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 208-315-1010 for payment arrangements.
Nutrition guidance and chiropractic care are available independently. Choose the care that fits your needs.
Your details
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 1 2 3 P Fatigue 1 2 3 P Low blood pressure 1 2 3 P Nail weak or ridged 1 2 3 P Tendency to hives 1 2 3 P Arthritic Tendency 1 2 3 P Perspiration increase 1 2 3 P Bowel Disorder 1 2 3 P Poor Circulation 1 2 3 P Swollen Ankles 1 2 3 P Crave Salt 1 2 3 P Crave Sugar 1 2 3 P Light sensitivity – need sunglasses 1 2 3 P Hot Flashes 1 2 3 P Loss of bodily hair 1 2 3 P Skin discoloration 1 2 3 P Brown spots or bronzing of skin 1 2 3 P Allergies, tendency to asthma 1 2 3 P Weakness after colds, influenza 1 2 3 P Exhaustion, muscular or nervous 1 2 3 P Respiratory disorder. (i.e, Asthma) 1 2 3 P
Anxiety - Sympathetic
Acid foods upset 1 2 3 P Get chilled often 1 2 3 P “Lump” in throat 1 2 3 P Dry mouth-eyes-nose 1 2 3 P Pulse speeds after meals 1 2 3 P Keyed up; fail to calm 1 2 3 P Cuts heal slowly 1 2 3 P Gag easily 1 2 3 P Unable to relax/ Tense Muscles 1 2 3 P Excessive Worrying 1 2 3 P Feeling Agitated 1 2 3 P Restlessness 1 2 3 P Excessive Fatigue 1 2 3 P Difficulty Concentrating on task 1 2 3 P Irritability 1 2 3 P Insomnia Falling or Staying Asleep 1 2 3 P Panic Attacks 1 2 3 P Avoiding Social Situations 1 2 3 P Irrational Fears 1 2 3 P Extremities cold clammy 1 2 3 P Strong light irritates 1 2 3 P Urine amounts reduced 1 2 3 P Heart pounds after eating 1 2 3 P Nervous stomach 1 2 3 P Appetite reduced 1 2 3 P Cold sweats often 1 2 3 P Fever easily raised 1 2 3 P Neuralgia-like pains 1 2 3 P Staring, blinks little 1 2 3 P
Digestion – Parasympathetic
Sour stomach frequent 1 2 3 P Joint stiffness after arising 1 2 3 P Muscle leg toe cramps at night 1 2 3 P “Butterflies” in stomach 1 2 3 P Eyes or nose watery 1 2 3 P Eyes Blink Often 1 2 3 P Eyelids Swollen 1 2 3 P Indigestion soon after meals 1 2 3 P Always feels hungry. Lightheaded Often 1 2 3 P Digestion Rapid 1 2 3 P Vomiting frequent 1 2 3 P Hoarseness frequent 1 2 3 P Breathing Irregular 1 2 3 P Pulse Slow. Feels irregular 1 2 3 P Gagging reflex slow 1 2 3 P Difficulty Swallowing 1 2 3 P Constipation/ Diarrhea alternating 1 2 3 P “Slow Starter” 1 2 3 P Get Chilled frequently 1 2 3 P Perspire easily 1 2 3 P Circulation Poor, sensitive to cold 1 2 3 P Subject to colds, asthma bronchitis 1 2 3 P
Blood Sugar
Eat when nervous 1 2 3 P Excessive appetite 1 2 3 P Hungry between meals 1 2 3 P Irritable between meals 1 2 3 P Get shaky if hungry 1 2 3 P Fatigue, eating relieves 1 2 3 P Lightheadedness if meals delayed 1 2 3 P Heart palpitates if meals missed or delayed 1 2 3 P Afternoon headaches 1 2 3 P Overeating sweets upsets 1 2 3 P Awaken after few hours of sleep. Insomnia 1 2 3 P Crave candy or coffee in afternoon 1 2 3 P Moods of depression, blues or melancholy 1 2 3 P Abnormal craving for sweets or snacks 1 2 3 P
Heart Support
Hands and feet go to sleep easily 1 2 3 P Sigh frequently “air hunger” 1 2 3 P Aware of breathing heavily 1 2 3 P High altitude discomfort 1 2 3 P Opens window in closed room 1 2 3 P Susceptible to colds and fever 1 2 3 P Afternoon yawner 1 2 3 P Get drowsy often 1 2 3 P Swollen ankles worse at night 1 2 3 P Muscle cramps worse with exercise. 1 2 3 P Charley Horse 1 2 3 P Shortness of breath with exertion 1 2 3 P Dull pain in chest or radiating into left arm. 1 2 3 P Pain in jaw 1 2 3 P Bruise easily. Black/Blue spots 1 2 3 P Tendency to anemia. 1 2 3 P Men – erectile dysfunction 1 2 3 P Nose bleeds frequently 1 2 3 P Ringing in ear 1 2 3 P Tension or tightness under breast bone 1 2 3 P
Liver/Gall Bladder
