Aspen Self Health L.L.C.

Dr. Lisa Fitzwilliams, D.C., C.N.

Alpine Center 0326 Hwy 133, Suite 270CCarbondale, CO 81623

Phone/Text: 970-987-4470Fax: 970-797-1493

Email: drlisafitz@gmail.com

Dear Potential Client,

Welcome to Aspen Self Health; where we teach you how to take care ofyourself and preventfuture disease! We are happy to offer youcomprehensive wellness care targeted specifically to your biochemicalindividuality.

Please fill out the attached packet of questionnaires and return by scanning,or mailing, or faxing to the above addresses provided. Also, please attachany pertinent prior laboratory records from the past 2 years. Upon

receiving your information, I will contact you to set up an appointment.This ensures there is ample time to review your case prior to your initialconsultation.

These questionnaires are extensive and comprehensive. They enable thedoctor to accurately discern your current health status.

Thank you for your cooperation in advance.

Yours for better health,

277. £ûa

Why Functional Medicine?

• Our society is experiencing a sharp increase in the number of people who

sufferfrom complex, chronic diseases, such as diabetes, heart disease,

cancer, mental illness, and autoimmune disorders like rheumatoid arthritis.The system of medicine practiced by most physicians is oriented toward

acute care, the diagnosis and treatment of trauma or illness that is of shortduration and in need of urgent care, such as a heart attack or a broken leg.

Physicians apply specific, prescribed treatments such as drugs or surgerythat aim to treat the immediate problem or symptom.

• Unfortunately, the acute-care approach to medicine is ill equipped to

address complex, chronic disease. In most cases, the model does not takeinto account the unique genetic makeup of each individual and does notallow timefor exploring the aspects of today's lifestyle that have a direct

influence on the rise in chronic disease in modern Western society; criticalenvironmental factors such as stress, diet, and exposure to toxins. As a

result, most physicians are not adequately trained to assess the underlyingcauses of complex, chronic disease, nor to apply strategies such as nutritiondiet, and exercise to both treat and prevent these illnesses in their patients.

• Functional Medicine is a different approach, with methodology and tools

that are specifically designed to prevent and treat chronic diseases.

• See more at: https://www.functionalmedicine.org

Name Date of Birth Today's Date

Occupation Age Height Sex Number of Children

Marital Status: O Single O Partner O Married O Separated O Divorced O Widow(er)

Are you recovering from a cold or flu? Are you pregnant

Reason for office visit· Date began:

Date of last physical exam Practitioner name and phone number

Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis):

Outcome

What types of therapy have you tried for this problem(s):

O diet modification O fasting O vitamins/minerals O herbs O homeopathy O chiropractic O acupuncture O conventional drugs

O other

List current health problems for which you are being treated:

Current medications (prescription or over-ther.ounter):

Major Hospitalizations, Surgeries, Injuries: Please list all procedures, complications (if any) and dates:

Year Surgery, Illness, Injury Outcome

Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 A 5 6 7 8 9 10

Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems):

Do you consider yourself· O underweight O overweight O just right Your weight today

Have you had an unintentional weight loss or gain of 10 pounds or more in the last three months?

Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g., fireman, former, miner]?

O Corrective lenses O Dentures O Hearing aid O Medical devices/prosthetics/implants, describe:

Recent changes in your ability to: O see O hear O taste O smell O feel hot/cold sensations

O move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers}

Strong like for any of the following flavors: O sour O bitter O sweet O rich/falty O spicy/pungent O sally

Strong dislike for any one of the following flavors: O sour O bitter O sweet O rich/fatty O spicy/pungent O sally

Do you: O Prefer warmth (i.e., food, drinks, weather, etc.) O Prefer cold (i.e., food, drinks, weather, etc.) O No preference

Is your sleep disturbed at the same time each night? If yes, what time?

Time of day you feel the most energy or the least symptoms: Time of day you feel the worst or your symptoms are aggravated:

O 7 a.m. - 9 a.m. O 9 a.m. - 11 a.m. O 1 1 a.m. - 1 p.m. O 7 a.m. - 9 a.m. O 9 a.m. - 11 a.m. O 11 a.m. - 1 p.m.O 1 p.m. - 3 p.m. O 3 p.m.-5 p.m. O 5 p.m.-7 p.m. O 1 p.m. - 3 p.m. O 3 p.m. - 5 p.m. O 5 p.m. - 7 p.m.O 7 p.m. - 9 p.m. O 9 p.m. - 11 p.m. O 11 p.m. - 1 a.m. O 7 p.m. -9 p.m. O 9 p.m. - 11 p.m. O 11 p.m. - 1 a.m.O 1 a.m. - 3 a.m. O 3 a.m. - 5 a.m. O 5 a.m.-7 a.m. O 1 a.m. - 3 a.m. O 3 a.m.- 5 a.m. O 5 a.m.-7 a.m.

