Escolar Documentos
Profissional Documentos
Cultura Documentos
Single
Marital Status:
Partner
Married
Separated
Divorced
Widow(er)
Are you recovering from a cold or flu? ____________ Are you pregnant? ____________
Reason for office visit
Date began
__________________________________________________________________________________________________________________
_________________________
__________________________________________________________________________________________________________________
_________________________
Date of last physical exam ___________ Practitioner name and phone number___________________________________________________________________________
Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis)
_______________________________________________________________________________________________________________________________________________
Outcome ______________________________________________________________________________________________________________________________________
What types of therapy have you tried for this problem(s):
diet modification
other
fasting
vitamin/mineral
herbs
homeopathy
chiropractic
acupuncture
conventional drugs
__________________________________________________________________________________________________________________________________
List current health problems for which you are being treated: __________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Current medications (prescription or over-the-counter): ________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates:
Year
Outcome
____________
_____________________________________________________________________________
_________________________________________________
____________
_____________________________________________________________________________
_________________________________________________
Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest):
10
Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems): ______________________________________________________
underweight
overweight
just right
Unintentional weight loss or gain of 10 pounds or more in the last three months
Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, farmer, miner)
_______________________________________________________________________________________________________________________________________________
Corrective lenses
Dentures
Hearing aid
see
hear
taste
smell
________________________________
move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers)
Strong like for any of the following flavors:
sour
bitter
sweet
rich/fatty
spicy/pungent
salty
sour
bitter
sweet
rich/fatty
spicy/pungent
salty
Do you:
Prefer warmth (i.e., food, drinks, weather etc.) Prefer cold (i.e., food, drinks, weather, etc.) No preference
Is your sleep disturbed at the same time each night? _______ If yes, what time? _______
Time of day you feel the most energy or the least symptoms:
7 a.m. - 9 a.m.
1 p.m. - 3 p.m.
7 p.m. - 9 p.m.
1 a.m. - 3 a.m.
9 a.m. - 11 a.m.
3 p.m. - 5 p.m.
9 p.m. - 11 p.m.
3 a.m. - 5 a.m.
Time of day you feel the worst or your symptoms are aggravated:
11 a.m. - 1 p.m.
5 p.m. - 7 p.m.
11 p.m. - 1 a.m.
5 a.m. - 7 a.m.
7 a.m. - 9 a.m.
1 p.m. - 3 p.m.
7 p.m. - 9 p.m.
1 a.m. - 3 a.m.
9 a.m. - 11 a.m.
3 p.m. - 5 p.m.
9 p.m. - 11 p.m.
3 a.m. - 5 a.m.
11 a.m. - 1 p.m.
5 p.m. - 7 p.m.
11 p.m. - 1 a.m.
5 a.m. - 7 a.m.
Debilitating fatigue
Depression
Disinterest in sex
Disinterest in eating
Shortness of breath
Panic attacks
Headaches
Dizziness
Insomnia
Nausea
Vomiting
Diarrhea
Constipation
Fecal incontinence
Urinary incontinence
Low grade fever
Chronic pain/inflammation
Bleeding
Discharge
Itching/rash
Medical History
Arthritis
Allergies/hayfever
Asthma
Alcoholism
Alzheimers disease
Autoimmune disease
Blood pressure problems
Bronchitis
Cancer
Chronic fatigue syndrome
Carpal tunnel syndrome
Cholesterol, elevated
Circulatory problems
Colitis
Dental problems
Depression
Diabetes
Diverticular disease
Drug addiction
Eating disorder
Epilepsy
Emphysema
Eyes, ears, nose, throat problems
Environmental sensitivities
Fibromyalgia
Food intolerance
Gastroesophageal reflux disease
Genetic disorder
Glaucoma
Gout
Heart disease
Infection, chronic
Inflammatory bowel disease
Irritable bowel syndrome
Kidney or bladder disease
Learning disabilities
Liver or gallbladder disease
