Lean Doc Consult Intake FormDr. Karl Nadolsky July 11, 2012Lean Doc Consult / Case Review Form Please fill this form out as accurately as possible. Thank you!Name* First Last Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Gender*MaleFemaleDate of Birth* Height*In feet and Inches (5'8 or 5 foot 8)Weight*In poundsDate* Email* PhoneSkype ID Please Upload a PicturePlease give a brief description of any current issue/problemBe as detailed as possible. Describe any/all feelings and findings as well as list labwork that has been done and previous doctors that have been seen.When did it start?Please be as specific as possibleDoes anything make it better / or help it?Medications, food, etcDoes anything make it worse?Foods, activity, etcPast Medical History Allergies (Seasonal) Asthma Anemia Angina Arthritis (any type) Eczema Epilepsy / seizures Cancer (any type) Diabetes Colitis Hepatitis Liver disease or elevated liver enzymes High Blood Pressure High Cholesterol Heart Disease / Heart Attack Stroke Ulcer GERD (Gastroesophageal reflux disease) Pancreatitis Prostatitis Sleep Apnea Kidney Disease Heart Murmer or Heart Valve AbnormalityClick on each that apply to you and explain each belowPast Medical History ExplanationsPlease give a brief history of each disease you clicked on above. Also list any other medical problems that were not in the list above.Past SurgeriesPlease list all surgeries you have had in the pastWomens Health - Menstrual CycleAbout every 4 weeksGreater than 5 weeksLess than 3 weeksChanges monthlyDon't have themWomens Health - Menstrual FlowHeavy (a lot of clots)ModerateLightAllergies*Please list any allergies to medications or foods that you haveMedications and Supplements*Please list ANY and ALL medications and supplements you are currently taking including dosages and how many times you take them per day. Also list the reason you are taking the medicine/supplement - e.g. Wellbutrin 300 mg once in the morning for depressionWhat do you do for a job?Stress Level12345678910How stressed do you feel on a daily basis on a scale from 1-10 with 1 being not stressed at all and 10 being extremely stressedSleep Health - Hours of sleepLess than 55-67-89 or moreDo you snore or has anyone told you that you snore?YesNoDo you smoke?YesNoHow many years and how many packs per day do you smoke?e.g. 10 years 1 pack per dayGeneral - Review of Symptoms Night sweats Unexplained weight loss/gain Snoring Difficulty sleeping Chronic fatigue Easy bruising/bleeding Enlarged lymph nodes / glands RashesPlease check all that applyEars, Eyes, Nose, Throat - Review of Symptoms Difficulty with night vision Change in vision Blurred or double vision Bleeding gums Frequent nosebleeds Frequent headaches Earaches Ringing/buzzing in ears Sore throat Runny nosePlease check all that applyPulmonary - Review of Symptoms Shortness of breath Chronic or frequent cough Sputum production Brown/blood-tinged sputum Wheezing Shortness of breath on exertion History of Pulmonary EmbolusPlease check all that applyHeart/Vascular - Review of Symptoms Palpitations (feeling like your heart is beating of your chest) Chest pain/pressure/discomfort High Cholesterol Lower leg or feet swelling History of blood clots in legs (DVT or deep vein thrombosis)Gastrointestinal - Review of Symptoms Frequent Vomiting Frequent Nausea Persistent Diarrhea Persistant Constipation Intermittent Diarrhea then Constipation Frequent indigestion/heartburn Hemorrhoids Black/bloody bowel movements Trouble swallowing Frequent abdominal pain HerniaPlease check all that applyCentral Nervous System - Review of Symptoms Fainting spells Recurrent dizziness Frequent headaches Tremors Memory loss Loss of coordination Difficulty concentrating Numbness/tingling in your extremeties Weakness in any part of bodyPlease check all that applyGenito-Urinary - Review of Symptoms Bladder trouble Blood in urine Irregular vaginal bleeding Currently pregnant Difficulty starting/stopping urination Frequent night time urinating Painful/burning urination Problems with sexual function Decreased erectile fullness Decreased morning erections Troubles keeping erectionsPlease check all that applyEndocrine - Review of Symptoms Increased thirst Frequently feeling hot or heat intolerance Frequently feeling cold or cold intolerance Blood sugar problems Dry hair and/or skin Loss of libidoPlease check all that applyMusculoskeletal - Review of Symptoms Back pain/trouble Neck pain/trouble Joint injury/pain/swelling Carpal tunnel syndromePlease check all that applyFamily History Heart disease / Heart attacks Strokes Cancer Crohns disease or Ulcerative Colitis Anemia (sickle cell, G6PD, etc) Autoimmune (Thyroid, Type 1 Diabetes, Celiac, etc) Type 2 Diabetes High blood pressurePlease check any disease that runs in your familyCurrent Exercise Plan Lean Eating Plan Weight lifting Cardio (running, biking, rowing, etc.) High intensity interval training CrossfitCheck all that applyExercise Frequency*Once weeklyTwo or three times weeklyFour or five times weeklySix or seven times weeklyNoneCurrent Diet / Nutrition Plan* Lean Eating Plan PN Low carb High carb Low fat High fat Low protein High protein Vegan Paleo / Primal No specific dietPast Medical Files #1Upload any past medical documents you have e.g. lab / diagnostic testsPast Medical Files #2Past Medical Files #3Please Sign Here*By signing here I understand that Dr. Spencer Nadolsky will not be diagnosing or treating any disease without first seeing him in person. The purpose of this consult is to improve health and not to treat disease.