New Patient Questionnaires

Transcription

1 New Patient Questionnaires Patient s Name (please print): Date: Last Name: First Name: MI: Marital status?: (Single, Single & Never Married, Married, Separated, Divorced, Widow/Widower) Welcome to Restoration Healthcare! } First thing to know about us: We re glad you re here! } Second thing to know about us: We use data and facts to help create your treatment plan, which is why we need your help in completing the attached New Patient Packet. Also, because we make it our business to stay up-to-date with the latest data and trends from the medical community atlarge, we tend to update our protocols every 6 to 12 months. } Third thing to know about us: We actively partner with you to discover and help you overcome chronic conditions that prevent you from living a long and healthy life. In other words, our approach to doctoring is different. We work to discover the underlying issues behind your pain or symptoms by working our way back to the point where we discover what prompted those symptoms in the first place. Then we work with you to make your life better. The data gathered from the forms and questionnaires that follow are important for us to help you. As you ll see, we want you to tell us why you are here, what you ve done to help yourself in the past, and what your medical and family history looks like. We also need you to complete a few questionnaires that will ultimately help us understand the genesis of your problem. Finally, we want you to tell us your story using the attached timeline. } Fourth thing to know about us: Our staff plays a critical role in your care. They will help our doctors map out your plan of care, work with you to solve or overcome anything financial that may seemingly get in the way of your treatment, manage your scheduling, and oversee the plan of how we are going to objectively measure your progress. } Last thing to know about us: In most cases, 9 months is the amount of time for us to work together to get you back on track. (continued on next page ) New Patient Packet_v PAGE 1 OF 25

2 SECTION I: Your Medical Story Thank you for the time you ve taken out of your life to be with us, and thank you for trusting us to give you back a healthy life! Please Note: } If you are here for a new sports injury, please take the fast track: Section IX: Orthopedic Localization Form. } If you are here for Bio Identical Hormone Replacement only, go directly to Section V: Hormone Health Checklist for Women / Men. List of questionnaires contained in this new patient packet: Required: Required ONLY if Applicable: 1. Metabolic Assessment 1. Chronic Illness Without a 2. Brain Localization Form Diagnosis Symptom Checklist 3. Heavy Metal Exposure Symptoms 2. Orthopedic Localization Form 4. Hormones Women / Men 5. Medical Timeline Plot out your medical history 1. I am suffering from the following: A. B. C. D. E. 2. I have had the following treatment(s) over the last months: 3. Do you have any prior ultra sounds or scans done, such as MRI, CT scan of what and when?: 4. Have you had any medical or lab testing done?: Please send all lab reports and related documentation including your name and birthday to: NewPatientPacket@RhealthC.com (please send WITH this packet). If you cannot send these files electronically, please mail them to: Restoration Healthcare; Teller Avenue, Suite 170; Irvine, CA Files may also be faxed to: (949) (continued on next page ) New Patient Packet_v PAGE 2 OF 25

3 SECTION I: Your Medical Story 5. Past Medical History: (Check all that apply): HIV Kidneys Liver Disease Lung Disease Bleeding Disorder Eating Disorder Arthritis Alcohol Abuse Thyroid Disease Heart Valve Disorder Heart Disease Anemia Cancer Gallbladder Disorder Psychiatric Illness Drug Abuse Other: 6. I estimate my % of the following in my daily diet: Gluten Free Dairy Free Sugar Free 7. I estimate that I consume the following number of alcoholic drinks per week: 8. I have the following food cravings: 9. My number of bowel movements per day is: 10. My bowel consistency is (loose, soft, hard): 11. Number (on average) of hours of sleep I get per night is: 12. Any snoring? (yes or no): 13. Wake up rested? (yes or no): 14. In regards to sex: A). Interest (normal / no interest): B). Ability (yes / no / some difficulty): C). Any pain or dysfunction (yes / no): D). My sexual activity level is best described as: 15. For women: when was your last menstrual cycle and describe (light, normal or heavy)?: 16. I do the following exercise on a (daily / twice a week / three-times a week) basis: 17. I enjoy doing the following things for fun: (continued on next page ) New Patient Packet_v PAGE 3 OF 25