(stones)
Mental illness
Mental retardation
Migraine headaches
Neurological problems
(Parkinsons, paralysis)
Sinus problems
Stroke
Thyroid trouble
Obesity
Osteoporosis
Pneumonia
Sexually transmitted disease
Seasonal affective disorder
Skin problems
Tuberculosis
Ulcer
Urinary tract infection
Varicose veins
Other ___________________________
_________________________________
Medical (Men)
BPH
Prostate cancer
Medical (Women)
Menstrual irregularities
Endometriosis
Infertility
Fibrocystic breasts
Fibroids/ovarian cysts
PMS
Breast cancer
Pelvic inflammatory disease
Vaginal infections
Decreased sex drive
STD
Other ___________________________
Age of first period ______
Date of last gynecological exam ____
Mammogram +
PAP +
(Parkinsons, paralysis)
Obesity
Osteoporosis
Stroke
Suicide
Other ___________________________
Health Habits
Tobacco:
Cigarettes: #/day _________________
Cigars: #/day ____________________
Alcohol:
Wine: #glasses/d or wk ___________
Liquor: #ounces/d or wk ___________
Beer: #glasses/d or wk ____________
Caffeine:
Coffee: #6 oz cups/d ______________
Tea: #6 oz cups/d ________________
Soda w/caffeine: #cans/d __________
Other sources _____________________
Water: #glasses/d_______________
Exercise
5-7 days per week
3-4 days per week
1-2 days per week
45 minutes or more duration per
workout
vegetable sources)
Vegetarian
Vegan
Salt restriction
Fat restriction
Starch/carbohydrate restriction
The Zone Diet
Total calorie restriction
Specific food restrictions:
dairy wheat eggs
soy corn all gluten
Other ___________________________
Food Frequency
Servings per day:
Fruits (citrus, melons, etc.) ___________
Dark green or deep yellow/orange
vegetables _______________________
Grains (unprocessed) ______________
Beans, peas, legumes _____________
Dairy, eggs _____________________
Meat, poultry, fish _________________
Eating Habits
Skip breakfast
Two meals/day
One meal/day
Graze (small frequent meals)
Food rotation
Eat constantly whether hungry
or not
Generally eat on the run
Add salt to food
Current Supplements
Multivitamin/mineral
Vitamin C
Vitamin E
EPA/DHA
Evening Primrose/GLA
Calcium, source ________________
Magnesium
Zinc
Minerals, describe _____________
Friendly flora (acidophilus)
Digestive enzymes
Amino acids
CoQ10
Antioxidants (e.g., lutein,
resveritrol, etc.)
Herbs - teas
Herbs - extracts
Chinese herbs
Ayurvedic herbs
Homeopathy
Bach flowers
Protein shakes
Superfoods (e.g., bee pollen,
phytonutrient blends)
Liquid meals (e.g., Ensure)
Other ___________________________
focused
Improve memory
Do better on tests in school
Not be dependent on over-thecounter medications like aspirin,
Tylenol, Benadryl, sleeping aids, etc.
Stop using laxatives or stool
softeners
Be free of pain
Sleep better
Have agreeable breath
Have agreeable body odor
Have stronger teeth
Get less colds and flus
Get rid of your allergies
Reduce your risk of inherited disease tendencies (e.g., cancer,
heart disease, etc.)
2000 Lyra Heller, Michael Katke and Chris Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.
MET427 7/00
Dysbiosis Questionnaire
Please read this prior to completing the Patient Response
Dysbiosis refers to the condition where the normal healthy population of beneficial bacteria
in the intestines has been disrupted, leaving it open to the overgrowth of yeast, fungi,
parasites, and potentially harmful strains of bacteria. This intestinal imbalance in turn
adversely effects other important organ systems via toxic stress and interfering with nutrient
absorption and utilization.
1399 Ygnacio Valley Road, Suite 31 Walnut Creek, CA 94598 925-930-0708 fx 925-930-9921 E-mail drbergman@chirokinetics.com
SECTION A: HISTORY
POINT
SCORE
1. Have you taken any tetracycline or any other antibiotics for skin, acne
or any thing else for a month or longer?
25
2. Have you, at any time in your life, taken other broad spectrum
antibiotics for respiratory, urinary or other infections in shorter courses
4 or more times in a 1 year period?
20
25
25
15
8
5
3
25
15
6
20
5
20
POINT
SCORE
______
______
3. Poor memory
______
______
5. Depression
______
______
7. Muscle aches
______
______
______
______
11. Constipation
______
12. Diarrhea
______
13. Bloating
______
______
10. Have you had athletes foot, ring worm, jock itch or other chronic
fungus infections of the skin or nails?
