Intuitive Health History Software. Allopathic

Size: px
Start display at page:

Download "Intuitive Health History Software. Allopathic"

Transcription

1 What is Integrative and Functional Medicine? How to Add This Field of Medicine To Your Practice: A Place to Start Part 1 of 7 in a Series of Web Conferences by Wayne L. Sodano DC, DABCI, DACBN, CFMP, BCTN Sponsored by: Integrative Medicine Health Services, LLC Intuitive Health History Software Copyright 2015 All Rights Reserved/ Integrative Medicine Health Services, LLC/Wayne L. Sodano, DC, DABCI, DACBN, ND/Catherine P. Sodano/ Reproduction in whole or part is prohibited without written permission Healing oriented Doctor-patient relationship: Practitioner and patient choose the appropriate therapy Promote health by utilizing the least invasive, least toxic, and least costly methods Encouraging disease prevention Whole person medicine The natural healing power of the organism The importance of lifestyle The critical role of the doctorpatient relationship Systems of Medicine: Traditional Chinese Medicine, Ayurveda, Homeopathy, Naturopathic Biologically Based Medicine: Botanical Medicine, Natural Medicine, Functional Medicine Manipulative Medicine: Chiropractic, Osteopathic, Massage Therapy, Movement Therapy Mind-Body Therapy: Counseling, Support Groups, Meditation, Prayer, Spiritual Healing, Hypnosis, Guided Imagery, Creative Outlets Energy Therapy: Biofield Therapy (e.g. Qi Gong), Bioenergetic Therapy (e.g. magnetic fields, AC current, DC current) Allopathic 1

2 What are the relative contributions of the patient history, physical examination, and laboratory findings in making a medical diagnosis? 82 % 9% 9% The eyes do not see what the mind does not know. 2

3 Fever can be caused by: infection, trauma (e.g. tissue necrosis, MI), cancer, blood disorders, drug reactions, and immune disorders (autoimmune disease). Mobility is the ease in which lifts up. Decreased mobility: edema, scleroderma Turgor indicates the speed in which it returns into place. Decreased turgor: free radical change, dehydration, loss of collagen Vitiligo is an acquired disorder in which patches of depigmented skin and overlying hair, and mucous membranes, are the result of progressive autoimmune loss of melanocytes from the involved areas. The risk of developing autoimmune disorders such as thyroid disease, diabetes mellitus, and pernicious anemia is increased in patients who are affected by vitiligo. There may be a relationship between celiac disease and vitiligo. This may indicate a common basic autoimmune mechanism that is an explanation for few case reports that gluten free diets were effective in the treatment of vitiligo patients. Int J Prev Med. Feb 2013; 4(2): Physical signs of nutritional deficiencies/excess: Dry, scaly, flaky skin: def. vitamin A, zinc Yellow pigmentation: carotene excess/jaundice Nasolabial seborrhea: def. EFAs Pallor: def. iron, B 12, folate Hyperpigmentation (niacin) Parotid gland enlargement: def. protein Cheilosis/angular fissures: B 2, B 3, B 6 3

4 Ophthalmological: Dermatological: Systemic diseases: Autoimmune: Nutritional: Infections: Drugs/supplements: Toxins: Inherited Disorders Trauma Madarosis (loss of eyebrows or eyelashes) eye infections eczema, acne rosacea, psoriasis, sarcoidosis hyperthyroidism, hypothyroidism, hyperparathyroidism hypopituitary, amyloidosis, hypoparathyroidism lupus, scleroderma hypoproteinemia, zinc deficiency, biotin deficiency, iron deficiency fungal, viral, bacterial niacin, miotics, antithyroid, anticoagulants, anticholesterol, propranolol, levodopa, lipid lowering, MMR, barbiturates hypervitaminosis A, arsenic, bismuth, gold, mercury, thallium Episcleritis The red appearance caused by this condition looks similar to conjunctivitis, but there is no discharge. Systemic inflammatory conditions: Crohn s disease Rheumatoid arthritis Lupus Gout Psoriatic arthritis Environmental toxin exposure The most common cause of red eye is conjunctivitis. Tongue Aphthous ulcers can be a sign of an immune system dysfunction, hormonal imbalance, food allergies, and nutritional deficiencies (iron, folate, B 12 ). Aphthous ulcers are frequent in children and adults with celiac disease. stanfordmedicine25.stanford.edu Smooth/Beefy Red Coated nhs.uk Nodules dermis.net stanfordmedicine25.stanford.edu dermis.net Geographic Scalloped Fissures Gums: Look for periodontal disease/low vitamin D stanfordmedicine25.stanford.edu 4

