Testimonials

Testimonial 1

I first consulted with Dr. Santo in Oct 2009 for hormonal issues which I had had for over 9 years. Profound hair loss, weight gain, fatigue and depression had become normal to me and the suggestion of three doctors was to get counseling and buy a wig. I was at the end of my rope when I came to him.  Within 2 months Dr. Santo was able to completely identify and treat these hormonal  issues and I can happily say my beautiful thick hair is growing back in record time.  The depression disappeared in a matter of weeks and my metabolism is exactly where it should be.  I now have my life back. Dr. Santo has achieved “Rock Star” status in my world and I couldn’t be more grateful.

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Testimonial 2

I first consulted with Dr. Santo in Oct 2009 for hormonal issues which I had had for over 9 years. Profound hair loss, weight gain, fatigue and depression had become normal to me and the suggestion of three doctors was to get counseling and buy a wig. I was at the end of my rope when I came to him.  Within 2 months Dr. Santo was able to completely identify and treat these hormonal  issues and I can happily say my beautiful thick hair is growing back in record time.  The depression disappeared in a matter of weeks and my metabolism is exactly where it should be.  I now have my life back. Dr. Santo has achieved “Rock Star” status in my world and I couldn’t be more grateful.

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Health History Form

Confidential When Completed

Your careful completion of our health history form helps us customize care options specific to your needs.  If you are uncertain of how to answer a certain question, just make a note of it in any of the comments sections and we will address it during our consultation.

*required field

*First Name		*Last Name
*Email Address		Title
Company
Address		Address 2
City		State/Zip
*Phone		Fax
How did you learn about our services?

Comments
Please post any additional information you would like to include that may have not been addressed in our questionnaire. If you were unsure as to how to answer anything please also post here.

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Personal information

Age Date of Birth (mm/dd/yyyy)
Height (in) Weight (lbs) Gender Male Female

Health History

In your own words please describe your interest in consulting with us

Which diagnoses and/or treatments have you received for these conditions?

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Past Medical History

Condition	Self	Father	Mother	Sibling	Grandparent
Heart Disease
Hypertension
Diabetes
Obesity
Mood Disorder
Addiction
Cancer (specify)
Other (specify)

Past Surgical/Hospitalization History

Date (mm/dd/yyyy)	Procedure

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Allergies

Medications
Foods
Environmental
Other

Current Medications (include bio-identical hormones and over-the-counter medications)

Name	Strength	Amount

Current Nutritional Supplements/Herbs

Name	Strength	Amount

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Women's Health History

What was your age at the start of menstruation?

First date of your last period? (mm/dd/yyyy) How many days did it last?

How many days between periods? Is your cycle regular? Y N

When was your last Pap exam? (mm/dd/yyyy) History of abnormal Pap? Y N

When was your last mammogram? (mm/dd/yyyy) History of abnormal mammogram? Y N

Pregnancies Living children Miscarriages Abortions

Current and previous methods of contraception

Method of contraception	Current	Previous
Not applicable
Hysterectomy
Partner has vasectomy
Condoms
Tubal ligation
IUD
Diaphragm
Pill (Name: # of years taken:)
Other

Men's Health History

What is the date of your last PSA blood test? Please list (if known)

Date of last digital rectal exam (mm/dd/yyyy) Normal Abnormal Please explain

 

History of abnormal bloodwork (cholesterol, sugar, triglycerides, iron, etc)?

How often do you exercise?

What type of exercise do you participate in?

What are your hobbies?

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Dietary profile

How many times per day (D), week (W) or month (M) do you eat, drink or use the following?

Item	D	W	M
Alcohol
Candy
Soda pop
Refined sugar
Artificial sweetener
Margarine
Milk products
Wheat products
Red meat
Pork
Poultry
Seafood
Fruits
Vegetables
Nuts/seeds
Beans
Tap water (glasses)
Purified water
Juices
Sweetened juices
Cigarettes
Chewing tobacco
Coffee
Tea

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Please read each description and select the number which best describes the frequency of your symptoms within the past year.