4 SECTION I: Your Medical Story 18. Allergies: Known drug allergies (list): Other allergies (list): Any allergy testing done (yes / no): 19. Do you smoke? (yes / no. If yes, for how many years and how much)?: 20. Living arrangements (house, apartment, who you live with)?: 21. Are you exposed to any potential environmental pathogens?: 22. Have you had any known exposures? (mold, heavy metals, tic bites, etc.): 23. Family History: Father: Current age? If he is deceased, at what age and how did he die?: Mother: Current age? If she is deceased, at what age and how did she die?: Maternal and paternal grandparents: if deceased, at what ages and how did they die?: (continued on next page ) New Patient Packet_v PAGE 4 OF 25

5 SECTION I: Your Medical Story Sibling s current ages and their health: If you have children, how many, what are their age(s) and gender?: 24. Family Medical History: (Check all that apply): High Blood Pressure Nervous Breakdown Heart Trouble Cancer Strokes Anemia Obesity Kidney Disease Suicide Migraines Allergies Bleeding (abnormal) Arthritis Epilepsy Syphilis 25. What is your preferred pharmacy s address, phone and fax number?: 26. How did you hear about us?: Patient s name (print): Date: Patient s signature or legally authorized representative: New Patient Packet_v PAGE 5 OF 25

6 SECTION I: Your Medical Story 28. Please tell us about your current health challenges and issues, including any history of treatment (please feel free to elaborate the text box below can handle up to 850 words) New Patient Packet_v PAGE 6 OF 25

7 SECTION II: Metabolic Assessment Form Patient s name (print): Date } Part I Instructions: The purpose of this questionnaire is to identify difficulties you may be experiencing. Please, answer every question, do not skip any questions. Rate your stress level on a scale of 1-10 during the average week? (1 being the lowest, 10 being the highest) How many alcoholic beverages do you consume per week? How many times do you work out per week How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat fish 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: Please list any medications you currently take and for what conditions: Please list any natural supplements you currently take and for what conditions: New Patient Packet_v PAGE 7 OF 25

8 SECTION II: Metabolic Assessment Form } Part II Please indicated with a check mark the appropriate number on all questions below. Instructions: The purpose of this questionnaire is to identify difficulties you may be experiencing. Please, answer every question, do not skip any questions. Follow the 0 to 3 key, and select, which best fits for all of your answers. KEY 0 = I never / rarely have symptoms 1 = I often have symptoms 2 = I frequently have symptoms 3 = I most / always have symptoms Category I Feeling that bowels do not empty completely 2. Lower abdominal pain relieved by passing stool or gas 3. Alternating constipation and diarrhea 4. Diarrhea 5. Constipation 6. Hard, dry, or small stool 7. Coated tongue or fuzzy debris on tongue 8. Pass large amount of foul-smelling gas 9. More than 3 bowel movements daily 10. Use laxatives frequently Total overall score for Category I = Category II Increasing frequency of food reactions 12. Unpredictable food reactions 13. Aches, pains, and swelling throughout the body 14. Unpredictable abdominal swelling 15. Frequent bloating and distention after eating 16. Abdominal intolerance to sugars and starches Total overall score for Category II = Category III Intolerance to smells 18. Intolerance to jewelry 19. Intolerance to shampoo, lotions, detergents, etc. 20. Multiple smell and chemical sensitivities 21. Constant skin outbreaks Total overall score for Category II = (continued on next page ) New Patient Packet_v PAGE 8 OF 25