Severe / persistent
Mild to Moderate
______
20
10
16. Prostatitis
______
10
17. Impotence
______
10
______
10
19. Endometriosis
______
10
______
______
15
______
15
______
15
______
20
20
20. Do you have or have you ever had an ulcer, colitis, crohns disease
or diverticulitis?
35
35
20
Total Score Section A
______
______
Patient
Name_______________________________________
1399 Ygnacio Valley Road, Suite 31 Walnut Creek, CA 94598 925-930-0708 fx 925-930-9921 E-mail drbergman@chirokinetics.com
POINT
SCORE
1. Drowsiness
______
2. Irritability or jitteriness
______
Scores
3. Incoordination
______
4. Inability to concentrate
______
______
6. Headaches
______
______
______
9. Itching
______
______
11. Heartburn
______
12. Indigestion
______
______
______
15. Hemorrhoids
______
______
______
______
______
______
______
______
______
24. Cough
______
______
______
______
______
______
______
______
______
Total Score, Section C
______
______
______
______
______
Patient
Name___________________________________________________
1399 Ygnacio Valley Road, Suite 31 Walnut Creek, CA 94598 925-930-0708 fx 925-930-9921 E-mail drbergman@chirokinetics.com
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
s
SECTION B
1. Strong emotions, or the thought or smell of food
aggravates your stomach or makes it hurt
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION A
1. Feel cold or chilledhands, feet, all overfor no
apparent reason
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1
Total points
Often
Occasionally
Often
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
s
SECTION B
1. Frequent urination day and night
4 8
4 8
4 8
4 8
4 8
8
s
PART V
SECTION A
1. Feel jittery
4 8
4 8
4 8
4 8
4 8
Total points
1
1
2
2
Total points
4 8
4 8
s
Total points
SECTION C
1. Do you feel pent up and ready to explode?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART VI
PART VII
SECTION A
1. Family, friends, work, hobbies or activities you hold
dear are no longer of interest
2. Do you cry?
4 8
4 8
4 8
4 8
4 8
4 8
5. Hoarse voice
4 8
4 8
4 8
4 8
11. Nosebleeds
4 8
4 8
4 8
4 8
8
Total points
Total points
4 8
Total points
4 8
4 8
4 8
4. Vision blurs
4 8
Total points
10. Body hair (on arms, hands, fingers, legs and toes)
is thinning or has disappeared
Rarely
Often
4 8
4 8
4 8
SECTION B
1
Frequently
Occasionally
4 8
Frequently
Rarely
Frequently
Occasionally
4 8
4 8
4 8
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION B (cont.)
4 8
Rarely
Frequently
Often
s
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1. A sense of weakness
4 8
4 8
4 8
PART II
1
Total points
4 8
4 8
4 8
4 8
4 8
4 8
PART V
SECTION B
When you miss meals or go without food for extended periods of time,
do you experience any of the following symptoms?
9. Constipation
SECTION C
PART IV
SECTION A
SECTION D
Total points
4 8
PART III
SECTION C (cont.)
Total points
Frequently
Often
Occasionally
Rarely
Frequently
Often
Rarely
Occasionally
DIRECTIONS
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help to keep track of
how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and
family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to
complete this questionnaire.
Please circle the number that best describes your symptoms. PLEASE LEAVE THE QUESTION BLANK if you never
experience the symptom.
1 = Rarelysymptom is familiar to you but you perceive it as insignificant (monthly or less)
