Health Evaluation Questions1

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Dr. Valerie Nelson

Board Certified Natural Integrative Doctor

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Name*

Email Address*

Top 3 Health Concerns*

Birthdate*

Please describe your sleep patterns*

Bowel habits? - normal, constipated, explosive, diarrhea?*

Please describe your stress level*

Please describe your energy level*

Are you in any type of pain? Please describe.*

Please check off anything that applies to your health history

• • Alcoholic tendencies

• • Allergies

• • Anemia

• • Anxiety

• • Arthritis

• • Asthma

• • Autism

• • Backache

• • Bad breath

• • Bed wetting

• • Bell's Palsy

• • Bipolar Disorder

• • Blood sugar issues

• • Cancer

• • Celiac

• • Depression Explosive bowels soon after eating

• • Diabetes

• • Diarrhea

• • Digestive Problems

• • Disturbed sleep (multiple awakenings)

• • Dizziness

• • Drooling while sleeping

• • Dry skin

• • Eczema

• • Emphysema

• • Endometriosis

• • Epilepsy

• • Excessive all over weakness

• • Excessive body odor

• • Excessive saliva

• • Fungus-Toenails

• • Heart pain

• • Heart Problems

• • Heavy menstrual bleeding

• • Hemorrhoids

• • Hepatitis B or C

• • Herpes

• • High Blood Pressure

• • High Cholesterol

• • High Triglyceride

• • Hives

• • Inability to gain weight

• • Inability to lose weight

• • Indigestion

• • Insomnia

• • Irregular heartbeat

• • Low energy

• • Lupus

• • Malabsorption syndrome

• • Manic Depressive

• • Memory problems

• • Meniere's Disease

• • Menopause

• • Menstrual Disorders

• • Migraines

• • Mood swings

• • Mucous in stools

• • Muscle pain

• • Narcolepsy

• • Nausea

• • Nerve Twitching

• • Rashes

• • Respiratory problems

• • Restless leg syndrome

• • Restlessness

• • Rosacea

• • Schizophrenia

• • Sinusitis

• • Skin Problems

• • Slow refluxes

• • Sudden weight loss

• • Teeth grinding at night

• • Ulcerative colitis

• Acid Reflux (GERD)

• All over body odor

• Bloody stools

• Bone Weaknesses

• Bronchitis

• Burning sensation in stomach

• Chronic constipation

• Chronic Fatigue

• Chronic Infections

• Constant Hunger

• Constant Thirst

• Crawling sensation under skin (night)

• Crohn's Disease

• Cysts & Fibroids

• Dark circles under eyes

• Eye Problems (e.g., Twitching)

• Fertility problems

• Fibrocystic Breasts

• Fibromyalgia

• Food allergies

• Forgetfulness

• Frequent urination

• Gallstones

• Gas & bloating

• Gout

• Hair loss

• Headaches

• Hot Flashes

• Irregular menstrual cycles

• Irritable bowel syndrome

• Itchy anus

• Itchy ears

• Itchy nose

• Itchy skin

• Joint pains

• Kidney Problems

• Kidney Stones

• Leaky gut syndrome

• Lethargy

• Liver Cirrhosis

• Long standing obesity

• Loss of appetite

• Nervousness

• Nicotene Addition

• Numbness/tingling in hands & feet

• Pain in shoulders that radiates down arm

• Pain in the navel

• Pain in the shoulders

• Pains in various parts of the body

• Pancreatitis

• Parkinson's Disease

• Polycystic Ovarian Syndrome

• Poor circulation

• Poor immune system

• Premenstrual syndrome

• Prostate problems (enlarged)

• Rapid heartbeat

• Sudden weight gain

• Thyroid Problems

• Tinnitus

• Unclear thinking

• Urinary Tract Problems

• Uterine fibroids

• Vaginal Dryness

• Varicose veins

• Vertigo

• Warts

• Water retention

• Yeast infections

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Abundant Life Wellness

Dr. Valerie Nelson, Board Certified Natural Integrative Doctor

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