Ann Shippy, MD

First Name * Last Name * Date of Birth * Today's Date * Genetic Background When, where and from whom did you last receive medical health care?

Current Health Concerns

Health Concern 1 Severity Health Concern 2 Severity Health Concern 3 Severity Health Concern 4 Severity Health Concern 5 Severity Health Concern 6 Severity Prior Treatment / Approach How helpful was this approach? Prior Treatment / Approach How helpful was this approach? Prior Treatment / Approach How helpful was this approach?

Allergies

Name of Medication / Supplement / Food:

Lifestyle Review

Sleep - How many hours of sleep do you get each night on average? Do you have problems falling asleep? Do you have insomnia? Do you feel rested upon awakening? Do you use sleep aids? If yes, please explain: Do you stay asleep? Do you snore?

Exercise - Current Exercise Program:

Activity (Running, Swimming, Yoga, Tai Chi, Pilates, Golf, Etc.) Do you feel motivated to exercise? Are there any problems that limit exercise? If yes, please explain: Do you feel unusually fatigued or sore after exercise? If yes, please explain:

Nutrition

Do you follow any of the following special diets or nutritional programs? Do you have sensitivities to certain foods? If yes, list foods and reaction/symptoms: Do you have an aversion to certain foods? If yes, explain your reaction Do you adversely react to: Other Are there any foods that you crave or binge on? If yes, what foods? Do you eat 3 meals a day? If no, how many? Does skipping a meal greatly affect you? If yes, how? How many meals do you eat out per week? Check the factors that apply to your current lifestyle and eating habits:

Diet

Please record what you eat in a typical day:

Breakfast Lunch Dinner Snacks Fluids

How many servings of these foods do you eat in a typical week:

Fruits (not juice) Legumes (beans, peas, etc.) Dairy/Alternatives Cans of soda (regular or diet) Vegetables (not including white potatoes) Red meat Nuts & Seeds Sweets (candy, cookie, cake, ice cream, etc.) Fish Fats & Oils Do you drink caffeinated beverages?

If yes, check amounts:

Coffee (cups per day) Tea (cups per day) Caffeinated sodas-regular to diet (cans per day) Do you have adverse reactions to caffeine? If yes, explain: When you drink caffeine do you feel:

Smoking

Do you currently smoke? If yes, packs per day: If yes, number of years: What type? Have you attempted to quit? If yes, using what methods?

If smoked previously:

Packs per day: Number of years: Are you regularly exposed to second-hand smoke?

Alcohol

How many alcoholic beverages do you drink in a week? Previous alcohol intake? If yes, how much? Have you ever had a problem with alcohol? If yes, when? If yes, explain the problem: Have you ever thought about getting help to control or stop your drinking?

Other Substances

Are you currently using any recreational drugs? If yes, what type? Have you ever used IV or inhaled recreational drugs?

Stress

Do you feel you have an excessive amount of stress in your life? Do you feel you can easily handle the stress in your life?

How much stress do each of the following cause on a daily basis?

(Rate the following on a scale of 1-10, 10 being the highest)

Work Family Social Finances Health Other Do you use relaxation techniques? If yes, how often? Which techniques do you use? Have you ever sought counseling?

Relationships

Are you currently in therapy? If yes, describe: Have you ever been abused, a victim of crime, or experienced a significant trauma? What are your hobbies or leisure activities? Marital/Relationship Status With whom do you live? (Include children, parents, relatives, friends, pets) Current occupation: Previous occupations: Do you have resources for emotional support? If yes, check all that apply: If other, please specify: Do you have a religious or spiritual practice? If yes, what kind?

How well have things been going for you?

(Mark the following on a scale from 1-10, 1 being poor, 5 being fine, 10 being very well, or N/A if not applicable):

Overall At school In your job In your social life With close friends With sex With your attitude With your boyfriend/girlfriend With your children With your parents With your spouse

History

Patient's Birth/Childhood history

You were born Were there any pregnancy or birth complications? If yes, explain: You were If breast-fed, how long? If bottle-fed, what formula? Age of introduction to solid food: Age of introduction to wheat: As a child, were there any foods that were avoided because they gave you symptoms? If yes, what foods and what symptoms? (Example: milk--gas and diarrhea) Did you eat a lot of sugar or candy as a child?

