We want to welcome you to Lemont Natural Healthcare. Our mission is to improve your
chronic health condition as much as possible and teach you how to manage your own health for
the rest of your life. Please review our office policy before we enter our trusted doctor/patient
relationship. Please initial after each point signifying that you understand:
1. What we offer is a holistic program, not medical therapy. This means that we may
recommend labs tests that your medical doctor would not or did not order. These lab
tests that we order can help determine the underlying causes of your health problems
and evaluate the multiple systems of your body that interact together. Our bodies are
a sum of these systems. These systems do not work independently. We then would
balance your body with proven natural therapies based on these lab tests. The lab
tests we order for you may or may not be covered by your insurance company. They
do not understand holistic care and the reason why we order these tests.
INITIALS: _______
2. Our office utilizes functional neurologic (brain balancing and therapy) and metabolic
therapy (balancing your digestive, immune and hormone systems as well as dietary
recommendations…what you should or should not eat), not medications.
INITIALS: _______
3. It is very important that you fully understand the “why” behind what we do. For this
reason we require that you watch our videos (posted on our website or on You Tube).
We have made some short (2 to 3 minute introductory videos) and longer versions (30
to 45 minutes) that go into greater detail regarding our Holistic program for your
condition. By initialing below, you are agreeing to watch the full length video.
INITIALS: _______
4. In order for you to regain your health, there will be dietary changes, neurological
and/or traditional exercises to be done as well as lifestyle changes.
INITIALS: _______
5. Holistic therapy is not covered by insurance. This is their choice not ours. Typically
Holistic therapy costs in our office range from $250-350 per month for up to 18
months if you chose to finance it. The exact cost of care and your options to pay for it
will be explained in detail at your next appointment. It is very important that your
spouse or significant other be with you during this appointment. They will be able to
hear our program details, ask questions and they will be more informed to help
support you while you are on our program.
INITIALS: _______
Dr. Forzley has been in practice for 30 years utilizing metabolic therapy. Dr. Imber is one of only
9 board certified chiropractic functional neurologists in the state of Illinois. Our Neuro-Metabolic
therapy program can drastically improve your health and get you back to enjoying your life.
I have read and fully understand all the above.
Signature: _________________________________
Sincerely,
Dr. Jeffrey E. Forzley
Dr. Matthew J. Imber
Date: _________
1192 Walter St, Suite C Lemont, IL 60439 Phone: 630.257.0550 Fax: 630.257.0555 PATIENT INFORMATION Date:______________________ www.LemontNaturalHealthcare.com Name: ___________________________________________________________________________________________ Last First Middle Home Address: ____________________________________________________________________________________ Street Address Apt. / Condo Number ______________________________________________________________________________________________________________________________________ City State Zip Code
Home Phone: ______________________________________ Cell Phone: _______________________________________ E-‐mail Address: ________________________________________________________________________________________ Major Medical Insurance: PPO:______ HMO: ______ Medicare: ______ Medicaid: _______ None: ______ How did you hear about us? [ ] Internet, [ ] Newspaper ______________ (which ?), [ ] Other___________________ [ ] Facebook [ ] Website [ ] Personal Referral , whom may we thank? __________________________________ SSN#: _________-‐-‐-‐-‐_______-‐-‐-‐-‐__________ Age: _____ Weight ______lb. Birthdate: _____/_____ /_____ Height: ____’____” Employer’s Name: __________________________________________ Occupation: _________________________ Address: _______________________________________________________________________________________ Marital Status: M S D W Name of Spouse:______________________ Phone ________________________ Emergency Contact Information Name: _________________________________________________________________________________________ First Last Relationship to you:_____________________________ Home Phone #:_________________________________ Mobile Phone #:_____________________________ CONSENT TO NUTRITION EVALUATION / RECOMMENDATIONS I authorize Lemont Natural Healthcare to perform a nutrition / health analysis. No claims are made to diagnose, treat, cure or prevent any specific disease or condition. X_________________________________________________________