5 Case Study: 02/08/2006 Patient: Occupation: Female 48 years-old School bus driver Previous Occupation: Worked with/around motor vehicles; family business. Pumped own fuel daily. Chief complaint: All joints hurt (patient questions possible MS? RA?) Started Synthroid.05 mg: 2/7/2006 Cancerous colon polyp removed 7/23/2004 Herpes simplex (chronic breakouts) Carpal Tunnel Syndrome Positive TPO (Thyroid Antibody) Enlarged thyroid Bruising easily and dry skin Weight gain, weakness, sleeping disturbances, hot flashes, low sex drive, low blood pressure, MVP, depression/mood swings Endometriosis/uterine fibroids Hysterectomy 2000; left ovary, adhesions and appendix 2001 Age 14: Menarche; irregular cycles days Age 17: Began BCP; regular periods for 8 years; no health problems 1984: First yeast infection 1984: Married; stopped BCP irregular periods began with heavy bleeding and clotting Age 33: Bleeding on/off during first pregnancydelivered 2 weeks early-breast fed 3 monthsstopped due to bleeding nipples Age 36: 2 nd pregnancy no bleeding breast fed 19 months no problems Ages 38-39: Menstrual cycles better Age 40: Began with heavy bleeding/clotting Age 43: Fibrocystic breast disease Age 46: Began treatment with medical doctor. Ht: 5 4 Wt: 140 lbs Pulse: 68 b/m Resp: 16 Temp: 98.2 BP: 110/64 R 116/70 L Neuro/Ortho: WNL Abd: left lower quadrant: significant tenderness Hair: Thin: pulls out easily Skin: Dry scalp Tongue: White coating, scalloped 5

6 What is Integrative and Functional Medicine? How to Add This Field of Medicine To Your Practice: A Place to Health Symptom Assessment Questionnaire Thyroglobulin AB.39 (less than 20) IU/mL 6

7 7

8 1. Begin supplement to increase estrogen metabolism 2. Continue with multivitamin, vitamin C, EFA s, probiotics 3. Calcium supplement 4. Discontinue thyroid supplements (supplement 1 and 2) She also made the decision to stop taking the synthroid. 5. Decrease natural progesterone and estrogen supplementation 6. Follow up in six to eight weeks 8

9 Integrative Medicine Approach to Thyroid Dysfunction Gastrointestinal Dysfunction TSH Environmental Factors Detoxification Dysfunction Thyroglobulin AB 39 <20 <20 Thyroid Dysfunction TPO AB Free T Free T Hormonal Imbalance Oxidative Stress Nutritional Factors Immune Dysfunction Stay Tuned for Part 2! October 31, 2017 Integrative and Functional Medicine Approach to Patient History Taking and Physical Examination: How to get to the root cause of chronic disease. Part 2 of 7 in a Series of Web Conferences by Wayne L. Sodano DC, DABCI, DACBN, CFMP, BCTN Sponsored by: Integrative Medicine Health Services, LLC Intuitive Health History Software Copyright 2015 All Rights Reserved/ Integrative Medicine Health Services, LLC/Wayne L. Sodano, DC, DABCI, DACBN, ND/Catherine P. Sodano/ Reproduction in whole or part is prohibited without written permission 9

Sequoia Education Systems, Inc. 1

Sequoia Education Systems, Inc.  1 Functional Diagnostic Medicine Training Program Module 7 * FDMT561A Introduction to Functional Endocrinology Wayne L. Sodano, D.C., D.A.B.C.I. & Ron Grisanti, D.C., D.A.B.C.O., M.S. Limbic System Stress

More information

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome: MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer

More information

WELCOME to the Florence Chiropractic and Wellness Center.

WELCOME to the Florence Chiropractic and Wellness Center. WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,

More information

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:

/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to: Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:

More information

Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:

Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?

