Medical Questionnaire – Systems Review - CMIE

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Check each item that applies to you most of the time.

Screening of problems by major physiological systems

Exploration of assimilation, digestion and the microbiome

I have a feeling of bloating or fullness and/or belching, burning, or flatulence right after meals.

I suffer from chronic yeast or fungal infections (fungal dermatitis, vaginal yeast infection, athlete’s foot, toenail fungus).

I feel nauseous after taking dietary supplements.

I feel tired after eating.

I have heartburn.

I regularly use antacids (Tums, Maalox, acid-blocking medications, etc.).

I suffer from chronic abdominal pain.

I have diarrhea.

I’m constipated (I have a bowel movement less than once or twice a day).

I have greasy, large, malformed or smelly stools.

I find food in my stool that is not fully digested.

I suffer from allergies, intolerances or food reactions.

I have carbohydrate intolerance (eating bread or other sugars causes bloating).

I suffer from thrush (whitish tongue).

I have itching.

I have bleeding gums or gingivitis.

I have a geographic tongue (rash on the tongue indicating a food allergy or yeast overgrowth).

I have sores on my tongue.

I have mouth ulcers.

I’m craving sweets and bread.

I consume more than 3 alcoholic beverages per week.

I suffer from excessive stress.

I use or have used antibiotics frequently in the past (more than 1-2 times in 3 years).

I have a history of using NSAIDs (ibuprofen, naproxen, etc.) or other anti-inflammatories.

I took birth control pills or hormone replacements.

I took prednisone or cortisone.

I have a personal or family history of any of the following diseases or conditions: Autism, ADHD, Rosacea, Acne After Adolescence, Eczema, Psoriasis, Celiac Disease (Gluten Allergy), Chronic Autoimmune Diseases, Chronic Urticaria, Inflammatory Bowel Disease, Irritable Bowel Syndrome, Chronic Fatigue Syndrome, Fibromyalgia

Exploring the Hormonal System – Carbohydrate Management

I crave sweets and eat them, and although I have a temporary boost of energy and mood, I collapse afterward.

I have a family history of diabetes, hypoglycemia, or alcoholism.

I’m irritable, anxious, tired, and nervous, or have headaches intermittently throughout the day, but temporarily feel better after meals.

I feel shaky 2-3 hours after a meal.

I’m on a low-fat diet but I can’t seem to lose weight.

If I miss a meal, I feel cranky and irritable, weak or tired.

If I eat a carbohydrate-based breakfast (muffin, bagel, cereal, pancakes, etc.), I can’t control my diet for the rest of the day.

As soon as I start eating sweets or carbs, I can’t stop.

If I eat fish or meat and vegetables, I feel fine, but I feel like I’m falling asleep or feeling “drugged” after a meal of pasta, bread, potatoes, and dessert.

At the restaurant, I opt for the bread basket.

I have palpitations after eating sweets.

I seem to be sensitive to salt (I tend to have water retention).

I get panic attacks in the afternoon if I skip breakfast.

I am often in a bad mood, impatient or anxious.

My memory and concentration are poor.

Eating makes me calm.

I’m tired a few hours after eating.

I have night sweats.

I’m tired most of the time.

I have excess weight around the waist (waist-to-hip ratio >0.8; measured around the belly button and bony prominence at the front of the top hip).

My hair lightens in places I don’t want (my head) and it grows in places it shouldn’t (my face, if I’m a woman).

I have a personal or family history of polycystic ovary syndrome or I am infertile

I have a personal or family history of high blood pressure.

I have a personal or family history of heart disease.

I have a personal or family history of type 2 diabetes.

I suffer from chronic fungal infections (itching, vaginal yeast infections, dry, scaly patches on my skin).

Exploring the Hormonal System – Female Sex Hormones (answer only if you are a woman)

I suffer from premenstrual syndrome.

I have monthly weight fluctuations.

I suffer from edema, swelling, puffiness or fluid retention.

I feel bloated.

I have headaches.

I have mood swings.

I have sensitive and swollen breasts.