9 SECTION II: Metabolic Assessment Form Category IV Excessive belching, burping, or bloating 23. Gas immediately following a meal 24. Offensive breath 25. Difficult bowel movements 26. Sense of fullness during and after meals 27. Difficulty digesting fruits and vegetables; undigested food found in stools Total overall score for Category IV = Category V Use of antacids 29. Stomach pain, burning, or aching 1-4 hours after eating 30. Feel hungry an hour or two after eating 31. Heartburn when lying down or bending forward 32. Temporary relief by using antacids, food, milk, or carbonated beverages 33. Digestive problems subside with rest and relaxation 34. Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine Total overall score for Category V = Category VI Roughage and fiber cause constipation 36. Indigestion and fullness last 2 4 hours after eating 37. Pain, tenderness, soreness on left side under rib cage 38. Excessive passage of gas 39. Nausea and / or vomiting 40. Stool undigested, foul smelling, mucus-like, greasy, or poorly formed 41. Frequent urination 42. Increased thirst and appetite Total overall score for Category VI = (continued on next page ) New Patient Packet_v PAGE 9 OF 25

10 SECTION II: Metabolic Assessment Form Category VII Abdominal distention after consumption of fiber, starches, and sugar 44. Abdominal distention after certain probiotic or natural supplements 45. Lowered gastrointestinal motility, constipation 46. Raised gastrointestinal motility, diarrhea 47. Alternating constipation and diarrhea 48. Suspicion of nutritional malabsorption 49. Frequent use of antacid medication 50. Have you been diagnosed with: Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome? Yes No Total overall score for Category VII = Category VIII Greasy or high-fat foods cause distress 52. Lower bowel gas and/or bloating several hours after eating 53. Bitter metallic taste in mouth, especially in the morning 54. Burpy, fishy taste after consuming fish oils 55. Difficulty losing weight 56. Unexplained itchy skin 57. Yellowish cast to eyes 58. Stool color alternates from clay colored to normal brown 59. Reddened skin, especially palms 60. Dry or flaky skin and / or hair 61. History of gallbladder attacks or stone 62. Have you had your gallbladder removed? Total overall score for Category VIII = Category IX Acne and unhealthy skin 64. Excessive hair loss 65. Overall sense of bloating 66. Bodily swelling for no reason 67. Hormone imbalances 68. Weight gain 69. Poor bowel function 70. Excessively foul-smelling sweat Total overall score for Category IX = (continued on next page ) New Patient Packet_v PAGE 10 OF 25

11 SECTION II: Metabolic Assessment Form Category X Crave sweets during the day 72. Irritable if meals are missed 73. Depend on coffee to keep going / get started 74. Get light-headed if meals are missed 75. Eating relieves fatigue 76. Feel shaky, jittery, or have tremors 77. Agitated, easily upset, nervous 78. Poor memory / forgetful 79. Blurred vision Total overall score for Category X = Category XI Fatigue after meals 81. Crave sweets during the day 82. Eating sweets does not relieve cravings for sugar 83. Must have sweets after meal 84. Waist girth is equal or larger than hip girth 85. Frequent urination 86. Increased thirst and appetite 87. Difficulty losing weight Total overall score for Category XI = Category XII Cannot stay asleep 89. Crave salt 90. Slow starter in the morning 91. Afternoon fatigue 92. Dizziness when standing up quickly 93. Afternoon headaches 94. Headaches with exertion or stress 95. Weak nails Total overall score for Category XII = (continued on next page ) New Patient Packet_v PAGE 11 OF 25

12 SECTION II: Metabolic Assessment Form Category XIII Cannot fall asleep 97. Perspire easily 98. Under a high amount of stress 99. Weight gain when under stress 100. Wake up tired even after 6 or more hours of sleep 101. Excessive perspiration or perspiration with little or no activity Total overall score for Category XIII = Category XIV Edema and swelling in ankles and wrist 103. Muscle cramping 104. Poor muscle endurance 105. Frequent urination 106. Frequent thirst 107. Crave salt 108. Abnormal sweating from minimal activity 109. Alteration in bowel regularity 110. Inability to hold breath for long periods 111. Shallow, rapid breathing Total overall score for Category XIV = Category XV Tired / sluggish 113. Feel cold hands, feet, all over 114. Require excessive amounts of sleep to function properly 115. Increase in weight even with low-calorie diet 116. Gain weight easily 117. Difficult, infrequent bowel movements 118. Depression / lack of motivation 119. Morning headaches that wear off as the day progresses 120. Outer third of eyebrow thins 121. Thinning of hair on scalp, face, or genitals, or excessive hair loss 122. Dryness of skin and/or scalp 123. Mental sluggishness Total overall score for Category XV = (continued on next page) New Patient Packet_v PAGE 12 OF 25

