Download FoodPharmacy Patient Intake Form

FoodPharmacy™ Patient Intake Form
*Practitioner Name: ____________________________________________________________________
Date: ____________
*Patient Name: __________________________________________________________________________________________
Address: ________________________________________ City: ___________________ State: _______ Zip: ____________
Phone:
Email:
Gender:
* Indicates required data
M
F
DOB:
(Gender and DOB required only for Calorie Calculations)
Measurements for Calorie Calculations (not recommended on first patient visit or for children & infants)
*Height (barefoot): _________ *Weight (clothed): ________ * Wrist (circumference of dominant hand at wrist folds): ________
*Activity Level
Current Health Factors
(check only one)
Surgery (recent only – check only one)
Sedentary (little or no exercise, desk job or bed ridden)
Light Activity (light exercise – sports 1 to 3 days per week)
Moderate Activity (moderate exercise – sports 3 to 5 days per week)
Very Active (hard exercise – sports 6 to 7 days per week)
Extra Active (hard daily exercise – sports and physical job)
Minor
Major
Infection (current – check only one)
Mild
Moderate
Severe
Lean Body Mass or Percent Body Fat (if known):
Trauma (current only)
Muscular/Skeletal (sprains, fractures, etc.)
* indicates required data for calorie calculations (all other data recommended) Pregnancy (Trimester: 1 2 3 )
-- ONLY MAKE SELECTIONS YOU ARE CERTAIN OF -Food Component Reactions
Amines
Salicylates
Citrus Fruits
Shellfish
Dairy (casein & lactose) Soy
Eggs
Sulfites
Glutamates
Theobromine
Gluten & Gliadin
Yeast
Toxins and Junk Food
Alcohol
Non-food Items (synthetics)
Caffeine
Pesticides (for organic diets)
Carcinogens & Toxins Refined sugars
Fluoride/Chlorine
Harmful Fats
Mercury Contaminated Foods
_______________________________________________________________________________________________________________________
Blood Type Allergens (use only if you wish to predict probable food allergies prior to actual testing)
Circle patient’s blood type :
O
A1
A2
B
A1B
A2B
Rh negative
_______________________________________________________________________________________________________________________
Blood Type Lectin Reactions (use only if you understand the affect of lectin reactions)
Circle patient’s blood type :
O
A
B
AB
_______________________________________________________________________________________________________________________
Vegetarian Intolerances (check to remove from diet)
Red Meat
Dairy Foods
Poultry
Eggs and Egg Products
Fish and Seafood
Ethnic Intolerances
Non-Hindu Foods
Non-Kosher Foods
Non-Muslim Foods
Organs and Systems Needing Support (check all that apply)
Adrenals
Gallbladder
Lungs
Bladder
Gums/Teeth
Lymphatic
Bones
Hair/Scalp
Male Reproductive Organs
Brain/Nerves (CNS)
Heart
Mammary Glands/Breasts
Bronchi
Intestines (GI tract)
Muscles
Ears (hearing)
Joints
Nails
Eyes (vision)
Kidneys
Pancreas
Female Reproductive Organs
Liver
Pituitary Gland
FoodPharmacy Patient Intake Form – page 1
Prostate
Skin
Spine
Thymus
Thyroid
Uterus
Veins/Arteries
Patient Name: ______________________________ Date: _______
Conditions and Complaints
-- SELECT ONLY THE MOST SIGNIFICANT ISSUES AND CIRCLE THE SINGLE WORST PROBLEM -
Acne (vulgaris)
Adrenal Hyper-function
Adrenal Hypo-function
AIDS or HIV
Alcoholism
Alzheimer's Disease
Amenorrhea
Anemia (macro & microcytic)
Angina Pectoris
Anxiety
Appetite Excessive
Appetite Reduced
Arteriosclerosis
Asthma
Atherosclerosis
Attention Deficit Disorder
Autism
Bell's Palsy
Benign Prostatic Hyperplasia
Biliary Insufficiency
Biliary Stasis
Bipolar Disorder
Bleeding Gums
Body Odor
Bone Spurs
Bradycardia
Bronchitis
Bruxism
Burning Feet
Burns (1st, 2nd, 3rd degree)
Bursitis
Cancer (prevention)
Canker Sores
Cardiac Arrhythmia
Cataracts
Celiac Disease (sprue)
Chemotherapy Support
Cervical Dysplasia
Chicken Pox
Cholesterol Decreased (total)
Cholesterol Elevated (total)
Chronic Fatigue Syndrome
Colic (mother's & child's diet)
Congestive Heart Failure
Constipation
COPD
Copper toxicity
Coronary Artery Disease
Crohn's Disease
Cystic Fibrosis
Cytomegalovirus (CMV)
Degenerative Joint Disease
Dental Caries (cavities)
Depression
Dermatitis
Detoxification Support
Diabetes (type I)
Diabetes (type II)
Diarrhea
Diverticulosis
Drug Addiction
Dry Eyes (Sjögren's synd.)
