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    How did you hear about us?

    General Information

    First Name

    Middle Name

    Last Name

    Date of Birth

    SSN #



    Marital Status

    Street Address

    Street Address Line 2


    State / Province

    Postal / Zip Code

    Home Phone Number

    Cell Phone Number



    Work Phone Number

    Emergency Contact

    Emergency Contact Number

    Relation to patient



    Major Complaint

    Referred by

    Responsible Party

    First Name

    Middle Name

    Last Name

    Date of Birth

    SSN #

    Street Address

    Street Address Line 2


    State / Province

    Postal / Zip Code

    Home Phone Number

    Cell Phone Number

    Drivers License # and State


    Work Phone Number

    Parent/Guardian Signature

    Health History

    Present Height

    Present Weight

    Minimum Adult Weight

    Maximum Adult Weight

    Ideal Weight (if applicable)

    Family History

    Has anyone in your family had any of the following? If positive, indicate mother/father/brother/sister/child/maternal/paternal




    Heart Disease




    Have you had any of the following?


    If so, when?



    Serious Illness not needing hospitalizations (include reasons, diagnosis, and date)

    Are you presently undergoing treatment for emotional or psychological problems?

    Have you ever been hospitalized for psychological problems?


    Please select Yes or No

    Frequent or constant headache

    Fainting spells, convulsions


    Loss of Hearing

    Change of Vision

    Dental Trouble

    Bleeding Gums

    Lumps on the Neck


    Please select Yes or No

    Chest Pain

    Shortness of Breath

    Chronic Cough


    Cramps in Legs

    Varicose Veins

    Phlebitis (inflamed leg veins)

    Swelling of Legs/Ankles

    Rapid/Irregular Heartbeat



    Please select Yes or No

    Indigestion or Heartburn


    Vomiting Blood

    Pain/Abdominal Cramps


    Black Diarrhea

    Bloody Diarrhea


    Average number of bowel movements per day

    Average number of bowel movements per week


    Daytime sleepiness


    Normal sleep (average 6-8 hours)

    Always hot

    Always cold

    Excessive Hair

    Loss of Hair

    Skin Texture (problems)

    Have you ever had a reaction to any of the following:

    Milk or dairy products


    Drugs or Medications


    Physical Activity

    Do you consider yourself an active person?

    Do you walk a mile or more per day?

    Do you exercise on a regular basis?

    If so, what type?

    How often?





    Frequent Night Time Urination

    Reproduction (men only)


    Reproduction (women only)

    Menstrual discharge

    Pain during intercourse

    Normal cycle

    Vaginal dryness

    Unusual complications

    Lumps on breast

    Discharge from nipple

    Excessive discomfort

    Last Menstrual Date

    Last Gynecological Exam


    Full Term Live







    Joint Pain

    Back Pain



    Do you ever use the following?







    Do you have diabetes?

    If so, for how long?

    Do you check your blood sugar?

    How often?

    Do you take insulin?

    Do you take medications?

    Do you have numbness, tingling, or burning in feet?

    Do you ever have hypoglycemia or low blood sugars (less than 70)?

    How often? ___/week?

    How do you treat?


    Do you have any allergies?


    Please list current medications and dosage

    Dr. Diet Psychological Profile

    (Score as pertains to most days)

    Depression (1 is Never, 10 is Suicidal Thoughts)

    Anxiety (1 is Never, 10 is Constant)

    Joy (1 is Never, 10 is Always)

    Motivation/Energy (1 is None, 10 is High)

    Libido (sex drive) (1 is None, 10 is High)

    Sleep (1 is Never sleep well, 10 is Perfect sleep)

    Eating Inventory

    (for patients interested in nutrition therapy)

    CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger

    Each feeling represents a different part of the brain and different neurotransmitters.

    Compulsions/Cravings – A feeling or urge to eat when not hungry, often associated with other emotions such as “stress eating”. You want food. There is no food in sight. You get an urge to eat which cannot be repressed. (1 is Never Occurs, 10 is Constant)

    Appetite – A feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room and there is food everywhere. It looks and smells good, and everyone is having fun. You: (1 is Never Eat, 10 is Always Eat)

    Satiety – A feeling of fullness acquired during eating. When you eat you usually: (1 is One Plate Always, 10 is Second or third servings)

    Hunger – That feeling of a true pain or ache in your stomach when really empty. This is a true pain or discomfort. (1 is Never Hungry, 10 is Constantly Hungry)

    Mood Disorder Questionnaire

    Has there ever been a period of time when you were not your usual self and…

    …you felt so good or so hyper that other people thought you were not your normal self or you were so hyper you got in trouble?

    …you were so irritable that you shouted at people or started fights or arguments?

    …you felt much more self-confident than usual?

