My top 3 concerns today:_____________________________________________________
____________________________(____________)
First name
Middle initial (Maiden name) Last name
Sex:  Male  Female
Date of Birth: ____-____-____ Age:_____________ City/state born:___________________
Phone:______________ _(Home)
________________ (Work)
(Cell)
___________________________________________________________________________
Street
City
State
Zip
My doctor’s name is:___ ______________My email address is:_____________________
My favorite 3 restaurant’s are:________________________________________________
Every day I consume:
(Please circle item or check box)
Servings of fresh fruits ………………………………5 or more 4
3
2
1
0
Servings of vegetables & salad …………………….. 5 or more
4
3
2
1
0
Servings of green foods………. …………………….. 5 or more
4
3
2
1
0
Servings of fried foods per day………………………5 or more
4
3
2
1
0
Servings of nuts per day (2 oz or ¼ cup)………… 5 or more
4
3
2
1
0
Number of 8 oz. glasses of water per day…………...more than 8 7 6
5 4 3 2 1 0
Number of 8 oz cups of coffee/pop/tea per day….... 5 or more
4
3
2
1
0
Number of bowel movements per day……………………… 4
3
2
1
0
Number of hours of sleep per night………………… 8 or more 7 6 5 4
3
2
1
0
Number of meals eaten per day………………………………………………….5 4 3 2 1 0
I drink this many alcohol drinks a week……………8 or more 7 6 5 4
3
2
1
0
I usually have back pain this many times a day…7 6 5 4 3 2 1 never constant
I usually eat this for breakfast:____________________________________________________
I usually eat this for lunch
:____________________________________________________
I usually eat this for supper :____________________________________________________
I usually eat these protein foods daily:______________________________________________
I usually eat these nuts daily between meals:________________________________________
I usually use the following oils when I cook: Coconut Olive Canola Vegetable Shortening
I usually eat the following: margarine or butter
I use the following to balance the flora in my gut: Acidophillus Kephir Yogurt
I use the following sweetners: white sugar brown sugar splenda sweet-n-lo Honey
Stevia Xylitol
I cook with the following cookware: Teflon aluminum stainless steel glass
I use the following deodorant:___________________________________________________
I use the microwave to cook the following foods:____________________________________
Servings of sugar products per day (candy, soda, white bread, white pasta, white sugar,
white rice, non-whole grain cereals, donuts, etc) ……5 or more
4
3
2
1
0
List 4 high fiber foods you eat daily:________________________________________________
I spend this amount of time on a cell phone Monthly:__________________________________
When I want a snack I reach for what?__________________________________
I do at least 20 min. of aerobic exercise this many times each week: 5 or more
I do strength training this many times each week:
3 or more
I have the following cravings:
4
3
2
2
1
1
0
0
*Salt (Adrenal) *Chocolate(Magnesium) *Peanut butter(B-complex) *Cheese(Calcium) *Banana’s(Potassium) *Apples(pectin to
lower cholesterol) * Nuts(B-vitamins/magnesium)*Pickles(Sodium) *Eggs(Choline) * Cantelope(Potassium) *Olives(Thyroid)
*Onions(lungs)*Milk(Calcium or tryoptophane) *Paint or dirt(Calcium or Vitamin D) *Tart fruits(Gallbladder)
I often have some of the following symptoms:
 Staying focused on my job while working  Don’t have much energy after working 8 hours
 Cold hands or feet
 Feel exhausted all the time
 Feel Dizzy upon standing
 Have hot flashes  Short term memory loss
 Have gained weight around my waist line in the last year
 Legs jerk while sleeping
 Have a hard time loosing weight
 Have indigestion or burning in stomach after eating
 I have dark circles under my eyes
 I crave chocolate  I crave salty foods
 I am loosing my hair or my nails are brittle
 I have allergies ________  My hair is falling out
I consider myself to have good health.
 yes  no
I am this ready to make lifestyle changes to become healthier:
 Not at all I Plan to make changes in next 6 months I Plan to make changes in next 30 days 
Already changing - less than 6 months
 Already changing - longer than 6 months
In the past two weeks, I have felt
 Down, depressed, or hopeless
 Little interest or pleasure in doing things
 Good
 Great
________
__________________________
I am coping with my stress level:
 Very well  Well  Some trouble  Often trouble coping
 Can’t cope anymore  Need help
On a scale of 1 to 10 with 10 being the highest, I would rate my stress as a:____________
___________________________________
I have had the health conditions I checked below.
 Heart attack
 High cholesterol
 Bypass surgery  Stroke
 Asthma
 Heart failure
 High blood pressure  Cancer
 Chronic pain_______(where)
 Lung disease
 Arthritis
 Depression
 Frequent headaches
 Diabetes:
Type 1 or
Type 2 (Age at onset
) I use insulin yes
no
I have a brother, sister or parent with diabetes
yes
no
I gave birth to a baby weighing more than 9 #’s
yes
no
 Surgeries (date):_________________________
_
 Other major medical problems:_________
 Number organs removed:____  Major infections in your lifetime:___
 Major toxic exposures in your lifetime:______
 Major traumas in your life time:_______
______
 Number of amalgam fillings in my teeth:______
 Number of steroid type drugs or street drugs used in the last year: _______________________
 Number of unresolved mental factors:_________
 Number of kilos overweight as seen by you :__
Tobacco Use
 Never
 Quit
years ago
Type of tobacco used
 Current user:  Cig. packs  Cigar  Pipe  Chew. Packs per day ____# years__
___________________________________
Medicine
I regularly take this number of prescription medicines: (please circle) 0 1-2 3-5 more than 5
My prescription medications are:_________________________________________________
I regularly take these over-the-counter drugs, herbs, vitamins
________________
_________________________________________________________________
___________________________________
___________________________________
Other
In the past four weeks I have experienced a persistent cough, chest tightness or heaviness, wheezing, extreme fatigue and/or acute shortness of
breath(Please circle which symptom)
 Never
 2 times/week
 Daily
 Continually
In past four weeks I have been awakened at night by cough, chest tightness or heaviness, wheezing, and/or shortness of breath(Please circle which
symptom)
Never  under 4 times/month  1-2 times/week  3 times or more/week
Taking care of me
I do the following things to help manage my stress:__________________________________________
___________________________________________________________________________________
I understand that Kari Uselman, Ph.D., biofeedback practitioner, non-medical doctor, is providing
biofeedback and stress reduction. I agree that I am receiving suggestions to improve my health.
It is my choice and responsibility to improve my health. These are only suggestions.
___________________________________
Signature
_________________________
Date