhea DENTAL HISTORY * Silver Mercury Fillings How many? __________ * Gold Fillings * Root Canals How many? ____________ * Implants * Tooth Pain * Bleeding Gums * Gingivitis * Problems with Chewing Do you floss regularly? �Yes �No ENVIRONMENTAL AND DETOXIFICATION ASSESSMENT Which of these significantly affect you? Check all that apply. *Cigarette Smoke *Perfumes/Colognes *Auto Exhaust Fumes *Other: __________________ In your work or home environment, are you exposed to: *Chemicals *Electromagnetic Radiation *Mold Have you ever turned yellow (jaundiced)? �Yes �No Have you ever been told you have Gilbert’s syndrome or a liver disorder? �Yes �No Do you have a known history of significant exposure to any harmful chemicals such as the following: *Herbicides *Insecticides (frequent visits of exterminator) *Pesticides *Organic Solvents *Heavy Metals *Other__________________________________________ Chemical Name, Date, Length of Exposure: ______________________________________________ Do you dry clean your clothes frequently? �Yes �No Have you lived/worked in a damp or moldy environment or had other mold exposures? �Yes �No Do you have any pets or farm animals? �Yes �No I currently live in a � house/� apartment that I � rent/ � own. Do you have any unrepaired leaks in your home? �Yes �No WOMEN’S HISTORY (IF APPLICABLE)


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Age at First Period: ______ How often do you get your period? ______ How many days does your period last? ______ Has your period ever skipped? ______ For how long? ______ Last Menstrual Period: ___________ Use of hormonal contraception such as: * Birth Control Pills *Patch *Nuva Ring How long? ______ Do you use contraception? �Yes �No *Condom *Diaphragm *IUD *Partner Vasectomy Are you in menopause? Yes No Age at Menopause___________ * Use of hormone replacement therapy How long?______________________ OBSTETRIC HISTORY (Check box if yes and provide number) Are you currently pregnant? O Yes O No Are you currently breastfeeding? O Yes O No * Pregnancies _________________ * Caesarean __________________ * Vaginal deliveries __________________ * Miscarriage _________________ * Abortion ____________________ * Living Children ___________________ * Post-‐Partum Depression * Gestational Diabetes (Baby Over 8 Pounds) * Breast Feeding For how long? Child #1 _______ Child #2 _______ Child #3 _______ Child #4 _____ MEN’S HISTORY (IF APPLICABLE) Have you had a PSA done? �Yes �No PSA Level: *-‐2 *2-‐4 *4-‐10 *>10 *Prostate Enlargement *Prostate infection *Change in Libido *Impotence *Difficulty Obtaining an Erection *Difficulty Maintaining an Erection *Nocturia (urination at night) How many times at night? ________ *Urgency/Hesitancy/Change in Urinary Stream *Loss of Control of Urine CURRENT MEDICATIONS


