Patient Information. Emergency Contact: Relationship: Telephone: Your Occupation: Your Employer: Current Physicians / Health Providers:

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1 Patient Infrmatin Name: Date f Birth: Scial Security Number: Hme Telephne: Wrk Telephne: Mbile Telephne: Address: Mailing Address: Street Address (if different): City / State: Zip Cde: Emergency Cntact: Relatinship: Telephne: Yur Occupatin: Yur Emplyer: Current Physicians / Health Prviders: Hw did yu hear abut us?

2 Ntice f Insurance, Billing & Missed Appintment Plicies Please read and initial each sectin thank yu! Advantage Integrative Medicine des nt participate in insurance plans, nr submit claims, nr cmplete paperwrk fr insurance claims. Payment is due in full at the time f service with cash, check r majr credit card. Our returned check charge is $25. Initials We gladly accept cancellatins up t 24 hurs in advance withut penalty. Missed appintments withut advance ntice will be charged 50% f the scheduled visit fee and future appintments will require a credit card number in advance. Initials We will prvide yu with an invice with diagnsis cdes (ICD9) listed that yu may submit t yur insurance cmpany fr reimbursement. Sme insurance cmpanies will hnr invices fr services prvided and sme will nt. We d nt have cntrl ver these practices. If yur insurance cmpany incrrectly submits claims t ther ffices that Dr. Rllins wrks in, then thse claims and any payments will be returned. Initials By signing belw, I cnfirm that I am neither a Medicare nr Medicaid beneficiary. Initials Dr. Rllins des nt see Medicare r Medicaid beneficiaries. I understand that Medicare r Medicaid beneficiaries need t see a prvider that has pted ut f Medicare. Initials I have read the abve plicy infrmatin and by signing belw agree t the terms utlined. Signature Date / /

3 Health Questinnaire Check if yu have ever had: Allergies Arthritis Asthma Autimmune disease Bld clts Bwel disease Cancer Diabetes Fibrmyalgia Frequent infectins Heart disease High bld pressure Kidney disease Liver disease Lung disease Mental illness Neurlgic disease Skin disrder Strke Thinning f bnes Ulcers Urinary infectins Check if yu have ever had (WOMEN nly): Abnrmal mammgram Abnrmal pap smear Abnrmal vaginal bleeding Breast cancer Cervical cancer Fibrcystic breasts Ovarian cysts Uterine cancer Uterine grwths Uterine infectins Check if yu have ever had (MEN nly): Enlarged prstate Mumps Prstate cancer Prstate infectins Testicle infectin Vasectmy Other / Explain abve: Surgeries (dates): Current Medicatins (dse/frequency) and Supplements:

4 Hrmnes taken in PAST (dates): Menstrual Histry (WOMEN nly): Age f first menses: Histry f abnrmal menses? Date f last menses: Explain: Date f last pap smear: Date f last mammgram: Family Histry (list any cnditins frm categry list n prir page fr deceased family members give cause f death and apprximate age) Father: Mther: Paternal GF: Paternal GM: Maternal GF: Maternal GM: Siblings: Scial Histry D yu smke r chew tbacc? D yu drink alchl? D yu exercise regularly? Hw much per day? Hw much per day? Hw much per week? What are yur GOALS fr yur cnsultatin?

5 General Review f Symptms. Please check any bxes fr which yu have r recently have had prblems with: General: Fever Night sweat Weight lss Weight gain Fatigue Change in appetite Change in hair Change in nails Truble tlerating ht r cld Mental: Anxiety Feeling blue r sad Mdiness Memry lss Sleep disturbance Thughts f suicide Difficulty with sex Family/marital difficulties Truble with alchl/drugs Ears/Nse Nasal cngestin Nasal discharge Bldy nse Sinus truble r pain Decreased hearing Ringing in ears Ear pain r drainage Eyes: Change in visin Sudden lss r decrease in visin Duble r blurry visin Redness Infectin Muth: Teeth r gum prblems Frequent sre thrat Difficulty swallwing r speaking Bleeding gums Muth pain Lesins Harseness Bad taste r breath Change in vice Heart/Lungs: Shrtness f breath Cugh Bld sputum Wheezing Pain with deep breath Chest heaviness Awaken at night shrt f breath Heart skip beats r races Fainting Sleep sitting up Chest pain r pressure Pain r tightness in neck r arms Leg r ankle swelling Abdmen: Abdminal pain Pain relieved r wrsened by fd Frequent gas r blating Heartburn r indigestin Nausea Vmiting Bld in vmit Cnstipatin Diarrhea Bld in feces Black r tarry clred feces Hemrrhids Rectal pain Nerves: Numbness Tingling Weakness in extremities Lss f balance Lss f crdinatin Tremr Shaking Paralysis Smell r taste change Bladder: Burning with urinatin Urinating frequently Get up at night t urinate Recurrent bladder infectins Slw start f urine flw r dribbling Lse urine with cugh r strain Brwn r pink urine Skin: Rash Lesin r unusual mle Recent change in mle size, clr r shape Bne: Bne r jint swelling r stiffness Back pain Neck pain Muscular: Aching r stiff muscles Pain in muscles Bld: Easy bruising Easy bleeding Bld clts Varicse veins Pain in calves when walking Female: Abnrmal perids Bleeding between perids Truble with perids Vaginal discharge, itch r dr Breast pain, swelling r lumps Nipple discharge Sexual difficulties Male: Discharge frm penis Testicular pain, swelling r lump

