Cola Clinic Intake - Cola Clinic

Share your symptoms, health concerns and usual food choices with Dr. Mark Colafranceschi.

Intake and recommendations: $120. This form does not collect payment. Contact Cola Clinic at 480-210-2345 for payment arrangements.

Nutrition guidance and chiropractic care are available independently. Choose the care that fits your needs.

Your details

Full name (required)Email (required)Cell phone (required)AgeDate of birth

Symptom survey

Choose 1 for mild symptoms (once or twice a year), 2 for moderate symptoms (several times a year), 3 for severe symptoms (almost constantly), or P for symptoms experienced in the past. Leave blank if not applicable. Open each section to respond.

The headings organize your responses; they do not establish a diagnosis. For chest pain, severe breathing difficulty or another medical emergency, call 911 rather than use this form.

Adrenal - Fatigue

Weakness, Dizziness upon rising
Fatigue
Low blood pressure
Nail weak or ridged
Tendency to hives
Arthritic Tendency
Perspiration increase
Bowel Disorder
Poor Circulation
Swollen Ankles
Crave Salt
Crave Sugar
Light sensitivity – need sunglasses
Hot Flashes
Loss of bodily hair
Skin discoloration
Brown spots or bronzing of skin
Allergies, tendency to asthma
Weakness after colds, influenza
Exhaustion, muscular or nervous
Respiratory disorder. (i.e, Asthma)

Anxiety - Sympathetic

Acid foods upset
Get chilled often
“Lump” in throat
Dry mouth-eyes-nose
Pulse speeds after meals
Keyed up; fail to calm
Cuts heal slowly
Gag easily
Unable to relax/ Tense Muscles
Excessive Worrying
Feeling Agitated
Restlessness
Excessive Fatigue
Difficulty Concentrating on task
Irritability
Insomnia Falling or Staying Asleep
Panic Attacks
Avoiding Social Situations
Irrational Fears
Extremities cold clammy
Strong light irritates
Urine amounts reduced
Heart pounds after eating
Nervous stomach
Appetite reduced
Cold sweats often
Fever easily raised
Neuralgia-like pains
Staring, blinks little

Digestion – Parasympathetic

Sour stomach frequent
Joint stiffness after arising
Muscle leg toe cramps at night
“Butterflies” in stomach
Eyes or nose watery
Eyes Blink Often
Eyelids Swollen
Indigestion soon after meals
Always feels hungry. Lightheaded Often
Digestion Rapid
Vomiting frequent
Hoarseness frequent
Breathing Irregular
Pulse Slow. Feels irregular
Gagging reflex slow
Difficulty Swallowing
Constipation/ Diarrhea alternating
“Slow Starter”
Get Chilled frequently
Perspire easily
Circulation Poor, sensitive to cold
Subject to colds, asthma bronchitis

Blood Sugar

Eat when nervous
Excessive appetite
Hungry between meals
Irritable between meals
Get shaky if hungry
Fatigue, eating relieves
Lightheadedness if meals delayed
Heart palpitates if meals missed or delayed
Afternoon headaches
Overeating sweets upsets
Awaken after few hours of sleep. Insomnia
Crave candy or coffee in afternoon
Moods of depression, blues or melancholy
Abnormal craving for sweets or snacks

Heart Support

Hands and feet go to sleep easily
Sigh frequently “air hunger”
Aware of breathing heavily
High altitude discomfort
Opens window in closed room
Susceptible to colds and fever
Afternoon yawner
Get drowsy often
Swollen ankles worse at night
Muscle cramps worse with exercise.
Charley Horse
Shortness of breath with exertion
Dull pain in chest or radiating into left arm.
Pain in jaw
Bruise easily. Black/Blue spots
Tendency to anemia.
Men – erectile dysfunction
Nose bleeds frequently
Ringing in ear
Tension or tightness under breast bone

Liver/Gall Bladder

Dizziness
Dry Skin
Burning Feet
Blurred Vision
Itching skin and feet.
Excessive hair loss
Frequent skin rashes
Bitter metallic taste in mouth in morning
Bowel movements painful or difficult
A worrier, feels insecure
Feeling queasy, headache over eyes
Greasy foods upset
Creamy foods upset
Stools light-colored
Skin peels on foot soles
Pain between shoulder blades
Use laxatives
Stools alternate between soft to watery
History of gallbladder attacks or gallstones
Sneezing attacks
Dreaming, nightmares; don't remember dreams
Bad Breath (halitosis)
Milk products cause distress
Sensitive to hot water
Burning or itching anus
Craves sweets