Dry Skin
Dysmenorrhea
Dyspepsia (indigestion)
Ear Infections
Eczema
Edema
Emphysema
Endometriosis
Enuresis (bed wetting)
Epilepsy (seizure disorders)
Epstein Barr Virus (EBV)
Fever
Fibrocystic Breast Disease
Fibromyalgia
Flatulence
Fractures
Gallbladder Dysfunction
Gallstones
GERD
Glaucoma
Goiter
Gout
Grave’s Disease
Halitosis
Hashimoto’s Disease
Headaches (non-migraine)
Heal Spurs
Heavy Metal Toxicity
Hemachromatosis
Hemophilia
Hemorrhoids
Hepatic Cirrhosis
Hepatic Disease Support
Hepatitis
Herpes Simplex (HSV-1)
Herpes Zoster (HSV-2)
Hiatal Hernia
High Cholesterol (LDL)
High Triglycerides
Homocysteine Elevated
Hot Flashes (menopausal)
Hyperglycemia
Hyperkinesis
Hypertension
Hyperthyroidism
Hypochlorhydria
Hypoglycemia
Hypotension
Hypothyroidism
Idiopathic Thrombo. Purpura
Ileitis
Ileocecal Valve Dysfunction
Immune Deficiency
Impotence (male)
Incontinence
Infection (bacterial)
Infection (parasitic)
Infection (prostate)
Infection (respiratory)
Infection (sinus)
Infection (urinary)
Infection (viral)
Infection (yeast/fungal)
Infertility (female)
Infertility (male)
Inflammation (general)
Inflammation (vascular)
Influenza (flu)
Insomnia
Interstitial Cystitis
Irritable Bowel Syndrome
Joint Pain
Kidney Stones
Lactose Intolerance
Liver-Colon Detoxification
Low Cholesterol (HDL)
Lung Problems (non-specific)
Lupus
Lyme Disease
Macular Degeneration
Manic Depression
Measles
Meniere's Disease
Menorrhagia
Menstrual Cramps
Metabolic Syndrome
Migraine Headache
Mitral Valve Prolapse
Mononucleosis
Mucous (allergy related)
Mucous (respiratory/sinus)
Multiple Sclerosis (MS)
Mumps
Muscular Dystrophy
Myasthenia Gravis
Nausea
Nausea (during pregnancy)
FoodPharmacy Patient Intake Form – page 2
Obesity
Osteoarthritis
Osteoporosis
Pain (musculoskeletal)
Pancreatitis
Panic Disorder
Parasthesia
Parkinson's Disease
PCOS
Peptic/Duodenal Ulcer
Periodontal Disease
Phlebitis
Phobias
Pituitary Dysfunction
PMS (premenstrual syndrome)
Pneumonia
Polycythemia (secondary)
Pregnancy (general support)
Pregnancy & Yeast Infection
Psoriasis
Purpura Simplex
Radiation Therapy Support
Raynaud's Disease
Reduced Circulation
Rhinovirus (common cold)
Rheumatoid Arthritis
Rhinovirus (common cold)
Schizophrenia
Sciatica
Scleroderma
Seborrhea
Sex Drive Diminished (female)
Sex Drive Diminished (male)
Skin Rashes
Sperm Count Reduced
Stroke (recovery support)
Sulfite Allergy-Sensitivity
Surgery Support (pre & post)
Tachycardia
Tendonitis
Thrombophlebitis
Tinea (ringworm)
Tinnitus
Trigeminal Neuralgia
Tuberculosis (TB)
Ulcerative Colitis
Urticaria (hives)
Uterine Fibroids
Varicose Veins
Vertigo
Vitiligo
Wilson’s Syndrome
Xerophthalmia
◄ RESTRICT
◄ REDUCE
◄ INCREASE
Patient Name: ______________________________ Date: _______