Do you experience any of these general symptoms EVERY DAY?

O Debilitating fatigue O Shortness of breath O Insomnia O Constipation O Chronic pain/inflammationO Depression O Panic attacks O Nausea O Fecal incontinence O Bleeding

O Disinterest in sex O Headaches O vomiting O Urinary incontinence O Discharge

O Disinterest in eating O Dizziness O Diarrhea O Low grade fever O liching/rash

Medical History Health Habits Current SupplementsO Arthritis O Decreased sex drive O Tobacco: O Multivitamin/mineral

O Allergies/hay fever O Infertility Cigarettes: #/day O Vitamin C

O Asthma O Sexually transmitted disease Cigars: #/day O Vitamin E

O Alcoholism Other O Alcohol: O EPA/DHA

O Alzheimer's disease Wine: #glasses/d or wk O Evening Primrose/GLA

O Autoimmune disease Liquor: #ounces/d or wk O Calcium, source

O Blood pressure problems Medical (Wornen) Beer #glasses/d or wk O Magnesium

O Bronchitis O Menstrual irregularities O Coffeine: O Zinc

O Cancer O Endometriosis Coffee: #6 oz cups/d O Minerals, describe

O Chronic fatigue syndromeO Infertility Tea: #6 oz cups/d O Friendly flora (acidophilus)

O Carpal tunnel syndromeO Fibrocystic breasts Soda w/calleine: #cans/d O Digestive enzymes

O Cholesterol, elevatedO Fibroids/ovarian cysts

OIher sources O Amino acids

O Circulatory problemsO Premenstrual syndrome (PMS) O Waler: #glasses/d O CoQ10

O Colitis O Breast cancer O Antioxidants (e.g., lutein,

O Dental problemsO Pelvic inflammatory disease Exercise resveratrol, etc.)

O Vaginal infections O 5-7 days per week O Herbs - teasO DepressionO Decreased sex drive O 34 days per week O Herbs - extractsO DiabetesO Sexually transmitted disease O 1-2 days per week O Chinese herbs

O Diverticular diseaseOther O 45 minutes or more duration per O Ayurvedic herbs

O Drug addiction workoutAge of first period O HomeopathyO Eating disorder O 3045 minutes duration per workoutDate of last gynecological exam O Bach flowersO Epilepsy

Mammogram O + O _ - O Less than 30 minutes O Protein shakesO Emphysema O Walk O Superfoods (e ., bee pollen,O Eyes, ears, nose, throat problems Form of birth controlO Run, jog, jump rope phytonutrient b ends)

O Environmental sensitivities # of childrenO Weight lift O Liquid meals

O Fibromyalgia # of pregnanciesO Swim Other

O Food intolerance O C-sectionBox

O Gastroesophageal reflux disease O Surgical menopauseO Yoga Would you like to:

O Genetic disorder O Menopause O Have more energyO Glaucoma Date of last menstrual cycle

Nutrition 8t Diet O Be stronger

Length of cycle daysera sour°ce O Have more enduranceO Heart disease

Interval of time between cycles O Vegetarian O Increase your sex driveO Infection, chromc days

O V an O Be thinnerO Inflammatory bowel disease Any recent chan es in normal men-

O Irritable bowel syndrome mual flow (e.g., eavier, large clots,O Sah restriction O Be more muscular

O Kidney or Madder diseaseSC°" °" lmProve your complexion

O Starch/carbohydrate restriction O Have stron er nailsO Learning disabilitiesO Th

O Liver or gallbladder disease Farnity Health History e zme Diet O Have heahhier hair

(stones) (Parents and Siblings)O Total colone remictim O Be less moody

O Mental illness O ArthritisSpecific food restrictions: O Be less depressed

O Mental retardation O AsthmaO dairy O wheat O eggs O Be less indecisive

O Migraine headaches O Alcoholism O Feel more motivated

O Neurological problems O Alzheimer's disease O Be more organized(Parkinson's, paralysis) O C O Think more clearly and be more

O Sinus problemsancer Food Frequency focused

O StrokeO Depressim Servings per day: O Improve memory

O Thyroid troubleO Diabetes Fruits (citrus, melons, etc.) O Do better on tests in school

O Obesity19 s d r eg I

en or deep yellow/orange O Not be dependent on over-the-counter medications like a Irm,Osteoporosis O Genetic disorder Grains (unprocessed) ibuprofen, anti-histamines, sTeepingO Pneumoni° O Gloucoma Beans, peas, legumes aids, eIc.

