New Client Information Form

www.AdvantageIntegrative.com

DrBohlmann@AdvantageIntegrative.com
New Client Personal Health History Form

This form is intended to give both you and your doctor a good insight into your current health status. It is thorough by design, so your first office visit can be optimized. Please allow ample time (approx. 30 minutes) to complete and submit this form prior to your first visit. If you have any questions send them to DrBohlmann@AdvantageIntegrative.com
How did you hear about Advantage Integrative Health?
Your Name*

First NameLast Name
What name do you prefer to be called?
E-mail*
Parent's or legal guardian's E-mail if considered a minor or ward
Birthday*

MonthDayYear
Home Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Parent's or legal guardian's phone number if you are considered a minor

Area CodePhone Number
Address*

Street Address

Address continued (if needed)

CityState

Zip Code

Family Medical History

Genetics can definitely play a part in our overall health. The following section is used to help us understand the possible influence that genetics might be having on your current health status.
With respect to your own biological parents:

Both are aliveMy mother is deceasedMy father is deceasedBoth are deceasedI don't know
Please briefly describe any health conditions of your own parents
if deceased, please list age and cause of death if known
Please list your siblings (if you have any) in order of eldest to youngest including yourself where you fall in the order and describe any health conditions.
if deceased, please list age and cause of death if known

Review of Symptoms

The following questions help us see your symptom picture more clearly. Use the choices provided to "grade" the severity of the symptom during the last 60 days.

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Difficulty with digestion
Diarrhea or loose stools
Constipation (longer than 1 day between bowel movements)
Alternating diarrhea/constipation
Incomplete bowel evacuation
Use laxatives
Pain in the lower abdomen
Blood in the stool
Passing a lot of gas

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Reactions to food you eat
Negative reaction to smell of specific foods
Aches and pains that wander throughout your body
Intolerance to smells in general
Intolerance to personal hygiene products
Frequent skin eruptions anywhere on the body
Acne
Excessive hair loss
Hormone imbalances
Weight gain
Excessive/foul smelling sweat
Body swelling or bloated feelings
Brain fog

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Bad breath
Coated tongue
Allergies
Belching
Frequent hiccups
Gas immediately following meals
Decreased taste or smell
Sense of fullness after eating even small meals
Use of antacids
Heartburn when lying down or bending forward
Acidic taste in mouth when you wake up in the morning
Sit more that 5 hours per day
Pain in upper abdomen relieved by eating
Sharp pain in stomach area after eating and relieved by milk or antacids
Spicy foods, chocolate, citrus, alcohol cause heartburn feeling
Undigested food seen in stool

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Pain or discomfort on the left upper abdomen under the ribs
Stool with undigested food, greasy appearance or poorly formed
Frequent loss of appetite
Difficulty digesting roughage or fiber
Crave sweets during the day
Irritable if you miss a meal
Get light-headed if you miss a meal
Energized by eating (if fatigued before)
Feel shaky or have tremors
Easily upset or agitated
Forgetful between meals but better memory when eating regularly
Blurred vision
Get sleepy after eating
Must have something sweet after meals
Waist measurement is greater than hip measurement
Frequent urination
Increased thirst and/or appetite
Trouble losing weight

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Abdominal distention shortly after eating fiber, starches, or sugar
Abdominal distention after probiotics
Suspicion of malabsorption of nutrients
History of antibiotic use
Pain in mid-abdominal area (periumbilical)
Lab results showing low vitamin D
Diagnosis of celiac disease
History of iron deficiency anemia

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Greasy, oily or high fat food cause discomfort
Low bowel gas several hours after eating
Burping up fishy odor when taking fish oil supplements
Unexplained itchy skin
Yellowing of skin or in the eyes
Stool has a very pale clay color not related to color of food you ate
Reddened skin in the palms
Dry, flaky skin or hair
History of gallbladder stones or collicky pain

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Trouble staying asleep
Crave salt
Slow to get going in the morning
Fatigue around 3pm
Dizziness standing up quickly
Headaches with exercise
Weak nails
Cannot fall asleep
Perspire very easily
Under high stress
Weight gain when under stress
Wake up tired even though had at least 6 hours of sleep
Swelling of ankles
Muscle cramping
Frequent clear urination esp. shortly after drinking any liquid
Feeling thirsty for sweet drinks
Shallow breathing
Cannot hold breath for very long
Experience air hunger or frequent need to yawn

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Feeling sluggish/no energy
Feel cold
Weight gain despite low calorie intake
Need a lot of sleep to function
Coffee needed as soon as you are awake
Depression or low motivation
Thinning or coarse feeling hair
Decreased memory or mental function
Heart races
Hard to gain or keep weight on
Pulse increased even while sitting still
Insomnia
Nervous or jumpy
Night sweats (not related to menopause)

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Chest pain
Short of breath after minimal effort
Blue color of lips or skin
Cramping in calves when walking
Heart palpitations
Trouble breathing when lying down
Cold hands and feet
Varicose veins

Relating to your current health status, how often do you experience:*

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Anxiety
Panic
Sleeplessness
Frustration with daily activities
Mood swings
Depression
Suicidal thoughts
Binge on food or drink
Hallucinations
Addiction of any kind

(Men) Relating to your current health status, how often do you experience:

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Difficulty or dribbling with urinating
Pain in groin or heels
Low back pain
Legs twitching at night
Low libido
Decreased morning erections
Decreased ability to get or maintain erection
Loss of ability to concentrate
Depressive episodes
Muscle weakness or fatigue
Increased fat in chest and/or hips
Feeling more emotional than in the past

(Menstruating females) Relating to your current health status, how often do you experience:

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Extended cycle (more than 32 days)
Shortened cycle (less than 24 days)
Pain and cramping with period
Scant flow
Heavy flow
Breast pain or tenderness with period
PMS
Acne outbreaks with or between menses
Facial hair growth

(Post-menopausal females) Relating to your current health status, how often do you experience:

Rows	Never	Sometimes	Frequently	Always	Doesn't apply to me
Uterine bleeding
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression episodes
Vaginal dryness, pain itching

Should be Empty:

Rows	Needs a lot of help!	Needs a little help	Satisfactory	Better than average	Right on track!
Sleep
Relaxation & Fun
Diet & Nutrition
Exercise
Flexibility
Hydration

www.AdvantageIntegrative.com

New Client Personal Health History Form

Lifestyle

Health History

Family Medical History

Review of Symptoms