Follow Up Visit Form

Please complete this form 1 week prior to your appointment if you have had an appointment within 1 year. If you have not been seen by our practice within the last calendar year please resubmit the questionnaire in the P2P portal.

An administrative team member will contact you 15 minutes prior to your appointment to check you in. To streamline this process please note any changes to your supplements in the space provided below. We request that you do not update your symptoms or supplements in your P2P medical record.

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale

0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2 – Occasionally have it, effect is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe

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

About You

Your Name(Required)

First Last

Email(Required)

Date(Required)

Please share your reason/top priorities to review at your appointment.(Required)

These can include recent bloodwork or lab testing, review of progress in your plan, new topics of interest, or supplement/nutraceutical review. Let us know all relevant information including physical and other symptoms, information updates, etc. If you have updated information about drug allergies, medical or family history, please also let us know. An example would be, “review stool study BECAUSE I have Hashi’s and osteoporosis and want to address root causes."

Head

Headaches(Required)

Faintness(Required)

Dizziness(Required)

Insomnia(Required)

Eyes

Watery or itchy eyes(Required)

Swollen, red or sticky eyelids(Required)

Bags or dark circles under eyes(Required)

Blurred or tunnel vision(Required)

Ears

Itchy ears(Required)

Earaches, ear infections(Required)

Drainage from ear(Required)

Ringing in ears, hearing loss(Required)

Nose

Stuffy nose(Required)

Sinus problems(Required)

Hay fever(Required)

Sneezing attacks(Required)

Excessive mucus formation(Required)

Chronic coughing(Required)

Mouth/Throat

Gagging, frequent need to clear throat(Required)

Sore throat, hoarseness, loss of voice(Required)

Swollen or discolored tongue, gums, lips(Required)

Canker sores(Required)

Skin

Acne(Required)

Hives, rashes, dry skin(Required)

Hair Loss(Required)

Flushing, hot flashes(Required)

Excessive sweating(Required)

Heart

Irregular or skipped heartbeat(Required)

Rapid or pounding heartbeat(Required)

Chest pain(Required)

Lungs

Chest congestion(Required)

Asthma, bronchitis(Required)

Shortness of breath(Required)

Difficulty breathing(Required)

Digestive Tract

Nausea, vomiting(Required)

Diarrhea(Required)

Constipation(Required)

Bloated feeling(Required)

Belching, passing gas(Required)

Heartburn(Required)

Intestinal/stomach pain(Required)

Joints/Muscle

Pain or aches in joints(Required)

Arthritis(Required)

Stiffness or limitation of movement(Required)

Pain or aches in muscles(Required)

Feeling of weakness or tiredness(Required)

Weight

Craving certain foods(Required)

Excessive weight(Required)

Compulsive eating(Required)

Water retention(Required)

Underweight(Required)

Binge eating/drinking(Required)

Energy/Activity

Fatigue, sluggishness(Required)

Apathy, lethargy(Required)

Hyperactivity(Required)

Restlessness(Required)

Mind

Poor memory(Required)

Confusion, poor comprehension(Required)

Poor concentration(Required)

Poor physical coordination(Required)

Difficulty in making decisions(Required)

Stuttering or stammering(Required)

Slurred speech(Required)

Learning disabilities(Required)

Emotions

Mood swings(Required)

Anxiety, fear, nervousness(Required)

Anger, irritability, aggressiveness(Required)

Depression(Required)

Other

Frequent or urgent urination(Required)

Frequent illness(Required)

Genital itch or discharge(Required)

Total

Please add all numbers above

Supplements and Medications

Subtract from my list:

Add these to my list:

Please change the following on my list (you may be updating brand, dosage or frequency):

Vaccinations(Required)

List the name and date of any recent vaccines since your last visit with our practice.

Have you or anyone in your household had any of the following symptoms in the last 10 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?(Required)

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