Dudley Chiropractic, Acupuncture and Functional Medicine

Comprehensive Functional Medicine Assessment

This form is detailed by design. To figure out what is actually causing your symptoms, we need a complete picture of your health history, not just the highlights. Every section gives us information we use to build your care plan. Please set aside 30-60 min, find a quiet spot, and answer each question as thoroughly as you can. The more specific you are, the more useful your first visit will be.

Confidential Patient Health Record

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A
Patient Information
Demographics and reason for visit
B
Primary Concern & Goals
Chief complaint, visit goals, and root-cause framework
This section sets the direction for everything else. Tell us what brought you in, how long it's been going on, and what you've already tried. The three questions at the end — about what set things up, what started them, and what keeps them going — are the most useful things you can answer. Specifics matter more than completeness here.
Primary concern
Describe your main reason for this visit in your own words *
Include what symptoms you have and how long they've been present.
How long has this been going on?
Over the past 6 months it has been:
Each concern gets its own description and timing — list separately so nothing gets overlooked.
1Visit goals — considering all your concerns, what does improvement look like to you?
Be specific: What would you be able to do that you can't do now? What medication would you like to stop? What would you want a lab test to show? What would you like to return to?
The Three Root-Cause Questions
These are the most important questions on this page. Answer as specifically as possible — they guide testing and treatment decisions more than any other information.
Genetics, childhood health history, family patterns, early exposures, formative events that may have set the stage
The event or change that seemed to start the decline — an infection, a stressor, a move, a medication, a life event
The ongoing factors that prevent recovery — the things keeping the problem active right now
One more question before we continue
Is your primary reason for this visit related to memory, cognitive health, or movement concerns?
If yes, a targeted assessment section will be added to your form. You will still complete the full intake, with more relevant questions included.
C
Background & Prior Care
Family history, prior providers, and previous testing
Knowing your family history, who you've seen before, and what's already been tested saves time and helps us focus on what hasn't been looked at yet. Fill in as much as you can remember — approximate dates are fine.
Family Health History
1Do any of the following conditions run in your immediate family — parents, siblings, or grandparents? (Check all that apply)
Include conditions even if a family member was only "borderline" or suspected — family patterns matter even without formal diagnosis.
Notes
2Is there a strong family history of early death or serious illness before age 65?
Notes
Personal Health History
3Significant surgeries, hospitalizations, or procedures
Include any surgery under general anesthesia, significant hospitalizations, or major procedures. Date fields appear when you check an item.
Notes
4Birth history — any of the following apply to you?
Early life exposures and birth circumstances have lasting effects on gut microbiome, immune programming, and detox capacity.
Prior Medical Care
5Current primary care physician
6Current specialists you are actively seeing
Check any that apply — name and reason fields appear when you check an item.
Notes
7Have you previously seen a functional medicine or integrative medicine provider?
Prior functional medicine experience
What was evaluated, what labs were run, what protocols were tried, and what happened?
Prior Lab & Diagnostic Testing
8Have you had any of the following tests done? (Check all that apply)
Check what has been done — fields appear to note whether results were normal or abnormal, and when tested.
Notes
9Do you have records, lab results, or reports you can share with Dr. Dudley prior to or at your first visit?
D
Medications & Supplements
Current prescriptions, supplements, and known drug or supplement reactions
Part 1
Medications
1Medications flagged for clinical review — are you currently taking any of the following?
These categories are specifically noted because they can interact with functional medicine protocols, affect lab results, or contribute to symptoms.
2All other current prescription medications
Include blood pressure, diabetes, thyroid, pain, psychiatric, and any prescriptions not listed above
Notes
3Known drug or supplement allergies or adverse reactions
Part 2
Supplementation
4Current supplements, vitamins, and nutraceuticals
Include everything — single ingredients, combination products, protein powders, greens drinks, herbals, enzymes, and homeopathic preparations. Use any or all of the three options below.
Three ways to document your supplements — use any combination:
Option A — Photo: Photograph each label. AI reads it and adds the supplement to Option C automatically.
Option B — Category checklist: Check each category that applies. Dose, timing, and duration fields appear when you check a box.
Option C — Proprietary brands or supplements not listed: Use the Add rows for specialty products, proprietary blends, or anything not covered in the checklist above.
Option A — Photograph supplement labels
Take a photo of each supplement label. AI reads the label and adds it to the list below automatically. No typing needed.
Tap the label area clearly. One bottle at a time works best.
Option B — Category checklist
Check each category that applies — brand, dose, frequency, and duration fields expand when you check a box.
Option C — Proprietary brands or supplements not listed
Use for practitioner brands, proprietary blends, or multi-ingredient formulas — such as Standard Process, Designs for Health, Metagenics, Ortho Molecular, Pure Encapsulations, Xymogen, or Apex Energetics products.
Additional notes on supplements
E
Energy, Tolerance & Readiness
Cellular energy, intervention tolerance, ANS regulation, and healing capacity
Some people feel worse before they feel better when starting a new program — especially if they've been unwell for a long time. These questions help us understand how sensitive your system currently is, so we can pace things in a way that actually works rather than causing setbacks.
Energy & Crash Patterns
