Integrative Health Evaluation Form

Initial Integrative Health Evaluation Form - Version 2

"*" indicates required fields

Name*

First Last

Date Of Birth*

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*

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:

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, CMV, herpes (I or II), EBV or Lyme Disease?*

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?*

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?*