2 = Occasionallysymptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
4 = Oftensymptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something
about it
8 = Frequentlysymptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity
on a monthly or cyclical basis
8 = YES
Some symptoms require a YES or a NO response. 1 = NO
SECTION A
PART II
Date
PART I
Occasionally
Name
Rarely
SECTION B
1. Does worrying get you down?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
s
SECTION B
1. Strong emotions, or the thought or smell of food
aggravates your stomach or makes it hurt
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION A
1. Feel cold or chilledhands, feet, all overfor no
apparent reason
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1
Total points
Often
Occasionally
Often
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
s
SECTION B
1. Frequent urination day and night
4 8
4 8
4 8
4 8
4 8
8
s
PART V
SECTION A
1. Feel jittery
4 8
4 8
4 8
4 8
4 8
Total points
1
1
2
2
Total points
4 8
4 8
s
Total points
SECTION C
1. Do you feel pent up and ready to explode?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART VI
PART VII
SECTION A
1. Family, friends, work, hobbies or activities you hold
dear are no longer of interest
2. Do you cry?
4 8
4 8
4 8
4 8
4 8
4 8
5. Hoarse voice
4 8
4 8
4 8
4 8
11. Nosebleeds
4 8
4 8
4 8
4 8
8
Total points
Total points
4 8
Total points
4 8
4 8
4 8
4. Vision blurs
4 8
Total points
10. Body hair (on arms, hands, fingers, legs and toes)
is thinning or has disappeared
Rarely
Often
4 8
4 8
4 8
SECTION B
1
Frequently
Occasionally
4 8
Frequently
Rarely
Frequently
Occasionally
4 8
4 8
4 8
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION B (cont.)
4 8
Rarely
Frequently
Often
s
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1. A sense of weakness
4 8
4 8
4 8
PART II
1
Total points
4 8
4 8
4 8
4 8
4 8
4 8
PART V
SECTION B
When you miss meals or go without food for extended periods of time,
do you experience any of the following symptoms?
9. Constipation
SECTION C
PART IV
SECTION A
SECTION D
Total points
4 8
PART III
SECTION C (cont.)
Total points
Frequently
Often
Occasionally
Rarely
Frequently
Often
Rarely
Occasionally
DIRECTIONS
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help to keep track of
how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and
family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to
complete this questionnaire.
Please circle the number that best describes your symptoms. PLEASE LEAVE THE QUESTION BLANK if you never
experience the symptom.
1 = Rarelysymptom is familiar to you but you perceive it as insignificant (monthly or less)
2 = Occasionallysymptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
4 = Oftensymptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something
about it
8 = Frequentlysymptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity
on a monthly or cyclical basis
8 = YES
Some symptoms require a YES or a NO response. 1 = NO
SECTION A
PART II
Date
PART I
Occasionally
Name
Rarely
SECTION B
1. Does worrying get you down?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
s
SECTION B
1. Strong emotions, or the thought or smell of food
aggravates your stomach or makes it hurt
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION A
1. Feel cold or chilledhands, feet, all overfor no
apparent reason
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1
Total points
Often
Occasionally
Often
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
s
SECTION B
1. Frequent urination day and night
4 8
4 8
4 8
4 8
4 8
8
s
PART V
SECTION A
1. Feel jittery
4 8
4 8
4 8
4 8
4 8
Total points
1
1
2
2
Total points
4 8
4 8
s
Total points
SECTION C
1. Do you feel pent up and ready to explode?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART VI
PART VII
SECTION A
1. Family, friends, work, hobbies or activities you hold
dear are no longer of interest
2. Do you cry?
4 8
4 8
4 8
4 8
4 8
4 8
5. Hoarse voice
4 8
4 8
4 8
4 8
11. Nosebleeds
4 8
4 8
4 8
4 8
8
Total points
Total points
4 8
Total points
4 8
4 8
4 8
4. Vision blurs
4 8
Total points
10. Body hair (on arms, hands, fingers, legs and toes)
is thinning or has disappeared
Rarely
Often
4 8
4 8
4 8
SECTION B
1
Frequently
Occasionally
4 8
Frequently
Rarely
Frequently
Occasionally
4 8
4 8
4 8
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
SECTION B (cont.)
4 8
Rarely
Frequently
Often
s
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
1. A sense of weakness
4 8
4 8
4 8
PART II
1
Total points
4 8
4 8
4 8
4 8
4 8
4 8
PART V
SECTION B
When you miss meals or go without food for extended periods of time,
do you experience any of the following symptoms?
9. Constipation
SECTION C
PART IV
SECTION A
SECTION D
Total points
4 8
PART III
SECTION C (cont.)
Total points
Frequently
Often
Occasionally
Rarely
Frequently
Often
Rarely
Occasionally
DIRECTIONS
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help to keep track of
how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and
family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to
complete this questionnaire.