Dental History

If applicable, how many of the following procedures have you had?

Silver mercury fillings Gold fillings Root canals Implants Caps/Crowns Check all of the following that are applicable: If other dental concerns, please explain: Have you had any mercury fillings removed? If yes, when? How many fillings did you have as a kid? Do you brush regularly? Do you floss regularly?

Environmental/Detoxification History

Do any of these significantly affect you? If other, please explain: In your work or home environment, are you regularly exposed to: If other, please explain: Have you had a significant exposure to any harmful chemicals? If yes, please provide the chemical name, length of exposure, and date: Do you have any pets or farm animals? If yes, do they live:

Women's History

Obstetric History

If applicable, how many of the following procedures have you had?

Pregnancies Miscarriages Abortions Living children Vaginal deliveries Cesarean Term births Premature births Birth weight of largest baby: Birth weight of smallest baby: Did you develop any problems in or after pregnancy, for example, toxemia (high blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.? If yes, please explain:

Menstrual History

Age at first period: Date of last menstrual period: Length of cycle: Time between cycles: Cramping/pain? Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)? If yes, please describe: Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)? If yes, please explain: Use of hormonal birth control: If other, please explain: How long have you been using this birth control? Do you have any problems with hormonal birth control? If yes please explain: Use of other contraception? Are you in menopause? If yes, age at last period: Was it surgical menopause? If yes, explain surgery: Do you currently have symptomatic problems with menopause? Are you on hormone replacement therapy? If yes, for how long and for what reason (hot flashes, osteoporosis prevention, etc.)? Other Gynecological Symptoms: If sexually transmitted disease(s), describe:

If applicable, please provide the date (as close as possible) and results of the last of each of the following Gynecological Screenings/Procedures:

Last Pap test (normal or abnormal?): Last mammogram (normal or abnormal?): Last bone density (high, low, within normal range?): Other tests/procedures (list type, dates, and results):

Family History

Fill out the following questions for each family member, if applicable:

Mother

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Father

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to individual: If other, please specify:

Brother(s)

Age(s) (if still alive): Age(s) at death (if deceased): Check off all of the following applicable to individual(s): If other, please specify:

Sister(s)

Age(s) (if still alive): Age(s) at death (if deceased): Check off all of the following applicable to individual(s): If other, please specify:

Child(ren)

Age(s) (if still alive): Age(s) at death (if deceased): Check off all of the following applicable to individual(s): If other, please specify:

Maternal Grandmother

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Maternal Grandfather

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Paternal Grandmother

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Paternal Grandfather

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Other Relative

Age (if still alive): Age at death (if deceased): Check off all of the following applicable to this individual: If other, please specify:

Medical History: Illness/Conditions

For the following sections, select YES if it is a condition that you currently have or PAST if it is a condition that you've had in the past. If you have never had the condition, select NO.

Gastrontestinal

Irritable bowel syndrome GERD (reflux) Crohn's disease/ulcerative colitis Peptic ulcer disease Celiac disease Gallstones If other, please list and state if past or present condition:

Respiratory

Bronchitis Asthma Emphysema Pneumonia Sinusitis Sleep Apnea If other, please list and state if past or present condition:

Urinary/Genital

Kidney stones Gout Interstitial cystitis Frequent yeast infections Frequent urinary tract infections Sexual dysfunction Sexually transmitted diseases If other, please list and state if past or present condition:

Endocrine/Metabolic

Diabetes Hypothyroidism (low thyroid) Hyperthyroidism (overactive thyroid) Polycystic Ovarian Syndrome Infertility Metabolic syndrome/insulin resistance Eating disorder Hypoglycemia If other, please list and state if past or present condition:

Inflammatory/Immune

Rheumatoid arthritis Chronic fatigue syndrome Food allergies Environmental allergies Multiple chemical sensitivies Autoimmune disease Immune deficiency Mononucleosis Hepatitis If other, please list and state if past or present condition:

Musculoskeletal

Fibromyalgia Osteoarthritis Chronic pain If other, please list and state if past or present condition:

Skin

Eczema Psoriasis Acne Skin cancer If other, please list and state if past or present condition:

Cardiovascular

Angina Heart attack Heart failure Hypertension (high blood pressure) Stroke High blood fats (cholesterol, triglycerides) Rheumatic fever Arrhythmia (irregular heart rate) Murmur Mitral valve prolapse If other, please list and state if past or present condition:

Neurologic/Emotional

Epilepsy/Seizures ADD/ADHD Headaches Migraines Depression Anxiety Autism Multiple sclerosis Parkinson's disease Dementia If other, please list and state if past or present condition:

Cancer

Lung Breast Colon Ovarian Skin If other, please list and state if past or present condition:

For the following sections, please enter the date for all of the following that are applicable and include any relevant comments:

Diagnostic Studies

Bone density CT Scan Colonoscopy Cardiac stress test EKG MRI Upper endoscopy Upper endoscopy Chest X-ray Other X-rays Barium enema If other, please list with corresponding dates and comments:

Injuries

Broken bone(s) Back injury Neck injury Head injury If other, please list with corresponding dates and comments:

Surgeries

Appendectomy Dental Gallbladder Hernia Tonsillectomy Joint replacement Heart surgery If other, please list with corresponding dates and comments: For any hospitalizations, please list below with the date and reason:

Symptom Review

For the following sections, please check if these symptoms occur presently or have occurred in the last 6 months:

General Head, Eyes, and Ears Musculoskeletal Mood/Nerves Cardiovascular Urinary Digestion Eating Respiratory Nails Lymph Nodes Skin, Dryness of Skin Problems Itching Skin

Medications/Supplements

Current medications (include prescription and over-the-counter)

For each of the current medications you are taking, please provide the name, dosage, start date, and reason for use:

Medication Medication Medication Medication Medication Medication Medication Medication

Nutritional supplements (vitamins/minerals/herbs, etc.)

For each of the current supplements you are taking, please provide the name and brand, dosage, start date, and reason for use:

Supplement Supplement Supplement Supplement Supplement Supplement Supplement Supplement If any of your medications or supplements ever caused unusual side effects or problems, please describe: Have you used any of these regularly or for a long time: NSAIDs (Advil, Aleve, etc.), Motrin, Aspirin? Tylenol (acetaminophen)? Acid-blocking drugs (Zantac, Prilosec, Nexium, etc.)?

How many times have you taken antibiotics?

Infancy/childhood Reason for use: Teen Reason for use: Adulthood Reason for use: Have you ever taken long term antibiotics? If yes, please explain:

How often have you taken oral steroids (e.g. cortisone, prednisone, etc.)?

Infancy/childhood Reason for use: Teen Reason for use: Adulthood Reason for use:

Readiness Assessment and Health Goals

Readiness Assessment

For the following, rate each on a scale of 5 (very willing) to 1 (not willing):

In order to improve your health, how willing are you to:

Significantly modify your diet Take several nutritional supplements each day Keep a record of everything you eat each day Modify your lifestyle (e.g., work demands, sleep habits Practice a relaxation technique Engage in regular exercise

Rate on a scale of 5 (very confdent) to 1 (not confdent at all):

How confdent are you of your ability to organize and follow through on the above health-related activities? If you are not confdent of your ability, what aspects of yourself or your life lead you to question your capacity to follow through?

Rate on a scale of 5 (very supportive) to 1 (very unsupportive):

At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):

How much ongoing support (e.g., telephone consults, email correspondence) from our professional staf would be helpful to you as you implement your personal health program? Comments

Health Goals

What do you hope to achieve in your visit with us? When was the last time you felt well? Did something trigger your change in health? What makes you feel better? What makes you feel worse? How does your condition afect you? What do you think is happening and why? What do you feel needs to happen for you to get better?