1After physical exertion — exercise, yard work, a busy day out — how do you typically feel in the following 24–48 hours?
Answer based on what actually happens, not what you think should happen. This is one of the most important questions in this section.
Notes
2After a mentally demanding day — long meetings, stressful decisions, heavy cognitive work — how do you typically feel afterward?
3Energy pattern throughout the day — which best describes your typical day?
Notes
4Day-to-day consistency — how much does your functioning vary from one day to the next?
Think about the past month. This is different from the within-day pattern above — this asks how predictable one day is compared to the next.
5When you wake up in the morning — before caffeine or food — how do you typically feel?
How you feel first thing in the morning tells us a lot about how well your body recovered overnight.
Temperature Regulation & Circulation
These are easy symptoms to dismiss, but they tell us a lot about how well your nervous system and energy production are working.
5How do you typically feel regarding temperature compared to others around you?
6Hands and feet — how do they typically feel?
7When you stand up quickly from sitting or lying down, do you experience any of the following?
This screens for orthostatic intolerance — a meaningful ANS and cellular energy signal.
Supplement & Medication Tolerance
If your body tends to react strongly to supplements or medications — even ones that seem harmless — that's useful information. It tells us to start gently and build up slowly rather than jumping straight into a full protocol.
8When you start a new supplement, how often do you notice reactions — even mild ones like fatigue, digestive upset, headache, or feeling "off"?
Notes
9Do you react to prescription medications more than most people — unexpected side effects, sensitivity at standard doses, or reactions that your doctor found unusual?
Notes
10Do perfumes, fragrances, cleaning products, or strong chemical smells cause symptoms for you?
11Overall system sensitivity — how easily does your health shift in response to small disruptions?
Think about things like a poor night of sleep, a stressful week, a new supplement, skipping meals, or a change in routine. How much do these affect how you feel overall?
Notes
Genetic & Genomic Testing
Certain gene variants affect how you process nutrients, tolerate supplements, and clear toxins. If you've already had genetic testing done, this helps us avoid approaches that won't work for your biology and focus on what will.
12Have you had any genetic or genomic testing done?
Genetic variants — check any you know about
If you have run your raw data through tools like Genetic Genie, SelfDecode, or StrateGene, check what applies. Plain-language descriptions are provided to help you match your results.
Any other variants you know about, or details about your results
Current Stress Load & Life Capacity
How much change you can realistically take on right now matters. This isn't a judgment — it just helps us recommend things that are actually doable given what else is going on in your life.
12How would you describe your current life stress level overall?
Notes
13How much bandwidth do you realistically have right now for making health changes — new eating habits, new supplements, new routines?
14Do you have reliable support around you — family, partner, or friends — as you go through this process?
Prior Health Program Experience
15Have you tried a structured health or wellness program before — functional medicine, elimination diet, detox, or similar — and had it not work or not stick?
Prior program experience
What did you try, what happened, and what got in the way?
16In your own words — what do you think is the main thing that has prevented you from getting better so far, if anything?
No wrong answers. This helps us understand what you have already figured out about your own situation — and what you haven't been able to figure out yet.
F
Toxic & Environmental Burden
Mold, heavy metals, chemicals, and environmental exposures
Environmental exposures are often the piece that gets missed. Mold, heavy metals, pesticides, and industrial chemicals can quietly drive chronic illness — and because they build up in the body over years, past exposures matter just as much as current ones. Many patients who haven't responded to treatment elsewhere find this section explains a lot. Please answer all items, including past history.
Mold & Water-Damaged Buildings
1Have you ever lived or worked in a building with visible mold, water stains, active leaks, flooding history, or a persistent musty odor?
Notes
2Have you ever noticed that your symptoms specifically developed or worsened after moving into a building, or improved after leaving one?
Water & Air Quality
3Primary drinking water source
4Do you live or work near any of the following? (Check all that apply)
Heavy Metal Exposure
Heavy metals like mercury, lead, and arsenic get stored in tissue and can stay there for decades. Even exposures from 20 years ago can still be contributing to symptoms today.
5Dental amalgam (silver) fillings — current or past
Notes
6High-mercury fish consumption
High-mercury fish: tuna (especially canned albacore), swordfish, shark, king mackerel, tilefish, orange roughy
7Other potential heavy metal exposures — have you had significant exposure to any of the following? (Check all that apply)
Notes
Pesticides, Herbicides & Chemical Exposures
8Pesticide and herbicide exposure — residential or occupational (Check all that apply)
9Occupational chemical or solvent exposure — current or past jobs (Check all that apply)
Include current and past employment — exposures from 20 years ago still matter.
Notes
Household Products & Personal Care
Everyday products — shampoo, lotion, cleaning supplies, cookware — are a surprisingly significant source of ongoing chemical exposure. These add up over years and are worth noting.
10Personal care products — which best describes your typical use?
11Food storage and cookware — which apply to your household? (Check all that apply)
Current Symptoms Associated With Toxic Burden
These symptoms can have many causes, but they're frequently seen in people with a significant toxic load. Rate how much each currently affects you.
12For each symptom below, select the level that best describes your current experience
13Have you ever had heavy metal testing done?
What metals were elevated, what was done about it, and what happened?
G
Diet, Nutrition & Lifestyle Inputs
Food quality, eating patterns, exercise, and daily lifestyle habits
