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1 OVERVIEW OF HISTORY Patient s Name Patient is from (city, state, country) Patient's Age & DOB Patient Marital Status Patient's Gender Patient's Ethnicity Age Birthdate Married Separated Divorced Widowed Single Partner Male Female Intersex / Hermaphrodite Transgender Caucasian African American Native American Asian Hispanic Hawaiian/Pacific Islander How did you hear about our clinic? What is your current Primary Diagnoses (if any)? HISTORY OF PRESENT ILLNESS Date symptoms began (onset of symptoms) WHAT was the first evidence of the problem? WHEN was first evidence of the problem beginning? Summarize pertinent history from initial symptoms to time of diagnosis. (provide more details in Initial Intake Synopsis on the last page of this form) Date diagnosed How was diagnosis made? Who made the diagnosis? INITIAL SYMPTOMS BEFORE DIAGNOSIS Constitutional symptoms prior to diagnosis Weight change Nausea Vomiting Diarrhea Appetite change Fever Chills Night sweats Pain Fatigue Exhaustion Sleep issues Swelling Discomfort Joint Pain Muscle Aches Weight when initial symptoms began lbs Eating Healthy Exercising Dieting Appetite when initial symptoms began SYMPTOMS AT TIME OF DIAGNOSIS Constitutional symptoms at time of diagnosis Excellent Good Poor No Appetite Weight change Nausea Vomiting Diarrhea Appetite change Fever Chills Night sweats Pain Fatigue Exhaustion Sleep issues Swelling Discomfort Joint Pain Muscle Aches Weight at time of diagnosis (lbs) lbs Eating Healthier Increased Exercise Continued Dieting Appetite at time of diagnosis Excellent Good Poor No Appetite Rev :45PM Center for Advanced Medicine Rashid A. Buttar, D.O. Page 1 of 5
2 CURRENT SYMPTOMS AS OF TODAY Constitutional symptoms as of today Weight change Nausea Vomiting Diarrhea Appetite change Fever Chills Night sweats Pain Fatigue Exhaustion Sleep issues Swelling Discomfort Joint Pain Muscle Aches Current weight (lbs) lbs Eating Healthier Increased Exercise Continued Dieting Current appetite Excellent Good Poor No Appetite HISTORY OF TREATMENTS RELATED TO DIAGNOSIS Surgeries history related to diagnosis (dates and type) Condition after treatment regimen or surgery CURRENT SITUATION Primary problem today? When did primary problem start? Where is primary problem located? When is problem worse, and for how long? How often does problem occur? When is the problem better? What has been done to help problem? What treatments have been successful in helping the problem? Experiencing any pain? Where? Complications since diagnosis Rev :45PM Center for Advanced Medicine Rashid A. Buttar, D.O. Page 2 of 5
3 Medications currently being taken and purpose Any other information regarding your diagnosis or problem you feel is pertinent for the provider to know? EXPOSURE HISTORY History and recent use of Tobacco (how much, how long, dates used) History and recent use of Alcohol (type used, how much, how long, dates used) History and recent use of Illicit Drug (type used, how much, how long, dates used) Chemical Exposure History (type, how much, how long, dates) Examples: Pesticides, Fuel, Fertilizers, Insecticides Metals Exposure History (type, how much, how long, dates) Examples: Lead, Aluminum, Mercury, Copper, Steel Any amalgams (mercury fillings) removed? Yes No If yes, how many? How many amalgams does patient currently have? Does patient have a high seafood diet? What vaccines has the patient had? (Give general information) How many antibiotics has patient taken in the past year? MEDICAL HISTORY Do you have any other medical conditions? Have you had any other surgeries? Rev :45PM Center for Advanced Medicine Rashid A. Buttar, D.O. Page 3 of 5
4 Any other treatment history? How many times have the patient been pregnant, at what age was the pregnancy, and did the pregnancy result in a live birth? (if applicable) Any other medical history that you feel is pertinent for the provider to know? FAMILY HISTORY Family History - Mother Family History - Father Family History - Siblings Additional Family History (if any) Heart issues/disease Diabetes Cancer Stroke Unknown Heart issues/disease Diabetes Cancer Stroke Unknown Heart issues/disease Diabetes Cancer Stroke Unknown REVIEW OF SYMPTOMS Average number bowel movements daily Experienced in last 3 mo - Constitutional Experienced in last 3 mo - Head Experienced in last 3 mo- Neuro Experienced in last 3 mo - Eye Experienced in last 3 mo Muscular/Skeletal Experienced in last 3 mo - Skin Experienced in last 3 mo - G.I. Experienced in last 3 mo - Respiratory Experienced in last 3 mo - Genito/Uri Experienced in last 3 mo - Cardio Experienced in last 3 mo - Endocrine Experienced in last 3 mo - Psych Experienced in last 3 mo - Allergy Fever Chills Sweats Tired Weight loss Ear Pain Mouth Pain Tooth Pain Throat Pain Poor Hearing Nose Discharge Headache Numbness Tingling Poor Balance / Coordination Urinary / Bowel Blurred Vision Double Vision Eye Pain Muscle Pain Joint Pain Rash Itching Bites Sores Redness Belly Pain Diarrhea Nausea Vomiting Constipation Shortness of Breath Cough Pain Wheeze Snoring Painful / Frequent Urination Waking to Urinate Periods (F) Irregular Periods (F) Itching Pain Discharge (F) Chest Pain / Pressure Light Headed Fluttering in Chest Swelling of Legs Fainting Palpation Often Cold Often Hot Over Tired Over Thirsty Depression / Feeling Blue Anxious Trouble Sleeping Itchy Eyes Sinus Sneezing Frequent Infection Rev :45PM Center for Advanced Medicine Rashid A. Buttar, D.O. Page 4 of 5