Patient Name (Printed)
Signature of Patient
_______________________________
Date
CONSENT TO TREATMENT OF A MINOR (UNDER 18 YEARS OF AGE) I hereby authorize Lemont Natural Healthcare to evaluate and perform treatment for my _________________________, named __________________________________, age________, and consent on his/her behalf. I am a legal guardian of this child. X_____________________________________________________
Guardian Name (Printed)
Signature of Guardian
________________________
Date
DESCRIBE YOUR MAJOR HEALTH CONDITIONS / CONCERNS: 1.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO 2.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO DESCRIBE YOUR MAJOR HEALTH CONDITIONS / CONCERNS: 3.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO 4.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO DESCRIBE YOUR MAJOR HEALTH CONDITIONS / CONCERNS: 5.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO 6.Conditions/Diagnosis:________________________________________________________________ Symptoms: _________________________________________________________________________ ____________________________________________________________________________________ When did this start? __________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: ____________________________________________________________________ Treatment: ___________________________________________________________________ Results: ______________________________________________________________________ Physician Seen: ______________________________________________ Date Seen_______________ Diagnosis: _____________________________________________________________________ Treatment: ____________________________________________________________________ Results: ______________________________________________________________________ Nutritional Supplements/Diet: _________________________________________________________ ___________________________________________________________ Did it Help? YES NO Other Treatment: ____________________________________________ Did it Help? YES NO PERSONAL HISTORY Please mark an “X” in front of any conditions you currently have or a “P” for previously had. Muscle/ Joint __ Arthritis __ Bursitis __ Hernia __ Low Back Pain __ Neck Pain __ Stiff Neck __ Pain Between Shoulders __ Swollen Joints __ Fractures (Where and when?) ____________________
____________________ Pain / Numbness __ Shoulders __ Arms __ Elbows __ Hands __ Hips __ Legs __ Knees __ Feet Respiratory __ Asthma __ Chronic cough __ Difficulty breathing __ Wheezing __ Bronchitis __ Emphysema Cardiovascular __ Arteriosclerosis __ Hardening of arteries __ Heart Attack __ High blood pressure __ Heart Disease __ Low blood pressure __ Pain over heart __ Poor circulation __ Pacemaker __ Rapid / Slow heartbeat __ Stroke Head __ Colds __ Deafness __ Dizziness __ Vertigo __ Dental decay __ Ear ache __ Ear ringing __ Enlarged glands __ Eye pain __ Failing vision __ Gum trouble __ Hay fever __ Hoarseness __ Light-‐headed __ Nose Bleeds __ Sinus infection __ Sore throat General __ Allergies_________ __ Anxiety __ Convulsions __ Cancer (Where?) ___________________ __ Diabetes __ Dizziness __ Epilepsy __ Fainting __ Fatigue __ Headache __ Nervousness __ Loss of sleep __ Poor posture __ Sciatica __ Seizures __ Low Energy __ Spinal Curvature __ Swelling of ankles __ Thyroid issues __ Weight Loss (abnormal) __ Weight Gain (abnormal) Skin __ Acne __ Bruise easily __ Eczema __ Hives __ Itching __ Varicose veins Genitourinary __ Bed-‐wetting __ Bladder infection __ Blood in urine __ Frequent urination __ Kidney infection __ Painful urination __ Prostate trouble Gastrointestinal __ Appendicitis __ Belching or gas __ Bloated abdomen __ Colitis __ Colon trouble __ Constipation __ Diarrhea __ Difficult Digestion __ Excessive hunger __ Gallbladder trouble __ Gallbladder Removed? __ Hemorrhoids __ Intestinal worms __ Liver trouble __ Nausea __ Pain over stomach __ Poor appetite __ Ulcers __ Vomiting __ Vomiting of blood Misc. Conditions: __ Alcoholism __ Anemia __Autoimmune Disease __ Cold Sores __ Diabetes – I or II? __ Edema __ Fever blisters __ Goiter __ Gout __ Herpes __ Multiple Sclerosis __ Polio __ Rheumatic fever __ Scarlet fever __ Tuberculosis Women Only __ Cramps __ Fibrocystic breasts __ Excess menstrual flow __ Hot flashes __ Irregular cycle __ Lumps in breasts __ Menopause __ Miscarriage __ Painful menstruation __ Vaginal discharge Are you pregnant? Yes No If yes, how far along? _____ months?