    …you got much less sleep than usual and found that you didn’t really miss it?

    …you were more talkative or spoke much faster than usual?

    …your thoughts raced through your head and you couldn’t slow your mind down?

    …you were so easily distracted by things around you that you had trouble concentrating or staying on track?

    …you had much more energy than usual?

    …you were much more active or did many more things than usual?

    …you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

    …you were much more interested in sex than usual?

    …you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

    …your spending money got you or your family in trouble?

    If you checked YES to more than one fo the above, have several of these every happened during the same period of time?

    How much of a problem did any of these cause you- like being able to work; having family, money, or legal trouble; getting into arguments or fights? (1 is No Problem, 5 is Serious Problem)

    Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had a manic-depressive illness or bipolar disorder?

    Has a health professional ever told you that you have a manic-depressive illness or bipolar disorder?

    Signature of Patient

    Symptom Score Sheet

    Please rate your symptoms below

    Heartburn (1 is None, 10 is Severe/Constant)

    Back Pain (1 is None, 10 is Severe/Constant)

    Joint Pain (Knee/hip/feet) (1 is None, 10 is Severe/Constant)

    Difficulty Breathing (1 is None, 10 is Severe/Constant)

    Depression (1 is None, 10 is Severe/Thoughts of suicide)

    Tiredness/Fatigue (1 is None, 10 is Severe/Constant)

    Headache (1 is None/Rare, 10 is Severe/Daily)

    Insomnia/Difficulty Sleeping (1 is Perfect Sleep, 10 is Never Sleep Well)

    Happiness (1 is Never Happy, 10 is Always Happy)

    Signature of Patient

    ADD Screening Questionnaire

    ***Patient privacy disclaimer*** The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for the use of Stanford Owen, M.D. If the content of this form reaches you and you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. If you have received this transmission in error, please notify us immediately at (228) 864-9669 or drowenmd@drdiet.com.

    Patient Instructions:

    Please rate yourself on each of the symptoms listed below using the following scale. For completeness, some questions will be asked more than once.

    If possible, to give us the most complete picture, have another person who knows you well (such as a spouse, partner, or parent) rate you too. Their answer can go below (under OTHER) in the form of a number.

    First Name

    Last Name

    Street Address

    Street Address Line 2


    State / Province

    Postal / Zip Code

    Phone Number


    1. Fail to pay close attention to details or make careless mistakes

    2. Trouble sustaining attention

    3. Do not seem to listen when spoken to directly

    4. Poor follow through

    5. Disorganized

    6. Avoid tasks that require sustained effort

    7. Lose things

    8. Easily distracted

    9. Forgetful checkbox q-9 “0 – Never” “1 – Rarely” “2 – Occasionally” “3- Frequently” “4 – Very Frequently” “N/A – Not Applicable”]


    Highly probable —– 6 questions with 3 or 4
    Probable —– 4 questions with 3 or 4
    May be possible —– 3 questions with 3 or 4

    10. Fidgety

    11. Trouble sitting still

    12. Restless

    13. Unable to play or engage in leisure activities quietly

    14. “On the go” or acting as if “driven by a motor”

    15. Talks excessively

    16. Blurt out answers before questions have been completed ( e.g., complete people’s sentences; cannot wait for turn in conversation)

    17. Difficulty waiting (e.g., waiting in line)

    18. Interrupts others


    Highly probable —– 6 questions with 3 or 4

    Probable —– 4 questions with 3 or 4

    May be possible —– 3 questions with 3 or 4

    19. Make decisions or behave impulsively (saying or doing things without thinking)

    20. Difficulty delaying what I want

    21. Accident prone, traffic violations or near accidents

    IMPULSIVITY SYMPTOMS: Questions 16 – 21

    Highly probable —– 6 questions with 3 or 4

    Probable —– 4 questions with 3 or 4

    May be possible —– 3 questions with 3 or 4

    22. Overwhelmed by the tasks of everyday life

    23. Difficulty expressing feelings

    24. Difficulty expressing empathy for others

    25. Late or in a hurry


    Highly probable —– 6 questions with 3 or 4

    Probable —– 4 questions with 3 or 4

    May be possible —– 3 questions with 3 or 4

    26. Get stuck on negative thoughts or behaviors

    27. Recurrent bothersome thoughts or images I try to ignore

    28. Compulsive behaviors (such as excessive hand washing, checking locks, counting, or spelling) to avoid feeling anxious

    29. Worry

    30. Upset when things do not go my way

    31. Upset when things are out of place

    32. Oppositional or argumentative

    33. Dislike change

    34. Hold grudges

    35. Hold onto own opinion and do not seem to listen to others

    36. Tend to say no without first thinking about the question

    37. Need to be perfect

    OVERFOCUSED SYMPTOMS: Questions 26 – 37

    Highly probable —– 8 questions with 3 or 4
    Probable —– 6 questions with 3 or 4
    May be possible —– 4 questions with 3 or 4