O Sexually transmitted disease O Heart disease Dairy, eggs O Stop using laxatives or stoolO Seasonal affective disorder O Infertility Meat, poltry, fish softenersO Skin problems O Learning disabilities O Be free of painO Tuberculosis O Mental illness Eating Habits O Sleep better

O Ulcer O Mental retardationO Skip breakfast O Have agreeable breath

O Urinary tract infection O Migraine headaches O Two meals/day O Have agreeable body odorO Varicose veins O Neurological disorders O One meal/day O Have stronger teeth

Other (Parkinson's, paralysis)O Graze (small frequent meals) O Get less colds and flus

O Obesity O Food rotati" O Get rid of your allergiesO Osteoporosis O Eat constantly whether hungry O Reduce your risk of inherited dis-

Medical (Men) O Stroke "°l ease tendencies (e.g., cancer,. . O Generally eat on the run heart disease, etc.)O Benign prostatic byperplosia (BPH) O Suicide

O Add salt lo foodO Prostate cancer Other

© 2000 Lyra Heller, Michael Katke. Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law.MET427 7/00 Rev1/03

HEALTH APPRAISAL QUESTIONNAIRE

Name Date

DIRECTIONS

This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track ofhow your physical, mental and emotional states respond to changes you make in your eatin habits, priorities, sup lement program, social andfamily life, level of physical activity and time spent on personal growth. All information is he d in strict confidence. ake all the time you need to

complete this questionnaire.For each question, circle the number that best describes your symptoms:

O = No or Rarely-You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly orless)

1 = Occasionally-Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger

4 = Often-Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it

8 = Frequently-Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on amonthly or cyclical basis

Some questions require a YES or NO response: O = NO 8 = YES

z o o 2 z o oSECTION A SECTION C set.)

1. Indigestion, food repeats on you after you eat 0 1 4 8 6. Stool odor is embarrassing 0 1 4 8

2. Excessive burping, belching and/or bloating 7. Undigested Food in your stool 0 1 4 8following meal O 1 4 8

8. Three or more large bowel movements daily O 1 4 83. Stomach spasms and cramping during or after eating 0 1 4 8

9. Diarrhea (frequent loose, watery stool) O 1 4 84. A sensation that food just sits in your stomach 10. Bowel movement shortly after eating (within 1 hour) O 1 4 8

creating uncomfortable fullness, pressure andbloating during or after a meal 0 1 4 8

5. Bad taste in your mouth 0 1 4 8SECTION D

6. Small amounts of food fill you up immediately 0 1 4 8. .1. Discomfort, pain or cramps in your colon

7. Skip meals or eat erratically because you (lower abdominal area) 0 1 4 8have no appetite O 1 4 8

.2. Emotional stress and/or eating raw fruits andvegetables causes abdominal bloating, pain,cramps or gas O 1 4 8

SECTION B3. Generally constipated (or straining during

1. Strong emotions, or the thought or smell of food bowel movements) 0 1 4 8

aggravates your stomach or makes it hurt O 1 4 8 4. Stool is small, hard and dry O 1 4 8

2. Feel hungr an hour or two after eating a 5. Pass mucus in your stool 0 1 4 8good-size meal 0 1 4 8

6. Alternate between constipation and diarrhea O 1 4 83. Stomach pain, burnin and/or aching over a

period of 1-4 hours a er eating 0 1 4 8 7. Rectal pain, itching or cramping O 1 4 8

4. Stomach pain, burning and/or aching relieved by 8. No urge to have a bowel movement (0)No (8)Yes

eatin food; drinking carbonated beverages, cream 9. An almost continual need to have a bowel movement (0)No (8)Yesor mi ; or taking antacids O 1 4 8

5. Burning sensation in the lower part of your chest,especially when lying down or bending forward 0 1 4 8

6. Digestive pro?ems that subside with rest and relaxation (0)No (8)Yes

7. Eating spicy and fatty (fried) foods, chocolate,coffee, alcohol, citrus or hot peppers causes your 1. When massaging under your rib cage on yourstomach to burn or ache O 1 4 8 right side, there is pain, tenderness or soreness 0 1 4 8

8. Feel a sense of nausea when you eat 0 1 4 8 2. Abdominal pain worsens with deep breathing 0 1 4 8

9. Difficulty or pain when swallowing food or beverage 0 1 4 8 3. Pain at ni ht that may move to your back orright shou der 0 1 4 8

4. Bitter fluid repeats after eating 0 1 4 8SECTION C

5. Feel abdominal discomfort or nausea when eating1. When massaging under your rib cage on your left rich, fatty or fried foods 0 1 4 8

side, there is pain, tenderness or soreness 0 1 4 86. Throbbing tem les and/or dull pain in forehead

2. Indigestion, fullness or tension in your abdomen is associated wit overeating 0 1 4 8delayed, occurring 2-4 hours after eating a meal 0 1 4 8

7. Unexplained itchy skin that's worse at night 0 1 4 83. Lower abdominal discomfort is relieved with the

passage of gas or with a bowel movement 0 1 4 8 8. Stool color alternates from clay colored to