Please circle the number that best describes your symptoms. PLEASE LEAVE THE QUESTION BLANK if you never
experience the symptom.
1 = Rarelysymptom is familiar to you but you perceive it as insignificant (monthly or less)
2 = Occasionallysymptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
4 = Oftensymptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something
about it
8 = Frequentlysymptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity
on a monthly or cyclical basis
8 = YES
Some symptoms require a YES or a NO response. 1 = NO
SECTION A
PART II
Date
PART I
Occasionally
Name
Rarely
SECTION B
1. Does worrying get you down?
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART VIII
1. Involuntary loss of urine when you cough, lift
something or strain during an activity
4 8
4 8
4 8
SECTION B (cont.)
8. Intermittent pain or ache on one side of head spreading
to cheek, temple, lower jaw, ear, neck and shoulder 1
4 8
4 8
4 8
4 8
Total points
1. Muscles stiff, sore, tense and/or ache
4 8
4 8
4 8
4 8
4 8
4 8
4 8
7. Headaches
2 4 8
4 8
2 4 8
4 8
2 4 8
4 8
4 8
4 8
1
1
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART X
ART X
4 8
4 8
4 8
4 8
2. Dizziness
4 8
1
1
1
1
1
2
2
2
2
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
[C ]
4 8
4 8
4 8
4 8
4 8
4 8
4 8
2 4 8
Total points
4 8
4 8
4 8
[D]
19. Confused and forgetful to the point that work suffers
4 8
4 8
4 8
4 8
Total points
Men Only
1
2
2
4 8
4 8
4 8
3 4
4 8
7. Headaches
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
2
4 8
4 8
4 8
4 8
SECTION A
4 8
4 8
7. Rectal pain
4 8
4 8
4 8
7. Difficulty breathing
4 8
8. Difficulty swallowing
4 8
[A]
1. Anxious, irritable or restless
4 8
4 8
4 8
4 8
Frequently
Often
Occasionally
Rarely
4 8
4 8
8
s
SECTION F
4 8
4 8
4 8
4 8
4 8
4 8
3. Spontaneous sweating
4 8
4 8
4. Chills
4 8
4 8
4 8
4 8
8. Dizziness
4 8
1. Urinary problems
4 8
2. Vaginal discharge
4 8
4 8
4. Vaginal dryness
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
8
s
Please mark an X to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or
texture (e.g., moles, rashes, etc.). Describe what you feel or observe in your own words. Write anywhere in this area.
SECTION C
1
Women Only
4 8
4. Diarrhea or constipation
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
PART XII
1
Total points
Total points
SECTION E
Total points
SECTION B
PART XI
Frequently
Often
4 8
Occasionally
4 8
Rarely
Frequently
Often
Occasionally
Rarely
Often
Occasionally
Frequently
4 8
SECTION B
4 8
4 8
16. Do you find yourself moving slower than you used to?
4 8
4 8
Total points
SECTION A
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
15. Headaches
4 8
4 8
7. Engorged breasts
4 8
4 8
4. Easily distracted
SECTION E (cont.)
4 8
SECTION D
1
4 8
4 8
SECTION A
13. Hands get tired when you write and your handwriting
is less legible and smaller than it used to be
1
PART XII
PART IX
4 8
Total points
4 8
[B]
Total points
SECTION A (cont.)
SECTION C
SECTION A (cont.)
SECTION B
PART X
Rarely
Frequently
Rarely
Often
Often
4 8
Occasionally
Occasionally
Frequently
Rarely
PART VII
4 8
4 8
4 8
Total points
8
s
1984 Lyra Heller and Michael Katke, revised 2000. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law. MET423 7/00
Total points
PART VIII
1. Involuntary loss of urine when you cough, lift
something or strain during an activity
4 8
4 8
4 8
SECTION B (cont.)
