Comprehensive Medical History Questionnaire Comprehensive Medical History Questionnaire Focus: Physiological Contributors to Psychological Symptoms Client Initials Part A: Childhood Medical History (Birth - Age 18) Birth & Early Development Premature birth (< 37 weeks) How many weeks? Birth complications (prolonged labor, cord around neck, emergency C-section) Low birth weight (< 5.5 lbs) NICU stay Duration Developmental delays (walking, talking, toilet training) Failure to thrive Childhood Infections & Illnesses Viral Infections Mononucleosis (EBV) Age Severity Select Mild Moderate Severe Chicken Pox Age Measles/Mumps/Rubella Age Influenza requiring hospitalization Age Other viral infections Please specify Bacterial Infections Meningitis Age Type Pneumonia Age Strep throat (frequent/severe) Frequency Lyme Disease Age Other serious bacterial infections Please specify Parasitic/Fungal Infections Persistent fungal infections Parasitic infections Details Childhood Neurological & Immune Issues Seizures or febrile convulsions Age Frequency Head injuries/concussions Age Severity Select Mild Moderate Severe Loss of consciousness Age Duration Frequent ear infections Chronic allergies or asthma Autoimmune conditions Chronic fatigue as a child Learning disabilities diagnosed ADHD/ADD diagnosis Age diagnosed Childhood Hospitalizations & Surgeries Hospitalizations Age Reason Duration Surgeries Age Type Complications Part B: Adult Medical History (Age 18 - Present) Major Infectious Diseases Post-Viral Syndromes Long COVID Year Duration Ongoing symptoms Chronic Fatigue Syndrome Year diagnosed EBV reactivation Year Tests confirming Other post-viral syndromes Please specify Serious Adult Infections Meningitis Year Type Encephalitis Year Cause Sepsis Year Source Pneumonia requiring hospitalization Year Other serious infections Please specify Neurological Conditions Traumatic Brain Injury Year Severity Select Mild Moderate Severe Lost consciousness Select Yes No Concussions Number Most recent Sports-related Select Yes No Migraines Frequency Triggers Seizures Type Frequency Last occurrence Multiple Sclerosis Parkinson's Disease Neuropathy Type Location Vertigo/Balance problems Memory problems Onset Progression Select Stable Worsening Improving Autoimmune & Inflammatory Conditions Ankylosing Spondylitis Year diagnosed Current status Select Stable Active Remission Rheumatoid Arthritis Year diagnosed Lupus (SLE) Year diagnosed Fibromyalgia Year diagnosed Inflammatory Bowel Disease (Crohn's/UC) Type Select Crohn's Disease Ulcerative Colitis Year Thyroid disorders (Hashimoto's/Graves') Type Select Hashimoto's Graves' Hypothyroid Hyperthyroid Year Celiac Disease Year diagnosed Psoriasis/Psoriatic Arthritis Other autoimmune conditions Please specify Endocrine & Metabolic Disorders Diabetes (Type 1/Type 2) Type Select Type 1 Type 2 Year Control Select Good Fair Poor Thyroid dysfunction Type Current levels Adrenal dysfunction Type Year Hormonal imbalances Type Year Metabolic syndrome Sleep disorders Type Treated Select Yes No Cardiovascular & Respiratory Heart disease Type Year High/Low blood pressure Type Select High Low Year Controlled Select Yes No Arrhythmias Type Year Asthma Severity Select Mild Moderate Severe Sleep apnea Diagnosed Select Yes No Treated Select Yes No Chronic lung disease Part C: Current Symptoms & Functional Impact Fatigue & Energy Rate current energy level compared to peers your age (1-10, 10=excellent): 1 2 3 4 5 6 7 8 9 10 Chronic fatigue Duration Severity (1-10) Post-exertional malaise (worsening symptoms 12-48 hours after activity) Unrefreshing sleep despite adequate hours Afternoon energy crashes Time typically occurs Need to rest during the day Unable to sustain previous activity levels Cognitive Symptoms Brain fog Frequency Select Daily Weekly Monthly Occasional Severity (1-10) Triggers Memory problems Type Select Short-term Long-term Both Word-finding difficulties Processing speed issues (taking longer to complete tasks) Executive function problems (planning, organizing) Attention/focus issues beyond ADHD symptoms Physical Symptoms Joint pain/stiffness Location Pattern Muscle weakness Location Onset Frequent infections Type Frequency Temperature regulation issues (feeling too hot/cold) Numbness/tingling Location Pattern Dizziness/lightheadedness Triggers Palpitations/rapid heart rate When occurs Sensory Issues Light sensitivity Severity (1-10) Impact on daily life Sound sensitivity Severity (1-10) Specific sounds Smell/taste changes When started Touch sensitivity (clothing, textures) Visual disturbances (floaters, halos, difficulty focusing) Part D: Lifestyle & Environmental Factors Sleep Patterns Typical bedtime Wake time Sleep quality (1-10) Hours needed to feel rested Frequent night wakings How many times Can you fall back asleep Select Yes No Difficulty falling asleep How long Early morning awakening Sleep study performed Results Treatment tried Exercise & Activity Pre-illness activity level (1-10) Current activity level (1-10) Exercise intolerance Details Post-exertional symptom worsening Delayed by how many hours Physical limitations affecting exercise Specify Diet & Inflammation Anti-inflammatory diet tried Type Duration Effect Elimination diets tried Type Results Food sensitivities noticed List foods Digestive issues Pattern Relation to mood Environmental Exposures Mold exposure When Duration Symptoms Chemical exposures Type When Symptoms Workplace exposures Type Duration Recent moves/new buildings When Symptom changes Part E: Testing & Evaluations Note: If you have recent bloodwork or test results (within the past 2 years), please send copies to your clinician prior to your appointment. Recent Lab Work (Past 2 Years) Check if completed and provide most recent results: Basic Panels Complete Blood Count Date Notable findings Comprehensive Metabolic Panel Date Notable findings Inflammatory Markers ESR (Sed Rate) Date Result C-Reactive Protein Date Result HLA-B27 Date Result Select Positive Negative Nutritional Status Vitamin D level Date Result B12 level Date Result Folate level Date Result Iron panel/Ferritin Date Result Endocrine Function Thyroid function (TSH, T3, T4) Date Results Reverse T3 Date Result Cortisol (morning) Date Result DHEA-S Date Result Infectious Disease Testing EBV panel (IgG, IgM, EBNA) Date Results CMV IgG/IgM Date Results Lyme testing Date Results Imaging Studies Brain MRI Date Reason Results Spine/Joint imaging Date Results Additional Comments Additional Comments or Observations: Previous Next Submit Form
