Functional Medicine Questionnaire

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Alternative Nutritional
& Natural Hormone
Replacement Therapies

Rate each of the following symptoms based on your typical health profile for the past 30 days.

Point Scale:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Frequently have it, effect is not severe
3 = Occasionally have it, effect is severe
4 = Frequently have it, effect is severe

Digestive Tract
Nausea or Vomiting:	0 1 2 3 4
Diarrhea:	0 1 2 3 4
Constipation:	0 1 2 3 4
Bloated Feeling:	0 1 2 3 4
Belching or Passing Gas:	0 1 2 3 4
Heartburn:	0 1 2 3 4
Ears
Itchy Ears:	0 1 2 3 4
Ear Aches, Ear Infections:	0 1 2 3 4
Drainage from Ears:	0 1 2 3 4
Ringing in Ears, Hearing Loss:	0 1 2 3 4
Emotions
Mood Swings:	0 1 2 3 4
Anxiety, Fear or Nervous:	0 1 2 3 4
Anger, Irritable, Aggressive:	0 1 2 3 4
Depression:	0 1 2 3 4
Energy & Activity
Fatigue, Sluggishness:	0 1 2 3 4
Apathy, Lethargy:	0 1 2 3 4
Hyperactivity:	0 1 2 3 4
Restlessness:	0 1 2 3 4
Eyes
Watery or Itchy Eyes:	0 1 2 3 4
Swollen Reddened/Sticky Eyes:	0 1 2 3 4
Bags/Dark Circles Under Eyes:	0 1 2 3 4
Blurred or Tunnel Vision:	0 1 2 3 4
Head
Headaches:	0 1 2 3 4
Faintness:	0 1 2 3 4
Dizzyness:	0 1 2 3 4
Insomnia:	0 1 2 3 4
Heart
Irregular or Skipped Heartbeat:	0 1 2 3 4
Rapid or Pounding Heartbeat:	0 1 2 3 4
Chest Pain:	0 1 2 3 4
Joints/Muscles
Pains or Aches in Joints:	0 1 2 3 4
Arthritis:	0 1 2 3 4
Stiffness or Limited Movement:	0 1 2 3 4
Pain or Aches in Muscles:	0 1 2 3 4
Feeling Weak or Tired:	0 1 2 3 4
Lungs
Chest Congestion:	0 1 2 3 4
Asthma, Bronchitis:	0 1 2 3 4
Shortness of Breath:	0 1 2 3 4
Difficulty Breathing:	0 1 2 3 4
Mind
Poor Memory:	0 1 2 3 4
Confusion, Poor Comprehension:	0 1 2 3 4
Difficulty Making Decisions:	0 1 2 3 4
Stuttering or Stammering:	0 1 2 3 4
Slurred Speech:	0 1 2 3 4
Learning Disabilities:	0 1 2 3 4
Mouth/Throat
Chronic Coughing:	0 1 2 3 4
Gagging/Frequently Need to Clear Throat:	0 1 2 3 4
Sore Throat, Hoarse/Lost Voice:	0 1 2 3 4
Swollen or Discolored Tongue, Gums, or Lips:	0 1 2 3 4
Canker Sores:	0 1 2 3 4
Nose
Stuffy Nose:	0 1 2 3 4
Sinus Problems:	0 1 2 3 4
Hay Fever:	0 1 2 3 4
Sneezing Attacks:	0 1 2 3 4
Excessive Mucus Formation:	0 1 2 3 4
Skin
Acne:	0 1 2 3 4
Hives, Rashes, Dry Skin:	0 1 2 3 4
Hair Loss:	0 1 2 3 4
Flushing or Hot Flashes:	0 1 2 3 4
Excessive Sweating:	0 1 2 3 4
Weight
Binge Eating:	0 1 2 3 4
Craving Certain Foods:	0 1 2 3 4
Excessive Weight:	0 1 2 3 4
Compulsive Eating:	0 1 2 3 4
Water Retention:	0 1 2 3 4
Underweight:	0 1 2 3 4
Other
Frequent Illness:	0 1 2 3 4
Frequent or Urgent Urination:	0 1 2 3 4
Genital Itch or Discharge:	0 1 2 3 4

So that we may contact you with the results of your questionnaire, please provide the following information. Our privacy policy states that we will not share your information with any third parties at any time.
Your Name:
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Your Phone Number:
Where did you hear about the Youthful Aging Center?

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This site is for informational and educational purposes only and the information contained herein does not constitute the rendering
of medical advice nor the provision of treatment or treatment recommendations. Browsing this site does not establish a professional
relationship with Dr. Ana M. Hernandez, DO or any member of her professional staff. Any medical or other decision should be made in
consultation with your qualified healthcare provider. The information contained on this Web site has not been evaluated by the FDA.
This information is not intended to treat or diagnose.