Hygeia Lifestyle Intake

1. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)
Example: Wendy, age 7, sister
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Do you have any pets or farm animals?
Yes____ No____
If yes, where do they live? 1. _____ indoors 2. _____ outdoors 3. _____ both indoors and outdoors
3. Have you lived or traveled outside of the United States?
Yes____ No____
If so, when and where? __________________________________________________________________
_____________________________________________________________________________________
4. Have you or your family recently experienced any major life changes?
Yes____ No____
If yes, please comment: __________________________________________________________________
_____________________________________________________________________________________
5. Have you experienced any major losses in life?
Yes____ No____
If so, please comment: ____________________________________________________________________
_____________________________________________________________________________________
6. How important is religion (or spirituality) for you and your familys life?
a. _____ not at all important
b. _____ somewhat important
c. _____ extremely important
7. How much time have you lost from work or school in the past year?
a. _____ 0-2 days
b. _____ 3 14 days
c. _____ > 15 days
8. Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading
contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can
also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now
an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and
optimize your treatment outcomes.
Please do your best to answer the following questions:
a. Did you feel safe growing up?
Yes
No
b. Have you been involved in abusive relationships in your life?
Yes
No
c. Was alcoholism or substance abuse present in your childhood home, or is it present now in your
relationships?
Yes
No

d. Do you currently feel safe in your home?

Yes
No
e. Do you feel safe, respected and valued in your current relationship?
Yes
No
f.

Have you had any violent or otherwise traumatic life experiences, or have you witnessed any
violence or abuse?
Yes
No

g. Would you feel safer discussing any of these issues privately?

Yes
No
9. How often have you have taken antibiotics?
< 5 times

> 5 times

Infancy/ Childhood
Teen
Adulthood
10. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
< 5 times
> 5 times
Infancy/ Childhood
Teen
Adulthood
11. What medications are you taking now? Include non-prescription drugs.
Medication Name
Date started
Dosage
1.
2.
3.
4.
5.
6.
12. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg
or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.
Vitamin/Mineral/Supplement Name
1.
2.
3.
4.
5.
6.
7.
8.

Date started

Dosage

13. Childhood:
Question

Yes

Dont
Know

No

Comment

1. Were you a full term baby?

a. A preemie?
b. Breast fed?
c. Bottle fed?
2. As a child did you eat a lot of sugar and/or candy?

14. As a child, were there any foods that you had to avoid because they gave you symptoms?
Yes____ No____
If yes, please: name the food and symptom (Example: milk gas and diarrhea)
________________________
____________________________________________________________________________________
15. Place a check mark next to the food/drink that applies to your current diet. (List continues on next page.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.

Usual Breakfast
None
Bacon/Sausage
Bagel
Butter
Cereal
Coffee
Donut
Eggs
Fruit
Juice
Margarine
Milk
Oat bran
Sugar
Sweet roll
Sweetener
Tea
Toast
Water
Wheat bran
Yogurt
Other: (List below)

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.

Usual Lunch
None
Butter
Coffee
Eat in a cafeteria
Eat in restaurant
Fish sandwich
Juice
Leftovers
Lettuce
Margarine
Mayo
Meat sandwich
Milk
Salad
Salad dressing
Soda
Soup
Sugar
Sweetener
Tea
Tomato
Water
Yogurt
Other: (List below)

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.

Usual Dinner
None
Beans (legumes)
Brown rice
Butter
Carrots
Coffee
Fish
Green vegetables
Juice
Margarine
Milk
Pasta
Potato
Poultry
Red meat
Rice
Salad
Salad dressing
Soda
Sugar
Sweetener
Tea
Water
Yellow vegetables
Other: (List below)

16. How much of the following do you consume each week?

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

Candy
Cheese
Chocolate
Cups of coffee containing caffeine
Cups of decaffeinated coffee or tea
Cups of hot chocolate
Cups of tea containing caffeine
Diet sodas
Ice cream
Salty foods
Slices of white bread (rolls/bagels)
Sodas with caffeine
Sodas without caffeine

17. Are you on a special diet?

_____ ovo-lacto
_____ diabetic
_____ dairy restricted

_____ vegetarian
_____ vegan
_____ blood type diet

Yes____ No____
_____ other (describe):
__________________________
__________________________