13 SECTION II: Metabolic Assessment Form Category XVI Heart palpitations 125. Inward trembling 126. Increased pulse, even at rest 127. Nervous and emotional 128. Insomnia 129. Night sweats Total overall score for Category XVI = Category XVII (Males Only) Difficult urination or dribbling 131. Frequent urination 132. Pain inside of legs or heels 133. Feeling of incomplete bowel emptying 134. Leg twitching at night 135. Decreased libido 136. Decreased number of spontaneous morning erections 137. Decreased fullness of erection 138. Difficulty maintaining morning erections 139. Spells of mental fatigue 140. Inability to concentrate 141. Episodes of depression 142. Decreased physical stamina 143. Muscle soreness 144. Unexplained weight gain 145. Increase in fat distribution around chest and hips 146. Sweating attacks 147. More emotional than in the past Total overall score for Category XVII = (continued on next page) New Patient Packet_v PAGE 13 OF 25

14 SECTION II: Metabolic Assessment Form Category XVIII (Menstruating Females Only Perimenopausal 149. Alternating menstrual cycle lengths 150. Extended menstrual cycle (greater than 32 days) 151. Shortened menstrual cycle (less than 24 days) 152. Pain and cramping during periods 153. Scanty blood flow 154. Heavy blood flow 155. Breast pain and swelling during menses 156. Pelvic pain during menses 157. Irritable and depressed during menses 158. Acne 159. Facial hair growth 160. Hair loss / thinning Total overall score for Category XVIII = Category XIX (Menopausal Females Only) How many years have you been menopausal? Years 162. Since menopause, do you ever have uterine bleeding? Yes No 163. Hot flashes 164. Mental fogginess 165. Disinterest in sex 166. Mood swings 167. Depression 168. Painful intercourse 169. Shrinking breasts 170. Facial hair growth 171. Acne 172. Increased vaginal pain, dryness, or itching Total overall score for Category XIX = (continued on next page) New Patient Packet_v PAGE 14 OF 25

15 SECTION III: Brain Region Localization Form Patient s name (print): Date } Instructions: The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers. KEY 0 = I never have symptoms (0% of the time) 1 = I rarely have symptoms (Less than 25% of the time) 2 = I often have symptoms (Half of the time) 3 = I frequently have symptoms (75% of the time) 4 = I always have symptoms (100% of the time) Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 12) Difficulty with restraint and controlling impulses or desires 2. Emotional instability (liability) 3. Difficulty planning and organizing 4. Difficulty making decisions 5. Lack of motivation, enthusiasm, interest and drive (apathetic) 6. Difficulty getting a sound or melody out of your thoughts (perseveration) 7. Constantly repeat events or thoughts with difficulty letting go 8. Difficulty initiating and finishing tasks 9. Episodes of depression 10. Mental fatigue 11. Decrease in attention span 12. Difficulty staying focused and concentrating for extended periods of time 13. Difficulty with creativity, imagination, and intuition 14. Difficulty in appreciating art and music 15. Difficulty with analytical thought 16. Difficulty with math, number skills and time consciousness 17. Difficulty taking ideas, actions, and words and putting them in a linear sequence Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6) Initiating movements with your arm or leg has become more difficult 19. Feeling of arm or leg heaviness, especially when tired 20. Increased muscle tightness in your arm or leg 21. Reduced muscle endurance in your arm or leg 22. Noticeable difference in your muscle function or strength from one side to the other 23. Noticeable difference in your muscle tightness from one side to the other (continued on next page) New Patient Packet_v PAGE 15 OF 25