4. Specific foods/beverages aggravate indigestion 0 1 4 8 DOrmO brOWn 0 1 4 8

5. The consistency or form of your stool changes9. General feeling of poor health 0 1 4 8

(e.g., from narrow to loose) within the course of a day 0 1 4 8

Z O O Z O O 210. Aching muscles not due to exercise O 1 4 8 SECTION A11. Retain fluid and feel swollen around the When you miss meals or go without food for extended periods of time,

abdominal area O 1 4 8 do you experience any of the following symptoms?12. Reddened skin, especially palms 0 1 4 8 1. A sense of weakness O 1 4 813. Very strong body odor 0 1 4 8 2. A sudden sense of anxiety when you get hungry O 1 4 8

14. Are you embarrassed by your breath? O 1 4 8 3. Tingling sensation in your hands O 1 4 8

15. Bruise easily (0)No (8)Yes 4. A sensation of your heart beating too quickly16. Yellowish cast to eyes (0)No (8)Yes or forcefully O 1 4 8

5. Shaky, jittery, hands trembling 0 1 4 8

6. Sudden profuse sweating and/or your skinfeels clammy O 1 4 8

7. Nightmares possi?y associated with going to bedon an empty stomach 0 1 4 8

SECTION A 8. Wake up at night feeling restless O 1 4 8

1. Feel cold or chilled-hands, feet or all over-for no9. Agitation, easily upset, nervous O 1 4 8

apparent reason O 1 4 8 10. Poor memory, forgetful 0 1 4 8

2. Your upper eyelids look swollen 0 1 4 8 11. Confused or disoriented O 1 4 8

3. Muscles are weak, cramp and/or trem?e 0 1 4 8 12. Dizzy, faint 0 1 4 8

4. Are you forgetful? 0 1 4 8 13. Cold or numb 0 1 4 8

5. Do you feel like your heart beats slowly? O 1 4 8 14. Mild headaches or head pounding O 1 4 8

6. Reaction time seems slowed down O 1 4 8 15- Blurred vision or dou?e vision O 1 4 8

7. In general, are you disinterested in sex because 16. Feel clumsy and uncoordinated O 1 4 8

your desire is low? 0 1 4 8

8. Feel slow-moving, sluggish 0 1 4 8

9. Constipation 0 1 4 8SECTION B

10. Dryness, discoloration of skin and/or hair (0)No (8)Yes1. Frequent urination during the day and night 0 1 4 8

11. Have you noticed recently that your voice2. Unusual thirst-feeling like you can't drink

is deepening? (0)No (8)Yes enough water 0 1 4 8

12. Thick, brittle nails (0)No (8)Yes3. Unusual hunger-eating all the time O 1 4 8

13. Weight gain for no apparent reason (0)No (8)Yes4. Vision blurs O 1 4 8

14. Outer third of your eyebrow is thinning5. Feel itchy all over 0 1 4 8

or disappearing (0)No (8)Yes 6. Tingling or numbness in your feet O 1 4 8

15. Swelling of the neck (0)No (8)Yes 7. Sense of drowsiness, lethargy during the daynot associated with missing meals or not sleeping 0 1 4 8

8. Eating starchy foods, even if they are healthy andSECTION Bunprocessed (like rice, corn, beans, whole wheat

1. Lingering mild fatigue after exertion or stress 0 1 4 8 or oats), causes you to gain weight or prevents youfrom losing weight (0)No (8)Yes

2. Do you find that you get tired and exhaust 9. Sores heal slowly (0)No (8)Yeseasily? O 1 4 8

3. Craving for salty foods 0 1 4 810. Loss of hair on your legs (0)No (8)Yes

4. Sensitive to minor changes in weather and surroundings 0 1 4 8

5. Diz when rising or standing up from aknee ing position 0 1 4 8

6. Dark ?uish or Mack circles under your eyes 0 1 4 8

7. Have bouts of nausea with or without vomiting 0 1 4 8 SECTION A

8. Catch colds or infections easily (0)No (8)Yes 1. Feel jittery O 1 4 8

9. Wounds heal slowly (0)No (8)Yes 2. First effort of the day causes ain, ressure,tightness or heaviness aroun the c est 0 1 4 8

10. Your body or parts of your body feel tender, sore, 3. Exhaustion with minor exertion 0 1 4 8sensitive to the touch, hot and/or painful 0 1 4 8

4. Heavy sweating (no exertion, no hot flashes) 0 1 4 811. Feel puffy and swollen all over your body 0 1 4 8

. . . .5. Difficulty catching breath, especially during exercise O 1 4 8

12. Skin is gradually tanning without exposureto sun or the ingestion of high levels of

6. Heart pounding sensation of heart beating too

carotene-rich foods (e.g., daily carrot juice intake) quickly, too si ly or irregularly O 1 4 8

or supplements (0)No (8)Yes 7, Swelling in feet, ankles and/or legs comes andgoes for no apparent reason O 1 4 8

c c

z o o a z o o aSECTION B SECTION B(cat.J

1. Muscle pain at rest O 1 4 8 12. Do you become suddenly scared for no reason? 0 1 4 8

2. Cramp-like pains in your ankles, calves or legs 0 1 4 8 13. Do you break out in a cold sweat? 0 1 4 8

3. Numbness, tingling and prickling sensation in 14. "Butterflies in your stomach," nausea and/or diarrhea 0 1 4 8hands and feet 0 1 4 8