18. Is there anything special about your diet that we should know?
Yes____ No____
If yes, please explain:
__________________________________________________________________________________
19. a. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?
Yes____ No____
b. If yes, are these symptoms associated with any particular food or supplement(s)?
Yes____ No____
c. Please name the food or supplement and symptom(s). Example: Milk gas and diarrhea.
___________________________________________________________________________________
___________________________________________________________________________________
20. Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident
for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes____ No____
21. Do you feel much worse when you eat a lot of :
high fat foods
high protein foods
high carbohydrate foods
(breads, pastas, potatoes)

refined sugar (junk food)

fried foods
1 or 2 alcoholic drinks
other ____________________________

22. Do you feel much better when you eat a lot of :

high fat foods
high protein foods
high carbohydrate foods
(breads, pastas, potatoes)

refined sugar (junk food)

fried foods
1 or 2 alcoholic drinks
other ____________________________

23. Does skipping a meal greatly affect your symptoms?

Yes____ No____

24. Have you ever had a food that you craved or really "binged" on over a period of time?
(Food craving may be an indicator that you may be allergic to that food.)
Yes____ No____
If yes, what food(s)? _______________________________________________________________
________________________________________________________________________________
25. Do you have an aversion to certain foods?
Yes____ No____
If yes, what foods? ___________________________________________________________________
26. Please fill in the chart below with information about your bowel movements:

a. Frequency
More than 3x/day
1-3x/day
4-6x/week
2-3x/week
1 or fewer x/week
b. Consistency
Soft and well formed
Often float
Difficult to pass
Diarrhea
Thin, long or narrow
Small and hard
Loose but not watery
Alternating between hard
and loose/watery
27. Intestinal gas:

b. Color

Medium brown consistently

Very dark or black
Greenish color
Blood is visible.
Varies a lot.
Dark brown consistently
Yellow, light brown
Greasy, shiny appearance

Daily
Occasionally
Excessive

_____ Present with pain

_____ Foul smelling
_____ Little odor

28. a. Have you ever used alcohol?

b. If yes, how often do you now drink alcohol?

Yes____ No____
___ No longer drinking alcohol
___ Average 1-3 drinks per week
___ Average 4-6 drinks per week
___ Average 7-10 drinks per week
___ Average >10 drinks per week
c. Have you ever had a problem with alcohol?
Yes____ No____
If yes, please indicate time period (month/year): from ________ to ___________.

29. Have you ever used recreational drugs?

Yes____ No____

30. Have you ever used tobacco?

Yes____ No____
If yes, number of years as a nicotine user _____. Amount per day _____. Year quit _____.
If yes, what type of nicotine have you used? _____Cigarette
_____ Smokeless
_____Cigar
_____Pipe
_____Patch/Gum
31. Are you exposed to second hand smoke regularly?

Yes____ No____

32. Do you have mercury amalgam fillings?

Yes____ No____

33. Do you have any artificial joints or implants?

Yes____ No____

34. Do you feel worse at certain times of the year?

If yes, when?
spring
summer

Yes____ No____
fall
winter

35. Have you, to your knowledge, been exposed to toxic metals in your job or at home? Yes____ No____
If yes, which one(s)?
lead
cadmium
arsenic
mercury
aluminum
36. Do odors affect you?

Yes____ No____

37. How well have things been going for you?

Very Well
a.
b.
c.
d.
e.
f.
g.

Fair

Poorly

Very
Poorly

Does not
apply

At school
In your job
In your social life
With close friends
With sex
With your attitude
With your boyfriend/girlfriend

h. With your children

i. With your parents
j. With your spouse
38. Have you ever had psychotherapy or counseling?
Yes____ No____
Currently? _____ Previously? _____ If previously, from ______ to _______.
What kind? ____________________________________________________________________________
Comments: ____________________________________________________________________________

39. Hobbies and leisure activities: _____________________________________________________________

________________________________________________________________________________________
40. Do you exercise regularly?
If so, how many times a week?
1.
1x
2.
2x
3.
3x
4.
4x or more
What type of exercise is it?
jogging/walking
basketball
home aerobics

Yes____ No____
When you exercise, how long is each session?
1.
<15 min
2.
16-30 min
3.
31-45 min
4.
> 45 min

tennis
water sports
other ______________________________________