Be honest with these answers — we're not grading you. We need to know what's actually happening right now, not what a healthy day looks like. Your real patterns are what tell us the most.
Overall Diet Pattern
1How would you describe your overall diet pattern?
Notes
Food Quality & Specific Intake
Answer based on what you actually eat, not what you think you should eat. The goal is an accurate picture, not an ideal one.
2How often do meals come from restaurants, fast food, or pre-packaged prepared foods?
3How much of your produce is organic vs. conventional?
4Eating schedule and timing — which best describes your typical pattern?
Glucose & Blood Sugar Patterns
Blood sugar swings affect energy, sleep, mood, and inflammation — even in people without diabetes. These questions help us spot patterns that don't always show up on standard bloodwork.
5Rate each of the following glucose-related symptoms according to how often they affect you
Hydration
6Average daily water intake — not including coffee, tea, juice, or other beverages
Exercise & Physical Movement
7How many days per week do you engage in intentional exercise or physical activity?
8What types of exercise do you typically do? (Check all that apply)
9How do you typically feel after moderate exercise — during or immediately after, and the following day?
10Has your exercise tolerance changed significantly in the past 1–3 years?
Notes
Occupation & Daily Activity Level
11How would you describe your typical daily activity level outside of intentional exercise?
12Current occupation or primary daily role
Sun Exposure
13Average daily sun exposure — skin directly exposed, not through glass or with heavy sunscreen
Substances
These questions are not about judgment — they affect how your body processes everything else and directly inform what we recommend. Answer based on what's actually typical for you.
14Alcohol — how often do you drink?
Notes
15Tobacco — current or past use?
Notes
16Caffeine — typical daily intake
When do you have your last caffeine of the day?
Notes
17Evening wind-down — what does the hour before bed typically look like?
Check all that regularly apply
18Recreational substances — do you currently use any of the following?
This includes cannabis, CBD, and other substances. All answers are confidential and used only to inform your care.
Notes
H
Stress & Psychological Load
Chronic stress, trauma history, and nervous system regulation
Chronic stress does real physical damage — it raises cortisol, disrupts sleep, increases gut permeability, and suppresses immune regulation. For many people, nothing else works until the stress piece is addressed. These questions help us understand how big a factor it is in your situation.
Current Stress Pattern
1How would you describe your current stress level overall?
↩
Carried forward from Section E: Not yet answered — complete Section E first.
Your stress level rating from the readiness section is recorded here. The questions below ask about duration, sources, and control — these are new.
2How long have you been experiencing a significant stress load?
3Primary sources of your current stress — check all that apply
4How much control do you feel you have over your primary stressors?
Feeling like you have no control over a situation is often harder on the body than the stress itself.
Childhood & Early Life Adversity
Difficult experiences in childhood can have lasting effects on how the body handles stress and inflammation. This is well established in the research and doesn't reflect anything about you personally — it's context that helps us understand what we're working with.
5Did you experience significant adversity, instability, or trauma during childhood or adolescence?
Early life adversity — types that apply (check all that apply)
You do not need to share details — checking the category is sufficient for clinical context.
Has this history been addressed in therapy or counseling?
6Significant psychological or traumatic events in adulthood with lasting effects? (Check all that apply)
Date fields appear when you check an item.
Notes
Nervous System & Body-Based Stress Responses
These are physical signs that the nervous system has been in overdrive for a while — not emotional symptoms. Rate how much each currently applies to you.
7Sympathetic (fight-or-flight) activation symptoms — rate each
8Parasympathetic (rest-and-digest) suppression symptoms — rate each
These symptoms suggest the rest-and-digest branch of the nervous system is underactive — the body has difficulty downshifting out of alert mode.
Mood & Anxiety Screening
These are two standard screening questionnaires for depression and anxiety. They're included here because mood significantly affects how the body heals — and vice versa. Over the past 2 weeks, how often have you been bothered by the following?
Mental Health History & Support
9Have you ever been diagnosed with a mental health condition? (Check all that apply)
Include past diagnoses even if you no longer receive treatment for them.
Notes
10Are you currently working with a mental health provider?
Body-Based Stress Patterns
These physical patterns often reflect how the nervous system is handling ongoing stress. They are not emotional symptoms — they are measurable body responses.
11Breathing under stress — which apply to you? (Check all that apply)
↩
Sighing and breathlessness were included in the Sympathetic Activation rating (Q7). These checkboxes capture whether these are stress-specific patterns.
12Muscle tension patterns — check any that regularly apply
↩
Jaw clenching and neck/shoulder tension were also captured in the Sympathetic Activation rating above (Q7). Your ratings there are already recorded — these checkboxes add clinical specificity about which patterns are most consistent.
13Sensory sensitivity — do any of the following bother you more than they seem to bother most people?
14Do you notice physical symptoms in your body when you are emotionally stressed?
For example — gut tightening, chest tightness, headache, fatigue, or other physical responses to emotional events.
Notes
Meaning, Purpose & Social Connection
Sense of purpose and quality of social connection are among the most consistent predictors of health outcomes in the research. These questions help us understand what is supporting you — or what may be missing.
15How would you describe your current sense of purpose or direction in life?
16How satisfied are you with your current work or primary daily role?
17Do you have outlets that give your life meaning outside of work? (Check all that apply)
18Do you have things you are actively working toward or looking forward to?
