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Clear M EDICAL C ENTERS INTAKE QUESTIONNAIRE You have likely already contacted us. We have asked you to complete this questionnaire and to forward your recent lab test results. If you have not contacted us then complete this form, forward it as directed below and we will contact you. Once we receive this questionnaire and your labs Dr. Haskell will review them. We will then contact you to either schedule your appointment or request additional labs to be done before your appointment. His reasons for requesting additional labs will be clearly explained. Our goal is to make this initial consultation as comprehensive and personal as possible. Please complete this questionnaire on your computer, then save it and attach it to an email to us. If there is not enough space after a question to include you answers press ‘Insert’ on your keyboard to expand the section. You can also print this questionnaire and complete it by hand. You may have to add more space after each section or question first to provide more room to enter your answers. This completed questionnaire can then be mailed to us or faxed (866.471.6698) or can be scanned and attached to an email. Name: Address: Gender: Date of Birth: Weight (lbs.) & Height (ft. & in.): Phone Numbers: Email Address: Occupation: 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Please state the primary reasons for why you wish to make an appointment. List them in order of importance. If you have not done so already list your most troublesome symptoms. Now, for each of the symptoms you’ve listed above, in parentheses, include the number of years you have experienced the symptom. Of the symptoms you’ve mentioned what makes each symptom worse and better. As an example a person with fatigue may notice that if they are hungry or do not eat on time their fatigue is worse. They may also notice that after a full night’s rest their fatigue is better. So what makes each of your symptoms either worse or better? How many years ago has it been since you’ve felt healthy and well? Do you think there were any circumstances or reasons for why your health declined at that time? This is a very important question. Reasons could include a move to a new home, a change in diet, an emotional event, an illness that you might not have fully recovered from, a dental procedure, a new medication, a trip to another country… any event that might be even a slight possibility. If not mentioned above include any diagnosis you have you received from your physician? Besides what you have already included, describe the highlights of your medical history in chronological order including surgeries. You do not need to go into great detail unless you feel 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE it is important. Please include health problems of parents, grandparents, sisters and brothers. You can use various abbreviations such as FM for father’s mother and B for brother. List prescriptions and over-the-counter medications you are presently taking and for how long. If you think it is important include medications you have taken in the past. If you have taken for example several types of anti-depressives you can state ‘many anti-depressives from 1997-2009.’ List supplements you are taking and for how long you’ve been taking them: WOMEN Are you are still cycling, in peri-menopause or in menopause? Explain any symptoms you relate to this. As an example you could still be cycling, your frequency is irregular and you have headaches that start one week out from your periods. How many times and for how many years have you taken birth control pills? GENERAL Do you have any known allergies or even mild reactions to medications, cosmetics, foods or environment? 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Approximately how many times in your life have you taken antibiotics including Tetracycline? Please note intravenous and injections. NUTRITION List the foods you choose from for meals and snacks. List them under headings of breakfast, lunch, dinner, snacks and include liquids. Breakfast: Snack: Lunch: Snack: Dinner: Snack: Part of designing a personalized nutritional program is to understand your ‘Metabolic Type.’ Please complete this section of the questionnaire by putting an ‘x’ in front of the statements that are true for you. Many people eat according to what they THINK they should be eating. In completing this section base your answers on your instincts, what your body tells you, your natural inclinations. If the statements below do not really apply then do not ‘x’ them… If I drink tea I prefer lemon with it. A hamburger tastes much better with a slice of raw onion on it. When I feel low I pick right up if I eat something sweet such as fruit, pastry, or candy. 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE I seem to crave sour-tasting foods. Raw salad vegetables such as radishes, green onions, green peppers, and lettuce agree with me and I like to eat them. If I don’t feel hungry and I eat something sweet, my appetite seems to pick up. I like lettuce, cottage cheese and fruit salad for lunch. I often have a craving for something sweet. When I’m hot and thirsty I can drink a lot of something like lemonade. I like to eat raw onions. I can easily skip breakfast without getting hungry of tired. For breakfast I feel good with something like toast and coffee. I like to drink a soured milk product like buttermilk. I get thirsty and drink a lot of water. I get so hungry that I have to eat something sweet between meals. Avocados taste oily or too fat to me. I can eat breakfast only if it is something sweet. I prefer to eat mustard, catsup, or steak sauce on my meat patty. If I feel a little nauseated I feel better if I eat something sour or sweet. I could drink a large glass of grapefruit or orange juice. If I eat liver I want onions with it. _____ 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE I could enjoy eating some form of potatoes every day. I could eat steak or roast beef almost every day. Fatty meat such as beef, short ribs or roast pork tastes better than lean meat. When I feel low I feel better if I eat something salty like nuts, potato