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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