More information

THE TONGUE. In Clinical Diagnosis

THE TONGUE. In Clinical Diagnosis THE TONGUE In Clinical Diagnosis A Colour Atlas of The Tongue in Clinical Diagnosis D.W. BEAVEN S.E. BROOKS BATES Guide to Physical Examination Lynn s. Bickley רויטל רחימי, תום כספי פנימית ב', תל-השומר

More information

Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form

Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify

More information

Patient History Form

Patient History Form Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age

More information

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE The National Centers for Whole Psychiatry wholepsych.com phone:

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE The National Centers for Whole Psychiatry wholepsych.com phone: 1 NAME DATE Please score the items you experience on a scale of 0-4: 0 (I do not experience this) 1 (This is a mild problem) 2 (This is a significant problem) 3 (This is a major problem) 4 (This is a severe

More information

Table of Contents WHAT IS THIS BOOK?... 10

Table of Contents WHAT IS THIS BOOK?... 10 Table of Contents WHAT IS THIS BOOK?... 10 SO WHO AM I TO DISAGREE WITH THE DOCTORS?... 10 NO ONE CARES ABOUT YOUR HEALTH LIKE YOU DO!... 14 ATTACKING THE SYMPTOM (YOUR TONGUE) WILL NOT SOLVE THE UNDERLYING

More information

New Patient Intake Form

New Patient Intake Form 501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work

More information

Complementary and Alternative Medicine

Complementary and Alternative Medicine Complementary and Alternative Medicine Approaches to Health Care Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not

More information

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN HORMONE BALANCE QUESTIONNAIRE FOR WOMEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a

More information

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE 1 NAME: DATE: Please score the items you experience on a scale of 0-4 [check the box, enter a number]: 0 (I do not experience this) 1 (This is a mild problem) 2 (This is a significant problem) 3 (This

More information

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Alivia Acupuncture Clinic, LLC. Address. City State Zip.  . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced

More information

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX 77375 281.290.0531 www.feelwellagain.com FEMALE MEDICAL QUESTIONNAIRE (POSTMENOPAUSAL) NAME: DATE OF BIRTH: CHIEF COMPLAINT What is your primary

More information

Adrenals: Review. Pathology Session #4. Adrenal Stress Stage #1: Alarm. Stage #2: Adrenal Fatigue

Adrenals: Review. Pathology Session #4. Adrenal Stress Stage #1: Alarm. Stage #2: Adrenal Fatigue Adrenals: Review Pathology Session #4 Adrenal glands Thyroid Dermatology http://www.flyfishingdevon.co.uk/salmon/year1/adrgln.gif Adrenal Stress Stage #1: Alarm Stress - adrenal stimulation = adrenaline

More information

Nutrient Assessment Chart

Nutrient Assessment Chart Vitamin A Assessment Chart Chicken skin on backs of arms Chronic acne Dry eyes Food allergies Poor night vision Recurrent infections and colds Reduced hair growth in children Ulcers B Vitamins Afternoon

More information

GENERAL OVERVIEW OF TYPES OF HAIR LOSS AND ALOPECIA TELOGEN EFFLUVIUM

GENERAL OVERVIEW OF TYPES OF HAIR LOSS AND ALOPECIA TELOGEN EFFLUVIUM GENERAL OVERVIEW OF TYPES OF HAIR LOSS AND ALOPECIA TELOGEN EFFLUVIUM Telogen effluvium is a form of diffuse hair loss that occurs during the telogen or resting phase of the hair growth cycle. Telogen

More information

Holistic Medicine for the 21 st Century

Holistic Medicine for the 21 st Century Holistic Medicine for the 21 st Century David Brownstein, M.D. Center for Holistic Medicine 5821 W. Maple Rd. Ste. 192 West Bloomfield, MI 48322 248.851.1600 www.drbrownstein.com Overcoming Thyroid Disorders

More information

Exercise: Hypothyroidism Symptom Evaluation

Exercise: Hypothyroidism Symptom Evaluation Assessing Your Thyroid Health Exercise: Hypothyroidism Symptom Evaluation This test will help you determine whether your thyroid gland may be underactive. Read the statements below, decide on the level

More information

Female New Patient Package

Female New Patient Package Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank

More information

Marcelo Garzon HOM.DSHomMed.Bsc. (Please be certain that all in take forms are completed and returned on time)

Marcelo Garzon HOM.DSHomMed.Bsc.   (Please be certain that all in take forms are completed and returned on time) Marcelo Garzon HOM.DSHomMed.Bsc. www.sagehomeopathy.ca (Please be certain that all in take forms are completed and returned on time) NAME: Personal Health History DATE: OHIP # D.O.B : AGE: PHONE: MAY WE