Breakfast (List foods):___________________________________________________________________ Lunch (List foods):______________________________________________________________________ Dinner (List foods): _____________________________________________________________________ Snacks (List foods):_____________________________________________________________________ Drinks (List): _____________________________________________________________________ How much pure water do you drink per day? ________oz Water source: Tap Bottled Filtered Filter Type: _____________________ Sleep: Hours per night ____ Difficulty falling asleep? Yes No Rested when you awake? Yes No Do you awaken during the night? Yes No If yes, can you fall right back asleep? Yes No Do you work a midnight shift? Yes No Do you exercise? Yes No Exercise Type: Aerobic Weights Yoga Other:____________ Exercise Frequency:_____/times per week Alcohol Use: Yes No Type: Wine Beer Hard Liquor Drinks per week? ________ Tobacco Use: Current? Yes No How many years? ___________ Type: Cigarettes (Packs per day? ____) Cigars Pipe Chewing Tobacco In the past? Yes No How many total years? ______ When did you quit? _____________ Stress Level: (none) 0 1 2 3 4 5 6 7 8 9 10 (high) Energy Level: (none) 0 1 2 3 4 5 6 7 8 9 10 (high) PERSONAL HISTORY (Cont.) List all current medications taken: __________________________________________________________ ______________________________________________________________________________________ List all nutritional supplements taken: _______________________________________________________ ______________________________________________________________________________________ Surgeries and the year performed: __________________________________________________________ ______________________________________________________________________________________ Vaccination history: Childhood vaccines? Yes No Flu vaccines: Currently receive? Yes No How many years? ________________ Tetanus vaccines: Yes No Date of last one? _______________________ Were you breastfed? Yes No For how long? _____________________ Have you been tested for allergies? Yes No Do you have any allergies? Yes No Food Allergies (list):______________________________________________________________________ Seasonal Allergies (list):___________________________________________________________________ Other Allergies (list):_____________________________________________________________________ Allergy Test Type: Skin Blood Electro-‐Dermal Muscle Testing / AK Have you been exposed to: Toxic Chemicals Mold Via… Work Hobbies Home Type: __________________________________________________________________________________ Dental History: Do you have gingivitis? Yes No How many fillings do you have? ____________________ How many are silver / amalgam fillings? ____ Have you had any silver / amalgam fillings removed? Yes All No How many crowns do you have? ___________ How many root canals have you had? _______________ Why do you think your previous treatments failed? _____________________________________________ _______________________________________________________________________________________ Do you think you can improve? _____________________________________________________________ _______________________________________________________________________________________ What emotional experiences are affecting your health? _________________________________________ _______________________________________________________________________________________ What is your purpose / motivation in life? _____________________________________________________ _______________________________________________________________________________________ What do you miss the most that your health condition is preventing you from doing? _________________ _______________________________________________________________________________________ What do you think is a realistic time to get better? ______________________________________________ _______________________________________________________________________________________ What specific improvements do you want? ____________________________________________________ _______________________________________________________________________________________ Is your family supportive of you seeking holistic therapy? ________________________________________ _______________________________________________________________________________________ Comments: _____________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
_ Lemont Natural Healthcare
HIPPA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices described how we may use and disclose your protected health information (PHI) to carry
out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health information. “Protected health information” is
information about you, including demographic information, that may identify you and that relates to your past, present or
future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information:
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your
health care bills, to support the operation of the physician’s practice and any other required by law.
Treatment:
We will use and disclose your protected health information to provide, coordinate, or manage your health care and any
related services. This includes the coordination or management of your health care with a third party. For example, we
would disclose your protected health information, as necessary, to a home health agency that provides care to you. For
example, your protected health information may be provided to a physician to whom you have been referred to ensure
that the physician has the necessary information to diagnose or treat you.
Payment:
Your protected health information will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the
health plan to obtain approval for the hospital admission.
Healthcare Operations:
We may use or disclose your protected health information in the following situations without your authorization; these
situations include: as Required By Law, Public Health issues as Required By Law, Communicable Diseases: Health
Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement:
Coroners, Funeral Directors, and Organ Donation: Criminal Activity: Military Activity and National Security: Workers’
Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when
required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance
with the requirements of Section 164.500.
