SIGNATURE OF PARENT/GUARDIAN

Transcription

1 Cory M. Blust, MT INFORMED CONSENT Signing this form indicates that you are voluntarily and knowingly undergoing a procedure referred to by FDA as Electro Dermal Screening. It is a form of modern bio-energetic science. The technique was discovered by Dr. Voll, M.D. of Germany around The procedure is totally non-invasive (the skin is not punctured). This procedure includes the application of an electronic probe of five volts to measure skin resistance at selected acupuncture sites located on the hands and feet. It will then be determined as to which natural substances will be needed to re-establish proper balance to the body s chemistry. Because the procedure involves only the measurement of changes in the meridian flow with a sensitive meter, it is completely safe. The only sensation that is usually felt is just the pressure of the electronic probe as it is pushed against the skin. The use of the computer makes the procedure extremely fast. Please note that the equipment utilized is nondiagnostic in nature. At no time will there be any implied and/or stated indication for any client to discontinue taking any medication as prescribed by his/her physician. At no time will there be any implied and/or stated indication to any client to discontinue care under the direction of any other physician. This procedure is approved by the FDA for investigative use only at this time and is non intended, implied or stated to take the place of any conventional medical test and/or diagnostic procedure. At no time can this office guarantee implied and/or stated resolvement, but it has been found that complete client compliance to the natural health care recommendation usually results in greater and more consistent changes towards better health. If you, the client, wish to decline participation in this program, you may do so at any time. This office reserves the right to dismiss any client at any time due to poor compliance to the program. I have fully read and understand the above information, the elements of informed consent, my responsibilities and rights, and hereby consent to the participation in the Electro Dermal Screening procedure. SIGNATURE DATE SIGNATURE OF PARENT/GUARDIAN DATE WITNESS DATE

2 Cory M. Blust, MT Homeopathy/Meridian Stress Assessment/Electro Dermal Screening MEDICAL CLIENT/FAMILY HISTORY GENERAL INFORMATION Name Address No./St./Rd. City State Zip Phone: Home Cell Phone Work Address Sex: F G M G Age Date of Birth Marital Status: S G M G D G W G Client employed by Referred By Current Treating Physician Current Rx (Prescription) Medications Current Over-the-Counter Medications Current Health Care Professional(s) You Are Working With (Therapists, Healers, Helpers, Etc.) Current Non-Rx Supplements (Vitamins, Minerals, Herbal, Homeopathic, Etc.) Illnesses, Operations, Accidents, Injuries, Diseases

3 Illnesses, Operations, Accidents, Injuries, Diseases (continued) MEDICAL CLIENT/FAMILY HISTORY - Page 2 _ REVIEW OF SYMPTOMS Chief Complaints/Symptoms in order of severity: 1) 2) 3) 4) 5) CLIENT S SOCIAL HISTORY Use of Alcohol G Never G Rarely G Moderate G Daily Use of Tobacco G Never G Previously, G Current Packs/Day But Quit Use of Drugs G Never Type/Frequency Excessive Exposure at Home or Work to: G Fumes G Dust G Solvents G Air-Borne Particles G Noise FAMILY MEDICAL HISTORY Age Diseases If Deceased, Cause Father Mother Siblings Spouse Children

4 1 - Acid foods upset 2 - Get chilled, often 3 - Lump in throat 4 - Dry mouth-eyes-nose 5 - Pulse speeds after meal 6 - Keyed up - fail to calm 7 - Cuts heal slowly Group One 8 - Gag Easily 9 - Unable to relax, startles easily 10 - Extremities cold, clammy 11 - Strong light irritates 12 - Urine amount reduced 13 - Heart pounds after retiring 14 - Nervous stomach Cory M. Blust, MT Homeopathy/Meridian Stress Assessment/Electro Dermal Screening Client Date Instructions: Write the number that applies to you. If a symptom does not apply, leave it blank. Write either: (1) for Mild symptoms (occurs rarely), (2) for Moderate symptoms (occurs several times a month), or (3) for Severe symptoms (occurs almost constantly) Appetite reduced 16 - Cold sweats often 17 - Fever easily raised 18 - Neuralgia-like pains 19 - Staring, blinks little 20 - Sour stomach frequent 21 - Joint stiffness after arising 22 - Muscle-leg-toe cramps at night 23 - Butterfly stomach, cramps 24 - Eyes or nose watery 25 - Eyes blink often 26 - Eyelids swollen, puffy 27 - Indigestion soon after meals 28 - Always seem hungry; Feels lightheaded often 42 - Eat when nervous 43 - Excessive appetite 44 - Hungry between meals 45 - Irritable before meals 46 - Get shaky if hungry 47 - Fatigue, eating relieves 48 - Lightheaded if meals delayed 56 - Hands and feet go to sleep Easily, numbness 57 - Sigh frequently, air hunger 58 - Aware of breathing heavily 59 - High altitude discomfort 60 - Opens windows in closed room 61 - Susceptible to colds and fevers 62 - Afternoon yawner Group Two 29 - Digestion rapid 30 - Vomiting frequent 31 - Hoarseness 32 - Breathing irregular 33 - Pulse slow; feels irregular 34 - Gagging reflex slow 35 - Difficulty swallowing 36 - Constipation, Diarrhea alternating Group Three 49 - Heart palpitates if meals Missed or delayed 50 - Afternoon headaches 51 - Overeating sweets upsets 52 - Awaken after few hours sleep - hard to get back to sleep Group Four 63 - Get drowsy often 64 - Swollen ankles Worse at night 65 - Muscle cramps, worse during Exercise: get charley horses 66 - Shortness of breath on exertion 67 - Dull pain in chest or radiating into left arm, worse on exertion 37 - Slow starter 38 - Get chilled infrequent 39 - Perspire easily 40 - Circulation poor, Sensitive to cold 41 - Subject to colds, Asthma, bronchitis 53 - Crave candy or coffee In afternoons 54 - Moods of depression - blues or melancholy 55 - Abnormal craving for Sweets or snacks 68 - Bruise easily, black and blue spots 69 - Tendency to anemia 70 - Nose bleeds frequent 71 - Noises in head, or ringing in ears 72 - Tension under the breastbone, or feeling of tightness worse on exertion

