Medical History Questionnaires

The Health Journey questionnaire covers less medical history details than the others but does includes some social history questions.

+ Start Health Journey: Comprehensive Case Review

+ Start Medical History Questionnaire - Version 1

Version 1 covers a bit more than Version 2 (such as blood type, GI history, dental history and allergies).

+ Start Medical History Questionnaire - Version 2

Version 2 and Version 3 are more specialized than Version 1.

+ Start Medical History Questionnaire - Version 3

Family History Questionnaires

+ Start Family History Questionnaire - Version 1

+ Start Family History Questionnaire - Version 2

Social History Questionnaires

Version 1 and Version 2 use different language to cover similar issues, while Version 1 is a little more extensive.

+ Start Social History Questionnaire - Version 1

+ Start Social History Questionnaire - Version 2

+ Start Gender Identity and Sexual Orientation Questionnaire

The information in this last form allows for non-binary gender identification and covers STD history.

Readiness Questionnaires

+ Start Readiness Assessment

Symptom Questionnaires

+ Start Medical Symptom/Toxicity Questionnaire

+ Start Review of Systems

+ Start Symptom Review Questionnaire

Specialized Symptom Questionnaires

+ Start Biotoxin Illness Survey

+ Start Digestion Questionnaire

+ Start Food and Yeast Allergy Questions

+ Start Hormone Questionnaire

Start Pain and Dysfunction Intake

+ Start Brief Pain Questionnaire

Start Pain Questionnaire (Short-form McGill)

Environmental Exposure Questionnaires

+ Start Toxic Exposure Questionnaire

+ Start Environmental Exposure Questionnaire

Lyme Questionnaires

Version 1 generates a score based on the patient's responses.

+ Start Lyme Symptom Questionnaire - Version 1

+ Start Lyme Symptom Questionnaire - Version 2

+ Start Lyme Symptom Questionnaire - Version 3

Male/Female Questionnaires

+ Start Women's Questionnaire

+ Start Postmen/Perimenopausal Questionnaire

+ Start Men's Questionnaire

Pediatric Questionnaires

The long form covers everything that the short form covers, plus more. The Symptom Review Part 1 covers social/emotional issues while Part 2 focuses on physical symptoms.

+ Start Pediatric Medical History (short form)

+ Start Pediatric Medical History (long form)

+ Start Pediatric Intake Form

+ Start Pediatric Symptom Review 1

+ Start Pediatric Symptom Review 2

Two Part Comprehensive Pediatric Questionnaires

+ Start Pediatric Intake Part 1

+ Start Pediatric Intake Part 2

Diet Questionnaires

+ Start Food Survey

+ Start 3-Day Diet Diary

Mental State Questionnaires

+ Start PHQ-9 Questionnaire (depression)

+ Start Becks Depression Questionnaire

+ Start Mood Disorder Form

+ Start GAD-7 Questionnaire (anxiety)

+ Start PC PTSD-5 (PTSD)

+ Start Memory Questionnaire

+ Start HPA AXIS Questionnaire

+ Start Hamilton Depression Rating Scale

+ Start Depression Anxiety Stress Scales

+ Start Alzheimers Questionnaire

+ Start Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

Other Questionnaires and Assessments

+ Start ACE Score

+ Start Adrenal Questionnaire

+ Start Blood Sugar and Insulin Resistance Questionnaire

+ Start Follow-Up Questionnaire

+ Start Insomnia Questionnaire

+ Start Metabolic Assessment Form

+ Start Neurotransmitter Assessment Form

+ Start Parasite Questionnaire

+ Start Thyroid Questionnaire

Consents

Note: You are required by law to have some version of the HIPAA form by the Health Insurance Portability and Accountability Act. For more information and guidelines, visit Model Notices of Privacy Practices.

+ Start Authorization to Release Medical Records

+ Start Authorization to Release Medical Records (Texas)

+ Start General Consent Form

+ Start HIPAA Model Notice of Privacy Practices (from HHS.gov)

+ Start Medicare Private Contract