Personal Health History Questionnaire

* This document has been secured with a HIPAA-compliant asymmetric encryption algorithm to guarantee the confidentiality of your health information.

Filling out this form as completely and thoroughly as possible will ensure that your consultation with Dr. Lonsdorf will be efficient and beneficial. This usually takes about 20-30 minutes. Please have your health information, medications and supplements handy when you sit down to fill it out.

Please complete it at least 3 full days prior to your consultation, so we can enter the information into your electronic health record and Dr. Lonsdorf has time to review it ahead of your session.

Thank you!

Please complete and submit in one sitting. HIPAA regulations do not allow saving and returning function.

We would love to hear from you! Please fill out this form and we will get in touch with you shortly. Make sure you see the "Thank You" - page after submitting the form. If you don't check that you have filled out all required fields.

"*" indicates required fields

Step 1 of 8

12%

Phone

This field is for validation purposes and should be left unchanged.

Section 1: Select Consultation Type

In person phone and office visits:

New: Phone (“Wellness”)

New: In Person - New to Ayurveda

New: In Person - Prior Maharishi Ayurveda consultation

Returning: In Person - Office Visit

Returning: Phone Consultation

How did you hear about us?

Section 2: Contact Information and Vital Statistics

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Daytime Phone (Please give best phone #(s) to contact you.) OLD

Cell Phone OLD

Daytime Phone (Please give best phone #(s) to contact you.)

Cell Phone

Evening Phone

Email*

Would you like a receipt to submit to your insurance company for your consultation today?

Yes

(Please note that this practice does not accept Medicare or Medicaid and most insurance companies do not cover phone or Skype consultations.)

Do you have long-term care insurance (i.e. for nursing home, or other extended care facility)?

Yes

Are you enrolled in Medicare?

Yes

Emergency Contact

Relationship*

Do not have an emergency contact

Phone*

(###) ###-####

Name*

First Last

Vital Statistics

Age

Height

Weight

Blood pressure, recent readings

Date of reading

Month

Day

Year

Date of Birth

Marital status

Single

Married

Divorced

Separated

Widowed

Genetic Sex*

Male

Female

Gender

Preferred pronouns

Ethnicity

Race

What is your occupation?

If retired, please list past occupation(s):

What are your usual working hours?

Number of children

Ages of children

COVID-19 Vaccination

Have you been fully vaccinated against COVID-19?

Yes

1 of 2 shots completed

If "yes," which vaccine did you receive?

Please give the date of your last COVID vaccine shot:

Section 3: Wellness Issues, Medications and Supplements

Please list any health conditions you have in order of severity. (You may enter up to 4 wellness issues.)

Wellness Issue 1

Severity Level

Severe

Moderate

Mild

Length of Time

> 5 years

1-4 years

< 1 year

Progress

Getting better

Getting worse

Staying the same

Wellness Issue 2

Severity Level

Severe

Moderate

Mild

Length of Time

> 5 years

1-4 years

< 1 year

Progress

Getting better

Getting worse

Staying the same

Wellness Issue 3

Severity Level

Severe

Moderate

Mild

Length of Time

> 5 years

1-4 years

< 1 year

Progress

Getting better

Getting worse

Staying the same

Wellness Issue 4

Severity Level

Severe

Moderate

Mild

Length of Time

> 5 years

1-4 years

< 1 year

Progress

Getting better

Getting worse

Staying the same

Past Health History

Are you allergic to any drugs or medications?

Please list any foods or spices you are allergic to or cannot tolerate.

If allergic, what reaction(s) did you have?

If had allergic reaction(s), how serious was it?

Please list all surgeries, hospitalizations and serious illnesses and injuries you have had.

Please list all serious disorders that run in your family and their relation to you (i.e., mother, brother, etc.).

Prescription Drugs

How often and for about how long have you taken antibiotics in the past?

On a separate document such as a WORD Doc, please list prescription drugs you take, including all hormones, the dosage, and the length of time you have taken them. Then find an email from healthoffice@drlonsdorf.com and reply to it and attach your list. This will ensure that your email is encrypted.

Supplements

On a separate document such as a WORD Doc, please list each supplement (vitamins, minerals, herbs or other supplements) that you take, the brand, the dose, the length of time you have been taking it, and how regularly you take it. Then find an email from healthoffice@drlonsdorf.com and reply to it and attach your list. This will ensure that your email is encrypted.

Section 4: Lifestyle & Health History Questionnaire

How is your sleep?

Insomnia most nights

Occasional insomnia

Good

What time do you usually go to sleep?

