Name Age Phone Number E-mail Address   List health concern/problem/conditon: 1 2 3 Which of the above bothers you the most? How long have you been bothered by this condition? Describe how it feels or affects you when it is at its worst. Does this cause you to be: Moody Irritable Interrupt Sleep Restricted on Daily Activities Does this affect your work: Decision Making Poor Attitude Decreased Productivity Exhausted at End of Day Unable to Work Long Hours Does this affect your life: Lose Patience with Spouse or Children Restricted Household Duties Hinders Ability to Exercise or Participate in Sports Interferes with Ability to Participate in Hobbies or other Desired Activities Do you smoke? Yes   No If your answer is Yes, how often Drink Alcohol? Yes   No If your answer is Yes, how often Medication/Vitamin/Supplement taken for what reason and how often Additional information/comment/question