Whole Health Assessment
​(Please copy and paste to a Word document. Highlight all of the symptoms/and answer questions that apply to you. turn into PDF & send to provider.)​
Whole Body Symptoms (ROS):
• GENERAL Body: burned out feeling, decreased stamina, difficulty falling asleep, difficulty staying asleep, excessive energy, can’t calm down, decreased motivation, addictive behavior (sex, food, alcohol, drugs), rapid aging, body dysphoria, unhealthy eating behaviors, dependence on alcohol, marihuana, or other substances.
•EYES, EARS, NOSE, THROAT: vision changes, hearing decreased, ringing in ears, hoarseness, neck fullness, bulging eyes, dental problems, hoarseness, ear pain, ear fullness, sinus issues, hay fever,
-MOUTH: Amalgam fillings, root canals, deep cleaning, gingivitis, tooth extractions, crowns, dentures, tooth pain, jaw pain, broken teeth, visible tooth decay, cavities, bad breath, coated tongue
• CARDIAC: cold extremities, elevated blood pressure, low blood pressure, irregular heartbeat, heart palpitations, slow pulse rate, rapid heart rate, fainting, feeling lightheaded w/standing
• RESPIRATORY: breathing difficulties, asthma history, easily short of breath, mucousy cough, congestion, tickle cough, dry cough, pain w/breathing
•GASTROINTESTINAL: heartburn, acid reflux, bloating, abdominal discomfort, milk intolerance, gluten sensitivity, constipation, loose stools, nervous stomach, increased farting, increased burping, vomiting, nausea
•GENITOURINARY: fluid retention (puffy feet or hands), decreased interest in sex, increased interest in sex, urinary frequency, urinary incontinence, infertility problems, miscarriage, pain w/sex, pain w/urinating
Females: vaginal dryness, irregeg periods, uterine fibroids, PCOS, ovarian cysts,t ender breasts, fibrocystic breasts, increased facial hair, increased body hair, last period:_____ Birth control method:_______________
Men: decr’d urine stream, increased urinary urge, prostate enlargement, Erectile issues, premature ejaculation
•ENDOCRINE: exhausted, morning fatigue, afternoon tiredness, evening tiredness, energized at bedtime, increased sweating, night sweats, sugar cravings, hot flashes, hair falls out easily, excessive hair growth, brittle hair, scalp hair loss, unintentional weight loss/gain, can't calm down, nervous energy, weight gain at waist
•SKIN: frequent breakouts, acne problems (face, back, chest) very dry skin; nails are thin, peel, or break easily; bruise easy, thinning skin, Rosacia, eczema, Psoriasis, red patches, nail fungus, skin easily red or flushed
• MSK: muscle/joint aches & pains, stiffness, fibromyalgia, decreased strength, decreased muscle mass, bone loss, fractured bones, head injury, whiplash history, stiff/tense neck & shoulders, decreased head pivot
•NEURO: decr mental sharpness, memory issues, regular headaches, frequent migraines, dizziness, light-headed, seizure history, tremors, easily overstimulated, Forgetfulness, Focus/Concentration issues, Distractible
•PSYCHIATRIC: stressed, overthinking, excessive worry, nervous, difficulty concentrating, forgetfulness, tearful, depressed, mood swings, OCD type behavior, poor impulse control, can’t turn off brain, isolating behaviors
•IMMUNE: allergies, food sensitivities, recent antibiotics, recent infections, catch colds/flus every 1-2 months, history of anaphylaxis to foods/medicines, dental problems, COVID illness, Cancer history
•LABS: high blood sugars, hypoglycemia, high A1C, high cholesterol, abnormal Vitamin D3, thyroid problems, Abnormal B12 levels, Abnormal MTHFR, history of anemia, Diabetic, liver disease, heart disease
Surgical History: Tonsillectomy, Appendectomy, Ear tubes placed, thyroid, wisdom teeth, other: __________
Strenuous Exercise
Poor Immune Health
Busy/Stressful Life
Inflammatory Habits
Wellness-Illness Assessment
​(Please copy and paste to a Word document. Highlight all of the symptoms/and answer questions that apply to you. turn into PDF & send to provider.)​
Wellness-IIlness Map
Psychiatric Symptoms: Depression, Anxiety, Insomnia, Mania, Irritability, Psychosis, Compulsions, Inattention, Brain Fog, Fatigue, headaches, Impulsivity, Self-harm, Hostility, Overthinking, Easily upset, Difficulty with schedule changes, Apathy, Low motivation
LIFESTYLE:
-Relationships: single, engaged, married, monogamous, polyamourous, heterosexual, homosexual, pansexual, healthy, unstable, changing
-Communication in relationships: superficial, deep; emotional; passive, healthy, volatile, blaming, balanced, loud, easily misunderstood
-Do you experience feelings of isolation? yes no
-What is your attachment style? secure, avoidant, ambivalent, anxious
What is your partner's attachment style? secure, avoidant, ambivalent, anxious
-What are your Sleep patterns like? Bed at _____ Wake at ____ Nap during day? yes No
Do you take anything to help you sleep? No Yes: _________________________________________________
-Do you struggle with falling asleep, staying asleep, Insomnia, circadian rhythm disruptions, or sleep apnea?
