Ronald B. Keys, JD, PhD
Free Initial Consultation Call: (954) 448-1515 E-mail: email@rkeysphd.com |
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Free Initial Consultation - Call Now (954) 448-1515 Ronald B. Keys, JD, PhD INTAKE QUESTIONNAIRE Please answer these questions as best as you can. Time that you invest in doing a careful job with this questionnaire will save us a lot of time making certain we have sufficient information in the office. =========================================================================== IMPORTANT !!!!! PLEASE PRESS YOUR "CAPS LOCK" KEY TYPE YOUR RESPONSES IN ALL CAPITAL LETTERS THIS WILL DISTINGUISH YOUR REPLY FROM THE INTAKE FORM =========================================================================== PEDIGREE INFORMATION First name, middle initial & last name:
Place of birth: City: State: Current Address: Street: City: State: ZIP Social Security Number: Home phone: Work phone: Sex: Eye color: Hair color: Complexion: Handedness: Height: Weight: Work address Street: City, State, ZIP: Responsible person: Referred by: Referral address Street: City, State, ZIP: Primary insurance: Secondary insurance: Please rank your problems by priority.
Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency: Problem: Severity: Onset: Frequency:
What diagnosis or explanations have been given in the past?
Is your problem(s) the subject of legal proceedings or a worker's compensation case?
How would you describe your experience as a child in your family? Happy & secure Okay Not so good Hard Felt abandoned Deprived No privacy Abused Verbally Physically sexually Comments:
Are there "funny " things that your body (or mind) does? What I mean is something peculiar that you have come to regard as probably not experienced by most people. This is not a really a symptom but comes in the absence of sickness and is not associated with any disability? If so, I would appreciate having a brief description of it When did it start? How often? What seems to provoke or relieve it? (Thank you)
Occupation:
Stress from work\school: Yes No If stress: Mild Moderate Severe How much time lost from work/school in past year? Previous jobs (explain):
Any learning problems (explain):
Where did you go to school? College? Major Degree Year Graduate School? Field Degree Year Professional School? Field Degree Year
With whom do you live? (include room mates, friends, partner, spouse, children, parents, relatives. Please include ages . Example: Betty, age 19, daughter, Albert, age 45, husband):
What pets live with you--indoors or outdoors--only?
When and where have you lived or traveled outside the USA?
Major decisions that you are facing?
Major life changes recent or soon?
How important to you is religion or spiritual life?
How important to you is a religious affiliation?
Operations: List When: Tonsillectomy Hysterectomy Gall Bladder Appendectomy Hernia P.E. tubes in ears Prostectomy Gut/Bowel Surgery Other operations
List When: Chicken pox Mononucleosis Measles Mumps German Measles Hepatitis Other illnesses
Injuries: List When: Head injury Broken? Neck injury Broken? Back injury
Diagnostic Studies: When have you had a Chest x-ray Mammogram EKG Sigmoidoscopy Colonoscopy Upper GI Series Barium Enema MRI, SPECT, Cat Scan of Brain Abdomen Spine Other Liver Scan Bone Scan Neck X-Ray Other Studies
Medications: How many times and at what ages have you taken: Infancy Childhood Teens Adulthood Antibiotics: Steroids: What medications are you taking now? Include non Rx's drugs. date started Date stopped Dosage Total per/day Aspirin Antihistamines
Vitamins, Minerals and Other Nutritional Supplements: List all vitamins, minerals, and other nutritional supplements. Indicate the mg, mcg or IU's and the form (e.g. chromium picolinate vs chromium polynicotinate, calcium carbonate vs calcium ascorbate), when possible. Date started Date stopped dosage Total/day Multi-vitamin Multi-mineral Vitamin C Vitamin B Complex Magnesium Garlic CoQ 10 Others Eating and Drinking: Did your mother smoke tobacco? or drink alcohol when she was pregnant with you. (don't know ,) Did she take estrogen? Were you a full term baby? or a preemie or don't know Were you breast fed? or bottle fed? or don't know As a child, did you live in an area where there was soft or hard water? (Hard water does not make suds easily) don't know As a child, did you eat a of sugar? candy sweet foods soda diet soda, white bread cookies ice cream ("by a lot", I mean on a daily basis--not just for treats) As a child, did you eat: a pretty much meat, vegetable and potato/rice/pasta diet a vegetable and grain based diet with little meat a vegetarian diet with milk and eggs a vegetarian diet with milk and eggs As a child, did you drink milk more than once a day? As a child, was there any food that you had to avoid because it gave you symptoms--such as milk/gas or diarrhea, abdominal bloating? (Please name the food and symptoms). What about now?
