New Patient Questionnaire
Dr. Rodger Murphree
Corporate Center
2700 Rogers Drive, Suite 204,
Homewood, AL 35209
Toll Free Phone - 1-888-884-9577
Fax to 1- 205-879-2381
INITIAL PATIENT HISTORY AND PROFILE
Name ______________________________________________________________Date ____________________
Home Phone (_______)______________________ Cell Phone (_______)________________________
Address_________________________________________________State__________Zip Code ______________
Social Security Number_________________________________________________________________________
Date of Birth_________________ Email Address____________________________________________________
Please briefly describe your health problems_________________________________________________________
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When was the last time you really felt good (date)? _____________. Were you healthy as a child?
If not please list health problems you had as a child-__________________________________________________________________________________________
What caused your PRESENT illness?
Significant Event at Onset:
Health Problem, Family Problem, Job Stressors, Surgery, Accident, not sure? Please briefly explain-__________________________________________________________________________________________
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Have you been diagnosed with Fibromyalgia or Chronic Fatigue Syndrome? ____YES____NO Which________________
Date of Diagnosis______ Who Diagnosed you?__________________________________
What type of doctor made diagnosis (family doctor, rheumatologist, OBGYN, orthopedic doctor, etc.)?___________________________
What makes your health problems worse? Stress, weather changes, poor sleep, exertion, etc_______________________________________________________________________________________
Sleep
Do you have trouble falling asleep? ___Yes ___No
Do you have trouble Staying Asleep? ___Yes ___No
When did you first start having trouble sleeping (months, years)? _______
Neurotransmitters
What over the counter or prescription medications have you taken for sleep?
__ Ambien ____ Zanaflex_____ Trazadone______ Sonata_________ Tylenol P.M. ___ Elavil ___ Neurontin
___Doxepin____Flexeril_____Xanax_____Klonopin_____Ativan_____Melatonin_____5HTP ___ Benadryl
____Others? Please list here___________________________________________________________________
Are you taking anti-depressants? ___Yes ___No Which ones? _______________________________________
Have you taken any anti-depressants in the past? ___Yes___ No
Which ones? Prozac_____Paxil_____Celexa____Lexapro_____Wellbutrin___Effexor____Zoloft____
Where they helpful? Please describe (didn’t help, had side –effects, stopped working, etc.)
__________________________________________________________________________________________
Do you crave carbohydrates or sugar? ___Yes ___No
Do you have normal, daily bowel movements (at least one bowel movement a day)? ___Yes ____No
If no - Do you have loose bowels (diarrhea), constipation, or both? ________________________________
Have you been diagnosed with Irritable Bowel Syndrome (IBS)? ____Yes ____No
What other medications are you taking? Please list here-
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Immune Function
DO YOU HAVE PROBLEMS WITH: Please those that apply.
____ Chronic Sinus Congestion ____ Chronic Sinus Infections (2 or more a year) ___ Chronic Sore Throats
____Chronic Colds or Flu infections each year ____Chronic Upper Respiratory Infections (Bronchitis, Pneumonia)
Liver Function
Have you ever had elevated or high liver enzymes on laboratory blood work? __Yes __ No __Not Sure
Do you have any funny reactions if you drink alcohol (little goes a long way, can’t drink red wine, etc.)?
If so please describe _________________________________________________________________________
Do you have any problems eating raw onions? ____ Yes ____No
The day after eating asparagus do you get a very strong odor when urinating (the next day?)
Do you have hepatitis? ___Yes ___ No Do you have a fatty liver? __ Yes __ No
Do you have funny reactions to medications? ___Yes ___No
Do strong odors (gasoline, smoke, cleaning supplies, perfume, etc.) bother you? ___Yes ___No
Adrenal Function
If you skip a meal do you feel bad (have headaches, become irritable, get jittery, tired, etc.) ___ Yes __No
Do you have low blood pressure? ___Yes ___ No __Don’t Know
Do you crave salty foods? ___Yes ___No
Does increased stress or stressful situations make your symptoms worse? ___Yes ____No
How's your energy level? Choose 1 to 5, with 5 being the best. ______
How is your concentration and memory on a scale of 1-5, with 5 being best? ________
How do you feel in the morning? ____Refreshed_____ Hung over_____ Exhausted_______ Nauseated_____ Achy All Over
Are you hungry in the morning? ___Yes ___No
DIGESTION
How is your digestion? Bloating ___Yes ___No Gas ___Yes ___No Indigestion ___Yes ___No
Are there certain foods that give you problems (sugar, spicy foods, fruits, meats, fats, dairy, etc.)?