Habits:
-What do you use to help you manage your moods? Nothing Meds Meditation Prayer Faith Alcohol Marijuana CBD other: _______
-____ hours/day screen time? Shows Movies Tick toc Instagram Facebook Reddit Social media Workscreen Phone
-Do you tend to: Avoid stress/problems/bills,
Eating habits: Skip meals, Forget to eat, under eat, Binge eat (continuing to eat after you are full)
-restrictive eating (skipping meals, limiting size of meals, limiting types of foods you'll eat, other:
-Marijuana use: none daily several times per week. Use to relax, cope with stress, manage your moods, have "fun", deal w/anxiety, other;
-Alcohol use: avoid, use regularly, to relax, help with sleep, calm down, decrease social anxiety, to have "fun", other:
--number of drinks tend to have per episode: 0 1 2 3 4 5 6 7, 8, >8
--types of drinks you enjoy: cocktails, hard seltzer, beer, wine, whiskey, bourbon, other:
Nutrition/Eating Habits:
-Nutrition Habits: Breakfast: none, small, med, large; Lunch: none, small, med, large; Dinner: small, Med, Large; Overeat, Restrict, Binge
-How often do you order out/eat out: ___ none, 1-2x wk, >3 times week How often do you eat food from a box/fast food:____ per wk
-Dietary Preferences: Standard diet, Vegan, Lacto-ovo vegetarian, Pescatarian, Keto, Paleo, Whole Foods, Gluten free, Casein Free, Fodmap
-Do you eat organic foods often?
-Alcohol use: none, rare, several times week, on weekends; wine, beer, cocktails, cider; average number of drinks in a session: _______
Toxic exposure risk:
-pollution, mold, non-organic foods, processed foods, High fructose corn syrup, Sodas, alcohol, nicotine, smoking
-Detox practices: Steam sauna, infared sauna, hyperbarics, cold therapy, fasting, intermittent fasting, other:______________________.
-Food Sensitivities: Nuts, Sugar, Soy, Corn, Gluten, Wheat, Dairy, Eggs, Shellfish, Seafood, Chicken, Red meat, other:
-Allergies: Metals, plastics, chemicals, perfumes, Gluten, Soy, corn, Casein, Iodine, Shellfish, Stone fruit, Peanuts, Tree nuts, Coconut
Physical Activity/Exercise:
-Flexibility: Low, medium, High; Muscular Strength: low, medium, high; Endurance: Low, medium, high; Heart rate variability: __________.
-Types of Exercise: stretching, yoga, pilates, walking, jogging, running, swimming,
MIND:
Learning: No problems. Slow to read. Math difficult. Higher math impossible. Auditory learner. Kinetic learner. Read to learn.
Trauma: childhood, adolescence, adult; exposure to domestic violence, assault, neglect, accident, witness/victim of crime, bullied
-Early significant loss in childhood or adolescence; Betrayal of significant other/friend,
-Symptoms: zoning out, losing time, memory triggers, physical reaction: heart racing, feeling stuck, feeling "in your head", freeze, flight
Beliefs-Political thoughts, disempowerment, values,
Spirituality
-Faith foundation: Agnostic, Atheist, Buddhist, Catholic, Evangelical, Jewish, Muslim, Universalist, New Age, Unsure
-spiritual betrayal, spiritual abuse; faith pursuit, making meaning, search for truth/meaning, other:
-Grief/loss: significant loss: friend, family, pet; cont to feel: numb, anger, bargaining, acceptance, disconnection
BODY:
Gut-Brain Axis: Gastrointestinal Dysbiosis, Microbiome,
-Leaky Gut (bloating, gas, rapid transit, constipation, allergies, skin issues, antibiotics, infection)
Metabolic-Regulation: Thyroid issues (Hypo/Hyper thyroid, Grave's disease, Hashimotos); Insulin Resistance, Hypoglycemia, Diabetes,
Difficulty losing weight, Hair thinning (eyebrows, scalp); weight gain around waist/hips
-Hormone imbalance (Estrogen, Progesterone, Testosterone, Insulin
Genetic Dysfunction: MTHFR, APOE4
Cancer: Brain, Breast, Blood, Bladder, Bone, Ovarian, Uterine, Prostate, Colon, Thyroid,
Brain Optimization:
-Head injury/TBI: minor injury, concussion, post concussion symptoms: sleep issues, irritability, word-finding, expressive issues, ADHD -Mitochondrial dysfunction, Neurodegenerative changes (slowed recall, memory, cognition,
Immune modulation: Infectious, autoimmune, inflammation
Detoxification: Metals, Molds, metabolites
