Patient Form Bodyscapes, 636 Church St.

Suite 505, Evanston, IL 60201

Date: ___________

General Information _________________________________________

First Name: _________________________________________
_______________________________ _________________________________________
Last Name: ___
_______________________________ List all medications and supplements you
Address: are currently taking:
_________________________________ _________________________________________
City: _________________________________________
_____________________________________ _________________________________________
State: ___________ Zip code: _________________________________________
________________ ____
Email: ___________________________________ Any long term or frequent use of
Home Phone: antibiotics?
_____________________________ _________________________________________
Cell Phone: _
_______________________________ Do you have allergies? _______ Describe:
Age: _________ Birth Date: _____
_________________ _________________________________________
Occupation: Digestion/Nutrition
______________________________ How is your appetite?
Emergency contact: _____________________
________________________ Check any issues that apply to you:
Phone: □ Constipation □ Loose stools □
___________________________________ Bloating
Primary Physician: □ Gas □ Acid reflux □ Abdominal
________________________ pain
Phone:
___________________________________ How many meals per day do you eat?
What would you like to be treated for: _______
1. Are you thirsty?
________________________________________ ___________________________
2. How much water do you drink per day?
________________________________________ _____
3. Do you prefer cold or hot beverages?
________________________________________ ________
Do you drink caffeinated beverages?
Health History _________
Have any of your blood relatives suffered How many per day?
from any of the following (please check): _______________________
□ Diabetes □ High blood pressure □ Do you drink alcohol?
Stroke _____________________
□ Cancer □ Heart disease □ Kidney How much?
disease ______________________________
List other beverages including juice, rice
List major events of your health history milk, almond milk, soy milk, tea, etc. you
(illnesses, surgery, accidents, drink;
hospitalizations, heavy metal or toxin
exposure, etc.):
_________________________________________ If not, describe:
_________________________________________ ___________________________
__ _________________________________________
What dairy products do you eat? _
____________ How many hours do you sleep in
_________________________________________ general? ___
_ Have lots of dreams?
Are you a vegetarian or vegan? ______________________
_____________ Do you feel rested when you wake?
List sources of meat/protein: _________
________________ What is your energy level in general on a
_________________________________________ scale of 1-10 (10 being best)?
_ _____________________
_________________________________________
_ Exercise/Lifestyle
List any food allergies or sensitivities: Do you exercise? _____ How often?
_______ __________
_________________________________________ What kind of exercise?
_ _____________________
What % of your diet is organic? _________________________________________
_____________ _
Do you have any particular cravings? How long do you exercise for?
________ ______________
Please specify Do you like to exercise?
_____________________________ ____________________
Times per week you eat out? Any awareness practices (meditation,
________________ prayer, affirmation, or other practices)?
Eat regularly at fast food restaurants? _____________
________ _________________________________________
Do you eat a lot of processed food? _
__________ Hours of TV you watch daily?
Do you eat late at night? ______________
___________________ Hours spent at the computer daily?
Do you chew your food thoroughly? __________
_________ Pain
Do you think you get enough fresh fruits, Describe any pain, stiffness, or swelling
vegetables, and whole grains daily? in your body:
_________ ____________________________________
How would you describe your diet: _________________________________________
□ Unhealthy □ Fair □ Good □ _________________________________________
Fantastic __
How would you rate your cooking skills Do you suffer from migraine or tension
on a scale of 1-10 (10 being best)? headache? _______ How often?
________________ _____________
Are you ready and willing to make Do you have any:
changes in your diet if need be? □ Dizziness □ Chest pain □
_______________________ Palpitations
Sleep □ Floaters in eyes □ Burning, red, itchy
Do you sleep soundly? eyes
_____________________
Skeletal
Any broken bones or fractures? Any problem with ED?
_____________ ____________________
How many? _____ Osteoporosis? Difficult urination?
____________ ________________________
Libido good?
Teeth _____________________________
Have you had lots of cavities? Other issues:
______________ ______________________________
Any root canals? _____ Gum disease?
________ Urination
Ringing in ears? _______ TMJ? Is your urine clear like water?____ cloudy?
______________ ___
Scanty? ____ Yellow? _____ Dark yellow?
Emotions (check all that apply to you): ____
□ Anger □ Depression □ Worry □ Do you get up at night to urinate?
Anxiety ___________
□ Sad □ Fearful □ Happy □ Other How many times?
__________ _________________________
Women’s Health Body Temperature
Are your periods regular? Feel cold often? ____ dislike the cold? ____
__________________ Feel hot often? ____ dislike the heat? ____
Check all that apply to you: Have afternoon flushes/fevers?
□ Painful periods □ Heavy flow □ ______________
Scanty flow Night or daytime sweats?
□ Clotted □ PMS □ Breast tenderness □ __________________
Fibroids
□ Hormonal migraine □ Endometriosis Thank you for taking the time to
□ Vaginal discharge □ Chronic UTI’s complete this form. If you have any
□ Birth control pills □ Other questions regarding filling out this
________________ form, please call Ellie at (847)864-
_________________________________________ 6464. If you have more information
_ you think I need to know, please use
How many pregnancies? the backside to write on.
___________________
Any miscarriages? _______ How many?
______
Are you currently undergoing fertility
treatment? ________ Please describe:
_________
_________________________________________
_________________________________________
__
Have you started menopause?
______________
Any problematic issues related to
menopause?
_________________________________________
_________________________________________
__

Men’s Health