19Who do you live with?
20How often do you have meaningful in-person contact with people you feel connected to?
I
GI & Digestive Health
Gut function, bowel patterns, digestive history
Gut health affects far more than digestion. When the gut lining is compromised, it can trigger a chain of problems — immune activation, hormone disruption, brain fog, and poor sleep — that don't obviously look like gut issues. Please answer these thoroughly even if your main complaint has nothing to do with your stomach.
Bowel Function
1How many complete bowel movements do you have per week?
A "complete" movement means you feel fully emptied afterward.
Notes
2Stool consistency — which best describes your typical stool?
Think about what is most common for you over the past month.
GI Symptoms
2Past 6 months — check any that apply
Notes
GI History
3History of gut-related conditions or treatments
Date fields appear when you check an item — enter approximate year or age. Links to your health timeline.
Notes
4Antibiotic use in adulthood — how often have you taken antibiotics in the past 10 years?
Frequent antibiotic use disrupts the gut microbiome and is one of the most common contributors to ongoing GI problems.
Notes
Digestive Function Patterns
These questions help narrow down where in the digestive process things are breaking down — low stomach acid, poor enzyme production, or bacterial imbalance each have different patterns and different solutions.
Rate each digestive pattern according to how often it applies to you
J
Food Reactions, Sensitivities & Intolerances
Immediate allergies, delayed sensitivities, and digestive intolerances
Food reactions come in three very different types, and they're treated differently. True allergies (immediate reactions) need strict avoidance. Delayed sensitivities often improve once the gut heals — they may not be permanent. Fermentation intolerances are a microbiome issue, not an immune issue. Knowing which type you're dealing with changes the whole approach.
Type 1 — Immediate Food Allergy (IgE-mediated)
True allergies come on fast — hives, throat tightening, swelling, or anaphylaxis within minutes. These need strict avoidance regardless of gut health.
1Do you have any known immediate food allergies — reactions that happen within minutes of eating?
Which foods, what symptoms, and have you been prescribed an EpiPen?
Type 2 — Delayed Food Sensitivity (IgG-mediated)
Delayed reactions are trickier because symptoms can show up a day or two later — fatigue, brain fog, joint pain, bloating, skin flares. The delay makes them hard to connect to a specific food without doing an elimination trial. These often improve as gut health improves.
2Have you ever noticed that certain foods consistently cause symptoms in the hours or days after eating — even if the timing makes the connection hard to identify?
3Have you ever done a structured elimination diet — removing a specific food completely for 3 or more weeks — and noticed what happened when you reintroduced it?
What did you eliminate, what happened during elimination, and what happened on reintroduction?
4Do any of the following foods consistently cause symptoms for you? (Check all that apply)
Check any food that reliably causes problems — even subtle or delayed ones.
Notes
5Overall food and input reactivity — how would you describe your body's general tolerance?
This is separate from specific food allergies. It asks whether your body feels broadly sensitive — to foods, supplements, medications, or other inputs.
Notes
Type 3 — Fermentation Intolerance (FODMAP / Microbiome)
Fermentation intolerances cause gas, bloating, and bowel changes within a few hours of eating — not an immune reaction, just the wrong bacteria fermenting certain foods. This usually improves when the microbiome is rebalanced.
5Do any of the following foods reliably cause gas, bloating, or digestive distress within 1–3 hours of eating? (Check all that apply)
Specific Digestive Intolerances
6Do milk or dairy products specifically cause digestive problems for you?
7Do greasy or high-fat foods cause digestive upset — nausea, bloating, or loose stools?
Greasy food intolerance can indicate bile insufficiency or gallbladder dysfunction — a different mechanism from other food reactions.
8Have you had any food sensitivity or allergy testing done?
What was tested, what were the findings, and what was done about it?
K
Immune, Infections & Autoimmune
Infection history, immune activation, and autoimmune conditions
Infection History
Unresolved infections and a chronically activated immune system are behind a lot of difficult-to-explain chronic illness. Things like Lyme, EBV, and mold illness can keep the immune system stuck in a low-grade active state for years — affecting hormones, sleep, and brain function along the way. This section helps us understand what your immune system has been dealing with.
1Have you been diagnosed with or treated for any of the following?
Date fields appear when you check an item — enter approximate year or age.
Notes
Immune & Autoimmune History
2History of autoimmune disease?
Date fields appear when you check an item.
Notes
Inflammatory Markers
3Any prior lab testing showing elevated inflammatory markers?
Notes
Immune Resilience & Allergy Burden
4How often do you get sick — colds, infections, or similar illnesses?
When you do get sick, how long does recovery typically take?
5Environmental allergies — do you have known or suspected reactions to any of the following? (Check all that apply)
Notes
6How well do cuts, scrapes, or minor injuries typically heal for you?
L
Hormonal & Endocrine
Thyroid, adrenal, sex hormones, and endocrine history
Hormone problems are often a consequence of something else going on upstream — gut issues, immune activation, or chronic stress that eventually disrupts the whole hormonal system. These questions map out the full picture so nothing gets overlooked.
Part 1
Thyroid
1Have you been diagnosed with a thyroid condition?
2Overactive thyroid functional symptoms — rate each
These may be present even without a formal diagnosis.
3Underactive thyroid functional symptoms — rate each
Part 2
Adrenal & Stress Response
4Adrenal or cortisol-related symptoms — check any that apply
Notes
5High cortisol / adrenal excess symptoms — rate each
6Low cortisol / adrenal insufficiency symptoms — rate each
Part 3
Sex Hormones
This section personalizes based on the birth sex you selected in Section A. If you haven't selected it yet, go back to Section A to set it first.
Part 4
Other Hormonal & Endocrine Diagnoses
These conditions apply regardless of sex. Female-specific and male-specific diagnoses are captured in Part 3 above.