Is there anything special about you diet that I should know about?
Has there ever been a food that you craved or really "pigged out" on over a period of time? Please specify what and when (Food craving is an indicator that you may be allergic to that food). Tobacco: Never used Smoked from age to packs/day. Cigars Pipe Snuff Chewing tobacco When used
Alcohol: Never used Social Alcohol problem from to Other family members alcoholic (If so, please list them) More Eating and Drinking---Present or Recent Diet:
Usual Breakfast: None Eggs Bacon/sausage Milk Coffee Tea Toast Bagel Donut, Sweet Roll Juice Fruit Cereal Oat Bran Sugar Sweetener Butter Margarine Other Usual Lunch: None Meat Sandwich Lettuce Fish Sandwich Leftovers Yogurt Soup Salad Dressing Coffee Tea Milk Soda Sugar Sweetener Butter Margarine Eat lunch in work cafeteria Eat lunch in restaurant Other Usual Dinner: None Red meat Times per week Poultry Times per week Fish Times per week Green vegetables Beans (legumes) Carrots or Yellow Vegetables Salad Dressing Potato Pasta Rice Brown Rice Butter Margarine Coffee Tea Sugar Sweetener Soda Juice Milk Other
Snacks: What snacks do you eat or drink between breakfast and lunch?
What snacks do you eat or drink between lunch and dinner?
What snacks do you eat or drink after dinner?
How much of the following do you consume each day or week? Daily or Weekly Slices f white bread (rolls/bagels) Cups of coffee containing caffeine Cups of tea containing caffeine Cups of hot chocolate Cups of deceased coffee or tea Diet sodas Sodas with caffeine Sodas without caffeine Candy Chocolate Cheese Sardines Carrots Salty Foods Ice Cream Past and Present Symptoms: General Symptoms: Instructions: If no symptoms for a particular complaint/symptom below, leave the entry blank. Only answer if there is in fact a complaint/symptom. PLACE AN X IN THE LEFT COLUMN IF IT APPLIES Cold all over Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cold hands & feet Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cold intolerance Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Chills Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Flushing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heat intolerance Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fever Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fatigue Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Malaise Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Difficulty falling asleep Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Night waking Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nightmares Mild Moderate Severe Occasional Frequent Constant Yr of onset/end No dreams recall Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Early Waking Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Daytime sleepiness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Headache or migraine Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Distorted vision Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Distorted Hearing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Distorted Taste Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Distorted Sense of Smell Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Distorted Sense or Feeling of Self Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Visual Hallucinations Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Auditory Hallucinations Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eyes and Ears Symptoms: Instructions: Same as above. Conjunctivitis Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eye Pain or Crusting (circle one or both, if applicable) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Lid Margin redness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ear Fullness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ear Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ear Ringing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ear Noises Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hearing Loss Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sensitivity to Loud Noises Mild Moderate Severe Occasional Frequent Constant Yr of onset/end ==================================== Family History:
Please give a brief description of any problems affecting various family members listed below. Mother: Father: Mother's Mother: Mother's Father: Father's Mother: Father's Father:
Brother/Sister: Brother/Sister: Brother/Sister: Brother/Sister: Spouse: Significant Other: Child: Child: Child: Child: Mother's Brothers: Mother's Sisters: Father's Brothers Father's Sisters:
Other Past And Present Symptoms: Instructions: If no symptoms for a particular complaint/symptom below, leave the entry blank. Only answer if there is in fact a complaint/symptom. Muscular: Calf Cramps Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Foot Cramps Mild Moderate Severe Occasional Frequent Constant Yr of onset/end TMJ Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Muscle Twitches Around Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eyes Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Arms Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Legs Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Chest Tightness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Difficulty in Swallowing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Constipation Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Tension Headache Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Muscle Spasms of the Neck Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Shoulders Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Back Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Muscle Weakness (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Muscle Pain (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Muscle Stiffness (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Muscle Tremor (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Mood/Nerves: Anxiety Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Irritability Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Depression Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Panic Attacks Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Agoraphobia Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Phobias Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fearfulness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Paranoia Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Suicidal Thoughts Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Light headedness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Dizzy (spins) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fainting Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Seizures Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Difficulty..... concentrating Mild Moderate Severe Occasional Frequent Constant Yr of onset/end With Balance Mild Moderate Severe Occasional Frequent Constant Yr of onset/end With Thinking Mild Moderate Severe Occasional Frequent Constant Yr of onset/end With Judgment Mild Moderate Severe Occasional Frequent Constant Yr of onset/end With Speech Mild Moderate Severe Occasional Frequent Constant Yr of onset/end With Memory Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Numbness (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Tingling Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Electrical Zaps Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Past And Present Eating Symptoms: Instructions: If no symptoms for a particular complaint/symptom below, leave the entry blank. Only answer if there is in fact a complaint/symptom. Map-like rash on tongue may indicate a food allergy. Eating Related Problems: Can't Loose Weight Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Can't Gain Weight Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Poor Appetite Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Carbohydrate Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Carbohydrate Intolerance Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bingeing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bulimia Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Salt Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Alcohol Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bread Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Chocolate Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Diet Soda Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Need Coffee Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Need Tea Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Smoke Tobacco Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Used Cocaine Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Used Marijuana Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Used Other Drugs [Specify which drug(s)] Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Digestion: Dentures With Poor Chewing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bad Teeth Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Gums Bleed Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Periodontal Disease Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Dry Mouth Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Geographical Tongue (map-like rash on tongue may indicate food allergy) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sore Tongue Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cancer Sores Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cold Sores Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cracking At Corner Of Lips Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Intolerance of ...... Lactose Mild Moderate Severe Occasional Frequent Constant Yr of onset/end All Milk Products Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Gluten (wheat) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fatty Foods Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Corn Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Yeast Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eggs Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Foods "Repeat" Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heartburn Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Further Gastrointestinal Symptoms:
Nausea Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Vomiting Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Upper Abdominal Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Lower Abdominal Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Lower Abdominal Bloating Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Whole Abdominal Bloating Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Burping Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Farting Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Diarrhea Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Undigested Food in Stools Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Mucous in Stools Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Blood in Stools Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hemorrhoids Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Anal Spasms Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fissures Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bowel Cancer Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Skin Symptoms: Instructions: If no symptoms for a particular complaint/symptom below, leave the entry blank. Only answer if there is in fact a complaint/symptom. Dull, dry skin and hair, dandruff, and thick calluses are signs of fatty acid deficiency. Psoriasis Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eczema Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hives Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Rash Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Athletes Foot Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Jock Itch Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bumps Upper Arms Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Acne On Back Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Acne On Chest Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Acne On Face Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Acne On Shoulders Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cellulite Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Easy Bruising Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Dark Circles Under Eyes Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Lackluster Skin Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Patchy Dullness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Thick Calluses Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Oily Skin Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Red Face Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Pale Skin Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ears Get Red Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Strong Body Odor (Specify if general, or if specific, where located) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bugs Love To Bite You Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sensitive To Bites Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Poison Ivy, Too Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Herpes-Genital Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Shingles Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Skin Cancer (specify location) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Vertigo Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Itching Of: Scalp Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ear Canals (specify if both or one) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Eyes (specify if both or one) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nose Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Roof Of Mouth Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Throat Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nipples (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Arms (Specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hands (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Legs (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Feet (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Penis Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Anus Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Skin In General Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Dryness Of: Hair Mild Moderate Severe Occasional Frequent Constant Yr of onset/end And Unmanageable Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Scalp Mild Moderate Severe Occasional Frequent Constant Yr of