4. Cold feet and/or toes appear ?ue 0 1 4 8

5. Brief moments of hearing loss O l 4 8 SECTION C

6. Nausea comes and goes quickly (unrelated to eating) 0 1 4 8 1. Do you feel pent up and ready to explode? 0 1 4 8

7. Feel worse standing: legs get heavy and fatigued O 1 4 8 2. Are you prone to noisy and emotional outbursts? 0 1 4 8

8. Leg discomfort or fatigue relieved by elevating legs O 1 4 8 3. Do you do things on impulse? 0 1 4 8

9. Fingers and toes get numb in cold weather even 4. Are you easily upset or irritated? 0 1 4 8when protected O 1 4 8

5. Do you go to pieces if you don't control yourself? 0 1 4 810. Notice chan es in your ability to feel pain or

differentiate Îetweensensations of hot or cold (0)No (8)Yes 6. Do little annoyances get on your nerves and make

you angry? 0 1 4 811. Body hair (on arm ,

hands, fi gers, legs and toes) 7. Does it make you angry to have anyone tell youis thinning or as isappeare (0)No (8)Yes0 1 4 8

12. Do you notice a decline in your ability to make . . ,decisions, concentrate, focus attention or 8. Do you flare up in anger if you can t have whatfollow directions? (0)No (8)Yes you want right away? 0 1 4 8

SECTION A 1. Eyes water or tear 0 1 4 8

1. Family, friends, work, hobbes or activities you hold 2. Mucus discharge from the eyes 0 1 4 8

dear are no longer of interest O 1 4 8 3. Ears ache, itch, feel congested or sore 0 1 4 8

2. Do you cry? 0 1 4 8 4. Discharge from ears 0 1 4 8

3. Does life look entirely hopeless? 0 1 4 8 5. Is your nose continually congested? 0 1 4 8

4. Would you describe yourself as feeling misera?e 6. Are you prone to loud snoring? (0)No (8)Yes

and sad, unhappy or Mue? 0 1 4 87. Does your nose run? 0 1 4 8

5. Do ou find it hard to make the best ofdifficult situations? O 1 4 8 8. Nose?eeds (0)No (8)Yes

6. Sleep pro?ems-too much or too little sleep O 1 4 8 9. Hoarse voice 0 1 4 8

7. Changes in your appetite and weight (0)No (8)Yes 10. Do you have to clear your throat? 0 1 4 8

8. Lately you've noticed an inability to think clearly11. Do you feel a choking lump in your throat? 0 1 4 8

or concentrate (0)No (8)Yes 12. Do you suffer from severe colds? (0)No (8)Yes

9. Difficulty making decisions and/or clarifying and 13. Do frequent colds keep you misera?e all winter? (0)No (8)Yes

achieving your goals (0)No (8)Yes14. Flu symptoms last longer than 5 days (0)No (8)Yes

15. Do infections settle in your lungs? (0)No (8)Yes

SECTION B 16. Chest discomfort or pain 0 1 4 8

1. Does worrying get you down? 0 1 4 8 17. Do you experience sudden breathing difficulties? 0 1 4 8

2. Does every little thing get on your nerves and wear 18. Do you struggle with shortness of breath? 0 1 4 8you out? O 1 4 8

19. Difficulty exhaling (breathing out) 0 1 4 83. Would you consider yourself a nervous person? 0 1 4 8

20. Breathlessness followed by coughing during exertion,4. Do you feel easily agitated? 0 1 4 8 no matter how slight 0 1 4 8

5. Do you shake and tremble? 0 1 4 8 21. Inability to breathe comfortaMy while lying down 0 1 4 8

6. Are you keyed up and jittery? 0 1 4 8 22. Do you cough up lots of phlegm? 0 1 4 8

7. Do you trem?e or feel weak when someone 23. Can you hear noisy rattling sounds when breathingshouts at you? 0 1 4 8 in and out? 0 1 4 8

8. Do you become scared at sudden movements or 24. Are you trou?ed with coughing? 0 1 4 8noises at night? O 1 4 8

25. Do you wheeze? 0 1 4 89. Do you find yourself sighing a lot? 0 1 4 8

26. Do you have severe soaking sweats at night? 0 1 4 810. Are you awakened out of your sleep by

frightening dreams? O 1 4 8 27. Do your lips and/or nails have a ?uish hue? 0 1 4 8