7Any of the following diagnosed? (Check all that apply)
Date fields appear when you check an item.
Notes
M
Sleep & Circadian
Sleep quality, schedule, environment, and circadian regulation
Poor sleep doesn't just make you tired — it makes everything else harder to treat. It raises inflammation, disrupts hormones, impairs blood sugar control, and prevents the brain from clearing waste overnight. Bad sleep can both result from and perpetuate the problems we're trying to fix, so it's one of the first things we look at.
Sleep Quality Rating
Rate each sleep symptom according to how often it currently affects you
Sleep Schedule & Environment
Typical sleep schedule
How consistent is your sleep schedule?
Sleep environment — which apply?
N
Cardiometabolic & Metabolic
Cardiovascular diagnoses, metabolic conditions, and cardiovascular symptoms
Metabolic and cardiovascular problems are often both a result of chronic inflammation and a driver of it — a loop that's hard to break. These questions map your cardiovascular and metabolic history so we can understand where things stand and what we're working against.
Cardiovascular Symptoms
1Any cardiovascular symptoms in the past year? (Check all that apply)
Notes
Cardiovascular History
2Cardiovascular or metabolic diagnoses? (Check all that apply)
Date fields appear when you check an item — links to your health timeline.
Notes
Liver, Kidney & Cancer History
3Liver or gallbladder history — any of the following? (Check all that apply)
Notes
4Kidney history — any of the following? (Check all that apply)
Notes
5Cancer history — personal diagnosis? (Check all that apply)
Include all prior cancer diagnoses, even if fully resolved. This helps us understand immune history and any treatment effects on your current health.
Notes
O
Neurological & Cognitive
Current symptom severity, peripheral neuropathy, headache patterns, and history
Brain fog, memory issues, and mood instability are usually the last thing to show up — the result of years of upstream problems finally reaching the nervous system. Head injuries are included here because even old concussions can keep inflammation going in ways that make everything else harder to treat. This section helps us understand what the brain has been dealing with.
Current Cognitive & Neurological Symptoms
Check any that have been present in the past 3 months. If cognitive concerns are your primary reason for visiting, the condition flag on Section 2 will open a more detailed cognitive evaluation after Section 15.
1Check any that currently apply
Notes
Current Neurological & Cognitive Symptom Severity
Rate each neurological and cognitive symptom according to how much it currently affects you
Sense of smell — has it changed in recent years?
Peripheral neurological symptoms — check any that currently apply
Headache pattern — which best describes your experience?
Notes
Head Injuries & Trauma
1Total number of head injuries causing any of the following: headache, confusion, brief blackout, or memory gap afterward
Notes
2Did any head injury cause loss of consciousness?
Contact Sports & High-Risk Activity
3History of contact sports or high-impact activities? (Check all that apply)
Notes
Other Neurological History
4Any diagnosed neurological conditions? (Check all that apply)
Date fields appear when you check an item.
Notes
Methylation
5Have you had MTHFR genetic testing?
Notes
P
Skin, Hair, MSK & Pain
Symptom severity, skin conditions, joint and muscle health, pain patterns
Skin, hair, and joint problems are rarely just local issues. Rashes, hair loss, and joint inflammation often reflect what's going on deeper — gut health, immune activity, thyroid function, and nutrient status can all show up on the surface first. These symptoms are worth taking seriously as clues.
Current Symptom Severity Rating
Rate each skin, hair, MSK, and pain symptom according to how much it currently affects you
Skin & Hair Symptoms
1Check any skin, hair, or nail symptoms present in the past 3 months
Duration and medication fields appear when you check an item.
Notes
2Are skin or hair symptoms triggered or worsened by any of the following?
Check all that apply
Musculoskeletal & Pain Symptoms
3Check any additional joint, muscle, or pain symptoms present in the past 3 months
The rating grid above covers joint pain, muscle pain, and back pain. Check here for any of the following that also apply.
If your concern includes tremor, stiffness related to movement, or balance issues — those questions are in a dedicated Movement Assessment section that opens when you select movement concerns on page 2.
Notes
4Pain or stiffness pattern — which best describes it?
Timing and triggers point to different mechanisms: morning stiffness that improves with movement = inflammatory; worsens with activity = structural; constant regardless of position = central sensitization.
Notes
Skin, Hair & MSK History
Note: Autoimmune skin and joint conditions — rheumatoid arthritis, psoriatic arthritis, lupus, and psoriasis — are captured with full detail and timeline dates in Section 4 — Infections & Immune. Use the list below for additional skin and MSK diagnoses not covered there.
5Any of the following diagnosed? (Check all that apply)
Date fields appear when you check an item — enter approximate year or age. Links to your health timeline.
Notes
Joint Laxity & Connective Tissue
6Do any of the following apply to you? (Check all that apply)
These patterns suggest connective tissue laxity, which affects joint stability, injury risk, and healing response.
Notes
Spinal History
Spinal and nerve history is directly relevant to your care here. Please be as specific as you can — imaging findings, prior treatment, and current symptoms all matter.
7Spinal diagnoses or findings — check any that apply
Notes
8Prior chiropractic care
Notes
Lymphatic Symptoms
9Do you notice any of the following? (Check all that apply)
Q
Health Timeline
Your chronological health story — diagnoses, events, injuries, and turning points
List significant health events in chronological order — diagnoses, injuries, infections, surgeries, medications, major stressors, and the first appearance of key symptoms. Approximate dates are fine. Items checked in earlier sections with a date will automatically appear here.
Health Timeline
This section generates your personal health timeline graphic. List major events in chronological order — diagnoses, injuries, infections, surgeries, medications, stressors, and first appearance of key symptoms. Approximate dates are fine. Add as many events as relevant.

