Ahmad Von Health History

21. Exercise per week  =  3Keys: 0 = over 12 months ago;   1 = within last 12 months;   2 = within last 6 months;   3 = within last 2 months

22. Changed jobs  =  3Keys: 0 = over 12 months ago;   1 = within last 12 months;   2 = within last 6 months;   3 = within last 2 months

23. Divorced  =  3Keys: 0 = never, over 2 years ago;   1 = within last two months;   2 = within last year;   3 = within last 6 months

24. Work over 60 hours/week  =  3Keys: 0 = never;   1 = occasionally;   2 = usually;   3 = always

25. Antacids  = 

26. Anxiety medication  = 

27. Antibiotics  = 

28. Anticonvulsants  = 

29. Antidepressants  = 

30. Antifungals  = 

31. Aspirin/Ibuprofen  = 

32. Asthma inhalers  = 

33. Beta blockers  =  1

34. Birth control pills/implant contraceptives  =  1

35. Chemotherapy  = 

36. Cholesterol lowering medications  = 

37. Cortisone/steroids  =  1

38. Diabetic medications/insulin  =  1

39. Diuretics  =  1

40. Estrogen or progesterone (pharmaceutical, prescription)  =  1

41. Estrogen or progesterone (natural)  = 

42. Heart medications  = 

43. High blood pressure medications  = 

44. Laxatives  =  1

45. Recreational drugs  =  1

46. Relaxants/Sleeping pills  = 

47. Testosterone (natural or prescription)  = 

48. Thyroid medication  = 

49. Acetaminophen (Tylenol)  =  1

50. Ulcer medications  =  1

51. Sildenafal citrate (Viagra)  = 

52. Belching or gas within one hour after eating  = 

53. Heartburn or acid reflux  = 

54. Bloating  = 

55. Vegan diet (no dairy, meat, fish, or eggs)  =  Keys: 0 = No;   1 = Yes

56. Bad breath (halitosis)  = 

57. Loss of taste for meat  =  3

58. Sweat has a strong odor  =  3

59. Stomach upset by taking vitamins  = 

60. Sense of excess fullness after meals  = 

61. Feel like skipping breakfast  = 

62. Feel better if you don’t eat  =  3

63. Sleepy after meals  = 

64. Fingernails chip, peel or break easily  = 

65. Anemia unresponsive to iron  =  3

66. Stomach pains or cramps  = 

67. Diarrhea, chronic  = 

68. Diarrhea, shortly after meals  = 

69. Black or tarry colored stools  = 

70. Undigested food in stool  =  3

71. Pain between shoulder blades  = 

72. Stomach upset by greasy foods  = 

73. Greasy or shiny stools  = 

74. Nausea  = 

75. Sea, car, airplane or motion sickness  = 

76. History of morning sickness  =  Keys: 0 = No;   1 = Yes

77. Light or clay colored stools  = 

78. Dry skin, itchy feet or skin peels on feet  = 

79. Headache over eyes  = 

80. Gallbladder attacks  = 

81. Gallbladder removed  =  1Keys: 0 = No;   1 = Yes

82. Bitter taste in mouth, especially after meals  = 

83. Become sick if you were to drink wine  =  1

84. Easily intoxicated if you were to drink wine  = 

85. Easily hung over if you were to drink wine  = 

86. Alcoholic drinks per week  =  Keys: 0 = < 3;   1 = < 7;   2 = < 14;   3 = > 14

88. History if drug or alcohol abuse  = 

89. Recovering alcoholic  = 

90. History of drug abuse  = 

91. Sensitive to tobacco smoke  =  3

92. Sensitive to chemicals (perfume, cleaning agents, etc.)  = 

93. Exposure to diesel fumes  = 

94. Pain under right side of rib cage  = 

95. Hemorrhoids or varicose veins  = 

96. Nutrasweet (aspartame) consumption  = 

97. Sensitive to Nutrasweet (aspartame)  = 

98. Chronic fatigue or Fibromyalgia  = 

99. Food allergies  = 

100. Abdominal bloating 1 to 2 hours after eating  = 

101. Specific foods make you tired or bloated  = 

102. Pulse speeds after eating  = 

103. Airborne allergies  = 

104. Experience hives  = 

105. 105. Sinus congestion, “stuffy head”  = 

106. Crave bread or noodles  = 

107. Alternating constipation and diarrhea  = 

108. Crohn’s disease  = 

109. Wheat or grain sensitivity  = 

110. Dairy sensitivity  = 

111. Are there foods you could not give up  = 

112. Asthma, sinus infections, stuffy nose  = 

113. Bizarre vivid dreams, nightmares  = 

114. Use over-the-counter pain medications  = 

115. Feel spacey or unreal  = 

116. Anus itches  = 

117. Coated tongue  = 

118. Feel worse in moldy or musty place  = 

119. Taken antibiotics for a total accumulated time of  = 

120. Fungus or yeast infections  = 

121. Ring worm, “jock itch”, “athletes foot”, nail fungus  = 

122. Yeast symptoms increase with sugar, starch or alcohol. Examples of yeast symptoms include fatigue, poor memory, feeling ‘spacey’ or ‘unreal’, muscle aches or weakness, pain or swelling in joints, and digestive issues such as constipation, diarrhea or bloating.  = 

