January 19, 2018 Danny Thomas Consultation Form First Name:* Last Name:* Age: Sex: MaleFemale Address:* City:* Province:* E-mail:* Postal Code: DOB: Phone Home (area):* (Phone): Phone Work (area): (Phone): Referral: Occupation: Below, describe all of your complaints, how long you have had them and how you are treating them. Be sure to mention any drugs, vitamin supplements. or other medicinal substances you are taking. Complaint 1: Treatment/Medication How long? Complaint 2: Treatment/Medication How long? Complaint 3: Treatment/Medication How long? Complaint 4: Treatment/Medication How long? Brief Health History: (list major diseases, surgeries, etc.) How many times per year do you get a cold or the flu? Diet:(summarize how you eat; list any special diet such as high protein, raw food, etc.) Family Medical History: Emotions: NormalProblem Depression Sadness Panic Attack Sensitive Worries Excited Angry Anxiety Describe: Energy: NormalProblem Low Up and Down Exhaust Hyperactive Nervous energy Abundant Describe: Sleep Pattern: NormalInsomnia Falling asleep: Sleep Difficult Sometimes very difficult Sleepy in daytime Always difficult Always very difficult Take Naps Waking up: Times per night Wake up too early Wake up at night and cannot go back to sleep again Sleep Quality: Deep Light Bad Many Dreams Bad Dreams Grinding teeth Talking in sleep Other Describe: Menstrual Cycle: RegularIrregular Age of onset: Date of last period: (mm/dd/yy) Days per cycle: Days it lasts: Color: Pale red Dark red Bright red Purplish Do you pass clots? YesNo Menstrual Pain: YesNo Before Flow During Flow After Flow Abdomen Back Breast Emotion around period: NormalAbnormal Before Flow During Flow After Flow Depression Irritability Anger Sadness Crying Other Describe: Temperature: NormalAbnormal Feel Cold easily Cold Hands Cold Feet Feel Hot easily Alternating Hot Hot Flash Sensitive to weather changes Describe: Perspiration: NormalAbnormal Too easily Too much Difficult Too little Night sweats Other Describe: Allergies: YesNo Environmental Drug Food Describe: Appetite and Digestion: RegularIrregular Rapid Hungering Poor Appetite Nausea Heartburn Indigestion Bloating Gas Other Describe: Thirst: NormalAbnormal Thirsty Dry mouth Dry mouth but no desire to drink Drink a lot Not thirsty, but drink a lot of water anyway Describe: Bowel Movement: NormalAbnormal Constipation Diarrhea Loose Watery Incomplete Hard and Dry Strong Smell With Mucous With Blood Other Describe: Urination: NormalAbnormal Frequent Urgent Burning Painful Cloudy Dark color Foul smell Bloody Difficult Retention Other Number of times per day: Number of times per night: Describe: Body Weight: NormalOverweightUnderweight If overweight: How many pounds would you like to lose? How many years ago did you first start to gain weight? Are you following a weight control program at this time? YesNo Describe: Please read and click the disclaimer before sending* Disclaimer Δ