New Patient Questionnaire

First Name

Last Name

Email

Presenting Complaint

Profession / Work

Weight

Height

Smoker / Quit ?

Smoker

Quit

Never Smoked

When did you quit Smoking?

If any of these do not apply to you, write n/a

Usual Diet

Beverages Consumed in 24 hr

Hours of Sleep

Bowel Movement Frequency and Texture

Bloating or Abdominal Pain

Energy Level Mood (1-10)

0

Stress Level (1-10)

0

If any of these do not apply to you, write n/a

Physical Activity

Drug Allergies

Food Allergies

Vaccination Status

Medication Supplements

Current Treatments

Medical History

Surgical History

Family History