Please list-________________________________________________________________________________________
Diet
What do you eat for breakfast? Please (honestly) describe here: ________________________________________________________
What do you eat for Lunch? _____________________________________________________________________________________
What do you eat for dinner? _____________________________________________________________________________________
What are your usually snack foods (popcorn, ice cream, cookies, potato chips, candies)? Please be honest and specific-
____________________________________________________________________________________________________________
Do you drink coffee? If so how many cups a day and when ____________________________________________________________
Do you drink sodas? If so how many and when? ____________________________________________________________________
Do you drink tea? If so how many glasses and when? ________________________________________________________________
Pain
Where do you have pain? ____Joint ____Muscle ____Neck ____Shoulder ____ Mid Back ____Low Back ___Chest
___ Hips____ Arms ____Back of Legs ____ Front of legs ___Knees ____ Feet____ Ankles_____ Hands ___Fingers___ Head
History
Please place a check mark by any that apply below.
Do you ever have-
HEENT: ____Headaches ____Vision Problems ____Frequent Colds/Sore Throats
____ Dizziness ____ Hearing Problems
Chemical Sensitivities/Allergies: _____________________________________
CVS: ____Chest Pain ____ Palpitations ____High Cholesterol ____ High Blood Pressure
LUNGS: ____Coughing ____Wheezing ____Breathing Problems ___ Frequent Respiratory Infections
GI: ____Swallowing Problems ____Stomach Pains ____Nausea ____Vomiting
____Diarrhea ____Constipation ____Digestive Difficulties
Food allergies __Yes ___No
GU: ____Urinary Frequency ____Urinary Hesitancy ____Irregular Periods ____ Decreased Sex Drive
SKIN: ____Rashes ____Dry Skin ____Fungus Infections ____Eczema ____Psoriasis
Social History: Do You Smoke? ____Yes ____No
Family History: ____Cancer ____Diverticulitis ____Thyroid ____Heart Disease____ Stroke ____Diabetes
____High Cholesterol
Intestinal Dysbiosis
Have you ever been on long term (more than 2 weeks) antibiotic therapy? ___ Yes____ No
Have you ever had vaginal yeast infections? __Yes __No
If yes, when was last infection? ________________
Do you have chronic vaginal yeast infections (more than 2 a year)? ___Yes __No
Are you bothered by memory or concentration problems? Do you sometimes feel spaced-out? ___
Do you feel “sick all over”, yet in spite of visits to different physicians, the causes haven’t been found? ______
Have you been pregnant TWO or more times? ______________
Have you taken birth control pills? _______ for more than 2 years?_____ for more than 1 year?___________6 months to 1 year?___________
Are your symptoms worse on damp, muggy days or in moldy places? ____________
Do you ever have itchy ears? __Yes __No Itchy nose? __Yes __No Rectal Itching? ____Yes __No
Do you crave Sugar? ____ Yes ___No Does eating sugar make your symptoms worse? __Yes __No
Do you have rectal itching after eating sugar, fruit, or a lot of starches? ___Yes ___No
Have you EVER been on long term (weeks) steroid therapy (prednisone, cortisone)? _____Yes ___No
Have you EVER been on long term (month or more) non-steroidal anti-inflammatory medications (Vioxx, Celebrex, Naprosyn, Advil, Bextra, Mobic, etc.)? __Yes __No
Yeast Questionnaire
Please mark your symptoms as follows: MI-mild M-moderate S-severe
Thyroid
Symptom Checklist
___ Fatigue ___ High Cholesterol
___ Headaches ___ Cold hands/feet
___ Migraines ___ Changes in skin pigmentation
___ PMS ___ Changes in skin pigmentation
___ Irritability ___ Irregular periods
___ Fluid retention ___ Severe menstrual cramps
___ Dry hair ___ Low blood pressure
___ Dry skin ___ Frequent colds and sore throats
___ Hair loss ___ Heat and/or cold intolerance
___ Depression ___ Lightheadedness
___ Decreased memory ___ Ringing in the ears
___ Decreased concentration ___ Infertility
___ Decreased sex drive ___ Asthma
___ Unhealthy nails ___ Low motivation
___ Constipation ___ Frequent infections
___ Irritable Bowel Syndrome ___ Allergies
___ Inappropriate weight gain ___ Falling asleep during the day
___ Hypoglycemia
Parasite Check List
____ Have you traveled outside the United States?
_____Do you have foul smelling stools?
_____Do you experience any stomach bloating, gas, or pain?
____ Any rectal itching?
_____Unexpected weight loss with increased appetite?
_____Food allergies that continue to get worse despite treatment.
_____Do you feel hungry all the time?
_____Have you been diagnosed with irritable bowel syndrome?
_____What about inflammatory bowel disease?
_____Do you have sore mouth and gums?
_____Do you experience chronic low back pain that’s unresponsive to treatment?
_____Do you have digestive disturbances?
_____Do you grind your teeth at night?
_____Do you own a dog, cat or other pet? Or are frequently around animals?
Brain Function Questionnaire
The "O" Group
Do ANY of these apply to your present feelings?
The "G" Group
Please note the items which apply to your present feelings.
The "D" Group
Please note the items which apply to your present feelings.
The "N" Group
Please note the items which apply to your present feelings.
The "S" Group
Please note the items which apply to your present feelings.