By 10 PM

10-11 PM

11 PM to midnight

After midnight

What time do you get up?

Before 6 AM

6-7 AM

After 7 AM

Have you been told that you snore?

Yes

Have you ever been tested for sleep apnea?

Yes

If yes, what was the result?

If diagnosed with sleep apnea, do you use any of the following?

C-Pap device

Dental appliance

Other airway management

Approximately what date was your last physical exam?

MM slash DD slash YYYY

Have you had a colonoscopy?

Yes

When was your last one?

MM slash DD slash YYYY

Was it completely normal? Any polyps or other abnormalities found?

How many bowel movements do you normally have a day?

Less than 1

1-2

More than 2

Is the stool hard, medium, soft or loose?

Hard

Soft

Medium

Loose

Are they easy or with strain?

Easy

With strain

Do they alternate between constipated and loose?

Yes

Do you have hemmorhoids?

Yes

If yes, do they bleed?

Yes

Have you had a recent change in bowel habits?

Yes

Do you have blood in your stool or black stools?

Yes

Do you feel now or in the past you have had an eating disorder? Please describe briefly if the answer is yes.

Do you have problems with gas or bloating?

Yes

Do you get heartburn or reflux regularly?

Yes

Do you have sour stomach or acid indigestion regularly?

Yes

Do you feel heavy after eating?

Yes

Do you feel sleepy after eating?

Yes

How is your appetite?

Strong

Weak

Variable

How is your energy during the day?

Strong

Weak

Variable

Do you have night sweats?

Yes

Do you have frequent urination?

Yes

Do you have urinary urgency or leakage?

Yes

Do you have numbness or tingling in hands or feet?

Yes

Have you lost or gained weight in the last 6 months and if so how much?

No change

Lost less than 5 pounds

Lost 5-10 pounds

Lost more than 10 pounds

Gained less than 5 pounds

Gained 5-10 pounds

Gained more than 10 pounds

What percentage of your food is from leftovers?

Less than 10%

10-30%

More than 30%

What percentage of your food is organically grown?

What percentage of your food is frozen or packaged food?

Less than 10%

10-30%

More than 30%

How often do you eat out in a restaurant each week?

0-3 times

3-7 times

More than once a day

How often do you microwave a week?

How many times do you eat meat a week?

None

1-3 times

3-7 times

More than once a day

Please list any foods that you are intolerant to.

How many alcoholic beverages do you consume per day?

2 or more

Please describe current and past use of recreational chemicals (marijuana, LSD, cocaine, ecstasy, etc).

How many caffeinated beverages on average do you consume per day on average?

2-5

More than 5

If you smoke how many cigarettes do you smoke a day?

1-10

10-20

More than 1 pack

Are you having memory issues?

Yes

If you answered "yes" to having memory issues, please describe.

Are you having balance issues (unsteadiness)?

Yes

If you answered "yes" to having balance issues, please describe.

Do you have a tremor?

Yes

If you answered "yes" to having a tremor, please describe.

How many diet sodas or other products containing aspartame do you drink a day?

2-5

More than 5

How often a week do you exercise (at least a brisk walk for 30 minutes or longer)?

1-2

3-5

Do you practice meditation or relaxation techniques daily?

Yes

If you answered yes above, what type of meditation or relaxation techniques do you use?

Are any of the following moods an issue for you? You may choose more than one.

Depression

Anxiety

Anger or irritability

Are you having work or family problems that are significantly affecting your health?

Yes

Which lifestyle changes are you most interested in making at this time?

Diet

Sleep

Exercise

Please list when you have breakfast and what you normally eat.

Please list when you have lunch and what you normally eat.

Please list when you have dinner and what you normally eat.

Please list when you have snacks and what you normally eat.

Environmental Health

What direction does the main entrance to your house face?

North

South

East

West

What side of the house do you enter?

North

South

East

West

What direction does the head of your bed point to?

North

South

East

West

Do you live near a power plant or high tension wires?

Yes

How many hours a day do you use your computer (number, not a range)?

How many minutes a day do you use a cell phone (number, not a range)?

Do you place the phone up to your ear?

Yes

Toxin Exposure and Sensitivity

Do you feel you are highly sensitive to chemicals?

Yes

Do you use mostly organic personal care products, fragrance free laundry products, and non toxic cleaning products in your home?

Yes

Are you exposed to chemicals, pesticides or toxins on a regular basis?

Yes

Have you recently renovated, or painted your home or office?

Yes

Are you exposed to mold, mildew regularly?