Note: Items you checked in earlier sections with a year or age will automatically appear here. Add anything additional below.
NC1
Cognitive & Memory Assessment Neuro Module
Cognitive driver mapping — memory, language, orientation, function, staging, and metabolic framing
Cognitive subtype model — Cognitive Driver Assessment. Each question maps to a physiologic driver type (tagged inline). Answer based on the past 6 months unless noted. These questions are specific to cognitive and memory concerns — movement symptoms are on the next page.
Subjective Decline — Anchor Question
1Compared to 5 years ago, how is your thinking and memory today? All Drivers
This anchors clinical staging from SCI → MCI → concern. Answer based on your own perception, not what others have said.
Notes
2When did you first notice cognitive changes?
3Since first noticed, symptoms have been:
3bDid cognitive symptoms begin or noticeably worsen after a specific event? Type 4
Notes
Cognitive Stage — Your Best Assessment
4Which description best matches your current situation?
🔍
SCI
I notice changes but testing is likely normal — Subjective Cognitive Impairment
⚠️
MCI
Noticeable to others, still fully independent — Mild Cognitive Impairment
🚨
Greater concern
I need help with things I previously handled independently
Notes
Memory — how often does each occur?  0 = Never  ·  1 = Occasionally  ·  2 = Weekly  ·  3 = Daily
Notes — Memory
Language and Communication
Notes — Language
Orientation and Navigation
Notes — Orientation
Daily Activities — Independence  0 = Fully independent  ·  1 = Some help  ·  2 = Regular help  ·  3 = No longer doing this
Notes — Daily Activities
Lewy Body & Differential Screens
5Within a single day, does thinking clarity shift dramatically — clearheaded in the morning but confused by afternoon, then clearer again by evening? Lewy Body Screen
This asks about sharp swings within hours — different from having good days and bad days overall.
Notes
6Have you seen things — people, animals, or objects — that others in the room did not see? Lewy Body Screen
Visual hallucinations are a specific feature of Lewy body dementia, distinct from ordinary misperceptions or poor eyesight.
Notes
7Are cognitive symptoms noticeably worse at a particular time of day?
8Personality or behavioral changes in the past 2 years? (Check all that apply) Frontal / Behavioral
Notes
9Have family members or friends noticed changes that you yourself may not have noticed?
Notes
Metabolic — Brain-Specific Indicators Glycotoxic Type 2
Type 2 — Glycotoxic. Insulin resistance is one of the most common and reversible drivers of cognitive decline. These questions extend the cardiometabolic data from Section 7 with brain-specific framing.
10Within 90 minutes after eating, do you feel sleepy, foggy, or unable to concentrate?
Post-meal cognitive fog is a specific signal of glucose-driven neuroinflammation and impaired brain insulin signaling.
Notes
11Are you following a low-glycemic or ketogenic diet specifically for brain health?
Notes
12Do you practice time-restricted eating or intermittent fasting?
Eating within a 10–12 hour window improves insulin sensitivity, reduces neuroinflammation, and supports glymphatic clearance — core metabolic interventions.
Notes
Cognitive Reserve & Sensory Health Neuroplasticity
Mental stimulation matters. Keeping the brain actively engaged is one of the most powerful things you can do to protect cognitive function. Passive activities like watching TV or scrolling don't provide the same benefit as learning, creating, or problem-solving.
13How do you primarily engage your mind on a typical week? (Check all that apply)
Notes
14Has hearing declined — needing higher TV volume, frequently asking people to repeat, or using hearing aids? Sensory / Neuro Risk
Hearing loss is an independent risk factor for cognitive decline and dopaminergic neurodegeneration.
15Estimated average daily protein intake Trophic
3 oz chicken ≈ 25g  ·  1 egg ≈ 6g  ·  ½ cup Greek yogurt ≈ 10g  ·  1 cup lentils ≈ 18g. Amino acid deficiency impairs neurotransmitter synthesis.
Notes
16How many servings of fatty fish (salmon, sardines, mackerel, herring, trout) per week? Trophic
1 serving = 3–4 oz. Omega-3 DHA is a primary structural component of brain cell membranes.
Notes
Sleep — Neurologic Extension Glymphatic / Circadian
Sleep is when the brain clears amyloid and tau via the glymphatic system. Untreated sleep apnea severely impairs this clearance. REM Sleep Behavior Disorder is one of the strongest predictors of Parkinson disease and Lewy body dementia — often appearing 10–20 years before motor symptoms.
17During sleep, have you moved, spoken, shouted, swung your arms, kicked, or physically acted out dream content? REM BD / PD Prodromal
In REM Sleep Behavior Disorder (RBD), normal sleep paralysis fails and the person acts out dreams. This is a highly specific early marker of Parkinson disease and Lewy body dementia.
Notes
18If diagnosed with sleep apnea, how consistently are you using your treatment device? Vascular / Glymphatic
Notes
18bDo you have difficulty distinguishing shades of the same color, or reading low-contrast text (such as light gray on white)? Type 4 / Biotoxin
Visual contrast sensitivity problems are a screening sign for biotoxin illness, mold-related cognitive impact, and CIRS. This is a separate issue from glasses prescription or near/farsightedness.
19Sleep environment and timing habits
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Covered in the Sleep & Circadian section.
Your sleep environment answers are already recorded. The items most relevant to neurological health — screen exposure, morning light, and sleep consistency — are carried forward automatically from your sleep section responses.
NC2
Parkinson & Movement Disorder Assessment Neuro Module
Motor symptoms, prodromal indicators, autonomic function, and caregiver observations
Prodromal Parkinson features precede motor symptoms by 10–20 years. Loss of smell, constipation, REM behavior, and early depression are the four strongest early markers — and were asked in earlier sections. Your responses are already recorded. This section focuses on motor symptoms, autonomic features, and clarifying observations.
Motor Symptoms
1Shaking, trembling, or tremor in a hand, finger, arm, or leg? Motor — Parkinson
Notes
2Stiffness or rigidity in arms, legs, or neck? Rigidity
Notes
3Do you feel slower overall — longer to get started, turn around, or complete movements that used to feel effortless? Bradykinesia
4Changes in walking pattern? (Check all that apply) Gait
Notes
5Falls or balance problems in the past 12 months
Notes
Fine Motor Function  0 = Never  ·  1 = Occasionally  ·  2 = Frequently  ·  3 = Almost always
Notes — Fine Motor
6Has handwriting become smaller or harder to read? Micrographia
7Voice changes? (Check all that apply) Hypophonia
8Have others commented that your face appears less animated or expressionless? Hypomimia
9Do motor symptoms fluctuate noticeably throughout the day? Motor Fluctuation
Fluctuating symptoms can indicate medication timing effects (Parkinson's) or Lewy body dementia.
Notes
Drug-Induced Parkinsonism — Commonly Missed. Certain medications block dopamine receptors and can cause or worsen tremor, stiffness, and slowed movement even in people who do not have Parkinson's disease. This is one of the most commonly missed diagnoses in movement disorders.
10Have you ever taken dopamine-blocking medications? Drug-Induced Parkinsonism
Examples: Haldol, Risperdal, Zyprexa, Seroquel, Reglan (metoclopramide), Compazine (prochlorperazine), some older antidepressants
List the dopamine-blocking medication(s)
Medication name
Duration taken
Notes
11Reflecting on those four prodromal indicators, how many apply to you?
Notes
Autonomic Nervous System Autonomic
Autonomic dysfunction is an early and consistent feature of both Parkinson disease and Lewy body dementia — often appearing before motor symptoms. It reflects early brainstem changes associated with alpha-synuclein accumulation.
12When standing up quickly, do you feel lightheaded, dizzy, or nearly faint? Orthostatic Hypotension
Orthostatic hypotension — blood pressure not rising quickly enough on standing — is a common autonomic feature of Parkinson disease.
Notes
13Urinary urgency — a sudden strong need to urinate that is difficult to delay? Autonomic — Bladder
Notes
14Unusual sweating patterns? (Check all that apply) Autonomic — Thermoregulation
15Increased oiliness or greasiness on face, forehead, or scalp? Seborrhea — Autonomic
Seborrheic dermatitis — flaky, oily skin on the scalp and face — is a common but little-known feature of Parkinson disease.
16Difficulty swallowing food or liquid, or choking while eating? Dysphagia
Notes
NC3
Caregiver Report, Prior Testing & Goals Neuro Module
Family observations, what has already been evaluated, and your goals for this visit
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To the Family Member or Caregiver
Patients with cognitive concerns often underreport symptoms — not out of deception, but because the nature of cognitive impairment affects self-awareness of deficits. Your observations are often more clinically accurate than the patient's self-report.

