Client Questionnaire – Lisa’s Natural Path

Bio-ldentical Questionnaire

Please answer all of the questions as accurately and as fully as possible

Please complete your questionnaire and all consent forms at least two (2) days before your scheduled appointment.

1. Patient lnformation

First Name

Last Name

Date of Birth

Age

3. Can you tell us more about who referred you?

Name of person who referred You

4. What are the top three symptoms/problems related to hormones you
would like to see improved, in the order of most important to least important?

Reason #1

Reason #2

Reason #3

5. Please score the factors below on a scale of 1 to 10 (1 = Awful, 10 = Outstanding)

	1	2	3	4	5	6	7	8	9	10
My energy level	1	2	3	4	5	6	7	8	9	10
My sense of well-being	1	2	3	4	5	6	7	8	9	10

Medical History

6. Please list your medical history - past and current.

7. List all medications you currently take and the dosage.

8. Please list any medication or latex allergies.

9. List any supplements or vitamins you use regularly.

10. How many hours do you sleep each night?

11. Do you smoke?

Yes - please comment how frequently

12. Do you drink alcohol?

Yes - please comment how frequently

13. Do you exercise?

Yes - please comment how frequently

14. Was your most recent blood work test done within the last year? (if so, please bring results consultation).

15. List of current stressors

Family History

16. Have you or any of your family members been diagnosed with:

Conditions	Yes	No
Autoimmune Condition	Yes	No
Cancer (Breast)	Yes	No
Cancer (Colon)	Yes	No
Cancer (Ovarian)	Yes	No
Cancer (Uterine)	Yes	No
Cancer (Other)	Yes	No
Dementia	Yes	No
Diabetes	Yes	No
Fibrocystic Breasts	Yes	No
Heart Disease	Yes	No
Osteoporosis	Yes	No
Psychiatric Disorder	Yes	No
Thyroid Disorder	Yes	No

List of Symptoms

C 17. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Poor tolerance to stress	Never	Few	Moderate	Much	Always
Anxiety with stress	Never	Few	Moderate	Much	Always
Low blood pressure	Never	Few	Moderate	Much	Always
Tired during the day	Never	Few	Moderate	Much	Always
Fatigue / mood improvement after sugar/sweets	Never	Few	Moderate	Much	Always
Salt cravings	Never	Few	Moderate	Much	Always
Nausea	Never	Few	Moderate	Much	Always
Inflammatory disease(arthritis, etc.)	Never	Few	Moderate	Much	Always
Food or medication allergies	Never	Few	Moderate	Much	Always
Brown spots or increased pigmentation	Never	Few	Moderate	Much	Always
Eczema, psoriasis or dandruff	Never	Few	Moderate	Much	Always
Weak or tired when standing up	Never	Few	Moderate	Much	Always
Frequent urination	Never	Few	Moderate	Much	Always

M 18. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Poor sleep	Never	Few	Moderate	Much	Always
Difficulty falling asleep	Never	Few	Moderate	Much	Always
Awakening during the night	Never	Few	Moderate	Much	Always
Excessive pondering of problems at night	Never	Few	Moderate	Much	Always
Waking up tired(too little sleep)	Never	Few	Moderate	Much	Always

