Anemia Patient Questionnaire Name* First Last Email* Date* MM slash DD slash YYYY At which Revitalize Health location are you a patient?* Sugar Land The Woodlands Do you regularly have any of the following symptoms? Dizziness Tiredness Fatigue Lethargy Light-headedness Malaise Weakness Fast heart rate Sensation of abnormal heartbeat Brittle nails Headache Pallor Shortness of breath Do you have a history of anemia and/or use an iron supplement? Yes No Are any of these dietary factors true for you? I am a vegetarian I do not or rarely eat red meat I am a vegan I do not or rarely eat leafy green vegetables Have you recently used or do you currently use any of the following types of medications? Corticosteroids Warfarin Chloramphenicol Anti-cancer drugs Sulphonamides Do you take any of the following medications or supplements regularly? Antacids Ibuprofen (Advil / Motrin) Aleve (Naproxen) Bayer / Aspirin Other NSAIDs Phosphorus Magnesium Calcium Have you recently had any: Ringing in your ears (tinnitus) Decreased appetite or weight loss Weight gain Abdominal pains Indigestion Change in bowel habits and/or constipation Muscle aches (myalgia) Aversion to cold temperatures Have you experienced heavy or prolonged menstrual bleeding recently? Yes No Not applicable Have you ever been diagnosed with: Diverticulosis/diverticulitis Inflammatory bowel disease (IBD) Colitis Gastrointestinal Reflux Disease (GERD) Peptic Ulcer Disease