We may use or disclose, as needed, your protected health information in order to support the business activities of your
physicians’ practice. We may also call you by name in the Reception Area when your physician is ready to see you. We
may also call you by name while under the care and treatment of our office.
We may use or disclose your protected health information, as necessary to contact you to remind you of your
appointment.
Other Permitted and Required Uses and Disclosures will be made only with your consent, Authorization or opportunity to
object unless required by law.
You may revoke this Authorization at any time, in writing, except to the extent that your physician or the physician’s
practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights:
Following is a statement of your rights with respect to your protected health information:
You have the right to inspect and copy your protected health information. Under federal law, however, you may not
inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in,
a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that
prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use
or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.
HIPPA – Page 2
You may also request that any part of your protected health information not be disclosed to family members or friends
who may be involved in your care of\or for notification purposes as described in this Notice of Privacy Practices. Your
request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best
interest to permit use and disclosure of your protected health information, your protected health information will not be
restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative
location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to
accept this notice alternatively, i.e., electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health
information.
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights
have been violated by us.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the
right to object or withdraw as provided in this notice.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy
practices with respect to protected health information. If you have any objections to this form, please ask to speak with
our HIPPA Compliance Officer person.
Signature below is only acknowledgement that you have received and read this Notice of our Privacy Practices:
Print Name: ___________________________________
Date: _____________________________
Signature: __________________________________________________________
or
Signature of Legal Representative: ____________________________________________
Relationship: __________________________________________
(e.g. Attorney-In-Fact, Guardian, Parent if Minor)
Metabolic Assessment Form
Name: ___________________________________________ Age: ______ Sex: _____
Date: ______________
PART I
Please list your 5 major health concerns in order of importance:
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
PART II
Please circle the appropriate number on all questions below.
0 as the least/never to 3 as the most/always.
Category I Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
Category II
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Abdominal intolerance to sugars and starches
Category III Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc.
Multiple smell and chemical sensitivities
Constant skin outbreaks
Category IV
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movement
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Category V
Stomach pain, burning, or aching 1-4 hours after eating
Use antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or
carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus,
peppers, alcohol, and caffeine
Category VI
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Copyright © 2012, Datis Kharrazian. All Rights Reserved. SMGEMAF04(052212)
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2 3
2 3
2 3
2 3
2 3
2 3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
1
2
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
1
1
2
2
3
3
0
1
2
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
Category VI (continued)
Nausea and/or vomiting
Stool undigested, foul smelling, mucous like,
greasy, or poorly formed
Frequent urination
Increased thirst and appetite
0
1
2
3
0
0
0
1
1
1
2
2
2
3
3
3
0
1
2
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
1
1
1
1
Yes
Category VIII
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category IX Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Category X
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category VII
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours
after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to
normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
2 3
2 3
2 3
2 3
No
Category XI
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
1
2
3
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
Category XV
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
Category XVI
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
0
0
0
1
1
1
2
2
2
3
3
3
Category XII
Cannot fall asleep
Perspire easily
Under high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little
or no activity
Category XIII
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing
Category XIV
Tired/sluggish
Feel cold―hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive
hair loss
Dryness of skin and/or scalp
Mental sluggishness
Category XVII
Increased sex drive
Tolerance to sugars reduced
“Splitting” - type headaches
0
0
0
1
1
1
2
2
2
3
3
3
Category XVIII (Males Only)
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XIX (Males Only)
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Category XX (Menstruating Females Only)
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning
0
0
0
0
0
0
0
0
0
Yes
Yes
Yes
Yes
1
1
1
1
1
1
1
1
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Category XXI (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching
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PART III
How many alcoholic beverages do you consume per week? Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day? How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds per week?