onset/end And Dandruff Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hands (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end And Cracking (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end And Peeling (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Skin In General (specify location, if applicable) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Eyes (specify which one or both) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nails: Bitten Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Frayed Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Soft/Brittle Mild Moderate Severe Occasional Frequent Constant Yr of onset/end White Spots/ Lines Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Thickening Of Fingernails Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Thickening of Toenails Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fungus-Fingers Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fungus-Toes Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Curve Up Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ridges Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Pitting Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ragged Cuticles Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Respiratory Symptoms:
Loss Of Sense Of Smell Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Loss Of Sense Of Taste Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Acute Sense/Smell Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nasal Stuffiness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sinus Fullness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sinus Infection Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Post Nasal Drip Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bad Odor In Nose Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bad Breath Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Nose Bleeds Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hay Fever--Spring Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hay Fever--Summer Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hay Fever--Fall Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hay Fever--Change Of Season Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Winter Stuffiness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Sore Throat Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hoarseness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cough-dry Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cough--Productive Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Wheezing Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Cardiovascular: High Blood Pressure Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Palpitations Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heart Pounding Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Rapid Pulse Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Irregular Pulse Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Angina Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heart Attack Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Mitral Valve Prolapse Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heart Murmur Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Varicose Veins Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Phlebitis Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Spidery Veins/Leg Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Urinary: Urgency Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Leaking Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Hesitancy Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bed Wetting Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Kidney Stone Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Infection Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bleeding Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Male Problems:
Prostate Infection Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Prostate Enlargement Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Infertility Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Impotence Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ejaculation Problems Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Genital Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Infection Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Poor Libido Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Female Reproductive Problems:
Vaginal Discharge Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Vaginal Odor Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Vaginal itch Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Vaginal Pain Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Poor Libido Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Breast Lumps Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Breast Cysts Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Breast Tenderness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end
Prementstrual: Bloating-Face Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Bloating-Abdomen Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Puffy-Hands Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Puffy-Feet Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Breast Tenderness Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Irritability Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Constipation Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Decreased Sleep Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Chocolate Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Carbohydrate Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Food Craving Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Diarrhea Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Increased Sleep Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fatigue Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Menstrual: Cramps Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Heavy Periods Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Irregular Periods Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Scanty Periods Mild Moderate Severe Occasional Frequent Constant Yr of onset/end No Periods Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Spotting Between Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Endometriosis Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Ovarian Cysts Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Fibroids Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Infertility (specify type if known) Mild Moderate Severe Occasional Frequent Constant Yr of onset/end Did you ever use birth control pills? No Yes in the past from to Did taking the pill agree with you? Taking the pill now? Contraception use now? Pregnancies: Yes No. If yes, then Miscarriages: # Abortions: # Preemies: # Term Births: # Birth weight of largest baby Birth weight of smallest baby Toxemia? High Blood Pressure Nausea/vomiting? Mild Moderate Severe Other problems during pregnancy
Age at first period Date of last pap smear
If you are past menopause, do you take: Estrogen? Ogen Estrace Premarin Other Progesterone? Provera Natural Progesterone Other Do you take these hormones orally by pill, capsule, or by vaginal insert, or as a topical or transdermal cream? If yes, please explain.