123. Stools hard or difficult to pass  = 

124. History of parasite  =  Keys: 0 = No;   1 = Yes

125. Less than one bowel movement per day  = 

126. Stools have corners or edges, are flat or ribbon shaped  = 

127. Stools are not well formed (loose)  = 

128. Blood in stool  = 

129. Irritable bowel or mucus colitis  = 

130. Mucus in stool  = 

131. Excessive foul smelling lower bowel gas  = 

132. Bad breath or strong body odors  = 

133. Painful to press along outer sides of thighs (Iliotibial Band)  = 

134. Cramping in lower abdominal region  = 

135. Dark circles under eyes  = 

136. History of carpal tunnel syndrome  =  Keys: 0 = No;   1 = Yes

137. History of lower right abdominal pains or ileocecal valve problems  =  Keys: 0 = No;   1 = Yes

138. History of stress fracture  =  Keys: 0 = No;   1 = Yes

139. Bone loss (reduced density on bone scan)  = 

140. Herniated disc  =  Keys: 0 = No;   1 = Yes

141. Calf, foot or toe cramps at rest  = 

142. Cold sores, fever blisters or herpes lesions  = 

143. Frequent fevers  = 

144. Frequent skin rashes and/or hives  = 

145. History of bone spurs  =  Keys: 0 = No;   1 = Yes

146. Excessively flexible joints, “double jointed”  = 

147. Joints pop or click  = 

148. Pain or swelling in joints  = 

149. Bursitis or tendonitis  = 

150. Are you shorter than you used to be?:  =  Keys: 0 = No;   1 = Yes

151. Morning stiffness  = 

152. Nausea with vomiting  = 

153. Crave chocolate  = 

154. Feet have a strong odor  = 

155. History of anemia  = 

156. Whites of eyes (sclera) blue tinted  = 

157. Hoarseness  = 

158. Difficulty swallowing  = 

159. Lump in throat  = 

160. Dry mouth, eyes and/or nose  =  3

161. Gag easily  =  3

162. White spots on fingernails  =  3

163. Cuts heal slowly and/or scar easily  =  3

164. Decreased sense of taste or smel  =  3

165. Experience pain relief with aspirin  =  Keys: 0 = No;   1 = Yes

166. Crave fatty or greasy foods  = 

167. Tension headaches at base of skull  =  3

168. Low or reduced-fat diet  =  3

169. Headaches when out in the hot sun  =  3

170. Sunburn easily or suffer sun poisoning  =  3

171. Muscles easily fatigued  =  3

172. Dry flaky skin or dandruff  =  3

173. Awaken a few hours after falling asleep, hard to get back to sleep  = 

174. Crave sweets  = 

175. Binge or uncontrolled eating  = 

176. Excessive appetite  = 

177. Crave coffee or sugar in the afternoon  = 

178. Sleepy in afternoon  = 

179. Fatigue that is relieved by eating  = 

180. Headache if meals are skipped or delayed  = 

181. Irritable before meals  = 

182. Shaky if meals delayed  =  3

183. Family members with diabetes  =  3

184. Frequent thirst  =  Keys: 0 = none;   1 = 1 or 2;   2 = 3 or 4;   3 = more than 4

185. Frequent urination  = 

186. Muscles become easily fatigued  = 

187. Feel exhausted or sore after moderate exercise  = 

188. Vulnerable to insect bites  = 

189. Loss of muscle tone, heaviness in arms/legs  =  3

190. Enlarged heart or congestive heart failure  = 

191. Pulse below 65 per minute  =  Keys: 0 = No;   1 = Yes

192. Ringing in the ears (Tinnitus)  = 

193. Numbness, tingling or itching in hands and feet  =  3

194. Depressed  = 

195. Fear of impending doom  = 

196. Worrier, apprehensive, anxious  = 

197. Nervous or agitated  = 

198. Feelings of insecurity  = 

199. Heart races  =  3

200. Can hear heart beat on pillow at night  = 

201. Whole body or limb jerk as falling asleep  =  3

202. Night sweats  =  3

203. Restless leg syndrome  = 

204. Cracks at corner of mouth (Cheilosis)  =  3

205. Fragile skin, easily chaffed, as in shaving  = 

206. Polyps or warts  =  3

207. MSG sensitivity  = 

208. Wake up without remembering dreams  =  3

209. Small bumps on back of arms  = 

210. Strong light at night irritates eyes  =  3

211. Nose bleeds and/or tend to bruise easily  = 

212. Bleeding gums especially when brushing teeth  = 

213. Tend to be a “night person”  =  3

214. Difficulty falling asleep  = 

215. Slow starter in the morning  = 

216. Tend to be keyed up, trouble calming down  = 

217. Blood pressure above 120/80  = 

218. Headache after exercising  =  3

219. Feeling wired or jittery after drinking coffee  = 

220. Clench or grind teeth  = 

221. Calm on the outside, troubled on the inside  = 

222. Chronic low back pain, worse with fatigue  =  3