16 SECTION III: Brain Region Localization Form Frontal Lobe Broca s Motor Speech Area (Area 44 and 45) Difficulty producing words verbally, especially when fatigued 25. Find the actual act of speaking difficult at times Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3, 1, 2 and 7) Notice word pronunciation and speaking fluency change at times 27. Difficulty in perception of position of limbs 28. Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall 29. Reoccurring injury in the same body part or side of the body 30. Hypersensitivities to touch or pain perception Parietal Inferior Lobule (Area 39 and 40) Right / left confusion [L] 32. Difficulty with math calculations [L] 33. Difficulty finding words [L] 34. Difficulty with writing [L] 35. Difficulty recognizing symbols or shapes [R] 36. Difficulty with simple drawings [R] 37. Difficulty interpreting maps [R] Temporal Lobe Auditory Cortex (Areas 41, 42) Reduced function in overall hearing 39. Difficulty interpreting speech with background or scatter noise 40. Difficulty comprehending language without perfect pronunciation 41. Need to look at someone s mouth when they are speaking to understand what they are saying 42. Difficulty in localizing sound 43. Dislike of left predictable rhythmic, repeated tempo and beat music [L] 44. Dislike of non-predictable rhythmic with multiple instruments [R] 45. Noticeable ear preference when using your phone; Check L= Left R= Right N= None L R None Temporal Lobe Auditory Association Cortex (Area 22) Difficulty comprehending meaning of spoken word [L] 47. Tend toward monotone speech without fluctuations or emotions [R] (continued on next page) New Patient Packet_v PAGE 16 OF 25

17 SECTION III: Brain Region Localization Form Medial Temporal Lobe and Hippocampus) Memory less efficient 49. Memory loss that impacts daily activities 50. Confusion about dates, the passage of time, or place 51. Difficulty remembering events 52. Misplacement of things and difficulty retracing steps 53. Difficulty with memory of locations (addresses) 54. Difficulty with visual memory 55. Always forgetting where you put items such as keys, wallet, phone, etc. 56. Difficulty remembering faces 57. Difficulty remembering names with faces 58. Difficulty remembering words 59. Difficulty remembering numbers 60. Difficulty remembering to stay or be on time Occipital Lobe (Area, 17, 18, and 19) Difficulty in discriminating similar shades of color 62. Dullness of colors in visual field 63. Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects 64. Floater or halos in visual field 65. Difficulty with balance, or balance that is worse on one side Cerebellum Spinocerebellum A need to hold the handrail or watch each step carefully when going down stairs 67. Feeling unsteady and prone to falling in the dark 68. Prone to sway to one side when walking or standing 69. Recent clumsiness in hands Cerebellum Cerebrocerebellum Recent clumsiness in feet or frequent tripping 71. A slight hand shake when reaching for something at the end of movement 72. Episodes of dizziness or disorientation (continued on next page) New Patient Packet_v PAGE 17 OF 25

18 SECTION III: Brain Region Localization Form Cerebellum Vestibulocerebellum Back muscles that tire quickly when standing or walking 74. Chronic neck or back muscle tightness 75. Nausea, car sickness, or sea sickness 76. Feeling of disorientation or shifting of the environment 77. Crowded places cause anxiety 78. Slowness in movements Basal Ganglia Direct Pathway Stiffness in your muscles (not joints) that goes away when you move 80. Cramping of hands when writing 81. A stooped posture when walking 82. Voice has become softer 83. Change in facial expression that leads people to frequently ask if you are upset or angry 84. Uncontrollable muscle movements Basal Ganglia Indirect Pathway Intense need to clear your throat regularly, or contract a group of muscles 86. Obsessive compulsive tendencies 87. Constant nervousness and restless mind 88. Dry mouth or eyes Autonomic Reduced Parasympathetic Activity Difficulty swallowing supplements or large bites of food 90. Slow bowel movements and tendency for constipation 91. Chronic digestive complaints 92. Bowel or bladder incontinence resulting in staining your underwear 93. Tendency for anxiety Autonomic Increased Sympathetic Activity Easily startled 95. Difficulty relaxing (continued on next page) New Patient Packet_v PAGE 18 OF 25

