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Dr. Justin Fortier
Please complete and submit. Thank you!
Date of Birth
How did your hear about me?
Describe to me in as many words as you’d like your current condition that your seeking help with.
How long have you experienced this?
What would be your goal in treatment?
Are you willing to make dietary adjustments as needed to resolve it? Do you have dietary restrictions?
List Current Other Health Issues and Problems
List Other Practitioners Seen, treatments, Self-Care Activities, and Results
List Of Surgeries You Have Had With Dates
List illnesses You Have Ever Had Previously If Any
List All Medications, Vitamins, Herbs, And Other Supplements You are taking, the dose, the reason for taking
List all medications and other substances (foods) to which you are allergic
Ever Been In An Accident Or Seriously Injured
Do You Have Dental Or TMJ Problems
Please list age(s) and health problems (if any); if deceased, please list age at death and cause of death: Father Mother Children Grandparents Brothers Sisters
Describe use of Tobacco Alcohol Other Drugs
Exercise Habits/ Physical Activity
How Many hours per night do you sleep? Do you fall right asleep?
Do you snore?
Do you remember your dreams?
Do you grind your teeth?
Do you have nightmares?
Do you have restless legs (RLS)?
Do you have night sweats?
Have you had any labs done recently? If yes, please attach or send to me
How Much do you drink each day: water juice soda diet, soda regular Coffee regular or decaf tea sweet energy Drinks
List Oils/Fats you are cooking with
Do you use butter, margarine, shortening, or coconut oil
Do you skip meals
Are you on any special diet or nutrition program
What foods do you dislike
What are your favorite foods
Are you allergic or sensitive to any foods If yes, name the food and describe
What foods do you crave: Meats, Fats, Sweets, Salty, Spicy, Sour, Cereals, Dairy, Vegetables, Fruits, Breads, Fatty Foods
Do you eat organic foods
Do you eat from fast food restaurants if yes how often
What do you eat for breakfast
What do you eat for lunch
What do you eat for dinner
What do you eat for snacks
What foods do you eat a lot of (at least once a day, every day)
How many bowel movements do you have per day
Do you get Aches, Pins & Needles, Burning, Stabbing, Numbness, Throbbing, Other? Where do you feel it? When do you feel it?
Check the symptom(s) if you are currently experiencing it, common occurrence, or have in the last 3 months
Lack of sleep
Reduced mental acuity
Frequent sore throats
Grind teeth at night
Hoarse voice/loss of voice
Ear discharge/excessive wax
Earaches or infections
Far or near sightedness
Spots specks or floaters
Cold or canker sores/fever blisters
Change in your skin/nails
Blood in urine
Urinate more than once at night
Muscles & Joints
Pain with specific movement
Pain relieved with anti-inflammatory drugs (aspirin ibuprofen..)
Pain tenderness or numbness in:
Neck shoulders arms elbows wrist/hands upper back lower back hips knees feet/ankles
Tend to hold breath
Trouble breathing with exercise
Black or tarry stool
Change in stool
Insomnia/ hard to sleep
Tend to worry
Excessive thirst or hunger
Lack of sweating
Heat or cold intolerance
Dizzy when standing up/rising quickly
Excessive weight gain
Excessive weight loss
High blood pressure
Shortness of breath
Swollen feet or lower legs
Racing or pounding heart
Bleeding between periods
Decrease sexual interest
Pain with intercourse
Number of days in cycle
Number of pregnancies
Usual length of period
Number of deliveries
Birth control method
Child form difference
Is he or she on a specific diet or nutrition program list
If "yes" please describe
Is he or she on a specific diet or nutrition program list List the diets you have tried in the past with results please list all lab work your child has done and include a copy
Is there anything else you would like to tell me or feel I should know
Thanks for submitting!
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