More information

Adult Health History

Adult Health History Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit

More information

Englewood Orthopedic Associates 401 South Van Brunt Street Englewood, NJ Tel: Fax: Jessica Fleischer, MD

Englewood Orthopedic Associates 401 South Van Brunt Street Englewood, NJ Tel: Fax: Jessica Fleischer, MD Englewood Orthopedic Associates 401 South Van Brunt Street Englewood, NJ 07631 Tel: 201.569.2770 Fax: 201.569.1774 Jessica Fleischer, MD Date: Name: Address: City: State: Zip Code: Age: DOB: / / Gender:

More information

Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA

Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA Please complete this Health History Form. You may email it back to the clinic (LBlakeLac@gmail.com) or print it out and bring it with you to your appointment. Thank You. Name: Date: Address: Phone (day):

More information

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you. Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information

More information

Bodily Conditions Rooted in Hormone Imbalance

Bodily Conditions Rooted in Hormone Imbalance Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.

More information

Name: Date of Birth: Age: Address: City State Zip

Name: Date of Birth: Age: Address: City State Zip Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?

More information

Hormone. for Women. Dr. Melanie MacIver, ND

Hormone. for Women. Dr. Melanie MacIver, ND Hormone Balancing for Women Dr. Melanie MacIver, ND Topics About hormones Benefits of balanced hormones Causes of hormone imbalance Bio-identical hormones Lifestyle and nutrition tips for balance Hormone

More information

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443) ! 30 E Padonia Rd, #305, Timonium, MD 21093 Phone: (410) 560-7404 Fax: (443) 705-0228 Email: info@waynebonliemd.com Today s Date: Patient Information Name: DOB: / / Address: City/Town: State: Zip: Home

More information

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other Welcome! Please complete this new client paperwork and return to us at least 48 hours prior to your appointment. This will allow our medical team to review your case in advance of your arrival. If you

More information

FDM Training Program: Mod 3: FDMT 521A-Dysfunctions of the Immune System Wayne L. Sodano, D.C., D.A.B.C.I. & Ron Grisanti, D.C., D.A.B.C.O., M.S.

FDM Training Program: Mod 3: FDMT 521A-Dysfunctions of the Immune System Wayne L. Sodano, D.C., D.A.B.C.I. & Ron Grisanti, D.C., D.A.B.C.O., M.S. Functional Diagnostic Medicine Training Program Module 3 * FDMT 521A Dysfunctions of the Immune System Dr. Wayne L. Sodano, D.C., D.A.B.C.I. & Dr. Ron Grisanti, D.C., D.A.B.C.O., M.S. Th1/Th2 Balance T

More information

Liver Health: Do you have liver problems? Yes No If so, please specify:

Liver Health: Do you have liver problems? Yes No If so, please specify: Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their

More information

Eastern Body Therapy

Eastern Body Therapy 2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security

More information

1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary

1405 NE Douglas Lee s Summit, MO Phone: Date: Fax: Female Information and Health Summary Tracy Dryer, RPh Sheryl Pfeiler, Pharm D, RPh 1405 NE Douglas Lee s Summit, MO 64086 Phone: 816-524-8444 Date: Fax: 816-246-5493 Female Information and Health Summary Name Date of Birth Address City/State/ZIP

More information

Hormone Consultation for Women

Hormone Consultation for Women Healthway Compounding Pharmacy 2544 McLeod Dr. N., Ste. 2 Saginaw, MI 48604 989-791-1691 Toll Free: 866-883-8868 Fax: 989-791-4603 Hormone Consultation for Women Today s Date: / / Patient Name: Birth date:

More information

medicine (CAM): group of practices used Alternative medicine: group of practices used as an Integrative medicine: use of conventional medicine in

medicine (CAM): group of practices used Alternative medicine: group of practices used as an Integrative medicine: use of conventional medicine in Chapter 17: Complementary and Alternative Medicine Approaches to Health Care Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products

More information

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions

More information

Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here):

Other doctors to receive copies of records : Chief complaint / history of present illness (Describe why you have been referred here): Patient Name: Date: Age: Date of Birth: Preferred Name: Preferred Language: Address: City: State: Zip: Phone: Cell Phone: Preferred Phone: Emergency Contact: Relationship: Email: If you would like to opt

More information

Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone

Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social

More information

Balancing Hormone Function in Women By Meghna Thacker, NMD

Balancing Hormone Function in Women By Meghna Thacker, NMD Balancing Hormone Function in Women By Meghna Thacker, NMD Hormone function is central to health and well being in both men as well as women. A problem encountered with any one endocrine gland can lead