11. Do frightening thoughts keep coming back in your mind? 0 1 4 8 28. Are you sleepy during the day? 0 1 4 8

Z O O a Z O O

29. Do you have difficulty concentrating? O 1 4 8 SECTION B &mt.)

30. Eyes, ears, nose, throat and lun symptoms seem 8. Intermittent pain or ache on one side of head s readingassociated with specific foods liÎe dairy or to cheek, temple, lower jaw, ear, neck and shoulder 0 1 4 8wheat products (0)No (8)Yes

9. Difficulty chewing food or opening mouth 0 1 4 831. Eyes, ears, nose, throat and lung symptoms are

associated with seasonal changes (0)No (8)Yes 10. Difficulty standing up from a sitting position 0 1 4 8

11. Shooting, aching, tingling pain down the back of leg 0 1 4 8

12. Is it difficult to reach up and et a 5-pound objectlike a bag of flour from just a ove your head? (0)No (8)Yes

13. Injure, strain or sprain easily (0)No (8)Yes

1. Involuntary loss of urine when you cough, liftsomething or strain during an activity 0 1 4 8

SECTION C2. Mild lower back ache or pain O 1 4 8

1. Muscles stiff, sore, tense and/or achy O 1 4 83. Abdominal achiness or pain 0 1 4 8

2. Burning, throbbing, shooting or stabbing muscle pain O 1 4 84. Pain or burning when urinating 0 1 4 8

3. Muscle cramps or spasms (involuntary or after5. Rarely feel the urge to urinate O 1 4 8exertion/exercise) 0 1 4 8

6. Feel the need to urinate less than every two hours 4. Is muscle pain or stiffness reater in the morningduring the day or night 0 1 4 8than other times of the day? O 1 4 8

7. Strong smelling urine O 1 4 8 5. Specific points on body feel sore when pressed O 1 4 8

8. Back or leg pains are associated with dripping 6. Feel unrefreshed upon awakening 0 1 4 8after urination 0 l 4 8

7. Headaches 0 1 4 89. Sore or painful genitals 0 1 4 8

8. Pain at the sides of your head or in your face10. Urine is a rose color O 1 4 8

especially when awakening 0 1 4 8

11. Sudden urge to void causes involuntary loss of urine O 1 4 8 9. Your jaw clicks or pops O 1 4 812. Generalized sense of water retention throughout 10. Muscle twitch or tremor-eyelids, thumb, calf muscle O 1 4 8

your body O 1 4 811. Irresistible urge to move legs 0 1 4 8

12. Legs move during sleep O 1 4 8

13. Unpleasant crawling sensation inside calves whenlying down 0 1 4 8

14. Hand and wrist numbness or pain (e.g., interferes withSECTION A writing or with buttoning or unbuttoning your clothes) 0 1 4 8

1. Bones throughout your entire body ache, feel tender 15. Feeling of "pins and needles" in your thumb andor sore O 1 4 8 first three fingers O 1 4 8

2. Localized bone pain O 1 4 8 16. Pain in forearm and sometimes in shoulder O 1 4 8

3. Hands, feet or throat get tight, spasm or feel numb 0 1 4 8

4. Difficulty sitting straight O 1 4 8

5. Upper back pain O 1 4 8

6. Lower back pain 0 1 4 8

7. Pain when sitting down or walking 0 1 4 8 SECTION A

8. Find yourself limping or favoring one leg 0 1 4 8 1. Head feels heavy O 1 4 8

9. Shins hurt during or after exercise O 1 4 8 2. Dizziness 0 1 4 8

3. Difficulty bending over, standing up from sittin ,

rolhng over in bed and/or turning your head romSECTION B

side to side 0 1 4 8

1. Are you stiff in the morning when you wake up? 0 1 4 8 4. Your hands trem?e, ever so slightly, for no

2. Difficulty bendin down and picking up clothing or °PParent reason 0 1 4 8

anything from the floor O 1 4 8 5. You feel like you're wearing heavy weights on your3. Joint swelling, ain or stiffness involvin one or more

feet when walking 0 1 4 8

areas (fingers, hands, wrists, elbows, sÎoulders,6. Bump into things, trip, stum?e and feel clumsy O 1 4 8

toes, arches, feet, ankles, knees or ankles) 0 1 4 87. Difficulty breathing O 1 4 8

4. Joints hurt when moving or when carrying weight 0 1 4 88. Difficulty swallowing 0 1 4 8

5. A routine exercise program, like daily walking,causes your knees to swell or hurt 0 1 4 8 9. Peo le tell you to speak up because they have

trou le heanng you O 1 4 86. Diff ulty opening jars that were previously easy

0 1 4 8 10. Speaking and forming words does not feel automatic O 1 4 8

7. Discomfort, numbness, prickling or tingling sensation,11. Need 10-12 hours of sleep to feel rested O 1 4 8

or pain in neck, shoulder or arm O 1 4 8

z o o a z o o 2SECTION A(mard SECTION A(cone.)