GH 19. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Thinning hair	Never	Few	Moderate	Much	Always
Thinning skin	Never	Few	Moderate	Much	Always
Longitudinal lines on nails	Never	Few	Moderate	Much	Always
Premature wrinkling on face	Never	Few	Moderate	Much	Always
Loose or sagging skin	Never	Few	Moderate	Much	Always
Thinning lips	Never	Few	Moderate	Much	Always
Overweight	Never	Few	Moderate	Much	Always
Decreased muscle strength or tone	Never	Few	Moderate	Much	Always
Flabby muscles(triceps of arm or other)	Never	Few	Moderate	Much	Always
Wrinkled Hands	Never	Few	Moderate	Much	Always
Flabby drooping belly	Never	Few	Moderate	Much	Always
Often sick	Never	Few	Moderate	Much	Always
Easily exhausted	Never	Few	Moderate	Much	Always
Difficult to do daily required tasks	Never	Few	Moderate	Much	Always
Poor motivation for required task	Never	Few	Moderate	Much	Always
Constant tiredness	Never	Few	Moderate	Much	Always
Difficult to stay up late	Never	Few	Moderate	Much	Always
Difficult to recover after staying up late	Never	Few	Moderate	Much	Always
Need for lots of sleep (over 10 hours)	Never	Few	Moderate	Much	Always
Low resistance to stress	Never	Few	Moderate	Much	Always
Difficult to recover after a stressful situation	Never	Few	Moderate	Much	Always
Not assertive	Never	Few	Moderate	Much	Always
Very emotional	Never	Few	Moderate	Much	Always
Mood Swings	Never	Few	Moderate	Much	Always
Anxiety	Never	Few	Moderate	Much	Always
Low self-esteem	Never	Few	Moderate	Much	Always
Depression	Never	Few	Moderate	Much	Always
Tendency to give sharp verbal retorts	Never	Few	Moderate	Much	Always
Tendency to isolate	Never	Few	Moderate	Much	Always

T 20. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Sensitive to cold	Never	Few	Moderate	Much	Always
Cold hands or feet	Never	Few	Moderate	Much	Always
Generalized fatigue	Never	Few	Moderate	Much	Always
Hoarse voice	Never	Few	Moderate	Much	Always
Sleepy during the day	Never	Few	Moderate	Much	Always
Distracted easily	Never	Few	Moderate	Much	Always
Poor motivation for required tasks	Never	Few	Moderate	Much	Always
Depression	Never	Few	Moderate	Much	Always
Headaches	Never	Few	Moderate	Much	Always
Water retention	Never	Few	Moderate	Much	Always
Constantly swollen eyelids	Never	Few	Moderate	Much	Always
Swollen eyes in the morning	Never	Few	Moderate	Much	Always
Swollen calves/feet	Never	Few	Moderate	Much	Always
Difficulty losing weight, despite dieting	Never	Few	Moderate	Much	Always
Constipation	Never	Few	Moderate	Much	Always
Coarse (rough) skin	Never	Few	Moderate	Much	Always
Slow heart palpitations	Never	Few	Moderate	Much	Always
Muscle cramps	Never	Few	Moderate	Much	Always
Tingling or numbness in extremities	Never	Few	Moderate	Much	Always
Stiff joints in the morning	Never	Few	Moderate	Much	Always
Joint pain worse with cold temperatures	Never	Few	Moderate	Much	Always
Hoarse voice in the morning	Never	Few	Moderate	Much	Always
Dry skin (feet/elbows/general)	Never	Few	Moderate	Much	Always
Slow growing or brittle nails	Never	Few	Moderate	Much	Always
Diffuse hair loss	Never	Few	Moderate	Much	Always
Muscle achiness or soreness	Never	Few	Moderate	Much	Always
Low body temperature	Never	Few	Moderate	Much	Always
Diminished sweating	Never	Few	Moderate	Much	Always

Yeast Questionnaire

The total score for this section helps us to determine the probability of yeast overgrowth as being a significant factor in your symptoms.

21 . Please answer the following questions.

Please calculate the total number of points for each "yes" answer and type it at the bottom of this page.

	Yes	No
Have you been treated for acne with tetracycline, erythromycin or any other antibiotic for one month or longer? [50 points]	Yes	No
Have you taken antibiotics for any type of infection for more than two consecutive months, or in shorter courses over three times in a 12-month period? [50 points]	Yes	No
Have you ever taken an antibiotic - even for a single course? [6 points]	Yes	No
Have you ever had prostatitis or vaginitis? [25 points]	Yes	No
Have you ever been pregnant? [5 points]	Yes	No
Have you ever taken birth control pills? [15 points]	Yes	No
Have you taken corticosteroids, such as Prednisone, Cortef, or Medrol? [15 points]	Yes	No
When you are exposed to perfumes, insecticides, or other chemicals or odors, do you experience wheezing, burning eyes, or other distress? [15 points]	Yes	No
Are you symptoms worse on damp or humid days or in moldy places? [20 points]	Yes	No
Have you ever had a fungal infection that was difficult to treat, such as jock itch, athlete's foot, or a nail or skin infection? [20 points]	Yes	No
Do you crave sugar or bread? [20 points]	Yes	No
Does tobacco smoke cause you discomfort, such as wheezing or burning eyes? [10 points]	Yes	No