19 SECTION III: Brain Region Localization Form 96. Sensitive to bright or flashing lights 97. Episodes of racing heart 98. Difficulty sleeping 99. Have you ever been diagnosed with a seizure disorder? Epileptiform Activity 100. Have you ever been diagnosed with epilepsy? 101. Have you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event? 102. Have you ever experienced sudden muscle stiffness and rigidity throughout your body? 103. Have you ever experienced sudden muscle jerks throughout your body? Have you ever experienced a total loss of your muscle tone that lead to loss of control of your muscles or fall? Have you ever been told that you stare into space while you re lip smacking chewing, or fidgeting? Do you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no reason? Do you ever experience sudden racing heart rate, sudden loss of bladder function, intestinal spasm, respiration, sweating, or any other sudden changes of function? Do you ever experience sudden involuntary muscle contractures or jerks involving any individual parts of your limbs or face? Do you ever experience sudden involuntary head rotation with your eyes moving forcefully to one side? 110. Do you ever experience sudden involuntary shifts in your eyes to the side or upward? Do you ever experience sudden vocalization of random words or notice a sudden 111. inability to speak? Do you ever experience any spontaneous sensations of tingling, pins and needles numbness, 112. coldness, burning or other random sensations in any region of your body? 113. Do you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously? Do you ever experience spontaneous perception of smells such as burning rubber, foul smells 114. without finding the source of the odor? 115. Do you ever experience flashing lights, stars, or jagged lines in your visual field? Yes No New Patient Packet_v PAGE 19 OF 25

20 SECTION IV: Heavy Metal Exposure Symptoms Questionnaire Patient s name (print): Date } Instructions: Please rate the following symptoms from 0 to 10 ( 0 = no symptoms, 10 = high level of symptoms). Rate these as true as possible. Do not over exaggerate. Do not underestimate. Please do not over think. Symptoms Depression / Mood changes 2. Headache 3. Diminished cognitive performance 4. Diminished reaction time 5. Diminished visual motor performance 6. Dizziness 7. Fatigue 8. Forgetfulness 9. Impaired concentration 10. Increased nervousness 11. Irritability 12. Lethargy 13. Malaise 14. Weakness Patient s signature or legally authorized representative: New Patient Packet_v PAGE 20 OF 25

21 SECTION V: Hormone Health Checklist For Women Patient s name (print): Date } Instructions: Please rate and check the following symptoms from Never-1, Mild-2 Moderate-3 to Severe-4. Rate these as true as possible. Do not over exaggerate. Do not underestimate. Please do not over think. Symptoms Never Mild Moderate Severe Impaired concentration Fatigue Memory Loss Mental confusion Decreased sex drive / libido Sleep problems Mood changes / Irritability Tension Migraine / severe headaches Difficult attaining sexual climax Bloating Weight gain Breast tenderness Vaginal dryness Hot flashes Night sweats Dry and wrinkled skin Hair falling out Cold all the time Swelling all over the body Joint pain Family History Yes No Relationship Heart disease Diabetes Osteoporosis Alzheimer s disease Breast cancer New Patient Packet_v PAGE 21 OF 25