chips or popcorn. Sometimes I can drag through the day but after a good protein meal I can snap out of it. Steak or ham for breakfast sound pretty good to me. Sometimes I get hungry between meals and I like a snack on nuts, or cheese and crackers or maybe a hot dog. For lunch I could eat a bacon and avocado sandwich with mayonnaise. I feel better is I have some eggs with bacon or some other kind of animal protein for breakfast. Steak and lobster is my idea of a real dinner and I could eat them together. When I take the cap off a jar of mustard the smell is so sharp that it hurts my nose. I like the taste of olive oil. If I drink coffee it seems to make me feel jittery or jumpy. I like to eat any kind of olives. I like to eat bacon. I like the taste of salt on my food even if I’ve not been using salt lately. I would like a pat of butter added to my soft-boiled eggs. I seem to want something more to eat like cheese or nuts even after I have eaten a regular meal. 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Sweet foods like candy or cake taste too sweet to me I would like a pat of butter on my steak or meat. I seem to feel a bit weak if I haven’t eaten for two or three hours. I could eat three or more pieces of bacon or some form of meat for breakfast. I don’t like the smell of cooking food even though it tastes right when I eat it. I’d like broiled lamb chops for dinner. Grapefruit juice tastes very sour to me. I would like to eat baked beans with lot of nice lean salt pork in them. If I feel a little nauseated I feel better if I eat something salty. If I were to eat liver I’d prefer bacon with it. Here is the next section related to foods… Do you crave any specific foods or tastes? Any aversions or reactions to foods? SYSTEMS We’ll go through various parts of the body now. You may have already mentioned some of the following symptoms but we just need to be sure that we cover everything. Just place an ‘X’ before any symptom you experience. Any additional notes can be included within each section. Head Headaches Concussion Dizziness Other… 3350 Highland Drive, SLC, UT 84106 Sinus Infections 801.987.9292 Fax 866.471.6698 [email protected] Clear M EDICAL C ENTERS Nose & Sinuses Discharge Post Nasal Drip Allergies Loss of Smell Frequent Colds Hay Fever Difficulty Swallowing Recurring Mouth Sores Enlarged Glands Recurring Sore Throats Loss of Taste Gum Problems Hoarseness Swelling of Thyroid History of Root Canals Dark Amalgam Fillings History of Tonsillectomy Coating on Tongue Other… Throat, Mouth & Teeth Other... Heart, Pulse, Circulation & Blood Pressure Pain in Chest Heart Valve Problems Swelling in Hands & Feet Blood Clots Irregular Pulse Leg Cramps Palpitations High Blood Pressure Low Blood Pressure Other… Stomach, Gastrointestinal & Liver Little or No Appetite Burping After Meals Nausea Vomiting Blood in Stool Abdominal Cramping Constipation Diarrhea Gas Light stools Greasy stools Hepatitis Fatty Liver History of Parasites Cannot Digest Certain Foods History of Ulcers Other… Kidney & Bladder Kidney Infections Recurring Bladder Infections 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Blood in Urine Increased Urination at Night Other… Musculoskeletal Osteoarthritis Rheumatoid Arthritis Bursitis Backaches Joint Swelling Osteoporosis or Osteopenia Muscle Spasms Tremors Injuries to Spine Acne Dermatitis Dry Skin Eczema Shingles Warts Itchiness Hives Others… Skin Other… Nervous System Weakness Paralysis Tingling in Hands or Feet Diabetes Blood Sugar Issues Hypoglycemia Possible Adrenal Fatigue Pancreas Issues Suspect Thyroid Problem Hashimoto’s Hot Flashes Mood Swings Before Menses Chilly Can’t Lose Weight Light headed Dizzy When Standing Eyes Sensitive to Light Seasonal Depression Restless Legs Sensitive to Molds Twitching Other… Endocrine Other… General Sensitive to Odors & Perfumes Under Tons of Stress 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Other… Infections Infections more than 3Xs per year Other… Females Only Age of First Menses: Number of Pregnancies: Abortions: Miscarriages: Date of Last Mammogram: Results: Date of Last Pap smear: Results: Place an ‘x’ in front of anything below that applies… Conization Cryosurgery Laser Surgery Fibrocystic Ovaries Malignancies Uterine Fibroids Abnormal Bleeding Endometriosis HPV Genital Warts Hysterectomy Complete Hysterectomy Partial Tubal Surgery Chronic Vaginal Yeast Infections Urinary Tract Infections Vaginal Discharge Painful Intercourse Lack of Sexual InterestHistory of Sexual Trauma Vaginal Itching Other… Office Policy Our aim is to provide you with effective services and treatments. Please note that any charges for services will be billed at the time of your consultation. Payment can be made through CC, cash or check. Billing for phone consultations can be through PayPal, Google or providing us with CC information. We remind you that we do not deal with insurance companies. 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected] P ERSONAL I NTAKE Q UESTIONNAIRE Statement of Patient Awareness & Responsibility I am aware that any therapy, no matter how well designed and carried out, may fail to alleviate my symptoms and improve my health. I agree to make every effort to pursue and put into practice the program that is mutually agreed upon. I am aware that many medical conditions require additional treatments and that follow-up visits are often necessary. I agree to accept responsibility for payment of all agreed upon charges relating to services and testing regardless of the outcomes or whether any insurance applies. I have read and agree to the above stated policies. Please include your name and the date below this line: If you are completing this form on your computer save it as a document and attach it to an email to us at [email protected]. If you have printed this form and are completing it by hand you can either fax it to 866.471.6698 or scan it and attach it to our email address. Once we receive your questionnaire we will contact you by email or phone within one business day. Thank you for your patience in completing this lengthy but important form. 3350 Highland Drive, SLC, UT 84106 801.987.9292 Fax 866.471.6698 [email protected]