22. Total the points to all questions to which you answered "yes" and please enter that number in the box provided.

23. Are you a male or female?

Male

Female

Women Only

24. Are you currently pregnant?

Yes

25. Do you plan to become pregnant within the next 12 months?

Yes

26. Female Medical History. Please enter "N/A" if not applicable.

Date of first menstrual period?

Date of menopause?

Number of pregnancies?

Number of live births?

Number of miscarriages?

27. Results Section. Please enter "N/A" if not applicable.

Date of last Pap smear?

Results of last Pap smear?

Date of last mammogram?

Results of last mammogram?

Date of last bone density test?

Results of last bone density test?

28. Complaints

Do you experience PMS? If so, what are your symptoms?

Describe any vaginal complaints?

29. Stress

What is your stress level (low, moderate, or high)?

Is your mind constantly "racing"?
Would you consider yourself a "worrier"?

P 30. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Irritable before menstruation(PMS)	Never	Few	Moderate	Much	Always
Swollen breasts/belly before menstruation	Never	Few	Moderate	Much	Always
Breast cysts	Never	Few	Moderate	Much	Always
Fibriods of uterus	Never	Few	Moderate	Much	Always
Endometriosis	Never	Few	Moderate	Much	Always
General irritability	Never	Few	Moderate	Much	Always
Generalized anxiety	Never	Few	Moderate	Much	Always

E 31. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Old looking than age	Never	Few	Moderate	Much	Always
Loss of attention to details	Never	Few	Moderate	Much	Always
Bleeding gums or poor teeth	Never	Few	Moderate	Much	Always
Fatigue throughout the day	Never	Few	Moderate	Much	Always
Poor recovery from physical exercise	Never	Few	Moderate	Much	Always
Depressed	Never	Few	Moderate	Much	Always
Poor Memory	Never	Few	Moderate	Much	Always
Hot flashes	Never	Few	Moderate	Much	Always
Excessive sweating	Never	Few	Moderate	Much	Always
Dry eyes	Never	Few	Moderate	Much	Always
Dry vagina	Never	Few	Moderate	Much	Always
Pain during intercourse	Never	Few	Moderate	Much	Always
Pale skin	Never	Few	Moderate	Much	Always
Wrinkles around eye/forehead/mouth	Never	Few	Moderate	Much	Always
New body hair	Never	Few	Moderate	Much	Always
Drooping breasts	Never	Few	Moderate	Much	Always
Bladder infections	Never	Few	Moderate	Much	Always
Urinary incontinence	Never	Few	Moderate	Much	Always
First menstruation before 12 or after 15	Never	Few	Moderate	Much	Always
Depression after menstruation	Never	Few	Moderate	Much	Always

T 32. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Low libido(sex drive)	Never	Few	Moderate	Much	Always
Difficulty achieving orgasm	Never	Few	Moderate	Much	Always
Poor muscle tone/decreased strength	Never	Few	Moderate	Much	Always
Excessive fat	Never	Few	Moderate	Much	Always
Cellulite	Never	Few	Moderate	Much	Always
Varicose veins	Never	Few	Moderate	Much	Always
Hemorrhoids	Never	Few	Moderate	Much	Always
Bruising easily	Never	Few	Moderate	Much	Always

Men Only

24. Male Medical History

Date of last prostate exam?

Date of last PSA?

T 25. Do you ever have the following symptoms?