6 Estrgen Deficiency Symptms (wmen) Ht Flashes r Night Sweats Temperature Swings Difficulty Cncentrating / Frgetfulness Md Changes Lss f Skin Radiance Weight Gain Back r Jint Pains Episdes f Rapid Heartbeat Vaginal Dryness Frequent Urinary Tract Infectins Painful Intercurse Inability t Reach Orgasm Prgesterne Deficiency Symptms (wmen) PMS Painful, Cystic r Swllen Breasts Water Retentin / Swllen Fingers Abdminal blating Depressed Md Anxiety, Irritability r Nervusness Headaches Insmnia Missed Perids Heavy and Frequent Perids Sptting a few days befre Perid Teststerne Deficiency Symptms Lack f Energy and Stamina Lack f Sexual Desire Flabbiness r Muscle Weakness Pr Bdy Image Lss f Crdinatin r Balance Decreased scalp, armpit, pubic, bdy hair Lack f Mtivatin Indecisiveness r Insecurity Lack f interest in activities Erectile difficulties (men)

7 Thyrid Deficiency Symptms Fatigue, especially in mrning Headaches, especially in mrning Swelling r "puffiness" Muscle aches r jint stiffness Weight Gain Lw Bdy Temperature Cld Intlerance Thinning Hair (diffusely all ver scalp) Thinning Eyebrws (especially uter third) Brittle r slw grwing nails Dry Skin Cnstipatin Slw Pulse Rate Inability t fcus r slw thinking Pr memry and cncentratin Depressed Md Lack f interest in activities Crtisl Deficiency Symptms Fatigue, especially in mrning Energy bst late mrning Afternn fatigue, "crash" Energy bst after supper / evening Dizziness r lightheadedness Lw bld sugar if nt eating frequently Shakiness r shaky hands Feeling f panic r inability t handle stress Inability t fcus r slw thinking Rage r sudden angry utbursts Emtinal hypersensitivity N patience r easily irritated Flu-like symptms, achey all ver Headaches Difficulty falling asleep Night-time awakening

8 Stmach Supprt Symptms Excessive belching r burping Gas immediately fllwing a meal Bad breath Sense f fullness during and after meals Difficulty digesting fruits and vegetables Undigested fds in stl Pass large amunt f ful smelling gas Mre than 3 bwel mvements daily Frequent use f laxatives Difficulty with bwel mvements Biliary Supprt Symptms Greasy r fatty fds are bthersme Gas r blating several hurs after eating Bitter taste in muth, esp in mrning Itchy skin Occasinal clay clred stls Pass large amunt f ful smelling gas Mre than 3 bwel mvements daily Frequent use f laxatives Histry f gallbladder prblems r remval Intestinal Supprt Symptms Fiber and rughage lead t cnstipatin Indigestin 2-4 hurs after eating Fullness 2-4 hurs after eating Excessive belching r burping Pass large amunt f ful smelling gas Nausea after eating Mucus r greasy appearing stls Lse stls Difficulty lsing weight Increased thirst and appetite Insmnia Questinnaire (IF APPLICABLE) Hw lng have yu had a sleep prblem? Did it begin after a stressful time? Des insmia run in yur family? What time d yu lie dwn t sleep? What time d yu fall t sleep? Hw ften d yu awaken? What times d yu awaken? Hw lng until yu fall back asleep?

9 Type 1 Sertnin/Melatnin Deficiency Night Owl - Hard t get t sleep Disturbed sleep, premature awakening Negativity, depressin Wrry, anxiety / Panic attacks / phbias Lw self esteem Obsessive thughts / behavirs Hyperactivity / tics Perfectinism, cntrlling behavir Winter blues Irritability, rage Dislike f ht weather Afternn / evening cravings carbs, alchl Type 2 GABA deficiency Overstressed and burned ut Unable t relax / lsen up Stiff r tense muscles May experience panic attacks Respnd well t meds e.g. xanax Type 3 High Crtisl "Wired but tired" befre bedtime Awaken alert "ready t get t wrk" Awaken agitated r hypervigilant Awaken startled r shcked feeling