I’m in a bad mood.

I feel unable to cope with ordinary demands.

I have back pain, joint or muscle pain.

I have premenstrual cravings (mostly sugar or salt).

I have irregular cycles, heavy or light bleeding.

I am infertile

I use birth control pills or other hormones.

I suffer from premenstrual migraines.

I have cysts or breast masses or fibrocystic breasts.

I have a personal or family history of breast, ovarian or uterine cancer.

I have a personal or family history of uterine fibroids.

I have perimenopausal or menopausal symptoms.

I have hot flashes.

I feel anxious.

I have night sweats.

I have insomnia.

I lost my libido.

I have dry skin, hair and/or vagina.

I have heart palpitations.

I have problems with memory or concentration.

I have bloating or weight gain in the waist area.

I have facial hair.

I’ve been exposed to pesticides or heavy metals (in food, water, air).

Hormonal System Exploration – Male Sex Hormones (answer only if you are a man)

I have a reduced libido and I have lost my vitality.

I’m having trouble getting or maintaining an erection.

I am infertile or have a low sperm count.

I am suffering from a loss of muscle mass.

I have an increase in belly fat.

I’m tired or lack energy.

I feel a loss of direction and purpose or a sense of apathy.

I have bone loss or fractures.

I have a personal or family history of high cholesterol.

I have a personal or family history of insulin or blood sugar problems.

I feel weak.

I’m in a bad mood.

I’ve been exposed to pesticides or heavy metals (in food, water, air).

Exploring the circulatory system

I suffer from heart disease (angina pectoris or heart attack).

I have high blood pressure.

I have poor circulation in my feet.

I have swelling in my hands and feet.

I have edema.

I suffer from erectile dysfunction.

I have muscle cramps.

My hands and feet are cold.

I suffer from Raynaud’s syndrome.

I have frequent infections.

I have varicose veins.

I have numbness and tingling in my extremities.

My wounds are slowly healing.

I have or have had blood clots.

Exploring the Hormonal System – Thyroid Hormones

I have thick skin and nails.

I have dry skin.

My hair is thinning, I’m losing it or it’s rough.

I am sensitive to cold.

My hands and feet are cold.

I feel fatigue, pain, or muscle weakness.

I have heavy menstrual bleeding, worsening PMS, other menstrual problems, or infertility.

My libido has decreased.

I have water retention (swelling of my hands and feet).

I feel tired (especially in the morning).

I have low blood pressure and heart rate.

I have problems with memory and concentration.

The outer third of my eyebrows thinned.

I’m struggling to lose weight or have recently gained weight.

I suffer from constipation.

I’m moody and apathetic.

I have a family history of autoimmune diseases (such as rheumatoid arthritis, multiple sclerosis, lupus, allergies, yeast overgrowth).

I have a family history of celiac disease or am sensitive to gluten.

I was exposed to radiation treatments.

I’ve been exposed to environmental toxins.

I eat a lot of tuna and sushi and/or I have several silver (mercury) dental fillings.

I have a personal or family history of thyroid problems.

I drink chlorinated or fluoridated water.

Exploration of the musculoskeletal and structural system

I’ve lost muscle mass over the years.

I find it more difficult to complete daily tasks that require strength.

I don’t do weight training.

I’m vegan.

I eat less than 25 to 30 grams of protein per meal.

I don’t eat fish and I don’t take omega-3 fatty acid supplements.

I eat fried foods.

I suffer from osteopenia or osteoporosis.

I don’t take a vitamin D3 supplement.

I lack energy and stamina.

Exploration of the detoxification/biotransformation system

I have stools that are difficult to pass every day or two.

I’m constipated and only go to the bathroom every other day or less often.

I urinate small amounts of dark, strong-smelling urine only a few times a day.

I hardly ever sweat.

I experience one or more of the following symptoms: Fatigue, Muscle aches, Headaches, Difficulty concentrating and remembering.

I have a personal or family history of fibromyalgia or chronic fatigue syndrome.

I drink unfiltered tap or well water or water from plastic bottles.