    38. Depressed or sad mood

    39. Crying spells

    40. Negativity

    41. Decreased interest in people or pleasurable activities

    42. Feel worthless helpless, hopeless, or guilty

    43. Fatigue, feeling tired, or lack of energy

    44. Decreased concentration or memory

    45. Recurrent thoughts of death or suicide

    46. Insomnia or trouble sleeping

    47. Excessive sleeping

    48. Irritable or easily agitated

    49. Recent decrease in appetite or weight

    50. Recent increase in appetite or weight


    Highly probable —– 7 questions with 3 or 4
    Probable —– 5 questions with 3 or 4
    May be possible —– 4 questions with 3 or 4

    51. Significant mood swings or cycles

    52. Periods of an elevated, high, or irritable mood

    53. Periods of very high self-esteem or grandiose thinking

    54. Periods of decreased need for sleep without feeling tired

    55. Periods of being more talkative than usual or feeling pressure to keep talking

    56. Racing thoughts or frequently jumping from one subject to another

    57. Easily distracted by irrelevant things

    58. Feel a marked increase in physical activity level

    59. Excessive involvement in pleasurable activities that have a high risk for negative consequences (e.g., spending money, sexual indiscretions, or gambling)

    60. Anxious, tense, or nervous

    61. Panic attacks, which are periods of intense, unexpected fear or emotional discomfort

    62. Fear of dying

    63. Fear of going crazy or doing something out-of-control

    64. Predict the worst

    65. Avoid conflict

    66. Excessive motivation or can’t stop working

    67. Freeze in anxious or upsetting situations

    68. Shy or timid

    69. Easily embarrassed

    70. Sensitive to criticism

    71. Bites fingernails or picks at skin

    72. Lack of confidence in abilities

    73. Need a lot of reassurance


    Highly probable —– 6 questions with 3 or 4
    Probable —– 4 questions with 3 or 4
    May be possible —– 3 questions with 3 or 4

    74. Avoid everyday places for 1) fear of having a panic attack or 2) needing to go with other people in order to feel comfortable

    75. Recurrent and upsetting thoughts of a past traumatic event (molestation, accident, fire, etc..)

    76. Recurrent distressing dreams of a past upsetting event

    77. Reliving a past upsetting event

    78. Panic or fear of events that resemble an upsetting past event

    79. Spend effort avoiding thoughts or feelings associated with past trauma

    80. Avoid activities/situations which remind me of past upsetting events

    81. Unable to recall an important aspect of a past upsetting event

    82. Avoid activities/situations which remind me of a past upsetting event

    83. Feel numb or restricted in my feelings

    84. Feel that my future is shortened

    85. Quick to startle

    86. Watch for bad things to happen

    87. Have a physical response to events that remind me of a past upsetting event (e.g., sweating, increased pulse, etc… when getting in a car if you have been in a car accident)

    88. Excessive fear of being judged by others, which causes me to avoid or get anxious in situations

    89. Persistent, excessive phobia (heights, closed spaces, specific animals, etc…)

    90. Involuntary physical movements and/or motor tics (such as eye blinking, shoulder shrugging, head jerking, or picking)

    91. Involuntary vocal sounds or verbal tics (such as coughing, puffing, blowing, whistling, or swearing)

    92. Stutter

    93. Refuse to maintain body weight above a level that most people consider healthy

    94. Intense fear of gaining weight or becoming overweight even though I am underweight

    95. Feel overweight, even though others say I am underweight

    96. Have recurrent episodes of binge eating large amounts of food

    97. Feel a lack of control over eating behavior

    98. Purge food, such as self-induced vomiting or using laxatives or diuretics; partaking in strict dieting, or partaking in strenuous exercise

    99. Overly concerned with my body shape and/or weight

    100. Unpredictable moods

    101. Irritability, short fuse, or easily angered

    102. Misinterpret comments as negative when they are not

    103. Experience illusions, such as hearing sounds that are not there (e.g., muffled voices or shots being fired); visual distortions (e.g., seeing shadows or things get bigger or smaller than they really are); or smelling odors that are not present (e.g., burned rubber)

    104. Periods of deja vu (the feeling of being somewhere you have never been)

    105. Dark, disturbing, or troubling thoughts

    TEMPORAL LOBE SYMPTOMS (TLS) PURE: Questions 100 – 105

    Highly probable —– 4 questions with 3 or 4
    Probable —– 3 questions with 3 or 4
    May be possible —– 2 questions with 3 or 4