223. Become dizzy when standing up suddenly  = 

224. Difficulty maintaining manipulative correction  = 

225. Pain after manipulative correction  = 

226. Arthritic tendencies  = 

227. Crave salty foods  = 

228. Salt foods before tasting  = 

229. Perspire easily  = 

230. Chronic fatigue, or get drowsy often  = 

231. Afternoon yawning  = 

232. Afternoon headache  = 

233. Asthma, wheezing or difficulty breathing  =  3

234. Pain on the medial or inner side of the knee  = 

235. Tendency to sprain ankles or  = 

236. Tendency to need sunglasses  = 

237. Allergies and/or hives  = 

238. Weakness, dizziness  =  3

239. Height over 6′ 6″  =  1Keys: 0 = No;   1 = Yes

240. Early sexual development (before age 10)  =  Keys: 0 = No;   1 = Yes

241. Increased libido  = 

242. Splitting type headache  = 

243. Memory failing  =  3

244. Tolerate sugar, feel fine when eating sugar  =  Keys: 0 = No;   1 = Yes

245. Height under 4′ 10″  =  Keys: 0 = No;   1 = Yes

246. Decreased libido  = 

247. Excessive thirst  =  3

248. Weight gain around hips or waist  = 

249. Menstrual disorders  =  3

250. Delayed sexual development (after age 13)  =  Keys: 0 = No;   1 = Yes

251. Tendency to ulcers or colitis  =  3

252. Sensitive/allergic to iodine  =  3

253. Difficulty gaining weight, even with large appetite  = 

254. Nervous, emotional, can’t work under pressure  = 

255. Inward trembling  = 

256. Flush easily  = 

257. Fast pulse at rest  =  3

258. Intolerance to high temperatures  = 

259. Difficulty losing weight  = 

260. Mentally sluggish, reduced initiative  =  3

261. Easily fatigued, sleepy during the day  = 

262. Sensitive to cold, poor circulation (cold hands and feet)  =  3

263. Constipation, chronic  = 

264. Excessive hair loss and/or coarse hair  = 

265. Morning headaches, wear off during the day  =  3

266. Loss of lateral 1/3 of eyebrow  = 

267. Seasonal sadness  =  3

268. Depression during periods  =  3

269. Mood swings associated with periods (PMS)  = 

270. Crave chocolate around periods  = 

271. Breast tenderness associated with cycle  = 

272. Excessive menstrual flow  = 

273. Scanty blood flow during periods  = 

274. Occasional skipped periods  = 

275. Variations in menstrual cycles  = 

276. Endometriosis  =  3

277. Uterine fibroids  = 

278. Breast fibroids, benign masses  = 

279. Painful intercourse (dysparenia)  = 

280. Vaginal discharge  = 

281. Vaginal dryness  = 

282. Vaginal itchiness  = 

283. Tendency to gain weight around hips, thighs and buttocks as opposed to other areas such as the mid- section  =  3

284. Excess facial or body hair  = 

285. Hot flashes  = 

286. Night sweats (in menopausal females)  = 

287. Thinning skin  =  3

288. Aware of heavy and/or irregular breathing  =  3

289. Discomfort at high altitudes  = 

290. Air hunger or sigh frequently  = 

291. Compelled to open windows in a closed room  = 

292. Shortness of breath with moderate exertion  = 

293. Ankles swell, especially at end of day  = 

294. Cough at night  =  3

295. Blush or face turns red for no reason  = 

296. Dull pain or tightness in chest and/or radiate into right  = 

297. Arm, worse with exertion  = 

298. Muscle cramps with exertion  =  3

299. Pain in mid-back region  =  3

300. Puffy around the eyes, dark circles under eyes  = 

301. History of kidney stones  =  1Keys: 0 = No;   1 = Yes

302. Cloudy, bloody or darkened urine  = 

303. Urine has a strong odor  =  3

304. Runny or drippy nose  =  3Keys: 0 = never;   1 = years ago;   2 = within past year;   3 = currently

305. Catch colds at the beginning of winter  =  Keys: 0 = never;   1 = years ago;   2 = within past year;   3 = currently

306. Mucus producing cough  =  Keys: 0 = never;   1 = years ago;   2 = within past year;   3 = currently

307. Frequent colds or flu  =  3

308. Other infections (sinus, ear, lung, skin, bladder, kidney, etc.)  = 

309. Never get sick  =  Keys: 0 = sick 1 or more times in the last 2 years;   1 = not sick in last 2 years;   2 = not sick in last 4 years;   3 = not sick in last 7 years

310. Acne (adult)  = 

311. Itchy skin (Dermatitis)  = 

312. Cysts, boils, rashes  = 

313. History of Epstein-Barr, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition  =  3Keys: 0 = no;   1 = yes in the past;   2 = currently mild condition;   3 = severe