12. Lack strength (your grip is weak, holding your head [B]or picking your arms up takes effort) 0 1 4 8

5. Abdominal Moating, feeling swollen (e.g., feet) (0)No (8)Yes

13. Hands get tired when you write and your handwritingis less legi?e and smaller than it used to be (0)No (8)Yes

6. Temporary weight gain (0)No (8)Yes

14. Muscles in arms and legs seem softer and smaller (0)No (8)Yesa te ess, swekg o es

15. Is our eyesight, sense of smell and taste or ability8. Appearance of breast lumps (0)No (8)Yes

to hear not as sharp as it used to be? (0)No (8)Yes 9. Discharge from nipples (0)No (8)Yes

16. Do you find yourself moving slower than you used to? (0)No (8)Yes 10. Nausea and/or vomiting (0)No (8)Yes

11. Diarrhea or constipation (0)No (8)Yes

SECTION B 12. Aches and pains (back, joints, etc.) (0)No (8)Yes

1. Difficulty absorbing new information 0 1 4 8

2. Tend to forget things 0 1 4 8 13. Craving for sweets (0)No (8)Yes

3. Trou?e thinking or concentrating 0 1 4 8 14. Increased appetite or binge eating (0)No (8)Yes

4. Easily distracted O 1 4 8 15. Headaches (0)No (8)Yes

5. Do you have a tendency to become 16. Being easily overwhelmed, shaky or clumsy (0)No (8)Yes

frustrated quickly? O 1 4 8 17. Heart pounding (0)No (8)Yes

6. Inabili to sit still for any length of time, even 18. Dizziness or fainting (0)No (8)Yes

at mea time 0 1 4 8[D]

7. Finishing tasks is easier said than done 0 1 4 819. Confused and forgetful to the point that work suffers (0)No (8)Yes

8. Do you have more trou?e solving pro?ems ormanaging your time than usual? 0 1 4 8 20. Overwhelmed with feelings of sadness and worthlessness (0)No (8)Yes

9. Low tolerance for stress and otherwise21. Difficulty sleeping or falling asleep (0)No (8)Yes

ordinary pro?ems 0 1 4 8 22. Engaging in self-destructive behavior (0)No (8)Yes

SECTION B

Do you experience any of these symptoms duringyour period?1. Cramping in lower abdomen or pelvic area (0)No (8)Yes

2. Lower abdominal pain is sharp and/or dull or intermittent (0)No (8)Yes1. Sensation of not emptying your Madder completely 0 1 4 8

3. Bloating and sense of abdominal fullness (0)No (8)Yes2. Need to urinate less than 2 hours after you have

finished urinating 0 1 4 8 4. Diarrhea or constipation (0)No (8)Yes

3. Find yourself needing to stop and start again5. Nausea and/or vomiting (0)No (8)Yes

several times while urinating O 1 4 8 6. Low back and/or legs ache (0)No (8)Yes

4. Find it difficult to postpone urination 0 1 4 8 7. Headaches (0)No (8)Yes

5. Have a weak urinary stream 0 1 4 8 8. Unusual fatigue (take naps) resulting in missed work (0)No (8)Yes

6. Need to push or strain to begin urinating 0 1 4 8 9. Painful and/or swollen breasts (0)No (8)Yes

7. Dripping after urination 0 1 4 8 10. Scanty Mood flow (0)No (8)Yes

8. Urge to urinate several times a night 0 1 4 8

SECTION C

1. Painful or difficult sexual intercourse 0 1 4 8

2. Low abdominal, back and vaginal painthroughout the month O 1 4 8

Women Only 3. Pelvic pressure or pain while sitting down or

(Menopausal women should skip to Sections E and F)standing up, relieved by lying down 0 1 4 8

4. Vaginal Meeding other than during your period 0 1 4 8SECTION A

5. Painful bowel movements O 1 4 8

Do you persistently experience any of these symptoms within three 6. Difficult (straining) urination O 1 4 8days to two weeks prior to menstruction? 7. Abnormal vaginal discharge O 1 4 8[A] 8. Offensive vaginal discharge 0 1 4 8

1. Anxious, irrita?e or restless (0)No (8)Yes 9. Vaginal itching or burning with or without intercourse O 1 4 82. Numbness, tingling in hands and feet (0)No (8)Yes 10. Pain during periods is getting progressively worse (0)No (8)Yes

3. Easy to anger, resentful (0)No (8)Yes 11. Profuse or prolonged menstrual ?eeding (0)No (8)Yes

4. Aggressive or hostile toward family/friends (0)No (8)Yes 12. Una?e to get pregnant (0)No (8)Yes

Z O O Z O O

SECTION D SECTION E (cat.)1. Absence of periods for six months or longer (0)No (8)Yes 5. Interest in having sex is low 0 1 4 82. Periods occur irregularly (e.g., 3 to 6 times a year) (0)No (8)Yes 6. Engorged breasts O 1 4 83. Profuse heavy bleeding during periods 0 1 4 8 7. Breast tenderness, soreness O 1 4 84. Menstrual Mood contains clots and tissue O 1 4 8 8. Difficulty with orgasm O 1 4 8