    106. Trouble reading the body language or facial expression of others

    107. Trouble learning new information

    108. Memory problems

    109. Trouble remembering recent events

    110. Difficulty memorizing things for school or work


    Highly probable —– 4 questions with 3 or 4
    Probable —– 3 questions with 3 or 4
    May be possible —– 2 questions with 3 or 4

    111. Delusional or bizarre thoughts (thoughts I know others would think are false)

    112. Auditory or visual hallucinations

    113. Periods of time where my thoughts or speech were disjointed or didn’t make sense to others

    114. Impaired ability to function at home or at work

    115. Lack personal hygiene

    116. Exhibit inappropriate mood for a given situation (e.g., laughing at sad events)

    117. Frequent feelings that someone or something is out to hurt or discredit me

    118. Am a poor reader

    119. Make mistakes when reading, such as skipping words or lines

    120. Have problems remembering what I read even though I have just read all the words

    121. Reverse or switch letters when I read (such as b/d, p/q)

    122. Light sensitive and bothered by glare, sunlight, headlights, or streetlights

    123. Become tired or experience headaches, mood changes, restlessness, or have an inability to stay focused with bright or fluorescent lights

    124. Have trouble reading words that are on white, glossy paper

    125. When reading, words or letters shift, shake, blur, move, run together, disappear, or become difficult to perceive

    126. Tense, tired, sleepy, or even get headaches when reading

    127. Problems judging distance and have difficulty with such things as escalators, stairs, ball sports, or driving

    128. Poor handwriting or prefer to print rather than to write in cursive

    129. Trouble getting thoughts from brain to my paper

    130. Tend to keep notebook/paperwork/room messy or disorganized

    131. Frequently late or in a hurry

    132. Clumsy

    133. More sensitive to lights, sounds or smells than others

    134. Sensitive to touch or tags in clothing

    135. Few or no friends

    136. Feel uncomfortable around people whom I do not know well

    137. Teased by others

    138. Friends do not call and ask me to do things with them

    139. Trouble with communication by at least one of the following (please select all that apply)

    140. Trouble with social interaction by at least two of the following (please select all that apply)

    141. Exhibit repetitive patterns of behavior, interests, and activities by at least one of the following (please select all that apply)

    142. Trouble getting or staying asleep

    143. Restless sleep

    144. Worry I won’t be able to fall asleep

    145. Early morning awakenings with trouble getting back to sleep

    146. Wake up tired and unrefreshed

    147. Nightmares

    148. Loud snoring

    149. Other say I stop breathing during sleep

    150. Get more than 7 hours of sleep at night

    151. Crave sweets during the day

    152. Irritable or easily upset if meals are missed

    153. Depend on caffeine to get started or keep me going

    154. Get lightheaded or shaky if meals are missed

    155. Eating relieves fatigue

    156. Put myself at risk for brain injuries by doing thing such as not wearing my seat belt, drinking and driving, engaging in high risk sports, etc..

    157. Chronic stress at work or home

    158. Thoughts tend to be negative, worried, or angry

    159. Problems getting at least 8 hours of sleep per night

    160. Drink or consume more than 2 cups of coffee, dark sodas, or energy drinks a day

    161. Consume food or drinks with artificial sweeteners or colors

    162. Am regularly around environmental toxins such as paint fumes, hair or nail salon fumes, or pesticides

    163. Spend more than one hour a day watching TV

    164. Spend more than one hour a playing video games

    165. Outside of school or work time, spend more than one hour a day on the computer

    166. Tend to have a poor and haphazard diet

    167. Exercise less than twice per week

    168. Have more than 3 normal-sized drinks of alcohol per week

    169. I smoke or am exposed to secondhand smoke

    170. I have one family member with Alzheimer’s disease or dementia

    171. I have more than one family member with Alzheimer’s disease or dementia

    172. I have a past brain injury

    173. I presently have or have had issues with alcohol dependence or drug dependence in past

    174. I have obesity or metabolic syndrome (obesity, hypertension, diabetes)

    175. I have cardiovascular disease, including heart arrhythmia or heart attack

    176. I have high blood pressure

    177. I have a past stroke

    178. I have diabetes

    179. I have a history of cancer or cancer treatment

    180. I presently have seizures or have had seizures in the past

    181. I have less than a high school education

    182. My job does not require new learning

    183. I have been diagnosed with sleep apnea

    184. I have a past or present diagnosis of depression

    185. I have had a diagnosis of attention deficit hyperactivity disorder

    186. I have been diagnosed with Parkinson’s disease

    187. I have had periodontal or gum disease

    188. I tend to have a poor and haphazard diet

    189. I exercise less than twice a week

    Signature of Patient

    Once you have submitted this form, someone from our office will be contacting you to schedule your initial appointment. What is the BEST way to reach you?