Digestion – Gut Microbe

Loss of taste for meat
Lower bowel gas several hour after eating
Burning stomach sensation--eating relieves
Tongue – white coating
Large amounts of foul smelling gas
Indigestion after meals
Food allergy, sensitivity
High sugar diet
Mucus on stools
Excessive Fatigue after eating
Gas shortly after eating
Stomach bloating after meals.
Bad breath (halitosis)
Diarrhea.
Weight gain
Insomnia
Skin problems
Autoimmune conditions
Difficulty urinating.
Vaginal or rectal itching

Hyperthyroid

Insomnia
Nervousness
Can't gain weight
Intolerance to heat
Highly emotional
Flush easily
Night Sweats
Thin moist skin
Inward Trembling
Heart Palpitates
Increased appetite without weight gain
Unusual stamina
Pulse fast at rest

Hypothyroid

Eyelids and face twitch.
Irritable and restless
Highly emotional
Tear up easily
Can't work under pressure
Increase in weight
Decrease in appetite
Fatigue easily
Ringing in Ear
Sleeping during day
Sensitive to cold
Dry or Scaly skin
Constipation
Mental Sluggishness
Hair Coarse
Depression
Headache upon rising, wears off during day
Slow Pulse below 65
Low Sex Drive
Impaired hearing
Reduced initiative

Female Reproduction

Very easily fatigued
PMS
Painful menses
Depression PMS
Excessive menses, prolonged
Painful breast
Menstruate too frequently
Vaginal discharge
Hysterectomy / ovaries removed
Menopausal hot flashes
Menses scanty or missed
Acne worse at menses
Depression long standing

Men Reproduction

Prostate trouble
Urination difficult or dribbling
Night urination frequent
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Lack of energy
Migrating aches and pain
Tire too easily
Avoids activity
Leg nervousness at night
Diminished sex drive

Microbe/Immune

Frequent Colds
Frequent Cold sores
Foot/Nail Fungus
Urinary Tract Infection
Yeast Infection
Coated tongue
Frequent Diarrhea
Resistance to antibiotics
Scaly Skin Rash
Frequent Blisters
Loss of taste
Vaginal Discharge (women)
Stiff Neck
Fever
Night Sweets
Hot Flashes
Runny Nose
Sinus Congestion
Lymphatic Congestion
Frequent Sore throat
Frequent achy muscles

Health history and priorities

Top 3 symptoms affecting my life
Foods I crave or cannot go without
Foods I stress eat
Present weight and past weight if changed (lbs)
Menstrual cycle — length, flow and symptoms, past and present, if applicable
Antibiotic use — total in the last year and lifetime
Current prescription medication conditions (list conditions, not medications)
Past prescription medication conditions (list conditions, not medications)
Over-the-counter items (vitamins, herbs, aspirin, etc.)
Root canals or major dental work completed
Stressors contributing to symptoms (trauma, conflict, work, family, anxiety, etc.)

Weekly food summary

Enter the number of times each item is consumed in an average week. For milk, enter cups per week; for alcohol, enter drinks per week. Leave blank if not applicable.

Food and drink frequency

Eggs, Scrambled
Eggs, Poached, Hard Or Soft Boiled
Grass Finished Beef, Lamb
Butter
Cream
Cheese
Bread Whole Grains
Brown Rice, Basmati Rice
Quinoa
Millet
Broccoli
Asparagus
Green Beans
Spinach,
Chard, Kale
Green Peas, Snap Peas
Celery
Walnuts, Pecan
Macadamia Pistachio
Almonds
Cashews
Pistachios
Avocados
Mushrooms, Onions
Oats
Beets
Olives
Olive Oil
Romaine, Iceburg
Carrots,
Cucumber
Carrots
Radish
Sprouts
Sweet Potato, Yams
Blueberries, Wild Berries
Strawberries
Pears, Apple
Pineapple
Papaya, Kiwi
Banana
Grapes
Beans Kidney
Green Tea
Coffee
Aspartame - Artificial Sweeteners
Breakfast Bars
Energy Bars
Chips - Potato Chips, Corn Chips
Donuts (Or Any Deep-Fried Pastry)
Soda/Pop
Fruit Juices
Energy Drinks -Monster, Red Bull.
Bleached Flour – Bread, Crackers
Pizza
Pasties
Chocolate Bars
Ice Cream
Sliced Meets/Cold Cuts
Microwave Popcorn
Pork
Bacon
Shrimp
Tuna
Raw Tomato
Sockeye/Pacific Salmon
Mackerel, Sardines, Anchovies
Cod, Halibut
White Potatoes
Chick Peas, Lentils
French Fries
Restaurant food
Take out foods
Frozen Meals
Meat (Any form)
Milk (total number of cups per week)
Yogurt
Alcohol (total number of drinks per week)