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Forbes Nutritional Consulting with Meg Forbes Dopp
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  • Home
  • About Meg
    • Meg’s Story
    • Frequently Asked Questions
  • Services
    • Supplements
      • Supplements Consent
    • Programs and Testing
    • Resources
    • Forms
      • Adult Medical Questionnaire
      • Pediatric Medical Questionnaire
      • HIPPA Consent
    • Payment for Services
  • Articles
  • Contact
    • Payment for Services
    • Forms

Adult Medical Questionnaire

Adult Medical Questionnaire

Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan.

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  • MM slash DD slash YYYY
  • Describe ProblemMild/Moderate/SevereTreatment ApproachSuccess 
  • End of Section 1 – Please continue

  • Click “+” to drop down more boxes
    NameDate StartedDosage 
  • Click “+” to drop down more boxes
  • NameDate StartedDosage 
  • Were you a full term baby?Preemie?Breast Fed?Bottle Fed?
  • FoodSymptom 
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  • Yes/NoDrinks Per Day/WeekRegular/Diet
  • Yes/NoPacks Per Day/Week 
  • Glasses Per DayPlain WaterJuiceOther
  • Last check-upCholesterol testBlood testRectal examStool blood test 
  • SigmoidoscopyMammogramPap smearBone density test 
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  • Please list your past illnesses by entering when they occurred as well as any other comments you wish to share.
  • AnemiaArthritis 
  • AsthmaBronchitis 
  • CancerChronic Fatigue Syndrome 
  • Crohn's Disease/Ulcerative ColitisDiabetes 
  • EmphysemaEpilepsy/Convulsions/Seizure 
  • GallstonesGout 
  • Heart AttackHeart Failure 
  • HepatitisHigh blood fats (cholesterol/triglycerides) 
  • High blood pressure (hypertension)Irritable bowel 
  • Kidney StonesMononucleosis 
  • PneumoniaRheumatic fever 
  • SinusitisSleep apnea 
  • StrokeThyroid disease 
  • Thyroid diseaseOther 
  • Back injuryBroken (describe) 
  • Head injuryNeck Injury 
  • Barium EnemaBone Scan 
  • CAT Scan- AbdomenCAT Scan- Brain 
  • CAT Scan- SpineChest X-Ray 
  • ColonoscopyEKG 
  • Liver ScanNeck X-Ray 
  • NMR/MRISigmoidoscopy 
  • Upper GI SeriesOther (describe) 
  • AppendectomyDental Surgery 
  • GallbladderHernia 
  • HysterectomyTonsillectomy 
  • Other (describe)Other (describe) 
  • WhereWhenFor What Reason 
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  • NoneBacon/SausageBagelButterCerealCoffeeDonut 
  • EggsFruitJuiceMargarineMilkOat BranSugar 
  • Sweet RollSweetenerTeaToastWaterWheat BranYogurt 
  • NoneButterCoffeeEat in CafeteriaEat in RestaurantFish SandwichJuice 
  • LeftoversLettuceMargarineMayoMeat SandwichMilkSaladDressing 
  • SodaSoupSugarSweetenerTeaTomatoWaterYogurt 
  • NoneBeans (legumes)Brown RiceButterCarrotsCoffeeFish 
  • Green VeggiesJuiceMargarineMilkPastaPotatoPoultryRed Meat 
  • RiceSaladDressingSodaSugarSweetenerTeaWaterYellow Veggies 
  • CandyCheeseChocolateCups of Coffee w/ CaffeineCups of decaf coffee or tea 
  • Cups of Hot ChocolateCups of tea w/ caffeineDiet Sodasice creamSalty foods 
  • Slices of white bread/rolls/bagelsSoda w/ caffeineSoda w/out caffeine 
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  • For how long?Amount per dayYear QuitCigarCigaretteSmokelessPipePatch/Gum 
  • Enter a value between 8 and 8
    Please enter a number from 8 to 8.
  • This field is for validation purposes and should be left unchanged.
Save and Continue Later

Let me know what’s going on with you.

Don’t hesitate to reach out. Together we can find solutions to help you achieve your optimal health.

Contact Us

303.710.5050

Runner’s Roost in Table Mesa Shopping Center
629 S. Broadway, Suite E
Boulder, CO

303.554.7837

Virtual or In-office Sessions (Zoom/phone call)

Monday-Friday 8:30 AM-5:30 PM

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