	Never or No Symptoms	Few or Sometimes	Moderate or Regularly	Much or Often	Always or Extreme
Older looking than age	Never	Few	Moderate	Much	Always
Loss of feeling of well-being	Never	Few	Moderate	Much	Always
Loss of attention to details	Never	Few	Moderate	Much	Always
Poorly motivated	Never	Few	Moderate	Much	Always
Excessive fat	Never	Few	Moderate	Much	Always
Fatigue	Never	Few	Moderate	Much	Always
Loss of muscle mass or strength	Never	Few	Moderate	Much	Always
Poor recovery from physical activity	Never	Few	Moderate	Much	Always
Poor endurance	Never	Few	Moderate	Much	Always
Poor motivation for required tasks	Never	Few	Moderate	Much	Always
Depression	Never	Few	Moderate	Much	Always
Passive	Never	Few	Moderate	Much	Always
Decreased memory	Never	Few	Moderate	Much	Always
Irritable	Never	Few	Moderate	Much	Always
Very emotional	Never	Few	Moderate	Much	Always
Hair loss	Never	Few	Moderate	Much	Always
Poor beard growth	Never	Few	Moderate	Much	Always
Scarce body hair	Never	Few	Moderate	Much	Always
Bleeding gums or poor teeth	Never	Few	Moderate	Much	Always
Dry eyes	Never	Few	Moderate	Much	Always
Pale skin	Never	Few	Moderate	Much	Always
Wrinkles on face/palm of hand	Never	Few	Moderate	Much	Always
Varicose veins	Never	Few	Moderate	Much	Always
Hemorrhoids	Never	Few	Moderate	Much	Always
Bruising easily	Never	Few	Moderate	Much	Always
Poor wound healing	Never	Few	Moderate	Much	Always
Poor muscle tone(triceps or other)	Never	Few	Moderate	Much	Always
Joint pains	Never	Few	Moderate	Much	Always
Excessive sweating	Never	Few	Moderate	Much	Always
Urination problems	Never	Few	Moderate	Much	Always
Urinary incontinence	Never	Few	Moderate	Much	Always
Loss of urine after urination	Never	Few	Moderate	Much	Always
Swollen prostate	Never	Few	Moderate	Much	Always
Low libido(Sex drive)	Never	Few	Moderate	Much	Always
Difficulty achieving orgasm	Never	Few	Moderate	Much	Always
Decreased ability to maintain an erection	Never	Few	Moderate	Much	Always
Decreased erections/firmness	Never	Few	Moderate	Much	Always

Bio-ldentical Questionnaire

1. Patient lnformation

2. How did you hear about us?

3. Can you tell us more about who referred you?

4. What are the top three symptoms/problems related to hormones you would like to see improved, in the order of most important to least important?

5. Please score the factors below on a scale of 1 to 10 (1 = Awful, 10 = Outstanding)

Medical History

6. Please list your medical history - past and current.

7. List all medications you currently take and the dosage.

8. Please list any medication or latex allergies.

9. List any supplements or vitamins you use regularly.

10. How many hours do you sleep each night?

11. Do you smoke?

12. Do you drink alcohol?

13. Do you exercise?

14. Was your most recent blood work test done within the last year? (if so, please bring results consultation).

15. List of current stressors

Family History

16. Have you or any of your family members been diagnosed with:

List of Symptoms

C 17. Do you ever have the following symptoms?

M 18. Do you ever have the following symptoms?

GH 19. Do you ever have the following symptoms?

T 20. Do you ever have the following symptoms?

Yeast Questionnaire

21 . Please answer the following questions.

22. Total the points to all questions to which you answered "yes" and please enter that number in the box provided.

23. Are you a male or female?

Women Only

24. Are you currently pregnant?

25. Do you plan to become pregnant within the next 12 months?

26. Female Medical History. Please enter "N/A" if not applicable.

27. Results Section. Please enter "N/A" if not applicable.

28. Complaints

29. Stress

P 30. Do you ever have the following symptoms?

E 31. Do you ever have the following symptoms?

T 32. Do you ever have the following symptoms?

Men Only

24. Male Medical History

T 25. Do you ever have the following symptoms?

4. What are the top three symptoms/problems related to hormones you
would like to see improved, in the order of most important to least important?