More information

Sonoma Skin Dermatology - 1 Appointment Date: 3/19/2013 Name: Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O

Sonoma Skin Dermatology - 1 Appointment Date: 3/19/2013 Name: Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O Sonoma Skin Dermatology - Appointment Date: /9/0 Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O Spouse/Partner s SSN: DL# State: Home #: Work #: Cell Phone #: E-mail Address: Preferred

More information

Medical History Form

Medical History Form Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart

More information

Alison McAllister, N.D. HRT Symposium Las Vegas, Nevada February 16 18, 2017

Alison McAllister, N.D. HRT Symposium Las Vegas, Nevada February 16 18, 2017 Adrenal & Thyroid Alison McAllister, N.D. HRT Symposium Las Vegas, Nevada February 16 18, 2017 Disclosure Alison McAllister, ND, is employed by ZRT Lab. Professional Education Services Group staff have

More information

Dr. Michelle Cruickshank

Dr. Michelle Cruickshank CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of

More information

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status

More information

My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.

My energy is lower than I would like it to. I feel exhausted after exercising or physical activity. SYMPTOMS Questionnaire Duplicate your answer across all of the 5 boxes that aren t blocked out. See example ENERGY My energy is lower than I would like it to be. I feel exhausted after exercising or physical

More information

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax: Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for

More information

Answers to 5 Common Thyroid Questions

Answers to 5 Common Thyroid Questions Answers to 5 Common Thyroid Questions http://www.grassfedgirl.com/answers-to-5-common-thyroid-questions/ This is a guest post from Dr. Justin Marchegiani who is a cutting edge functional medicine practitioner

More information

ADDITIONAL GEMS OF WISDOM TO HELP YOU OVERCOME CFIDS, CANDIDIASIS AND FIBROMYALGIA

ADDITIONAL GEMS OF WISDOM TO HELP YOU OVERCOME CFIDS, CANDIDIASIS AND FIBROMYALGIA October 7-8, 2005. Milwaukee, Wisconsin ADDITIONAL GEMS OF WISDOM TO HELP YOU OVERCOME CFIDS, CANDIDIASIS AND FIBROMYALGIA Luis Paez, M.D. CFIDS Severe fatigue Anxiety Brain fog and confusion Prolonged

More information

Inner Balance Acupuncture

Inner Balance Acupuncture Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:

More information

Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area:

Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area: Whole Woman Health Patient Registration Form Welcome New Patient! We are pleased you have chosen Whole Woman Health. Below is your registration form as well as Medical History and Assessment forms. Please

More information

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES abdominal pain acne aging process accelerated allergies, including asthma, hives, rashes, sinus congestion anemia (blood hemoglobin low) anorexia anovulatory (no ovulation) anxiety anxious depression appetite

More information

Facial Assessment. Color. Lines in the Skin.

Facial Assessment. Color. Lines in the Skin. Facial Assessment Color. Red. Heat, inflammation, upward movement. White. Closure of capillaries, cold, shock, downward/inward movement. Blue. Lack of oxygen. Purple. Stagnation, bruises. Yellow. Liver,

More information

Adrenals: Review. Pathology Session #7. Adrenal Stress Stage #1: Alarm. Stage #2: Adrenal Fatigue

Adrenals: Review. Pathology Session #7. Adrenal Stress Stage #1: Alarm. Stage #2: Adrenal Fatigue Adrenals: Review Pathology Session #7 Adrenal glands Thyroid Dermatology http://www.flyfishingdevon.co.uk/salmon/year1/adrgln.gif Adrenal Stress Stage #1: Alarm Stress - adrenal stimulation = adrenaline

More information

Evolve180 / Ideal Northwest Health Profile

Evolve180 / Ideal Northwest Health Profile Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital

More information

Vitamins Minerals Chapter 12

Vitamins Minerals Chapter 12 DH 250 Water soluble B1 Thiamin B2 Riboflavin B3 Niacin Vitamins Minerals Chapter 12 Role RDA Source Deficiency Toxicity Clinical Use intermediary coenzymes 1.2mg 1.1mg 1.2mg 1.1mg 16mg 14mg dairy B6 Pyridoxine

More information

The Changing Face of Celiac Disease. John Snyder, MD

The Changing Face of Celiac Disease. John Snyder, MD The Changing Face of Celiac Disease John Snyder, MD Special Thanks Blair and Steve Raber, founders of the Children s National Celiac Disease Program Rhonda and Peter Resnick, for providing a generous gift