If you are the patient completing this alone, skip to "Prior Testing" below and check "Form completed by patient only."
Who is completing this section?
Memory and Cognition — Caregiver Report
1Does the patient repeat the same question or story within a single conversation?
2Has the patient become lost while driving or navigating a familiar area?
3Personality or behavioral changes noticed in the past 2 years? (Check all that apply)
Notes
4Has the patient had difficulty managing medications, bills, or finances they previously handled independently?
5How does the patient's thinking and alertness vary throughout the day?
Notes
6Additional observations for Dr. Dudley not captured elsewhere in this form
Prior Cognitive or Neurological Testing
Knowing what has already been evaluated prevents duplicate testing and identifies gaps. Even "normal" prior results are worth recording — functional medicine reference ranges often differ from conventional ranges.
7Cognitive assessments completed? (Check all that apply)
Notes
Haven't taken the MoCA XpressO yet? It's a free, self-administered memory screen from the makers of the MoCA test, takes about 5–7 minutes on a phone, tablet, or computer, no prior account needed to register. It's a pre-screening tool, not a diagnosis, bring your score to your visit and we'll go over it together. Take the MoCA XpressO test →
8Brain imaging history (Check all that apply)
Notes
9Genetic testing done? (Check all that apply)
Notes
If homocysteine has been tested, what was your result? Type 3 / Methylation
Homocysteine above 7 µmol/L accelerates brain atrophy. Above 14 is a significant risk factor for cognitive decline. This is one of the most modifiable cognitive risk factors — lowered with B12, folate, and B6.
10Specialists seen for these concerns? (Check all that apply)
Notes
11Interventions already tried? (Check all that apply)
Notes
Your Goals for This Evaluation
12What are the most important outcomes you hope to achieve from this evaluation?
13Anything else Dr. Dudley should know that was not covered in this form?
✓
Your Health Pattern — Summary
How your answers map to the biology of your situation
This is not a diagnosis. What you see below is a pattern map — a picture of which biological systems your answers have activated, organized by how they relate to each other. Dr. Dudley will review this alongside the full detail of your responses before your first visit. It is meant to help you see your health as a connected picture rather than a list of separate problems.
Generating your pattern summary…
What happens next
Dr. Dudley will review your complete intake before your first visit and use it to prepare a personalized assessment. The pattern you see above will be one of the first things discussed — connecting your symptoms to the upstream biology and mapping out a sequenced plan for addressing them in the right order.