Environmental Questions: Do you have or use any of the following at/near home (h) or work (w)? Please circle H or W, if applicable. CLINICAL ECOLOGY NOTES BELOW: Spring water H/W Well Water H/W Water Purifier H/W Damp Cellar H/W Wooded Area H/W Swamp H/W Power Lines H/W Microwave Transmitter H/W Smoke Stacks H/W Dump H/W Gas Stove H/W Wood Stove H/W Coal Stove H/W Kero Space heater H/W Forced Hot Air Heat H/W Electric Blanket H/W Polyester Blend in: Sheets H/W Pillow Case H/W Pajamas H/W Shirts H/W Skirts H/W Pants H/W Feather Pillows H/W Foam Rubber Pillows H/W Feather Down Comforter H/W Coat/Jacket H/W Stuffed Upholstery H/W Stuffed Animals H/W Exterminator H/W Moth Balls H/W Molt On: Shower curtain H/W Basement Walls H/W 1st Story Walls H/W 2nd Story Walls H/W Under Garage H/W Living Space H/W Urea Formaldehyde Insulation H/W Are you bothered by: CLINICAL ECOLOGY NOTES BELOW yes (y) or no (n) Gasoline Fumes Y/N Diesel Exhaust Y/N Soaps Y/N Detergents Y/N Chlorinated Water Y/N Moth Balls Y/N Asphalt/Tar Y/N Hair Spray Y/N Cosmetics Y/N Perfumes Y/N Dust Y/N Fabric Stores Y/N New Car Smell Y/N Air Conditioner Y/N Newsprint Y/N Tobacco Smoke Y/N Cats Y/N Dogs Y/N Other Animals Y/N Mold Y/N Tree Pollen Y/N Grass Pollen Y/N Ragweed Pollen Y/N Bedroom: Bedroom Carpet Y/N Area Rugs Y/N Wall to Wall Carpet Y/N Wool? Y/N Synthetic Pad Y/N Glued Down Y/N How Old Y/N On Slab Y/N Ever Damp Y/N Moldy Y/N Living Room: Living Room Carpet Y/N Area Rugs Y/N Wall to Wall Y/N Wool Y/N Synthetic Pad Y/N Glued Down Y/N How Old Y/N On Slab Y/N Ever Damp Y/N Moldy Y/N Please list any medications you have had allergic reactions to:
==================================== 1=Very 4=Very Poor 2=Fair 5=Does Not Apply 3=Poor Please place numbered response after each question How well have things been going for you? Psychotherapy or Counseling? In your job? Never Now At School From In your social life Until With close friends What kind? With your spouse With boyfriend/girlfriends With your parents With your children Comments With sex When were you married? Spouse's Occupation: When were you separated? When were you divorced? When were you remarried? New Spouse's Occupation: Comments
Hobbies and Leisure Activities:
Any other family history I should know about?
FUNCTIONAL CAPACITY ASSESSMENT FORM Caregivers: Name: Address: Tx Name: Address: Tx If patient unable to answer, please identify source of information (caregiver or other). 1. How is your hearing? Good Fair Poor 2. How is your eyesight? Good Fair Poor 3. Any trouble using your glasses or hearing aide, if you use them? Yes No 4. List your favorite entree: desert: snack: 5. Have you ever been diagnosed/treated for food allergies? Yes No If yes, which foods 6. Are there foods you have trouble digesting? Yes No 7. If yes, please list them 8. Problems chewing your food? Yes No 9. Has your weight changed in the last year? Yes No If yes, Loss or gain? How many lbs is the weight difference? 10. Are you on a special diet for medical reasons? Yes No If yes, is it Low cholesterol: Low Triglyceride: Diabetic: Low Fat: Weight Loss: Weight Gain: Other (list): 11. Have you fallen or had an accident in the past 6 months? Yes No If yes, please specify what medications you were taking on that day, if any.
Medication List Dose/Units 1. 2. 3. 4. 5. 6. 12. How many different doctors prescribe drugs that you are taking now? For each doctor, please list: Name address phone 1. 2. 3. 4. 5. 6.