CHECK NO MORE THAN ONE BOX PER ITEM AND
ONLY SELECT ITEMS YOU ARE CERTAIN ABOUT
MACRONUTRIENTS -
Medium purine protein foods
Low purine protein foods
AMINO ACIDS -
Oxalic acid containing foods
Essential
Phytic acid containing foods
Standard Nutritional Options
High protein foods
High carbohydrate foods
High calorie foods
High fiber foods
High water content foods
Acid ash foods
Alkaline ash foods
Advanced Nutritional Options
High glycemic load foods
Medium glycemic load foods
High purine protein foods
Thyroid suppressing foods
Phytoestrogenic foods
High fructose foods
High ORAC foods
MICRONUTRIENTS Vitamins & Associated Nutrients
Biotin
Choline
Flavonoids
Folates
Inositol
Lycopene
PABA
Provitamin A (retinol)
Vitamin A (carotenoids)
Vitamin B1 (thiamine)
Vitamin B2 (riboflavin)
Vitamin B3 (niacin)
Germanium (Ge)
Iodine (I)
Iron (Fe)
Magnesium (Mg)
Manganese (Mn)
Molybdenum (Mo)
Phosphorus (P)
Potassium (K)
Histidine
Isoleucine
Leucine
Lysine
Methionine
Phenylalanine
Threonine
Tryptophan
Valine
Alanine
Arginine
Aspartic acid
Cysteine
Glutamic acid
Glycine
Proline
Serine
Tyrosine
FATTY ACIDS -
Vitamin B12 (cobalamin)
Vitamin C (ascorbic acid)
Vitamin D (calciferol)
Vitamin E (tocopherol)
Vitamin K (pylloquinone)
Boron (B)
Calcium (Ca)
Chromium (Cr)
Alpha-linolenic (ALA)
Docosapentaenoic (DPA)
Docosahexaenoic (DHA)
Eicosapentaenoic (EPA)
Omega 6 Fatty Acids (specific types)
Linoleic (LA)
Gamma-linolenic (GLA)
Arachidonic (AA)
Omega 9 Fatty Acids (specific types)
Oleic
Tetracosenoic
Saturated Fatty Acids (specific types)
DIET THERAPIES -
General Fatty Acid Options
Zinc (Zn)
Sulfur (S)
Vitamin B6 (pyridoxine)
Vanadium (V)
Sodium (Na)
Non-essential
Selenium (Se)
Vitamin B5 (pantothenic acid)
Minerals
Minerals (continued)
Omega 3 Fatty Acids (specific types)
High omega 3 foods
High omega 6 foods
High omega 9 foods
High monounsaturated fats
High polyunsaturated fats
High saturated fats
High total fat content foods
High cholesterol foods
High phytosterol foods
Copper (Cu)
NOTES
FoodPharmacy Patient Intake Form – page 3
Lauric
Myristic
Palmitic
Stearic
Metabolic Type® (select only one)
Parasympathetic Dominant
Sympathetic Dominant
Balanced Dominant
Fast Oxidation Dominant
Slow Oxidation Dominant
Mixed Dominant
Metabolic Modifiers (select only one)
Dysaerobic imbalance (catabolic excess)
Anaerobic imbalance (anabolic excess)
Endocrine Type (select only one)
Ovarian (gonadal) Dominant
Adrenal Dominant
Thyroid Dominant
Pituitary Dominant
Ayurvedic Type (select only one)
Vata
Vata-Pitta
Vata-Kapha
Pitta
Pitta-Vata
Pitta-Kapha
Kapha
Kapha-Vata
Kapha-Pitta
TCM Food Qualities (multiple options)
Sour foods
Bitter foods
Sweet foods
Pungent foods
Salty foods
Warming foods
Cooling foods