Please proceed to the Consent & Signature page to complete your intake.
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Consent & Signature
Informed consent and electronic signature
Save your copy first
Download a copy of your completed intake for your records before signing and submitting.
Please read the following consent carefully before signing.

Consent and Authorization for Functional Medicine and Nutritional Services

I understand that the services provided by Dudley Chiropractic, Acupuncture and Functional Medicine are intended to support optimal health and wellness through evidence-based functional medicine approaches including nutritional counseling, lifestyle modification, and laboratory testing interpretation.

I understand that these services are not a substitute for emergency medical care, and that I should seek emergency services for any acute medical emergency. I understand that functional medicine evaluation and recommendations are intended to complement, not replace, care provided by my primary care physician or specialist.

I authorize the release of information from this intake form to be used in the evaluation and development of my health plan. I understand that my responses will be kept confidential in accordance with HIPAA regulations.

Release and Acknowledgment

I hereby release John Dudley, D.C., and Dudley Chiropractic and Acupuncture from any liability for results stemming from my implementation of the health strategies discussed. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the nature, purpose, and limitations of the services provided.

Electronic Signature
By typing your name above and checking both boxes, you are providing a legally valid electronic signature under the Electronic Signatures in Global and National Commerce Act (ESIGN Act).

Thank you — your intake is complete

Your health history has been received by Dudley Chiropractic, Acupuncture and Functional Medicine. Dr. Dudley will review your responses before your appointment.

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One more thing: a 4-day food log
Takes about 10 minutes. Best done before your first visit.

What you eat and how your body responds to it is one of the most useful things we can know going into your first visit. A brief food log covering 4 typical days gives us a much clearer picture than general questions can. We've sent it to the email you provided so you can complete it whenever it's convenient, including on your phone.

Sends to the email you provided in Section A
You can safely close this window. If you have questions before your visit, please contact the practice directly.