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Home
About
Deanna
Genomind
Genetic
Testing
Fullscript
Supplement
Dispensary
Enlyte
Fees, Forms
& Services
Gift Cards
Contact
Initial Integrative Health Evaluation Form - Version 2
"
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" indicates required fields
Name
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First
Last
Date Of Birth
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MM slash DD slash YYYY
Address
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Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email Address
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Phone Number
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Preferred Pharmacy
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Current Mental Health Symptoms
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On a scale of 1-10 (10 being the worst symptoms) please rate your degree of depression and anxiety
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Are you currently working with a therapist? If so-please list name
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Current and Past Mental Health Diagnoses
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Current and Past Primary Care Medications
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Current Supplements and Vitamins
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Current Psychiatric Medications
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Past Psychiatric Medication Trials And Responses
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Psychiatric Hospitalizations
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Psychiatric Family History
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Current and Past Suicidal Thoughts
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Current and Past Psychotic Thoughts (includes hearing voices, seeing things that aren’t there and delusional/irrational thoughts)
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Primary Care Physician
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Please List Any Other Health Care Providers You Are Currently Seeing
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Current Height and Weight
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Any Recent Changes in Weight
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Medical History with Current and Past Diagnoses
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Have you had any lab work done in the past 6 months?
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If female, please describe your menstrual history and current status:
Have you had any genetic testing done (23 and me, nutrigenomic, Genomind, Genesight)? If so-please list
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Allergies
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Current and Past Gastrointestinal Symptoms (nausea, diarrhea, bloating, constipation)
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Please list any lifetime antibiotic use:
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Do you experience any kind of unexplained pain on a regular basis? If so-please explain
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Do you experience headaches? If so-please describe type and frequency
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Do you have any ongoing skin issues (rashes, vibratory sense, numbness or tingling)? If so-please describe:
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Medical Family History (diabetes, heart disease, cancer, autoimmune disease)
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Surgical History
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Dental History (root canals, extractions, silver fillings, etc)
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Any known moisture/mold in homes you have lived in?
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Are there any high-powered wires or cell towers within a mile of your home?
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Do you have any known current or past infections such as HIV, CMV, herpes (I or II), EBV or Lyme Disease?
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Have you ever been infected with COVID 19? If so, when and please describe your course of illness. Do you think you have any lingering symptoms?
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Have you ever had a tick bite that you remember?
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Current and Past Nicotine Use
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Current and Past THC/CBD Use
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Current and Past Alcohol Use
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Current Caffeine Use
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Any other current substance use (please include pain pills, over the counter medications, stimulants or other prescription drug use/abuse)
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Current Diet (Standard American, vegan, vegetarian, plant-based, ketogenic, etc.)
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Current Dietary Restrictions (dairy-free, low FODMAP, gluten-free, low-oxalate, nut-free, etc.)
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Current Use of Artificial Sweeteners
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Current Level of Exercise and Frequency
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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?)
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How Do You Relax?
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Education (GED, high school grad, level of college achievement)
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Current Employment
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If working-do you enjoy your job?
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Primary Support System (who do you turn to for support when needed?)
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Please list current household members
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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)
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Do you practice any religion?
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Have you experienced any childhood trauma? Do you feel that it still affects you today? If so, please briefly share
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Have you experienced any adult trauma? If so, please briefly share
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Please list hobbies and interests
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Please describe a time when you felt at your best
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Do you believe you are able to achieve this state again?
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What are your current health and mental health goals?
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What is your current level of motivation toward these goals? (highly-motivated, fairly-motivated, not very motivated)
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Do you have any additional information that would be helpful for us to know?
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