5 73 - Dizziness 74 - Dry skin 75 - Burning feet 76 - Blurred vision 77 - Itching skin and feet 78 - Excessive falling hair 79 - Frequent skin rashes 80 - Bitter, metallic taste in mouth in mornings 81 - Bowel movements painful or difficult 82 - Worrier, feels insecure Homeopathy/Meridian Stress Assessment/Electro Dermal Screening - Page 2 Group Five 83 - Feeling queasy; headache over eyes 84 - Greasy foods upset 85 - Stools light-colored 86 - Skin peels on foot soles 87 - Pain between shoulder blades 88 - Use laxatives 89 - Stools alternate from soft to watery 90 - History of gallbladder attacks or gallstones 91 - Sneezing attacks 92 - Dreaming, nightmare type bad dreams 93 - Bad breath (halitosis) 94 - Milk products cause distress 95 - Sensitive to hot weather 96 - Burning or itching anus 97 - Crave sweets 98 - Loss of taste for meat 99 - Lower bowel gas several hours after eating Burning stomach sensations, eating relieves (A) Insomnia Nervousness Cant t gain weight Intolerance to heat Highly emotional Flush easily Night sweats Thin, moist skin Inward trembling Heart palpitates Increased appetite without gain Pulse fast at rest Eyelids and face twitch Irritable and restless Can t work under pressure (B) Increase in weight Decrease in appetite Fatigue easily Ringing in ears Sleepy during day Sensitive to cold Dry to scaly skin Constipation Mental sluggishness Hair coarse, falls out Headaches upon arising wear off during day Group Six Coated tongue Pass large amounts of foulsmelling gas Indigestion ½ - 1 hour after Group Seven Slow pulse, below Frequency of urination Impaired hearing Reduced initiative (C) Failing memory Low blood pressure Increased sex drive Headaches, splitting or rendering type Decreased sugar tolerance (D) Abnormal thirst Bloating of abdomen Weight gain around hips or waist Sex drive reduced or lacking Tendency to ulcers, colitis Increased sugar tolerance Women: menstrual disorders Young girls: lack of menstrual function Mucous colitis or irritable bowel Gas shortly after eating Stomach bloating eating; may be up to 3-4 hours after (E) Dizziness Headaches Hot flashes Increased blood pressure Hair growth on face or body (female) Sugar in urine (not diabetes) Masculine tendencies (female) (F) Weakness, dizziness Chronic fatigue Low blood pressure Nails, weak, ridged Tendency to hives Arthritic tendencies Perspiration increase Bowel disorders Poor circulation Swollen ankles Crave salt Brown spots or bronzing of skin Allergies - tendency to asthma Weakness after colds, influenza Exhaustion - muscular and nervous Respiratory disorders

6 Group Eight Apprehension Irritability Morbid fears Never seems to get well Forgetfulness Indigestion Poor appetite Craving for sweets Muscular soreness Depression; feelings of dead Noise sensitivity Acoustic hallucinations Tendency to cry without reason Hair is coarse and/or thinning Weakness Fatigue Skin sensitive to touch Tendency toward hives Nervousness Headache Insomnia Anxiety Anorexia Inability to concentrate; confusion Frequent stuff nose; sinus infections Allergy to some foods Loose joints Homeopathy/Meridian Stress Assessment/Electro Dermal Screening - Page 3 Female Only Male Only Very easily fatigued Premenstrual tension Painful menses Depressed feelings before menstruation Menstruation excessive and prolonged Painful breasts Menstruate too frequently Vaginal discharge Hysterectomy/ovaries removed Menopausal hot flashes Menses scanty or missed Acne, worse at menses Depression of long standing Prostate trouble Urination difficult or dribbling Night urination frequent Depression Pain on inside of legs or heels Feeling of incomplete bowel evacuation Lack of energy Migrating aches and pains Tire too easily Avoids activity Leg nervousness at night Diminished sex drive

7 Cory M. Blust, MT DENTAL QUESTIONNAIRE 1) Do you brush your teeth at least twice daily? Yes G No G 2) Do you floss regularly? Yes G No G 3) Do you have silver mercury fillings in your mouth? Yes G No G 4) If you answered yes, how many fillings do you have? 5) How old are your fillings? 6) Are any of your fillings cracked, chipped or damaged? Yes No If so, for how long? 7) Have you ever swallowed a piece of broken or chipped filling? Yes G No G 8) Do you have any crowns? Yes G No G 9) If you answered yes, how many crowns do you have? 10) What type of crowns do you have? Gold Porcelain With Gold Base Other 11) Do you have any bridges or other dental appliances in your mouth? Yes G No G 12) If you answered yes, please explain 13) Do you wear dentures? Yes G No G 15) Do you have any root canals? Yes G No G 16) If you answered yes, how many root canals do you have? 17) Have you had any teeth extracted due to abscess or infection? Yes G No G 18) Have you ever taken antibiotics for a dental abscess, infection or root canal work? Yes G No G