More information

Acupuncture Patient Health History

Acupuncture Patient Health History Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership

More information

Medical History Form

Medical History Form Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your

More information

RHEUMATOLOGY PATIENT HISTORY FORM

RHEUMATOLOGY PATIENT HISTORY FORM !! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant

More information

NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)

NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have

More information

8605 SW Creekside Place Beaverton, OR Phone: Fax: Height 5 ft 8 in BMI Weight 154 lb

8605 SW Creekside Place Beaverton, OR Phone: Fax: Height 5 ft 8 in BMI Weight 154 lb TEST REPORT 218 8 2 2 SB Ordering Provider: Jane Getuwell, MD 865 SW Creekside Place Beaverton, OR 978 Phone: 53-466-2445 Fax: 53-466-1636 Samples Received 8/2/218 Report Date 8/8/218 Samples Collected

More information

??? Why should you care? 9/26/2016. Lee Anne Hellesto, NP Discover Health, LLC

??? Why should you care? 9/26/2016. Lee Anne Hellesto, NP Discover Health, LLC Lee Anne Hellesto, NP Discover Health, LLC Brings me back to my roots Framework to help patients/clients Tools in my toolbox It is the way of the future Why should you care???? 1 (IM) is a healing-oriented

More information

All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.

All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge. Nutritional Counseling Food Sensitivity Testing Neurotransmitter Testing Hormone Testing Wellness & Prevention 111 O Fallon Commons Drive O Fallon, MO 63368 Phone: 636-978-0970 Fax: 636-978-7570 Dr. Olivia

More information

New Patient Medical History Intake Form

New Patient Medical History Intake Form New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd

More information

Treatments used Topical including cleansers and moisturizer Oral medications:

Treatments used Topical including cleansers and moisturizer Oral medications: Discipline: Dermatology Extended Topic: Acne & Rosacea : Onset: Location: Face Chest Back Menses if female: Regular Irregular PCOS Treatments used Topical including cleansers and moisturizer Oral medications:

More information

Welcome to About Women by Women

Welcome to About Women by Women Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner

More information

PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?

PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( )  May we contact you by  ? PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation

More information

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - - ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:

More information

what vitamins are what vitamins are for

what vitamins are what vitamins are for what vitamins are and what vitamins are for www.eurovit.eu page 1/23 Vitamins are essential for human body life. Vitamins are organic compounds that are needed in small quantities to sustain life. No vitamins

More information

Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA

Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA 30328 404 255-8388 www.metroacupuncture.com Patient Information Last Name: First Name: Middle Initial: Street Address: City: State: Zip: Preferred

More information

Southern Maine Integrative Health Center Adult Intake Form

Southern Maine Integrative Health Center Adult Intake Form Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:

More information

Personal Data. Present Symptoms

Personal Data. Present Symptoms Chris A. Pate, MD 2280 Hwy 70 West, Suite B 265 Racine Drive, Suite 102 Goldsboro, NC 27530 Wilmington, NC 28403 (919) 988-9332 Fx(919) 581-0353 (910) 399-6661 Fx(910) 399-6667 Name Personal Data Address

More information

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1 Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma

More information

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY Patient Information: Name: Date of Birth: Social Security #: Gender: Marital Status: Primary Address: City: State: Zip Code: Please put a check mark next to any phone number that we may leave a message

More information

Metabolic Assessment Form

Metabolic Assessment Form Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please

More information

SYMPTOMS THINGS TO TRY. Evaluation Report. Loose Skin (loss of collagen) Hair Loss. Poor Night Vision. Salt Cravings. Allergies.

SYMPTOMS THINGS TO TRY. Evaluation Report. Loose Skin (loss of collagen) Hair Loss. Poor Night Vision. Salt Cravings. Allergies. Evaluation Report Louise Louise 52 years oldfemale 60 pounds SYMPTOMS Loose Skin (loss of collagen) THINGS TO TRY *Wheat Grass Juice Powder This symptom is related to Low Stomach Acid Hair Loss This symptom

More information

The Oral Cavity. Image source:

The Oral Cavity. Image source: The Oral Cavity Anatomy Image source: http://anatomyforlayla.blogspot.co.za/2007/04/blog-post.html The major structures of the oral cavity are the lips, the teeth, the alveolar ridges (bony areas that

