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 1 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 _______ years Yes No 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 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) No No No No 2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 2 3 NEUROLOGICAL ASSESSMENT FORM NAME: ______________________________________________________ DATE:______________ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 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 Left No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No Patient Signature:__________________________________________________________ Date: ________________
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