5 Initial Intake Synopsis If you feel all your pertinent medical history may need further explanation or you think the provider should be aware of any additional information, please provide us with a synopsis of this information in chronological order (i.e. health timeline, diagnoses, treatments undergone, type of practitioners seen, and etc.) See Initial Intake Synopsis Example on next page as reference. Date: Patient Name: Rev :45PM Center for Advanced Medicine Rashid A. Buttar, D.O. Page 5 of 5
6 Immune Intake Form Initial Intake Synopsis Example If you feel all your pertinent medical history may need further explanation or you think the provider should be aware of any additional information, please provide us with a synopsis of this information in chronological order (i.e. health timeline, diagnoses, treatments undergone, type of practitioners seen, and etc.) See Initial Intake Synopsis Example on next page as reference. Date: Patient Name: September 17, 2009 I had surgery to remove a fibroid. The fibroid was a tumor. My obgyn removed the tumor. left ovary and left fallopian tube. 97% chance tumor would be benign. It was cancer. Very rare tumor. Granulosa cell tumor. I went to MD Anderson for a second opinion. In Kansas City I had 6 rounds (1 every 3 weeks from November 2009 to March 2010) of chemo (carboplatin and Taxol). God blessed us with a miracle! January we had a healthy baby girl! Because of my history my obgyn asked me to decide if we were having other children and if not do at hysterectomy. November I at 40 I had a my port removed. total hysterectomy. and omentum removed. While removing the ontentum they found 3 more nodules. I woke up to my husband telling me they found more nodules and they wanted to do chemo. I knew at that moment chemo did not work and I was not doing it again. December of 2012, I read the Knock out book by Suzann Somers. We went to Clinic M and to Dr A for a second opinion. Clinic M had never worked with my tumor. Dr A recommended more chemo even when the chemo sensitivity test from Caris results showed no compatible chemo with my tumor. I chose to go a natural approach. March of 2013 I started with Dr. G. I am still on the program. I do coffee enemas twice daily. drink 4 carrot juices daily and take almost 200 pills daily. I soak in the bathtub and do monthly cleanses. E X A M P L E June of 2014 my OBGYN felt something during my annual exam. He requested a CT scan and found 3 masses. My local oncologist used a robot surgery in July of to remove the masses. We discovered my tumor marker is inhibin B. Every couple months we checked inhibin B after surgery and it continued to go up. Oncologist requested a scan in November of Found another mass. (I believe the mass was there during surgery but it was too small for Dr. to see). December of 2OI4. we were going to try hormonal therapy. I went on Megas for 2 weeks and Tamoxifen for 2 weeks. However, on 2 day of Tamoxifen. I had such terrible pain I went to the emergency room. The ER doctor did a chest X-ray, blood and urine test. All was normal. I stopped taking the pills. June I was having terrible pain on my right side and thought I was having an appendicitis. Blood work and urine work showed an infection. CT scan showed 2 masses in my pelvic and multiple locations suggesting widespread abdominal and peritoneal tumor involvement." I believe I had gastroenteritis (also mentioned in the CT scan) and that is why my intestines were looped. My husband had a similar infection the week before. I went to my primary doctor 2 days later and they did an X-ray to confirm there was no bowel obstruction and loops were back to normal. I should have gone to a different hospital because this hospital misdiagnosed me in 2009 but I was in pain and went to the closest hospital. July I4. 2OI 5. my local oncologist did an exam and could feel the tumors. She said it felt like a grapefruit and a pear connected. not sure she could use the robot to remove. Oncologist requested I contact Dr. A for a second opinion and commit to a therapy before she can do surgery. August 2015 I went to Dr. F in Reno. I was interested to see what their sensitivity test and hair analysis would show. October 20l 5. I asked my primary doctor to have my blood tested for inhibin B. my tumor marker. It was 85 in August and is 154. I need a new doctor and a plan to shrink the tumors. I am very interested to hear about your program and if you think it can help me. I appreciated your comments on the Quest for the Cure. I believe God has blessed me every step of the way and I am praying for direction for the next step. Rev pm Center for Advanced Medicine Rashid A. Buttar, D.O. Page 6 of 6
Select the appropriate option and/or provide an answer to each of the items below: Married Separated Divorced Widowed Single Partner
OVERVIEW OF HISTORY Patient s Name Patient is from (city, state, country) Patient's Age Patient Marital Status Patient's Gender Patient's Ethnicity Married Separated Divorced Widowed Single Partner Male
Select the appropriate option and/or provide an answer to each of the items below:
OVERVIEW OF HISTORY Patient s Name & Current Date Patient's Age & DOB Age Birthdate Patient Marital Status Married Separated Divorced Widowed Single Minor Child Engaged Domestic Partner Patient's Ethnicity
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