I dry clean my clothes.

I work or live in a building that is poorly ventilated or has windows that don’t open.

I live in a large urban or industrial area.

I use household or gardening chemicals, or I have my house or apartment treated by an exterminator.

I have more than 1 or 2 amalgams (fillings) with mercury in my teeth.

I eat big fish (swordfish, tuna, shark, tilefish) more than once a week.

I am bothered by one or more of the following: Gasoline or diesel fumes, Perfumes, New car smell, Fabric stores, Dry cleaned clothing, Hairspray, Other strong odors, Soap, Detergents, Tobacco smoke, Chlorinated water.

I react negatively when I consume foods containing monosodium glutamate, sulfites (found in wine, salads, dried fruit), sodium benzoate (preservative), red wine, cheese, bananas, chocolate, garlic, onions, or even a small amount of alcohol.

When I consume caffeine, I feel excited, experience increased joint and muscle pain, and/or have symptoms of hypoglycemia (anxiety, palpitations, sweating, dizziness).

I regularly use any of the following substances or medications: Acetaminophen (Tylenol), Acid-blocking medications (Tagamet, Zantac, Pepcid, Prilosec, Prevacid), Hormonal medications in the form of pills, patches, or creams (birth control pill, estrogen, progesterone, prostate medications), Ibuprofen or naproxen, Medications for recurring headaches, allergy symptoms, nausea, diarrhea, or indigestion.

I’ve had jaundice (skin and whites of my eyes turn yellow) or I’ve been told I have Gilbert’s syndrome (elevated bilirubin).

I have a personal or family history of any of the following: Breast Cancer or Lung Cancer from Smoking, Other Type of Cancer, Prostate Problems, Food Allergies, Sensitivities or Intolerances

I have a personal or family history of Parkinson’s disease, Alzheimer’s, ALS (amyotrophic lateral sclerosis), other motor neuron diseases, or multiple sclerosis.

Exploring the immune and inflammatory system

I suffer from seasonal or environmental allergies.

I have food allergies or sensitivities, or I don’t feel well after eating (lethargy, headaches, confusion, etc.).

I work in a poorly lit, chemically contained, and/or poorly ventilated environment.

I am exposed to pesticides, toxic chemicals, loud noises, heavy metals, and/or toxic bosses and colleagues.

I have a history of chronic infections such as hepatitis, skin infections, canker sores, and/or cold sores.

I suffer from sinusitis and allergies.

I have a personal or family history of bronchitis or asthma.

I have a personal or family history of irritable bowel syndrome.

I suffer from depression, anxiety, ADHD, or bipolar illness (inflammation of the brain).

I’ve had a heart attack or have a family history of heart disease.

I am overweight (BMI over 25) or have a family history of obesity or diabetes.

I have a family history of Parkinson’s or Alzheimer’s disease.

I have a stressful life.

I drink more than 3 glasses of alcohol a week.

I exercise less than 30 minutes 3 times a week.

Exploring energy and mitochondria

I suffer from chronic or prolonged fatigue.

I feel muscle pain or discomfort.

I have sleep problems (difficulty staying asleep, falling asleep, or waking up early).

My sleep is not restorative.

I don’t tolerate physical exercise well and I feel very tired after exertion.

I have muscle weakness.

I have problems concentrating or remembering.

I’m irritable and moody.

Fatigue prevents me from doing what I would like to do.

Fatigue interferes with work, family, or social life.

I experienced prolonged stress.

My symptoms came on after acute stress, infection, or trauma.

I suffer from chronic fatigue syndrome or fibromyalgia.

I have a history of chronic infections.

I eat too much or too much sugar

I have been exposed to environmental chemicals (pesticides, unfiltered water, non-organic food).

I have been in the Gulf War or some other military engagement and I have suffered the negative consequences.

I have a family history of neurological diseases, including Alzheimer’s disease, Parkinson’s disease, ALS, etc.

I have a family history of autism or ADHD.

I have a family history of depression, bipolar illness, or schizophrenia.

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