Full Name* (* = required)

Birth Date*

Background*

African AmericanNative AmericanMediterraneanHispanicCaucasianNorthern EuropeanAsianOther

Street Address

City

State

Zipcode

Country

Preferred Primary Phone *

Secondary Phone

Best way to contact? *

Primary Physician *

Your Email *

Referred By

What do you hope to achieve in your visit(s)? *

Name your three main health/nutrition concerns you would like to remove from your life if you could. *

Please describe any pain complaints you would like to address in order of priority. *

Can you recall when was the last time you felt well? *

Did something trigger your change in health? *

What makes you feel better? *

What makes you feel worse? *

Additional Comments:

Nutrition

Check all the factors that apply to your current lifestyle and eating habits:

Fast eaterStruggle with eatingLove to cookNegative relationship with foodLove to eat"Eat because I have to" issuesErratic eating patternsEmotional eaterEat too much/overeatEat fast food frequentlyLate night eatingLive or often eats aloneConfused about food/nutritionTime constraintsFamily members have different tastesDislike "healthy food"Rely on convenience itemsPoor snack choicesDo not plan mealsTravel frequentlyVeganVegetarianMacrobioticHigh ProteinOrganicLocalRaw FoodsStandard American Diet (USDA)Gluten-FreeGluten/Casein Free

Please note any additional comments about your nutrition/eating habits: *

Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? *

yesno

Please indicate the type of exercise you are currently engaging in.

Stretching/Yoga Type/Intensity : lowType/Intensity : medType/Intensity : high

days per week 0 days per week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week
Duration ( in minutes )

Cardio/Aerobics Type/Intensity : lowType/Intensity : medType/Intensity : high
days per week 0 days per week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week
Duration ( in minutes )

Strength Training Type/Intensity : lowType/Intensity : medType/Intensity : high
days per week 0 days per week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week
Duration ( in minutes )

Sports or Leisure Type/Intensity : lowType/Intensity : medType/Intensity : high
days per week 0 days per week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week
Duration ( in minutes )

Other Type/Intensity : lowType/Intensity : medType/Intensity : high
days per week 0 days per week1 day per week2 days per week3 days per week4 days per week5 days per week6 days per week7 days per week
Duration ( in minutes )

Daily Stressors
Rate on a scale of 1 (low) to 10 (high)

Work : 12345678910

Family : 12345678910

Relationships : 12345678910

Finances : 12345678910

Health : 12345678910

Education : 12345678910

Physical Activity : 12345678910

Career Choice : 12345678910

Other : 12345678910

Lifestyle Information
Is there any unusual excess stress in your life? * yesno

please explain :

Do you easily handle stress? * yesno

please explain :

What nourishes you :

Do you feel comfortable discussing any past physical/emotional/sexual abuse history during our encounter? yesno

Do you wake up during the night? * yesno

If yes, how many times? * 12345678910

How would you rate the overall quality of your sleep? (0-poor, 5-good) 012345

How many hours of sleep do you get per night? * 3 or less45678910111212+

If you take any supplements to help with sleep, please list them: :

In order to improve your health, how willing are you to:(Rate on scale of 5-very willing to 1-not willing)

Significantly modify your diet 54321
Take nutritional supplements each day 54321
Keep a record of everything you eat each day 54321
Modify your lifestyle (work demands, sleep habits, exercise) 54321
Practice a relaxation technique 54321
Engage in regular exercise/physical activity 54321
Have periodic lab tests to assess your progress 54321

What do you think would make the most difference in your overall health?

Patient Narrative
Please SHARE your health and medical story that would help us help you.
SHARE your challenges and goals you would like to accomplish on this journey to wellness.

Please list all medical conditions for which you are treated:

Please list all past surgeries:

Please list any hospitalizations including the reason and date:

Please list all pertinent family history:

Please list all medications and supplements you currently take including dosage and frequency:

Please list any food/drug allergies. If no known allergies, write "none"

Do you use or have you used in the past tobacco, alcohol, or illicit drugs? : yesno

If yes, please list the substance, amount, and last time used:

Acknowledgement :

I am solely responsible for the decision to see Dr. Danielle Forster, DO for Integrative and Regenerative medicine. I recognize that some recommendations may not prove to be successful. I understand some recommendations may be novel. I agree to participate in an active manner, monitor my progress, and report any concerns to Dr. Forster. I also understand that any significant symptoms should be reported to Dr. Forster immediately. I understand that Dr. Forster does not practice primary care medicine. I agree to maintain a relationship with my own primary care physician for general medical needs. I understand that Dr. Forster does not practice chronic pain management with opioid analgesics.

By entering your name, you certify that the information you have provided is accurate and that you acknowledge the paragraph above.