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MEDICATION DOSE FREQUENCY START DATE (MONTH/YEAR) REASON FOR USE

PREVIOUS MEDICATIONS: Last 10 years MEDICATION DOSE FREQUENCY START DATE (MONTH/YEAR) REASON FOR USE

NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY) SUPPLMENT AND BRAND

DOSE FREQUENCY START DATE (MONTH/YEAR) REASON FOR USE

NUTRITION HISTORY


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Height (feet/inches) __________ Current weight ___________ Usual Weight Range +/-‐ 5 lbs ___________ Desired Weight Range +/-‐ 5 lbs ____________ Highest adult weight _______________ Lowest adult weight _______________ Weight Fluctuations (>10 lbs) �Yes �No Have you ever had a nutrition consultation? �Yes �No Have you made any changes in your eating habits because of your health? �Yes �No Describe: ________________________________________________________________________________________ Do you currently follow a special diet or nutritional program? �Yes �No Check all that apply: * Low Fat * Low Carbohydrate * High Protein * Low Sodium * Diabetic * Dairy-‐Free * 100% Gluten-‐Free * Gluten-‐Limited * Vegetarian * Vegan * Paleo * Other __________________________________________________________________________________________________ Why do you follow this diet? ________________________________________________________ __________________________________________________________________________________________________________________________________________________________ Are you willing to change your diet? __________________________________________________________________ How often do you weigh yourself? � Daily � Weekly O Monthly � Rarely � Never Do you avoid any particular foods? �Yes �No If yes, types and reason _____________________________________________________________ _____________________________________________________________________________ Do you feel like you digest your food well? �Yes �No Do you feel bloated after meals? �Yes �No What foods do you eat most often? ___________________________________________________________________ __________________________________________________________________________________________________ Do you grocery shop? �Yes �No If no, who does the shopping? _______________________________________________________________________ Do you read food labels? �Yes �No Do you cook? �Yes �No If no, who does the cooking? _______________________________________________ How many meals do you eat out per week? * 0-‐1 * 1-‐3 * 3-‐5 * >5 meals per week What are your barriers to eating well? __________________________________________________ ____________________________________________________________________________ The most important thing I should change about my diet to improve my health is:


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SOCIAL HISTORY SMOKING Currently Smoking? �Yes �No How many years? __________ Packs per day: __________ Attempts to quit: __________ Previous Smoking: How many years? __________ Packs per day? __________ Second Hand Smoke Exposure? __________ CAFFEINE INTAKE Caffeine Intake: �Yes �No Coffee cups/day: *1 *2-‐4 *> 4 | Tea cups/day: *1 *2-‐4 *> 4 Caffeinated Sodas or Diet Sodas Intake: �Yes �No 12-‐ounce can/bottle *1 *2-‐4 *> 4 per day List favorite type (Ex. Diet Coke, Pepsi, etc.): _______________________________________________ Rate your willingness to temporarily remove caffeine from your diet, if advised � 5 � 4 � 3 � 2 � 1 SUGAR INTAKE Do you have frequent sugar cravings? �Yes �No How often do you eat sugary foods or beverages per week? ___________ Do you add sweeteners (honey, maple, agave, stevia, sugar, artificial sweeteners) to your food/beverages? �Yes �No Rate your willingness to temporarily remove sugar from your diet � 5 � 4 � 3 � 2 � 1 ALCOHOL INTAKE How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits * None * 1-‐3 *4-‐6 * 7-‐10 *> 10 If “None,” skip to Other Substances Previous alcohol intake? �Yes (�Mild �Moderate �High) � None Rate your willingness to temporarily remove alcohol from your diet � 5 � 4 � 3 � 2 � 1 DRUGS Are you currently using any recreational drugs? �Yes �No Type_______________________________________________________________________________________________________ Have you ever used IV or inhaled recreational drugs? �Yes �No EXERCISE Current Exercise Program: (List type of activity, number of sessions/week, and duration)

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Rate your level of motivation for including exercise in your life? � Low � Medium � High

List problems that limit activity: ________________________________________________________ PSYCHOSOCIAL Are you happy? �Yes �No Do you feel your life has meaning and purpose? �Yes �No Do you like the work you do? �Yes �No


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STRESS/COPING Have you ever sought counseling? �Yes �No Are you currently in therapy? �Yes �No Describe: __________________________________________________________________________________________ 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 Daily Stressors: Rate on scale of 1-‐10 Work _____ Family _____ Social _____ Finances_____ Health_____ Other_____ Do you practice meditation or relaxation techniques? �Yes �No How often? __________ Check all that apply: *Yoga *Meditation *Imagery *Breathing *Tai Chi *Prayer *Other: _________________________________________________________________________ SLEEP/REST Average number of hours you sleep per night: *>10 *8-‐10 *6-‐8 *< 6 Do you have trouble sleeping? �Yes �No Do you snore? �Yes �No Do you use sleeping aids? �Yes �No Explain: ___________________________________________________________________________________________ ROLES/RELATIONSHIP Marital status: � Single � Married � Divorced �Gay/Lesbian � Long Term Partnership �Widow List Children:

Child’s Name Age Gender

Who is living in Household? Number: _________________________________________________________________ Names:____________________________________________________________________________________________ Their employment/Occupations:______________________________________________________________________ Resources for emotional support? Check all that apply: *Spouse *Family *Friends *Religious/Spiritual *Pets *Other: _______________________________________ Are you satisfied with your sex life? �Yes �No