Yes

Had water damage in your home/office that was not fully remediated?

Yes

Does your home or office have a "musty odor"?

Yes

Do you get condensation (with or without mold) on the window edges or in your shower?

Yes

Women's Health

Your menstrual cycles are?

Regular

Irregular

Stopped

When was your last menstrual period?

When was your last Pap smear?

Within the last year

1-2 years ago

Over 2 years ago

When was your last mammogram?

Within the last year

1-2 years ago

Over 2 years ago

Have you reached menopause (i.e., is it over 1 year since your last period)?

Yes

Are you experiencing any problems with periods or menopause? Please describe.

How many pregnancies have you had?

Number of miscarriages?

Number of abortions?

How many live births?

Please comment on any question above or describe any other aspects of your health or your life you feel it is important for Dr. Nancy to know.

Section 5: Please describe what you hope to achieve from your consultation.

Outcome 1

Outcome 2

Outcome 3

If you are having a phone or Zoom consultation, please fill out sections 6, 7 and 8. If you are coming for an office visit, it is recommended but not required that you fill out sections 6 and 7, and you may skip to Section 8 if you wish."

Section 6: AMA Questionnaire

Check each of the following signs of accumulated “ama” or metabolic blockage that applies to you.

You wake up tired even after a good night's sleep.

You feel lethargic.

Your tongue is coated.

You have too much saliva.

You don't feel real hunger, even when you haven't eaten for several hours.

You have generalized aches and pains.

You lack mental clarity and energy.

You feel a sense of heaviness in the abdomen, arms, or legs; or in the body as a whole

You feel weary and unenthusiastic.

You experience frequent indigestion, such as gas, bloating or heartburn.

You feel blocked anywhere in the body, including constipation, sinus congestion, and difficulty breathing.

Section 8: Your Dosha Balance (for Women)

V Type:

Gas or bloating

Hot flashes

Feeling cold or cooler than normal

Forgetfulness

Easily distracted

Crying spells

Tension headache

Irregular cycles

Urinary urgency, frequency or leakage

Irregular heartbeat or palpitations

Fluctuating blood pressure

Trouble getting to sleep

Joint pains or muscle aches

Low libido

Vaginal dryness

Anxiety or excessive worry

Mood swings

Dry swings

Constipation

P Type:

Anger or irritability

Frequent bowel movements or loose stools

Skin rash, rosacea or acne

Unpleasant body odor

Urinary tract infections

Difficulty getting back to sleep if wake up at night

Night sweats or sweating during the day

Hot flashes

Feeling warmer than usual when not flashing

Heavy bleeding

More days of heavy flow than usual

Migraine headaches

K Type:

Excessive weight gain

Fluid retention

Breast swelling or fullness

Abdominal heaviness

Food "sits there," slow to digest

Stiffness or heaviness in the body

Lethargy

Lazy or unmotivated feeling

Depression or melancholy

Elevated cholesterol

Yeast infections

Excess mucus, allergies or sinus problems

Asthma, bronchitis or chronic cough

Section 7: Your Dosha Balance (for Men)

Anxiety or excessive worry

Moodiness

Dry skin

Constipation

Easily feeling cold or cooler than others

Forgetful

Easily distracted

Tension headaches

Low back pain

Gas or bloating

Urinary urgency, frequency or slow stream

Erectile dysfunction

Low libido

Irregular heartbeat or palpitations

Fluctuating blood pressure

Trouble getting to sleep

Joint pains or muscle aches

P Type

Easily feeling hot or warmer than usual

Migraine or cluster headaches

Anger or irritability

Over-aggressiveness, “pushy”

Frequent bowel movements or loose stools

Skin rash, rosacea or acne

Unpleasant body odor

Urinary tract infections, include prostatitis

Frequent or profuse sweating

• Difficulty getting back to sleep if wake up in the night

K Type

Excessive weight gain

Fluid retention

Abdominal heaviness

Food “sits there,” slow to digest

Stiffness or heaviness in the body

Lethargy

Lazy or unmotivated feeling

Depression or melancholy

Elevated cholesterol

Excess mucus, allergies or sinus problems

• Asthma, bronchitis or chronic cough

Submit Your Form

NOTE: Click the “Submit” button below to submit your form.

AFTER SUBMITTING, you will be redirected to the Informed Consent Agreement that you must read and sign.

If after submitting you remain on this page, then be sure to scroll up and complete the required questions you may have missed. These will be highlighted in red.

IF YOU HAVE PROBLEMS, PLEASE CONTACT US AT 641-469-3174.