8. Intermittent pain or ache on one side of head spreading
to cheek, temple, lower jaw, ear, neck and shoulder 1
4 8
4 8
4 8
4 8
Total points
1. Muscles stiff, sore, tense and/or ache
4 8
4 8
4 8
4 8
4 8
4 8
4 8
7. Headaches
2 4 8
4 8
2 4 8
4 8
2 4 8
4 8
4 8
4 8
1
1
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART X
ART X
4 8
4 8
4 8
4 8
2. Dizziness
4 8
1
1
1
1
1
2
2
2
2
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
[C ]
4 8
4 8
4 8
4 8
4 8
4 8
4 8
2 4 8
Total points
4 8
4 8
4 8
[D]
19. Confused and forgetful to the point that work suffers
4 8
4 8
4 8
4 8
Total points
Men Only
1
2
2
4 8
4 8
4 8
3 4
4 8
7. Headaches
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
2
4 8
4 8
4 8
4 8
SECTION A
4 8
4 8
7. Rectal pain
4 8
4 8
4 8
7. Difficulty breathing
4 8
8. Difficulty swallowing
4 8
[A]
1. Anxious, irritable or restless
4 8
4 8
4 8
4 8
Frequently
Often
Occasionally
Rarely
4 8
4 8
8
s
SECTION F
4 8
4 8
4 8
4 8
4 8
4 8
3. Spontaneous sweating
4 8
4 8
4. Chills
4 8
4 8
4 8
4 8
8. Dizziness
4 8
1. Urinary problems
4 8
2. Vaginal discharge
4 8
4 8
4. Vaginal dryness
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
8
s
Please mark an X to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or
texture (e.g., moles, rashes, etc.). Describe what you feel or observe in your own words. Write anywhere in this area.
SECTION C
1
Women Only
4 8
4. Diarrhea or constipation
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
PART XII
1
Total points
Total points
SECTION E
Total points
SECTION B
PART XI
Frequently
Often
4 8
Occasionally
4 8
Rarely
Frequently
Often
Occasionally
Rarely
Often
Occasionally
Frequently
4 8
SECTION B
4 8
4 8
16. Do you find yourself moving slower than you used to?
4 8
4 8
Total points
SECTION A
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
15. Headaches
4 8
4 8
7. Engorged breasts
4 8
4 8
4. Easily distracted
SECTION E (cont.)
4 8
SECTION D
1
4 8
4 8
SECTION A
13. Hands get tired when you write and your handwriting
is less legible and smaller than it used to be
1
PART XII
PART IX
4 8
Total points
4 8
[B]
Total points
SECTION A (cont.)
SECTION C
SECTION A (cont.)
SECTION B
PART X
Rarely
Frequently
Rarely
Often
Often
4 8
Occasionally
Occasionally
Frequently
Rarely
PART VII
4 8
4 8
4 8
Total points
8
s
1984 Lyra Heller and Michael Katke, revised 2000. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law. MET423 7/00
Total points
PART VIII
1. Involuntary loss of urine when you cough, lift
something or strain during an activity
4 8
4 8
4 8
SECTION B (cont.)
8. Intermittent pain or ache on one side of head spreading
to cheek, temple, lower jaw, ear, neck and shoulder 1
4 8
4 8
4 8
4 8
Total points
1. Muscles stiff, sore, tense and/or ache
4 8
4 8
4 8
4 8
4 8
4 8
4 8
7. Headaches
2 4 8
4 8
2 4 8
4 8
2 4 8
4 8
4 8
4 8
1
1
2
2
4 8
4 8
4 8
4 8
4 8
4 8
Total points
PART X
ART X
4 8
4 8
4 8
4 8
2. Dizziness
4 8
1
1
1
1
1
2
2
2
2
2
2
2
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
[C ]
4 8
4 8
4 8
4 8
4 8
4 8
4 8
2 4 8
Total points
4 8
4 8
4 8
[D]
19. Confused and forgetful to the point that work suffers
4 8
4 8
4 8
4 8
Total points
Men Only
1
2
2
4 8
4 8
4 8
3 4
4 8
7. Headaches
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
2
4 8
4 8
4 8
4 8
SECTION A
4 8
4 8
7. Rectal pain
4 8
4 8
4 8
7. Difficulty breathing
4 8
8. Difficulty swallowing
4 8
[A]
1. Anxious, irritable or restless
4 8
4 8
4 8
4 8
Frequently
Often
Occasionally
Rarely
4 8
4 8
8
s
SECTION F
4 8
4 8
4 8
4 8
4 8
4 8
3. Spontaneous sweating
4 8
4 8
4. Chills
4 8
4 8
4 8
4 8
8. Dizziness
4 8
1. Urinary problems
4 8
2. Vaginal discharge
4 8
4 8
4. Vaginal dryness
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
Total points
8
s
Please mark an X to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color or
texture (e.g., moles, rashes, etc.). Describe what you feel or observe in your own words. Write anywhere in this area.