13. Medical devices and aides: Item Needs has/ok has not/ok a. eyeglasses b. dentures c. hearing aid d. telephone amplifier e. any emergency notify system f. cane g. walker h. wheelchair i. crutches j. oxygen k. transfer equipment l. grab bars or hand rails m. tub/shower seat n. hand held shower o. special toilet seat p. urinal/bedpan q. commode chair r. foley catheter s. ostomy supplies t. prosthesis (external) u. bionic implant v. other 14. Hygiene and grooming: Place an x beside the appropriate answer Are you able to comb your hair, shave, brush your teeth? a. independent-no-assistance required. b. minor assistance--needs reminders to bathe, shave, comb hair. c. needs minor assistance, preparation of grooming materials and help with dentures. d. needs limited physical assistance, steadying of hands when shaving or combing hair, assistance needed because of physical disabilities. e. needs total assistance, wash and comb hair, clip nails, brush teeth, shaving, etc. 15. Bathing: Place an x beside the appropriate answer Are you able to take a bath or shower? a. independent--no assistance needed. b. preparation of both water needed, preparing of bathing articles (wash cloth, towels and soap). c. for safety reasons, steadiness may require assistance. d. assistance needed to wash face and hands, only. e. total assistance needed with preparation. 16. Dressing: Place an x beside the appropriate answer Can you dress yourself, putting on proper clothing? a. independent--no assistance required. b. needs Occasional help with zippers, buttoning, tying shoe laces, etc. c. needs structuring--daily assistance with same. d. Moderate assistance with same. e. fully dependent--needs total assistance. 17. Meal preparation: Place an x beside the appropriate answer Are you able to prepare your own meals? a. needs no assistance--independent. b. heats and prepares prepared foods. c. heats meals but needs prompting, help with use of kitchen equipment. d. only prepares cold foods--cannot be trusted with kitchen equipment. e. needs total assistance--must be served, also. 18. Dining--eating only: Place an x beside the appropriate answer Can you eat by yourself? a. needs no assistance--totally independent. b. minor assistance in opening cartons, jelly packets, cracker wrappers, etc. c. more assistance in cutting meats, etc., but can still self feed. d. Moderate assistance required--untidy, cannot hold cup, needs someone to prompt. e. totally dependent including physical assistance. 19. Telephone: Place an x beside the appropriate answer Are you able to use a telephone? a. needs no assistance--totally independent. b. someone else needed to initiate calls. c. can only dial a few numbers. d. can only answer but cannot initiate calls or remember telephone number sequence. e. others must make and receive calls--totally dependent for reasons other than loss of hearing. 20. Housekeeping: Place an x beside the appropriate answer Are you able to keep up the apartment/house? a. keeps place clean--needs help with heavy work. b. light tasks--dishwashing, bed making. c. light tasks but cannot maintain acceptable levels of cleanliness. d. cannot maintain orderliness of personal items and clothing. e. needs all tasks performed by others. 21. Laundry: Place an x beside the appropriate answer Do you do your own laundry? a. sends it out or does own. b. needs help using laundry machines. c. does small hand items, only. d. needs reminders to clean personal clothing and assistance with dispensing soap and bleach. e. laundry must be done by others. 22. Finances: Place an x beside the appropriate answer Do you manage your own money? a. does all finances and banking independently. b. capable to shopping and routine transactions, only c. must be reminded to write checks, pay bills. d. needs assistance in every transaction. e. requires a guardian or trustee to handle all financial matters. 23. Method of transportation: Place an x beside the appropriate answer What type of transportation do you use? a. learns the public transportation system or drives a car. b. uses taxi or other mode of transportation--makes own arrangements. c. travel depends upon someone else? d. needs special customized handicapped car/van for transportation. e. doesn't travel. 24. Driving: specify "yes" or "no" Can you drive a car? a. independent use of own or other car. b. has unrestricted drivers license? c. only limited daily car use and access. d. has no daily access to and use of car. e. if restricted drivers license, specify how it is restricted 25 Sleep: Can you describe the quality of your sleep? a. How much time does it usually take you to fall asleep? b. What time do you retire and what time do you wake up? c. What is your usual total sleep time? d. How many times do you usually wake up at night? e. How long are you up each time you wake up during the night?
