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Please answer all questions. If menopausal answer questions about how your period was in the past.
What are your health goals regarding your women’s health and/or menstrual cycle and hormones?
Date of first period
Date Format: MM slash DD slash YYYY
Menopausal (defined as no period in 12 months or more)?
Yes
No
Cycle length (normal is 28 days)?
Please enter a number from
1
to
31
.
Number of days of bleeding?
Heavy, light or normal bleeding?
Heavy
Light
Normal
PMS symptoms?
Yes
No
Describe
Cramps and pain during period?
Yes
No
If yes, rate severity on a scale from 1-10.
Please enter a number from
1
to
10
.
Clots during period?
Yes
No
Please list gynecological diagnosis or surgeries. Including endometriosis, PCOS, C-sections, ablation, hysterectomy, and other surgeries)
If menopausal, list symptoms (hot flashes, insomnia, palpitations, anxiety, etc.)
List any other gynecological symptoms of concern
Have you had a recent cold or flu?
Yes
No
If yes, when?
Do you have a history of head injury or trauma? If yes, please explain.
About how many times a week do you experience HA or migraine?
What is the average pain scale, with 0 being no pain and 10 being the worst pain imaginable?
Please enter a number from
1
to
10
.
What part of the head is most affected? Pick all that apply
Back of head
Front of head (forehead, above/around eyes)
Sides of head (around ears)
Very top of head
What best describes the type of pain? Pick all that apply
Sharp and stabbing
Dull and aching
Numb and tingling
Empty-feeling
Is the pain worse in the morning or evening?
Yes
No
What other symptoms do you have with the pain (nausea, irritable, insomnia, ringing in the ears, dizziness, etc.)?
Have you been diagnosed with an autoimmune disease?
Yes
No
How many years have you been experiencing symptoms of this disease?
Are you experiencing pain, swelling, inflammatory symptoms currently?
How are you affected by your particular autoimmune disease?
When was your last blood panel and evaluation with your doctor?
Date Format: MM slash DD slash YYYY
What types of doctors are you working with to manage your disorder?
Have you taken comprehensive Food Inflammation Testing and Comprehensive blood work before?
Yes
No
Are you open to taking a Food Inflammation Test?
Yes
No
How often are you unable to work, or participate in your typical daily activity because of your symptoms?
How many medications have you tried before your current medication regimen?
Have you been hospitalized because of your condition?
Yes
No
How have you tailored your diet to promote healing and to relieve the symptoms of your condition?
How long have you been trying to conceive?
When do you hope to conceive?
Have you had hormone testing? If yes, what were the results? (FSH, Testosterone, Progesterone (day 21), Estradiol, DHEA, Cortisol, LH surges?
Do you take ovulation tests each month?
Yes
No
When do you typically ovulate?
How many days do your cycles last?
Do you experience pain at any time during your cycle? When? How long does it last?
How many pregnancies?
How were your previous children, if applicable, conceived? Naturally? With medical intervention?
Miscarriages?
Are you open to taking a Food Inflammation Test? (We test through KBMO, testing for 4+ reactions in the blood, not just IgG, but the formation of immune complexes and the activation of Compliment as well)
Yes
No
Are you considering or are you receiving IUI or IVF treatments?
Yes
No
If so, how many rounds of IUI or IVF have you received?
Do you experience night sweats?
Yes
No
What is your stress level from 0-10 on average?
Are you able to sleep through the night?
Do you have any lower back pain, injuries or soreness?
Have you experienced digestive disorders or discomfort of the lower intestines for longer than 2 months? Pain, swelling, cramping, constipation, loose stools, diarrhea or blood in your stool?
Have you ever taken birth control?
Yes
No
What type?
How long did you take Birth Control for?
When did you discontinue?
Have you had any abdominal surgeries?