22 SECTION V: Hormone Health Checklist For Men Patient s name (print): Date } Instructions: Please rate and check the following symptoms from Never-1, Mild-2 Moderate-3 to Severe-4. Rate these as true as possible. Do not over exaggerate. Do not underestimate. Please do not overthink. Symptoms Never Mild Moderate Severe Decline in general well being Fatigue Joint pain/muscle ache Excessive sweating Sleep problems Increased need for sleep Irritability Nervousness Anxiety Depressed mood Exhaustion / lacking vitality Declining mental ability / focus / concentration Feeling you have passed your peak Feeling burned out/hit rock bottom Decreased muscle strength Weight gain / belly fat / inability to lose weight Breast development Shrinking testicles Rapid hair loss Decrease in beard growth New migraine headaches Decreased desire / libido Decreased morning erections Decreased ability to perform sexually Infrequent of absent ejaculations No results from E.D. medications Family History Yes No Relationship Heart disease Diabetes Osteoporosis Alzheimer s disease Prostate cancer New Patient Packet_v PAGE 22 OF 25

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25 SECTION VIII: Chronic Illness without Diagnosis Patient s name (print): Date } Instructions: Think about how you have been feeling over the previous month and how often the following has bothered you. Check the number you feel best applies to you. Section I: Symptoms Never Sometimes Most of the time All of the time 1. Unexplained fevers, sweats, chills or flushing Unexplained weight loss or gain Fatigue, tiredness Unexplained hair loss Swollen glands Sore throat Testicular pain / Pelvic pain Unexplained menstrual irregularity Unexplained breast milk production, breast pain Irritable bladder or bladder dysfunction Sexual dysfunction / loss of libido Upset stomach Change in bowel function (constipation or diarrhea) Chest pain or rib soreness Shortness of breath / cough Heart palpitations, pulse skips, heart block History of heart murmur or valve prolapse Joint pain or swelling Stiffness of the neck or back Muscle pain or cramps Twitching of the face or other muscles Headaches Neck cracks or neck stiffness Tingling, numbness, burning or stabbing sensations Facial paralysis (Bell s Palsy) Eyes / vision double, blurry Ears / hearing buzzing, ringing, ear pain Increased motion sickness, vertigo (continued on next page ) New Patient Packet_v PAGE 25 OF 25

26 SECTION VIII: Chronic Illness without Diagnosis Section I: Symptoms cont. Never Sometimes Most of the time All of the time 29. Lightheadedness, poor balance, difficulty walking Tremors Confusion, difficulty thinking Difficulty with concentration or reading Forgetfulness, poor short-term memory Disorientation; getting lost, going to wrong places Difficulty with speech or writing Mood swings, irritability, depression Disturbed sleep too much, too little, early awake Exaggerated symptoms or worsening hangovers from alcohol Totals = Please add up your totals from each column, then add up the 4 column totals. This is your first score. This is your score from Section I: } Instructions: Please check off each yes answer to with the following questions: Section II Yes No 39. You have had a tick bite with rash or flu-like symptoms. 3 Points 0 Points 40. You have had a tick bite, an Erythema migrains or undefined rash, followed by flu-like symptoms. 5 Points 0 Points 41. You live in what is considered a Lyme endemic area. 2 Points 0 Points 42. You have a family member diagnosed with Lyme and /or tick-bourne infections. 1 Points 0 Points 43. You experience migratory muscle pain. 4 Points 0 Points 44. You experience migratory joint pain. 4 Points 0 Points 45. You experience tingling / burning/ numbness that migrates and / or comes and goes. 4 Points 0 Points 46. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia. 3 Points 0 Points 47. You have received a prior diagnosis of a non-specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis). 3 Points 0 Points 48. You have had a positive Lyme test (ELISA, Western Blot, PCR). 3 Points 0 Points Totals = Please add up your points from Section II: + Score from Section I: This is your ongoing score = (continued on next page ) New Patient Packet_v PAGE 26 OF 25