5. Bleeding between periods can occur anytime O 1 4 8 9. Vaginal ?eeding after sexual intercourse O 1 4 86. Periods occur greater than every 35 days (0)No (8)Yes 10. Do you skip periods? (0)No (8)Yes

7. Intense upper stomach pain ,lasting several hours 11. The length (number of days) of your eriod variesat the time you ovulate (approximately day 14 of month to month, with the number of ays ofyour cycle) 0 1 4 8 ?eeding getting fewer (0)No (8)Yes

8. eeding ccurs at ulation (approximately

9. Monthly abdominal pain without beeding O 1 4 8 SECTION F

10. Abundant cervical mucus 0 1 4 8 1. Sense of well-being fluctuates throughout the dayfor no apparent reason O 1 4 8

11. Acne and/or oily skin O 1 4 82. Sudden hot flashes O 1 4 8

12. Overwhelming urges for sexual intercourse 0 1 4 83. Spontaneous sweating 0 1 4 8

13. Aggressive feelings O 1 4 84. Chills 0 1 4 8

14. Increased growth of dark facial and/or body hair (0)No (8)Yes5. Cold hands and feet O 1 4 8

1 5. Poor sense of smell (0)No (8)Yes6. Heart beats rapidly or feels like it is fluttering 0 1 4 8

16. Voice is becoming deeper (0)No (8)Yes7. Numbness, tingling or prickling sensations O 1 4 8

17. Breasts seem to be getting smaller (0)No (8)Yes8. Dizziness O 1 4 8

18. Receding hairline (0)No (8)Yes9. Mental fogginess, forgetful or distracted O 1 4 8

10. Inability to concentrate O 1 4 8SECTIONE 11. Depression, anxiety, nervousness and/or irritability O 1 4 8

1. Vaginal discharge O 1 4 8 12. Difficulty sleeping O 1 4 82. Vaginal secretions are watery and thin O 1 4 8 13. Conscious of new feelings of anger and frustration O 1 4 8

3. Vaginal dryness O 1 4 8 14. Skin, hair, vagina and/or eyes feel dry 0 1 4 84. Sexual intercourse is uncomforta?e O 1 4 8 15. Stopped menstruating around six months ago, yet

still experience some vaginal bleeding (0)No (8)Yes

Please mark an "X" to indicate areas where you feel pain, swelling or discomfort, or areas of your skin that have changed color ortexture (e.g., moles,rashes, etc.). Describe what you feel or observe in your own words. Write anywhere in this area.

• . / I

00 1984 Lyra Heller and Michael Katke, revised 2002 Reproduction, photocopying, storage or transmission by magnetic or electronic means without permission is strictly prohibited by law, MET423 11/02

ConsentfDisclaimer FormfHIPPA

I, , hereby attest to the following:

• I understand that Dr. Lisa Fitzwilliams is a licensed primary care physician in the state ofColorado. She is a Doctor of Chiropractic (D.C.) and federally licensed CertifiedNutritionist (C.N.). She is not a Medical Doctor (M.D.) and not performing MedicalDiagnostic and treatment procedures.

• The services performed by Dr. Lisa Fitzwilliams are at all times restricted to consultationand evaluation on the subject of lifestyle and clinical nutritional matters. These servicesare intendedfor the maintenance and optimization of general health and do not involvediagnosing, prognosticating or treatment of disease.

• That I am consenting treatment, on this day and any subsequent visit, on my own behalf.

• That my personal health information will not be disclosed without my approval. That I

may obtain a copy of privacy practices and policies in writing upon request.

Date:Name (Please print):

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Mailing Address with Zip code:

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Email:

Dr. Lisa Fitzwilliams, D.C., C.N.

drlisafitz@gmail, www.drfitzwilliams.comAspen Self Health, LLC

Alpine Center, 0326 Hwy 133, Suite 270 C&D

Carbondale, CO 81623970-987-4470, Fax: 970-797-1493

"Promoting exceptional self health...One step at a time! "

Aspen Self Health, L.L.C.

Fee Schedule- 2019

• Functional Medicine Initial appointment: 60 min.$190 Minor: $120

• Functional Medicine Follow-up appointments 45 min:$140 Minor: $95

• Functional Medicine Phone consultations: $95

• Please note that payment via cash, check or creditcard is due at time of service. No insurance is

processed.

• Please note laboratory analysis and nutritionalsupplements are not included in above fees and areseparate charges.

• Please note that Email, Voice Mail and Text Supportincluded in client fee.