More information

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency

More information

Pure Health Natural Medicine

Pure Health Natural Medicine Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell

More information

Whole Health Clinic 6632 S. 191 st Place, Suite E-110; Kent, WA (425) Fax (425)

Whole Health Clinic 6632 S. 191 st Place, Suite E-110; Kent, WA (425) Fax (425) 1 Whole Health Clinic 6632 S. 191 st Place, Suite E-110; Kent, WA 98032 (425) 656-0700 Fax (425) 656-0705 Date: Name: Age: Birth Date: Gender: M F Address: City Zip: Phone: Home Can messages be left for

More information

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information. Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell

More information

HEALTH SURVEY. This is a health survey designed to help you assess where you are; recognition is well on the way to healing.

HEALTH SURVEY. This is a health survey designed to help you assess where you are; recognition is well on the way to healing. HEALTH SURVEY This is a health survey designed to help you assess where you are; recognition is well on the way to healing. PLEASE BRING THIS FORM BACK WITH YOU EACH TIME. I do not diagnose or treat any

More information

Free Report: How Your Hormones Can Make You Overweight and Miserable

Free Report: How Your Hormones Can Make You Overweight and Miserable Free Report: How Your Hormones Can Make You Overweight and Miserable 39111 Six Mile Road Suite 160 Livonia, MI 48152 (734) 769-1650 HOW YOUR HORMONES CAN MAKE YOU OVERWEIGHT AND MISERABLE This report explains

More information

Multivitamins are a mixture of vitamins and minerals which are essential for the body to work and stay healthy.

Multivitamins are a mixture of vitamins and minerals which are essential for the body to work and stay healthy. MULTIVITAMINS Multivitamins are a mixture of vitamins and minerals which are essential for the body to work and stay healthy. Vitamins are vital substances that are required for normal growth and functioning

More information

55 S. Main Street, Driggs, ID (208)

55 S. Main Street, Driggs, ID (208) Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F

More information

Inspired Chiropractic and Wellness

Inspired Chiropractic and Wellness General Information Preferred Name Date of Birth Name First Middle Last Age Gender Male Female Genetic Background African Caucasian European Native American Asian Hispanic Middle Eastern Highest Education

More information

Sentelligent Medical Intuitive Body Scan

Sentelligent Medical Intuitive Body Scan Sentelligent Medical Intuitive Body Scan 1 1) Ask for presenting symptoms. Get clear channel and set sacred space. 2) Ask if any resistance or interference. 3) Ask Source to provide information only on

More information

Female New Patient Package

Female New Patient Package Female New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank

More information

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4 Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:

More information

BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.

BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major

More information

Patient Name: 3866 Johns St Madison, WI DATE: Acupuncture Patient Health History

Patient Name: 3866 Johns St Madison, WI DATE: Acupuncture Patient Health History Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender: Marital status (please circle one): Single Married Domestic Partnership Divorced Widowed

More information

Name Date. Street City ST Zip. Home Phone Cell. . Age Date of Birth Male Female HT WT. Occupation. Referred by. Emergency Contact Relation to

Name Date. Street City ST Zip. Home Phone Cell.  . Age Date of Birth Male Female HT WT. Occupation. Referred by. Emergency Contact Relation to HEALTH HISTORY QUESTIONNAIRE Healing Arts of Memphis 1541 Overton Park Ave. (Rear) Memphis, TN 38112 901 726 1485 Name Date Street City ST Zip Home Phone Cell Email Age Date of Birth Male Female HT WT

More information

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status

More information

THE OB/GYN CENTRE NEW PATIENT HISTORY

THE OB/GYN CENTRE NEW PATIENT HISTORY PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH

More information

Name. Preferred Name. Date of Birth. Highest Education Level High School Under-Graduate Post-Graduate. Job Title Nature of Business.

Name. Preferred Name. Date of Birth. Highest Education Level High School Under-Graduate Post-Graduate. Job Title Nature of Business. General Information Name Preferred Name Date of Birth Gender Male Female Genetic Background African European Native American Asian Middle Eastern Highest Education Level High School Under-Graduate Post-Graduate

More information

Digestion: Small and Large Intestines Pathology

Digestion: Small and Large Intestines Pathology Digestion: Small and Large Intestines Pathology Dr. Ritamarie Loscalzo Medical Disclaimer: The information in this presentation is not intended to replace a one onone relationship with a qualified health

More information