New Patient Questionnaire



DrRodgerM@yahoo.com

Dr. Rodger Murphree

3401 Independence Dr
Suite 121
Homewood, AL 35209


INITIAL PATIENT HISTORY AND PROFILE


Name _________________________________________Date ____________________

Phone_________________Address________________________________________________________________

Social Security Number_______________________________

Date of Birth_________________ Email Address____________________________________________________

 

Please briefly describe your health problems_________________________________________________________

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

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-__________________________________________________________________________________________

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

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_____Mealtonin_____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-

__________________________________________________________________________________________

 __________________________________________________________________________________________

 __________________________________________________________________________________________

 

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.


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