Dizziness 1 2 3 P Dry Skin 1 2 3 P Burning Feet 1 2 3 P Blurred Vision 1 2 3 P Itching skin and feet. 1 2 3 P Excessive hair loss 1 2 3 P Frequent skin rashes 1 2 3 P Bitter metallic taste in mouth in morning 1 2 3 P Bowel movements painful or difficult 1 2 3 P A worrier, feels insecure 1 2 3 P Feeling queasy, headache over eyes 1 2 3 P Greasy foods upset 1 2 3 P Creamy foods upset 1 2 3 P Stools light-colored 1 2 3 P Skin peels on foot soles 1 2 3 P Pain between shoulder blades 1 2 3 P Use laxatives 1 2 3 P Stools alternate between soft to watery 1 2 3 P History of gallbladder attacks or gallstones 1 2 3 P Sneezing attacks 1 2 3 P Dreaming, nightmares; don't remember dreams 1 2 3 P Bad Breath (halitosis) 1 2 3 P Milk products cause distress 1 2 3 P Sensitive to hot water 1 2 3 P Burning or itching anus 1 2 3 P Craves sweets 1 2 3 P
Digestion – Gut Microbe
Loss of taste for meat 1 2 3 P Lower bowel gas several hour after eating 1 2 3 P Burning stomach sensation--eating relieves 1 2 3 P Tongue – white coating 1 2 3 P Large amounts of foul smelling gas 1 2 3 P Indigestion after meals 1 2 3 P Food allergy, sensitivity 1 2 3 P High sugar diet 1 2 3 P Mucus on stools 1 2 3 P Excessive Fatigue after eating 1 2 3 P Gas shortly after eating 1 2 3 P Stomach bloating after meals. 1 2 3 P Bad breath (halitosis) 1 2 3 P Diarrhea. 1 2 3 P Weight gain 1 2 3 P Insomnia 1 2 3 P Skin problems 1 2 3 P Autoimmune conditions 1 2 3 P Difficulty urinating. 1 2 3 P Vaginal or rectal itching 1 2 3 P
Hyperthyroid
Insomnia 1 2 3 P Nervousness 1 2 3 P Can't gain weight 1 2 3 P Intolerance to heat 1 2 3 P Highly emotional 1 2 3 P Flush easily 1 2 3 P Night Sweats 1 2 3 P Thin moist skin 1 2 3 P Inward Trembling 1 2 3 P Heart Palpitates 1 2 3 P Increased appetite without weight gain 1 2 3 P Unusual stamina 1 2 3 P Pulse fast at rest 1 2 3 P
Hypothyroid
Eyelids and face twitch. 1 2 3 P Irritable and restless 1 2 3 P Highly emotional 1 2 3 P Tear up easily 1 2 3 P Can't work under pressure 1 2 3 P Increase in weight 1 2 3 P Decrease in appetite 1 2 3 P Fatigue easily 1 2 3 P Ringing in Ear 1 2 3 P Sleeping during day 1 2 3 P Sensitive to cold 1 2 3 P Dry or Scaly skin 1 2 3 P Constipation 1 2 3 P Mental Sluggishness 1 2 3 P Hair Coarse 1 2 3 P Depression 1 2 3 P Headache upon rising, wears off during day 1 2 3 P Slow Pulse below 65 1 2 3 P Low Sex Drive 1 2 3 P Impaired hearing 1 2 3 P Reduced initiative 1 2 3 P
Female Reproduction
Very easily fatigued 1 2 3 P PMS 1 2 3 P Painful menses 1 2 3 P Depression PMS 1 2 3 P Excessive menses, prolonged 1 2 3 P Painful breast 1 2 3 P Menstruate too frequently 1 2 3 P Vaginal discharge 1 2 3 P Hysterectomy / ovaries removed 1 2 3 P Menopausal hot flashes 1 2 3 P Menses scanty or missed 1 2 3 P Acne worse at menses 1 2 3 P Depression long standing 1 2 3 P
Men Reproduction
Prostate trouble 1 2 3 P Urination difficult or dribbling 1 2 3 P Night urination frequent 1 2 3 P Depression 1 2 3 P Pain on inside of legs or heels 1 2 3 P Feeling of incomplete bowel evacuation 1 2 3 P Lack of energy 1 2 3 P Migrating aches and pain 1 2 3 P Tire too easily 1 2 3 P Avoids activity 1 2 3 P Leg nervousness at night 1 2 3 P Diminished sex drive 1 2 3 P
Microbe/Immune
Frequent Colds 1 2 3 P Frequent Cold sores 1 2 3 P Foot/Nail Fungus 1 2 3 P Urinary Tract Infection 1 2 3 P Yeast Infection 1 2 3 P Coated tongue 1 2 3 P Frequent Diarrhea 1 2 3 P Resistance to antibiotics 1 2 3 P Scaly Skin Rash 1 2 3 P Frequent Blisters 1 2 3 P Loss of taste 1 2 3 P Vaginal Discharge (women) 1 2 3 P Stiff Neck 1 2 3 P Fever 1 2 3 P Night Sweets 1 2 3 P Hot Flashes 1 2 3 P Runny Nose 1 2 3 P Sinus Congestion 1 2 3 P Lymphatic Congestion 1 2 3 P Frequent Sore throat 1 2 3 P Frequent achy muscles 1 2 3 P
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)