Integrative Health Evaluation Form

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Allmond Wellness 37

About
Deanna
Holistic
ADHD Certified
Genomind
Genetic
Testing
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About
Deanna
Holistic
ADHD Certified
Genomind
Genetic
Testing
Fullscript
Supplement
Dispensary
Fees, Forms
& Services
Gift Cards
Contact

Initial Integrative Health Evaluation Form - Version 2

"*" indicates required fields

Name*

First Last

Date Of Birth*

MM slash DD slash YYYY

Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Phone Number*

Preferred Pharmacy*

Current Mental Health Symptoms*

On a scale of 1-10 (10 being the worst symptoms) please rate your degree of depression and anxiety*

Are you currently working with a therapist? If so-please list name*

Current and Past Mental Health Diagnoses*

Current and Past Primary Care Medications*

Current Supplements and Vitamins*

Current Psychiatric Medications*

Past Psychiatric Medication Trials And Responses*

Psychiatric Hospitalizations*

Psychiatric Family History*

Current and Past Suicidal Thoughts*

Current and Past Psychotic Thoughts (includes hearing voices, seeing things that aren’t there and delusional/irrational thoughts)*

Primary Care Physician*

Please List Any Other Health Care Providers You Are Currently Seeing*

Current Height and Weight*

Any Recent Changes in Weight*

Have you experienced any concerns related to brain or nervous system function? (Check all that apply.)*

Memory problems or increased forgetfulness

Difficulty concentrating or staying focused

"Brain fog" or mental sluggishness

Difficulty finding words or following conversations

Slower thinking or processing information

Frequent headaches or migraines

Dizziness or balance problems

Tremors or shaking

Numbness or tingling

Changes in vision not explained by your eye doctor

None of the above

Medical History with Current and Past Diagnoses*

Have you had any lab work done in the past 6 months?*

If female, please describe your menstrual history and current status (please include hormonal contraception history):

Have you had any genetic testing done (23 and me, nutrigenomic, Genomind, Genesight)? If so-please list*

Allergies*

Current and Past Gastrointestinal Symptoms (nausea, diarrhea, bloating, constipation)*

Please list any lifetime antibiotic use:*

Do you experience any kind of unexplained pain on a regular basis? If so-please explain*

Do you experience headaches? If so-please describe type and frequency*

Do you have any ongoing skin issues (rashes, vibratory sense, numbness or tingling)? If so-please describe:*

Medical Family History (diabetes, heart disease, cancer, autoimmune disease)*

Surgical History*

Dental History (root canals, extractions, silver fillings, etc)*

Any known moisture/mold in homes you have lived in?*

Are there any high-powered wires or cell towers within a mile of your home?*

Do you have any known current or past infections such as HIV, HPV, CMV, herpes (I or II), EBV or Lyme Disease?*

Have you had COVID 19? If so, when? Any long term consequences? Have you had COVID vaccines or boosters? Please list dates and company used.*

Have you ever had a tick bite that you remember?*

Current and Past Nicotine Use*

Current and Past THC/CBD Use*

Current and Past Alcohol Use*

Current Caffeine Use*

Any other current substance use (please include pain pills, over the counter medications, stimulants or other prescription drug use/abuse)*

Current Diet (Standard American, vegan, vegetarian, plant-based, ketogenic, etc.)*

Current Dietary Restrictions (dairy-free, low FODMAP, gluten-free, low-oxalate, nut-free, etc.)*

Current Use of Artificial Sweeteners*

Current Level of Exercise and Frequency*

Current Typical Sleep-Wake Pattern (What time do you go to bed? How often do you wake? What time do you wake up? Do you feel well rested during day? Do you snore?)*

How Do You Relax?*

Education (GED, high school grad, level of college achievement)*

Current Employment*

If working-do you enjoy your job?*

Primary Support System (who do you turn to for support when needed?)*

Please list current household members*

Please list all members of your immediate family (siblings and parents) and any pertinent dynamics (ie. Are you close/estranged and did you grow up with them)*

Do you practice any religion?*

Have you experienced any childhood trauma? Do you feel that it still affects you today? If so, please briefly share*

Have you experienced any adult trauma? If so, please briefly share*

Please list hobbies and interests*

Please describe a time when you felt at your best*

Do you believe you are able to achieve this state again?*

What are your current health and mental health goals?*

What is your current level of motivation toward these goals? (highly-motivated, fairly-motivated, not very motivated)*

Do you have any additional information that would be helpful for us to know?*

About
Deanna
Holistic
ADHD Certified
Genomind
Genetic
Testing
Fullscript
Supplement
Dispensary
Fees, Forms
& Services
Gift Cards
Contact

Menu

About
Deanna
Holistic
ADHD Certified
Genomind
Genetic
Testing
Fullscript
Supplement
Dispensary
Fees, Forms
& Services
Gift Cards
Contact

Any recommendations being provided should be discussed with current health provider.

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