SECTION C
1
Women Only
4 8
4. Diarrhea or constipation
4 8
2 4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
PART XII
1
Total points
Total points
SECTION E
Total points
SECTION B
PART XI
Frequently
Often
4 8
Occasionally
4 8
Rarely
Frequently
Often
Occasionally
Rarely
Often
Occasionally
Frequently
4 8
SECTION B
4 8
4 8
16. Do you find yourself moving slower than you used to?
4 8
4 8
Total points
SECTION A
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
4 8
15. Headaches
4 8
4 8
7. Engorged breasts
4 8
4 8
4. Easily distracted
SECTION E (cont.)
4 8
SECTION D
1
4 8
4 8
SECTION A
13. Hands get tired when you write and your handwriting
is less legible and smaller than it used to be
1
PART XII
PART IX
4 8
Total points
4 8
[B]
Total points
SECTION A (cont.)
SECTION C
SECTION A (cont.)
SECTION B
PART X
Rarely
Frequently
Rarely
Often
Often
4 8
Occasionally
Occasionally
Frequently
Rarely
PART VII
4 8
4 8
4 8
Total points
8
s
1984 Lyra Heller and Michael Katke, revised 2000. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law. MET423 7/00
Name: ________________________________
ACTIVITY DAY 1
Morning
Meal
time:
Snack
Noon
Meal
time:
Snack
Evening
Meal
time:
Snack
Water
(cups per day)
Additional
Beverages
Fats/Oils
Condiments
(sugar/salt/
spices/herbs etc.)
Exercise
Type:
Duration:
Pulse before:
Pulse During:
Relaxation
Type:
Duration:
DATE
WEEK:
ACTIVITY DAY 2
Morning
Meal
time:
Snack
Noon
Meal
time:
Snack
Evening
Meal
time:
Snack
Water
(cups per day)
Additional
Beverages
Fats/Oils
Condiments
(sugar/salt/
spices/herbs etc.)
Exercise
Type:
Duration:
Pulse before:
Pulse During:
Relaxation
Type:
Duration:
DATE
WEEK:
DAY 3
DATE
WEEK:
ACTIVITY DAY 4
Morning
Meal
time:
Snack
Noon
Meal
time:
Snack
Evening
Meal
time:
Snack
Water
(cups per day)
Additional
Beverages
Fats/Oils
Condiments
(sugar/salt/
spices/herbs etc.)
Exercise
Type:
Duration:
Pulse before:
Pulse During:
Relaxation
Type:
Duration:
DATE
WEEK:
DAY 5
DATE
WEEK:
ACTIVITY DAY 6
Morning
Meal
time:
Snack
Noon
Meal
time:
Snack
Evening
Meal
time:
Snack
Water
(cups per day)
Additional
Beverages
Fats/Oils
Condiments
(sugar/salt/
spices/herbs etc.)
Exercise
Type:
Duration:
Pulse before:
Pulse During:
Relaxation
Type:
Duration:
DATE
WEEK:
DAY 7
DATE
WEEK:
Insomnia
Early Miscarriage
Cyclical Headaches
Anxiety
Infertility
TOTAL BOXES CHECKED
SYMPTOMS GROUP 2
Vaginal Dryness
Night Sweats
Painful Intercourse
Memory Problems
Bladder Infections
Lethargic Depression
Hot Flashes
SYMPTOMS GROUP 3
Puffiness and Bloating
Breast Tenderness
Mood Swings
Heavy Bleeding
Anxious Depression
Migraine Headaches
Insomnia
Foggy Thinking
Gallbladder Problems
Weepiness
SYMPTOMS GROUP 4
A combination of the symptoms in #1 and #3
SYMPTOMS GROUP 5
Acne
Infertility
Ovarian Cysts
Mid-Cycle Pain
TOTAL BOXES CHECKED
SYMPTOMS GROUP 6
Debilitating fatigue
Foggy Thinking
Intolerance to Exercise