f. How restorative or refreshed do you usually feel after you wake up? (1) not at all. (2) a little refreshed. (3) somewhat refreshed. (4) well rested. (5) very well rested. g. Do you feel tired during the day while you are awake? (1) not at all. (2) a little tired. (3) somewhat tired. (4) fairly tired. (5) very tired. h. Do you nap during the day? If so, when? morning, afternoon, evening (1) not at all. (2) a few times. (3) more than a few times. (4) nap Frequently. (5) nap very Frequently. i. Have you experienced recent changes in your sleeping patterns? Yes No If so, please describe j. Have you ever been treated for sleep problems before? Yes No If so, please describe
k. When you sleep, do you (specify "yes" or "no"); (1) snore? Yes No (2) have breathing problems? Yes No (3) Are you restless? Yes No l. Can you describe the intensity of the lighting in the room where you sleep when you go to sleep? (1) no lighting--total darkness. (2) some, low lighting. (3) Moderate lighting. (4) bright lighting. (5) very bright lighting. 26. The remaining questions are to be answered only by the caregiver of the patient, if the caregiver has asked the questions; please circle the appropriate response. During the interview, did the patient's behavior rate "yes" or "no" for each of the following? a. yes no mentally alert and stimulating? b. yes no pleasant and cooperative? c. yes no depressed and/or tearful? d. yes no withdrawn or lethargic? e. yes no fearful, anxious or extremely tense? f. yes no full of unrealistic physical complaints? g. yes no unreasonable or suspicious? h. yes no bizarre or inappropriate in thought or action? i. yes no excessively talkative or overtly jovial or elated? j. yes no oriented as to person (knows who he/she is)? k. yes no oriented as to time (knows date, year and time)? l. yes no oriented as to place (knows where he/she is)? WHO SUPPLIED THE INFORMATION FOR THIS ENTIRE, COMPLETE QUESTIONNAIRE? 100% BY THE CLIENT. 75% BY THE PATIENT, 25% BY THE CAREGIVER 50% BY THE CLIENT, 50% BY THE CAREGIVER 25% BY THE CLIENT, 75% BY THE CAREGIVER 100% BY THE CAREGIVER
Free Initial Consultation - Call Now (954) 448-1515 RONALD B. KEYS, JD, PhD CLINICAL & OPERATIONS DIRECTOR Ronald B. Keys, JD, PhD 2402 N. 28th Avenue Hollywood, Florida, 33020-1814 USA 954-448-1515 primary email: email@rkeysphd.com secondary email: rkeysphd@brainlink.com secondary email: rkeysphd@yahoo.com by pre-arrangements for voice/text chat: Mostly, Dr. Keys works as a Consulting PhD Doctor, usually from a distance, with and through a proper local anchor physician to order blood work. Advanced treatment protocols may develop from the advanced blood chemistries he requests. If you have no local doctor, Dr. Keys finds one through an affiliate physician network. His work is global, oftetimes involving patients from other countries as well as all over the continental USA. There are many tests and treatments to help people; Oftentimes, anchor physicians are not familiar or comfortable with them. Dr. Keys teaches and helps to direct individual patients AND their physicians with laboratory-work for these treatment options. This is measured work and clinical biochemistry. Opinion evidence standards are not employed here since this is a measured and laboratory-based or empirical study of the patient. Numbers are sought from the results of these tests that, usually, "...jump up and grab you..." that dictate what is needed and how much. Patient-advocacy is frequently involved to get advanced and necessary clinical biochemistries ordered and to help interpret them in filed reports..Chat room capabilities in voice or text, besides email, may be employed. This may include conference calls online. In a perfect world, if your physician knew everything, people like Dr. Keys would not exist. Physicians themselves are caught frequently in the traps of their own standards of care that may be very limited in many cases. Methods used by Dr. Keys are rational, scientific and disciplined. Designed by Fencl Web Design.Com DISCLAIMER: Ronald B. Keys, JD, PhD is not a physican. He acts here, when hired, only as a consulting PhD doctor. Any information offered on this site is intended for prevention and education. It is the responsibility of your anchor doctor or chosen physician to diagnose and treat diseases through their medical licenses. By using this web site you agree that you will seek professional medical advice from your doctor before using any of the information presented on this web site. All tests are ordered through your physician, only, and not Dr. Keys. Most jurisdictions require that an attending physician is required by law to take patient and family history, conduct a physical examination of the patient and to order tests appropriate and necessary. As an online consultant, he cannot do these things required together, as a whole, as a practice of medicine. Any emergencies should only be handled in a hospital emergency room or by your physician. |