			0 = Never	1 = Mild (Occurs once a month or less)	2 = Moderate (Occurs several times a month)	3 = Severe (Aware of it almost constantly)
Category 1
	Section A
	1.	Bad breath, halitosis
	2.	Loss of taste for high protein foods (meat, etc)
	3.	Burning ("acid") or nervous stomach, eating relieves
	4.	Gas shortly after eating
	5.	Indigestion 1/2 to 1 hour after eating may last 3 - 4 hrs
	6.	Difficulty digesting fruits or vegetables; undigested foods found in stools
	7.	Acid or spicy foods upset stomach
	Section B
	8.	Lower bowel gas and or bloating several hours after eating
	9.	"Whites" of eyes (sciera) yellow
	10.	Dry Skin, itchy feet and/or skin peels on feet
	11.	Brown spots or bronzing of skin
	12.	Bitter metallic taste in mouth
	13.	Blurred vision
	14.	Headache over eyes
	15.	Feel nauseous, queasy or gag easily
	16.	Greasy or high fat foods cause distress
	17.	Dark circles under eyes
	18.	History of gallbladder attacks or gallstones OR gallbladder removed
	Section C
	19.	Coated tongue or "fuzzy" debris on tongue
	20.	Irritable bowel or mucous colitis
	21.	Constipation, diarrhea alternating or stools alternate from soft to watery
	22.	Bowel movements painful or difficult constipation and/or laxatives used
Category 2
	Section A
	23.	Head congestion/sinus fullness
	24.	Sneezing attacks
	25.	Milk products and/or wheat products cause distress
	26.	Eyes and nose watery
	27.	Eyes swollen and puffy
	28.	Pulse speeds after meals and/or heart pounds after retiring
Category 3
	Section A
	29.	Crave sweets or coffee in afternoon or mid morning
	30.	Hungry between meals or excessive appetite
	31.	Overeating sweets
	32.	Eat when nervous
	33.	Irritable before meals
	34.	Get "shaky" or light-headed if meals delay
	35.	Fatigue, eating relieves
	36.	Heart palpitates if meals missed or delayed
	37.	Awaken a few hours after sleep, hard to get back to sleep
Category 4
	Section A
	38.	Sex drive increased
	39.	"Splitting" type headaches
	40.	Memory failing
	41.	Tolerance for sugar reduced
	Section B
	42.	Sex drive reduced or absent
	43.	Abnormal thirst
	44.	Weight gain around hips or waist
	45.	Tendency to ulcers or colitis
	46.	Increased ability to eat sugar without symptoms
	47.	Menstrual disorders (women)
	48.	Lack of menstruation (young girls)
	Section C
	49.	Difficulty gaining weight, even if large appetite
	50.	Heart palpitations
	51.	Nervous, emotional, and/or can't work under pressure
	52.	Insomnia
	53.	Inward Trembling
	54.	Night Sweats
	55.	Fast pulse at rest
	56.	Intolerant to high temperatures
	57.	Easily flushed
	Section D
	58.	Difficulty losing weight
	59.	Reduced initiative and/or mental sluggishness
	60.	Easily fatigued, sleepy during day
	61.	Sensitive to cold, poor circulation (cold/hands/feet)
	62.	Dry or scaly skin
	63.	"Ringing" in ears noises in head
	64.	Hearing Impaired
	65.	Constipation
	66.	Excessive falling hair and/or coarse hair
	67.	Headaches when awaken/wear off during day
	Section E
	68.	Blood pressure increased
	69.	Headaches
	70.	Hot flashes
	71.	Hair growth on face or body (Question to females)
	72.	Masculine tendencies (Question to females)
	Section F
	73.	Blood pressure low
	74.	Crave salt
	75.	Chronic fatigue/get drowsy
	76.	Afternoon yawning
	77.	Weakness/dizziness
	78.	Circulation poor
	79.	Muscular and nervous exhaustion
	80.	Subject to colds, asthma, bronchitis (respiratory disorders)
	81.	Allergies and/or hives
	82.	Arthritic tendencies
	83.	Nails weak, ridged
	84.	Perspire easily
	85.	Slow starter in morning
	86.	Afternoon headaches
Category 5
	Section A
	87.	Aware of heavy and/or irregular breathing
	88.	Discomfort in high altitudes
	89.	"Air hunger"/sigh frequently
	90.	Swollen ankles/worse at night
	91.	Shortness of breath with exertion
	92.	Dull pain in chest and/or pain radiating into left arm, worse on exertion
Category 6 - Female Only
	Section A
	93.	Premenstrual tension
	94.	Painful menses (cramping, etc.)
	95.	Menstruation excessive or prolonged
	96.	Painful/tender breasts
	97.	Menstruate too frequently
	98.	Acne, worse at menses
	99.	Depressed feeling before menstruation
	100.	Vaginal discharge
	101.	Menses scanty or missed
	102.	Hysterectomy/ovaries removed
	103.	Menopausal hot flashes
	104.	Depression
Category 7 - Male Only
	Section A
	105.	Prostate trouble
	106.	Urination difficult or dribbling
	107.	Night urination frequent
	108.	Pain on inside of legs or heels
	109.	Feeling of incomplete bowel evacuation
	110.	Leg nervousness at night
	111.	Tire easily/avoid activity
	112.	Reduced sex drive
	113.	Depression
	114.	Migrating aches and pains

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