New Patient Questionnaire

Healing Chronic Illness

Located in Bloomington, IL. Most appointments virtual.

309 663-2423

Questionnaire is encrypted and meets HIPAA requirements.

Patient Information

First name

Last name

Address

City, State Zip code

Home phone number

Cell phone number

Email address

Date of birth

Occupation

Employer

Spouses name

Marital Status

Single

Married

Divorced

Separated

Widowed

Preferred method of contact

Phone

Best time for contact (generally)

Medical History

Approximate Height and Weight

Describe your major complaint in detail. (Please limit to major complaint) Example: Date and cause of onset, what makes it better or worse, severity and intensity. Please be specific.

Are you willing to change your diet and lifestyle? Food allergy testing often requires elimination of certain foods. Some conditions require elimination of certain foods whether allergic or not. Toxins are often an issue and require elimination from the diet.

Yes

Maybe, with conditions

Are you willing to work with a personal health coach to make the changes neccessary? Your health coach helps with diet and toxin removal in the diet and environment. Your health coach will often make exercise recommendations but it is not a personal trainer working out with you. This is different. Your health coach also helps with accountability.

Yes

Maybe, with conditions

Are you willing to gather or help us gather your medical records?

Yes

Maybe, with conditions

Is your spouse or significant other willing to come with you to appointments and support you with diet and lifestyle changes?

Yes

Maybe, with conditions

Approximate date of your last physical exam

Is there a chance that you are pregnant? (if applicable)

Yes No Not sure

Please list any previous surgeries.

Please list all the medications you are taking. Please list the dosage and what condition you are taking it for.

Do you have any medication or other allergies? Please list.

List any herbs, vitamins, minerals or other nutritional supplements you are taking. Please also list dosage and the reason you are taking it.

Please describe second complaint in detail. Please limit this field to second major complaint.

Please list third major complaint in detail. (if applicable)

Did something trigger the changes in your health?

When was the last time you felt good?

What makes you feel better?

What makes you feel worse?

Have you had prolonged use of antibiotics?

Yes

Have you had prolonged use of stomach acid blocking drugs?

Yes

Have you had prolonged use of NSAIDS? (Ibuprofen, Advil, Nuprin, Alleve, Motrin or aspirin)

Yes

Have you had prolonged use of Tylenol?

Yes

Have you used steroids?

Yes

Have you used oral contraceptives?

Yes

Have you traveled to a foreign country?

Yes

Do you have any of the following respiratory conditions?

Asthma / Bronchitis

Shortness of breath

Chronic sinusitis

Sleep apnea

Stuffy nose

Sneezing attacks

Excessive mucous

Seasonal allergies

Chest congestion

Do you have any of the following genital or urinary conditions?

Kidney stones

Gout

Excessive thirst

Frequent bladder or urinary tract infections

Frequent yeast infections

Erectile dysfunction

Do you have any conditions or symptoms not listed above. Is there anything else we need to know about you?

Do you drink alcohol?

Yes

Beer

Wine

Hard alcohol

Do you?

Smoke cigarettes or cigars

Vape

Use recreational drugs

No, I do not use recreational drugs

Do you regularly do any of the following?

Walk

Run

Yoga / stretching

Lift weights / Resistance

Swimming

Bicycling

Other exercise

How much time do you spend exercising per week?

Less than an hour

One to three hours

More than three hours

Stress and coping: Do you do any of the following?

Prayer

Yoga / mindfulness

Tai chi

Imagery

Other stress reduction techniques

Are you happy?

Yes

Does your life have meaning and purpose?

Yes

Do you feel stress is reducing your quality of life?

Yes

Do you like the work you do?

Yes

Have you experienced a major loss in your life?

Yes

Have you been in therapy or are currently in therapy?

Yes

Was your childhood safe and secure?

Yes

Have you had any of the following situations when or since your health problem began?

Divorce

Change of job

Relocation

Death of a loved one

Financial problems

Chronic inadequate sleep

How many hours of sleep do you get a night?

less than six

six to eight

eight to ten

more than 10

Do you have trouble falling asleep?

Yes

Sometimes

Do you wake up refreshed?

Yes

Sometimes

Do you snore?

Yes

Sometimes

Is your bedtime and wake time regular?

Yes

Sometimes

Do you do any of the following?

Watch TV or listen to radio falling asleep

Have an illuminated clock in the bedroom

Read in bed

Drink caffeine after noon

Eat after 7PM

Please click submit when finished. We will contact you after we review, usually within one or two business days. Not all patients are accepted. We only accept patients we are sure we can help. There will be a more extensive consultation after records are received. There is no charge for a consultation. There is only a fee if you decide to accept treatment and we decide to accept you. Please put best contact time for phone calls.

Your information will be encrypted.

Dr. Robert Hermann

Dr Hermann has been practicing for more than 30 years, specializing in functional medicine. He treats chronic illness not responding to other treatment. These include IBS, IBD, ulcerative colitis, fibromyalgia, auto immune conditions, autism, metabolic syndrome and more.

309 663-2423 2415 East Washington Bloomington, IL
Midwestfunctionalmedicine.net