Date * First Name * Last Name * Billing Street Address 1 * Billing Street Address 2 Billing City * Billing State * Billing Postal Code * Home Phone Please select oneWorkHomeMobileOther Cell Phone * Work Phone Email * Age * Birthday * Gender * Status * MarriedSeparatedDivorcedWidowedSinglePartnership Education Occupation Hours Worked Per Week Employer Work Address Work City Work State Work Postal Code Emergency Contact * Emergency Contact Relationship Emergency Contact Phone * How did you hear about Revived Living? * What is your major complaint and when did these symptoms begin? * What are your current medications? * What are your current vitamins and/or supplements? Please list your current & past health conditions (i.e. Diabetes) * Is there anything in your medical history you consider relevant * What is your employment history? Please provide brief summary. Please list past or present allergies Please list all past surgeries Patient History Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank. Mercury Do you have amalgam (silver) fillings in your teeth currently? YesNo Have you ever had them in the past? YesNo Did your mother have amalgam when pregnant with you? YesNo Have you ever worked in a dental office? YesNo Have you had any crowns, bridges, root canals, dry socket? YesNo Do you have any dental implants or other metal in your mouth? YesNo Did you wear contact lenses during the 1980’s or early 1990’s? YesNo Did you take oral contraceptives during the 1980’s or early 1990 YesNo Have you ever received a flu shot? YesNo Have you noticed any adverse reactions to vaccinations? YesNo Do you have any tattoos with red ink? YesNo Do you eat large amounts of seafood (more than twice a week)? YesNo Lead Does your occupation involve soldering, metal salvage, old home YesNo Was your home built before 1978? YesNo Have you ever worn cosmetics containing kohl? YesNo General Toxicity Have you ever lived near a freeway, tension wires, or power grid? YesNo Have you ever had any chemical exposures? YesNo Mold How old is the house you are living in? How long have you lived there? Do you see mold growing at home, work or school? YesNo Have you ever had water damage at home, work or school? YesNo Does your home, workplace or school have a damp or mildew smell? YesNo Does your basement ever get wet? YesNo Does spending time in a different location improve your symptoms? YesNo Lyme Disease Have you ever been diagnosed with Lyme Disease? YesNo Have you ever been bitten by a tick or recluse spider? YesNo Have you ever seen a bulls-eye rash on your body? YesNo Do you frequently go camping or spend a lot of time outdoors? YesNo Health History Has anyone in your family been diagnosed with fibromyalgia, chro YesNo Does anyone in your family experience similar symptoms to you? YesNo What is your birth order, i.e. first born, second, third, etc.? Do you have any history of kidney dysfunction? YesNo Do you or any family member have a history of cancer? YesNo Do you have any history of heart disease, myocardial infarction YesNo Are you currently having any thoughts of suicide? YesNo Have you ever been diagnosed with a mental illness? YesNo Have you ever been diagnosed with diabetes mellitus? YesNo Have you ever been in an accident or received major physical trauma? YesNo Are you in menopause? YesNo Do you have any allergies to food or medication? Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank. Point Scale 0 = Never had the symptom 1 = Occasionally have it, mild effect 2 = Occasionally have it, severe effect 3 = Frequently have it, mild effect 4 = Frequently have it, severe effect Section 1 Anxiety 01234 Mood swings 01234 Enraged behavior or anger for no reason 01234 Excessive shyness, timidity, social phobia (not typical to your personality) 01234 Irritability (not typical to your personality) 01234 Low body temperature (below 97.5o) 01234 Insomnia (can’t get to sleep or return to sleep 01234 Checkbox Dizziness 01234 Sound in ears (ringing or hearing your heart beat) 01234 Psychological symptoms, even thoughts of suicide 01234 Sensitivity to sound 01234 Indecisiveness 01234 Feeling of being overwhelmed or fearful 01234 Metallic taste in your mouth 01234 Bad breath 01234 Bleeding gums 01234 Sensitive teeth 01234 Canker sores or other sores in the mouth 01234 Floaters, shadows or swimmers when you read or look into the sky 01234 Dyslexia or loss of place while reading, even as a child 01234 Swelling eyelids 01234 Peeling on top layer of skin (hands, feet) 01234 Dry Skin 01234 Heart pain (angina) and you are under 45 years old 01234 Depression 01234 Gout (arthritic pain, especially in big toes) 01234 Pain in shoulders or upper back 01234 Twitching eyelids 01234 Anemia (low iron/hemoglobin on blood test) 01234 Wrist/ankle drop or weak extensor muscles 01234 Hair falls out (not normal male pattern baldness) 01234 Section 2 Sensitivity to light 01234 Fatigue after exercising (feeling worse) 01234 Bad night vision or seeing halos around lights 01234 Shortness of breath, with very little effort 01234 Excessive thirst and/or frequent urination 01234 Red eyes or tearing 01234 Blurred vision at times 01234 Morning stiffness 01234 Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners 01234 Chronic fatigue or weakness 01234 Non-restful sleep 01234 Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.) 01234 Trouble processing new information 01234 Word reversal or trouble finding words 01234 Sensitivity to touch 01234 Short-term memory loss 01234 Chronic sinus congestion 01234 Dry non-productive cough 01234 Muscle twitching 01234 Excessive sweating, especially at night 01234 Joint pain-not necessarily true arthritis-can move from joint to joint 01234 Difficulty losing weight regardless of diet or exercise 01234 Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis 01234 Frequent illness, prolonged illness or sick days 01234 Numbness or weakness in arms and legs 01234 Headaches 01234 Trouble adding or dividing numbers in your head 01234 Fluctuating constipation and diarrhea 01234 Stomach pain for no apparent reason 01234 Appetite swings 01234 Satisfaction Questionairre Please rate the following: (On a scale of 1 to 10, 10 being the best) My Health Please select one12345678910 My Commitment to my Health Please select one12345678910 My Energy Please select one12345678910 My Happiness Please select one12345678910 My Commitment to Excercise Please select one12345678910 My Spiritual Life Please select one12345678910 My Productivity Please select one12345678910 The Quality of My Personal Relationships Please select one12345678910 Submit