27 SECTION VIII: Chronic Illness without Diagnosis Section III 1. Thinking about your overall physical health, how many days during the past 30 days was your physical health not good? 2. You have had a tick bite with rash or flu-like symptoms 0 5 Days = 1 point 6 12 Days = 2 points Days = 3 points Days = 4 points Please add up your points from Section III: + Score from Section I: This is your ongoing score = Section IV Lastly, if you rated a 3 in Section I for ALL of the following symptoms, give yourself 5 points: } Fatigue } Forgetfulness, poor short-term memory } Joint pain or swelling } Tingling, numbness, burning or stabbing sensations } Disturbed sleep too much, too little, early awake Only give yourself these 5 points if you rated 3 for ALL of the above symptoms. Final scoring: 0 20 = Tick borne illness not likely = Tick borne illness possible 46 & above = Tick borne illness highly likely Please, give yourself 5 points and add it to the final score after Section III. This is your final score = New Patient Packet_v PAGE 27 OF 25

28 SECTION IX: Orthopedic Localization Form Patient s name (print): Date } Instructions: The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions and select with a checkmark which best fits for all of your answers. Section I: Symptoms Yes No 1. Do you have pain in your spine? 2. Do you have pain in your arms? 3. Do you have pain in your legs? 4. Do you have pain over your abdomen / torso? 5. Do you have weakness in your back? Pain Level: Do you have weakness in your shoulders? Mild Moderate Severe 7. Do you have weakness in your hips or glutes? 8. Do you have weakness in your arms? Mild Moderate Severe 9. Do you have weakness in your legs? Mild Moderate Severe 10. Do you have weakness in your feet? Mild Moderate Severe 11. Do you have weakness on one side of the body? Mild Moderate Severe 12. Do you have cramping? Mild Moderate Severe 13. Do you get weak with exercises or movement? Mild Moderate Severe 14. Do your muscles cramp and freeze with movement? Mild Moderate Severe 15. Do you have a loss in muscle size? Where? Mild Moderate Severe 16. Have your noticed your muscles jumping? Where? Mild Moderate Severe 17. Do you have weakness in your face? Mild Moderate Severe 18. Do you have problems talking? Mild Moderate Severe 19. Do you have problems swallowing? Mild Moderate Severe 20. Do you have sensory loss or pain down your arm? Mild Moderate Severe 21. Do you have sensory loss or pain down your leg? Mild Moderate Severe 22. Do you have sensory loss on one side of the body? Mild Moderate Severe 23. Do your have sensory loss over your shoulders? Mild Moderate Severe 24. Do you have sensory loss with one arm or portion of the arm? Mild Moderate Severe 25. Do you have sensory loss with one or both hands or a single finger? If so, which areas: Mild Moderate Severe 26. Do you have bowel or bladder control issues? Mild Moderate Severe 27. Do you have sensory loss over your abdomen or torso? Mild Moderate Severe 28. Do you have pain or sensory loss over your hips? Mild Moderate Severe (continued on next page ) New Patient Packet_v PAGE 28 OF 25

29 SECTION IX: Orthopedic Localization Form 29. Do you have pain or sensory loss in one or both legs? Mild Moderate Severe Do you have sensory loss in your feet or a portion of your foot? If so, where?: Do you have sensory loss in your face? If so, where?: Mild Moderate Severe Mild Moderate Severe 32. Do you have high arches? Mild Moderate Severe 33. Do you have hammertoes? Mild Moderate Severe Pain Level: Gait Yes No Do you fall? How often? Mild Moderate Severe 35. Do you have a hard time standing on your toes or heels? Mild Moderate Severe 36. Do you fall to one side? Mild Moderate Severe 37. Do you walk with your legs wide apart? Mild Moderate Severe 38. Do you waddle when you walk? Mild Moderate Severe 39. Do you have a hard time going up or down stairs? Mild Moderate Severe 40. Is an arm or both arms tight or spastic? Mild Moderate Severe 41. Is a leg or both legs spastic? Mild Moderate Severe 42. Do your feet slap when you walk? Mild Moderate Severe 43. Do you have to high step when you walk? Mild Moderate Severe 44. Do you shuffle when you walk? Mild Moderate Severe 45. Is it hard to start walking? Mild Moderate Severe 46. Is it hard to turn if you stop walking? Mild Moderate Severe Patient s name (print): Date New Patient Packet_v PAGE 29 OF 25