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CAREGIVER INFORMATION If parents were married, when? ___________________________ If separated, when? _________________ If divorced, when? __________________________ If remarried, when? ________________________________ Custody arrangements: ________________________________________________________________________ MOTHER – PERSONAL FATHER – PERSONAL Age at your birth ____________________________ Age at your birth __________________________ Education __________________________________ Education ________________________________ Ethnicity ___________________________________ Ethnicity ________________________________ Blood type __________________________________ Blood type ______________________________ 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.................................................................................... O 5 O 4 O 3 O 2 O 1 Take several nutritional supplements each day......................................................... O 5 O 4 O 3 O 2 O 1 Keep a record of everything you eat certain days............................................................O 5 O 4 O 3 O 2 O 1 Modify your lifestyle (e.g., work demands, sleep habits) .............................................. O 5 O 4 O 3 O 2 O 1 Practice a relaxation technique ....................................................................................... O 5 O 4 O 3 O 2 O 1 Engage in regular exercise ............................................................................................. O 5 O 4 O 3 O 2 O 1 Comments ________________________________________________________________________________________ __________________________________________________________________________________________________ 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? O 5 O 4 O 3 O 2 O 1 If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in the above activities? ___________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 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 life will be to your implementing the above changes? O 5 O 4 O 3 O 2 O 1 Comments: _______________________________________________________________________________________


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ADDITIONAL QUESTIONS FOR PEDIATRIC PATIENTS (Ages 0-‐13) PATIENT BIRTH HISTORY Pediatric Patients MOTHER’S PAST PREGNANCIES Number of: Pregnancies _________ Live births: __________ Miscarriages: ____________ MOTHER’S PREGNANCY Check box if yes and provide date

* Difficulty getting pregnant(more than 6 months) ______

______________________________

* Group B strep infection _____________________________

* Infertility drugs used Specify:_______________________ * Have c-‐section because of__________________________

* In vitro fertilization _______________________________ * Use induction for labor (such as Pitocin)_______________

* Drink alcohol ____________________________________ * Have anaesthesia – what was used? ___________________

* Smoke tobacco __________________________________ * Use oxygen during labor ____________________________

* Take Progesterone ________________________________ * Have Rhogam, if so how many shots_________________

* Take prenatal vitamins ____________________________ How many when pregnant? _________________________

* Take antibiotics � During Labor?____________________ * Gestational Diabetes________________________________

* Take other drugs Specify:___________________________ * High blood pressure(pre-‐eclampsia)___________________

* Excessive vomiting, nausea (more than 3 weeks)_____ * High blood pressure/toxemia_______________________

* Have a viral infection _____________________________ * Have chemical exposure ____________________________

* Have a yeast infection _____________________________ * Father have chemical exposure ______________________

* Have amalgam fillings put in teeth__________________ * Move to newly built house ___________________________

* Have amalgam fillings removed from teeth____________ * House painted indoors ____________________________

* Number of fillings in teeth when pregnant?____________ * House painted outdoors ____________________________

* Have bleeding (which months?)____________________ * House exterminated for insects _______________________

* Have birth problems ______________________________

PREGNANCY Total weight gain during pregnancy: ______lb Total weight loss during pregnancy: _______lb Please describe diet during pregnancy:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Please describe labor: ____________________________________________________________________________________________

PERINATAL

Pregnancy duration: X preceding the week of gestation Ο 24 Ο 25 Ο 26 Ο 27 Ο 28 Ο 29 Ο 30 Ο 31 Ο 32 Ο 33 Ο 34 Ο 35 Ο 36 Ο 37 Ο 38 Ο 39 Ο 40(full term) Ο 41 Ο 42 Ο 43 Ο 44 Weeks Very active before birth? Ο Yes Ο No Hospital/Birthing Center? Ο Yes Ο No Who are the main people who care for your child? ________________________________________________ Their Employment/Occupation: ________________________________________________________________


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Resources for emotional support? SPACE FOR ADDITIONAL NOTES


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Combined Intake Draft 8.4.14amymyersmd.com.s3.amazonaws.com/downloads/Intake-9.29.14.pdf"""""...

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