10 Candida Questinnaire and Scre Sheet This questinnaire is designed fr adults and the scring system isn't apprpriate fr children. It lists factrs in yur medical histry which prmte the grwth f the cmmn yeast, Candida Albicans (Sectin A), and symptms cmmnly fund in individuals with yeast-cnnected illness (Sectins B and C). Fr each Yes answer in Sectin A, circle the Pint Scre in that sectin. Ttal yur scre and recrd it in the bx at the end f the sectin. Then mve n t Sectins B and C and scre as directed. Filling ut and scring this questinnaire shuld help yu and yur prvider evaluate the pssible rle f yeasts in cntributing t yur health prblems. Yet it will nt prvide an autmatic Yes r N answer. SECTION A: HISTORY Have yu taken antibitics fr acne fr 1 mnth (r lnger)? 35 Have yu taken ther antibitics fr 2 mnths r lnger, r in shrter curse multiple times in a single year? Have ever yu taken a brad spectrum antibitic? 6 Have yu, at any time in yur life, been bthered by persistent prstatitis, vaginitis r ther prblems affecting yur reprductive rgans? Have yu been pregnant 2 r mre times? 1 time? Have yu taken birth cntrl pills fr mre than 2 years? Fr 6 mnths t 2 years? Have yu taken sterids, such as prednisne r crtisne mre than 2 weeks? Fr 2 weeks r less? Des expsure t perfumes, insecticides, fabric shp drs r ther chemical prvke mderate t severe symptms? Mild symptms? Are yu symptms wrse n damp muggy days r in mldy places? 20 Have yu had athlete s ft, ringwrm, jck itch r ther chrnic fungal infectins f the skin r nails, with severe r persistent symptms? With mild t mderate symptms? D yu crave sugar? 10 D yu crave breads? 10 D yu crave alchlic beverages? 10 Des tbacc smke really bther yu? 10 TOTAL SCORE, SECTION A

11 SECTION B: MAJOR SYMPTOMS Fr each symptm which is present, enter the apprpriate figure in the Pint Scre clumn: If a symptm is ccasinal r mild score 3 pints If a symptm is frequent and/r mderately severe SCORE 6 pints If a symptm is severe and/r disabling SCORE 9 pints Add ttal scre fr this sectin and recrd it in the bx at the end f this sectin. Symptm Fatigue r lethargy Feeling f being drained Pr memry Feeling spacey r unreal Inability t make decisins Numbness, burning r tingling Insmnia Muscle aches Muscle weakness r paralysis Pain and/r swelling in jints Abdminal pain Cnstipatin Diarrhea Blating, belching r intestinal gas Trublesme vaginal burning, itching r discharge Prstatitis Imptence Lss f sexual desire r feeling Endmetrisis r infertility Cramps and/r ther menstrual irregularities Premenstrual tensin Attacks f anxiety r crying Cld hands r feet and/r chilliness Shaking r irritable when hungry TOTAL SCORE, SECTION B Pint Scre

12 SECTION C: OTHER SYMPTOMS Fr each symptm which is present, enter the apprpriate figure in the Pint Scre clumn: If a symptm is ccasinal r mild score 1 pints If a symptm is frequent and/r mderately severe SCORE 2 pints If a symptm is severe and/r disabling SCORE 3 pints Add ttal scre fr this sectin and recrd it in the bx at the end f this sectin. Symptm Drwsiness Irritability r jitteriness Lss f crdinatin Inability t cncentrate Frequent md swings Headaches Dizziness r lss f balance Pressure abve ears r feeling f head swelling Easy bruising Chrnic rashes r itching Psriasis r recurrent hives Indigestin r heartburn Fd sensitivity r intlerance Mucus in stls Rectal itching Dry muth r thrat Rashes r blisters in muth Bad breath Ft, hair r bdy dr nt relieved by washing Nasal cngestin r pst nasal drip Nasal itching Sre thrat Laryngitis r lss f vice Cugh r recurrent brnchitis Pain r tightness in chest Urinary frequency, urgency r incntinence Burning n urinatin Pint Scre

13 Spts in frnt f eyes r erratic visin Burning r tearing f eyes Recurrent infectins r fluid in ears Ear pain r deafness TOTAL SCORE, SECTION C TOTAL SCORE, SECTION B TOTAL SCORE SECTION A GRAND SCORE (add up ttal scre frm sectins A, B and C) The Grand Ttal Scre will help us decide if yur health prblems are yeastcnnected. Scres in wmen will run higher as 7 items in the questinnaire apply exclusively t wmen, while nly 2 apply exclusively t men. WOMEN If yur GRAND SCORE is less than If yu GRAND SCORE is: < 60 then yeast cnnected health prblems are nt likely present >60 then yeast cnnected health prblems are pssibly present >120 then yeast cnnected health prblems are prbably present >180 then yeast cnnected health prblems are very likely present MEN If yur GRAND SCORE is less than If yu GRAND SCORE is: < 40 then yeast cnnected health prblems are nt likely present >40 then yeast cnnected health prblems are pssibly present >90 then yeast cnnected health prblems are prbably present >140 then yeast cnnected health prblems are very likely present This questinnaire is adapted frm The Yeast Cnnectin Handbk by William Crk, MD.