List the three worst foods you eat during the average week:
List the three healthiest foods you eat during the average week:
PART IV
Please list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Copyright © 2012, Datis Kharrazian. All Rights Reserved. SMGEMAF04(052212)
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NEUROLOGICAL ASSESSMENT FORM
NAME: ______________________________________________________ DATE:______________
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Are you left or right handed?……………………………………………………………………………….. Right
Have you had a head injury?………………………………………………………………………………. Yes
Do you currently experience or have a past history of vertigo or balance disorders?……………..… Yes
Do you have any ringing or pressure in your ears? …………………………………………………….. Yes
Do you experience nausea? ………………………………………………………………………………. Yes
Do you find that your balance is getting worse? ………………………………………………………… Yes
Do you have difficulties walking down stairs?………………………………………………………….… Yes
Do you find yourself searching for words frequently when you speak?……………………………..… Yes
Have you noticed your ability to concentrate is getting worse? ...………………………………...…… Yes
Do you get lost often or have a hard time with directions?…………………………………………...… Yes
Do quick flashes of light on TV or loud noises bother you? ……………………………………….…… Yes
Do you feel like you need to wear sunglasses outside?………………………………………………… Yes
Has your handwriting changed in recent years? ………………………………………………………… Yes
Do you have a hard time swallowing? ……………………………………………………………………. Yes
Do to gag easily?……………………………………………………………………………………………. Yes
Do you experience blurriness in you vision or have double vision? …………………………………... Yes
o CIRCLE ALL THAT APPLY: Blurriness, Double Vision
Do you have any changes in smell or smell foul things that are not present?………………………... Yes
Do you have any difficulty with taste or taste things differently than what you are eating? ………… Yes
Have you noticed clumsiness in hand coordination? …………………………………………………… Yes
o Which hand? CIRCLE: Right, Left
Do you have difficulty with short-term memory? ………………………………………………………… Yes
Have you been told you have or noticed any memory loss of past events?………………………….. Yes
Have you noticed uneven sweating or temperature on one side of your body?……………………… Yes
Do you have any tightness, weakness or instability in your back or neck?…………………………… Yes
o CIRCLE ALL THAT APPLY: Back, Neck
Do you have tightness or feelings of weakness in you arms/hands or legs/feet?……………………. Yes
o CIRCLE ALL THAT APPLY: Arms/hands, Legs/feet
Do you ever have any numbness or tingling in your arms/hands, legs/feet or face?………………... Yes
o CIRCLE ALL THAT APPLY: Arms/hands, Legs/feet, Face
Do you have any difficulty with falling asleep or staying asleep?……………………………………… Yes
o CIRCLE ALL THAT APPLY: Falling asleep, Staying asleep
Do you get motion sickness easily (car sick or sea sick)? ……………………………………………... Yes
Do you ever experience flashes of light in you visual fields?…………………………………………… Yes
Do you ever experience dry eyes or mouth?…………………………………………………………….. Yes
o CIRCLE ALL THAT APPLY: Eyes, Mouth
Do you ever experience increased tearing or salivation?………………………………………………. Yes
o CIRCLE ALL THAT APPLY: Tearing, Salivation
Do you ever have slurred speech?………………………………………………………………………... Yes
Have you noticed any drooping of your eyelids or facial muscles?……………………………………. Yes
o CIRCLE ALL THAT APPLY: Eyelids, Facial Muscles
Do you ever notice increased heart rate or pulse during the day? ……………………………………. Yes
Have you ever experienced or been diagnosed with arrhythmia (fluctuating heart rate)? …………. Yes
Do you experience Deja Vu? ……………………………………………………………………………… Yes
Does driving cause you fatigue, headaches or any other symptoms?………………………………… Yes
o CIRCLE ALL THAT APPLY: Fatigue, Headaches, Other Symptoms
Does working on a computer cause you fatigue, headaches or other symptoms? …………………. Yes
o CIRCLE ALL THAT APPLY: Fatigue, Headaches, Other Symptoms
Have you lost your interest in hobbies and functions you used to enjoy? ……………………………. Yes
Do you have a hard time motivating yourself to engage in activities?………………………………… Yes
Do you ever have a fluttering of the eye or noticed you are blinking frequently? ……………………. Yes
Do you have difficulty distinguishing right and left?……………………………………………………… Yes
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Patient Signature:__________________________________________________________ Date: ________________