Please answer the questions on this form as they relate to the person being evaluated.
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1 Please answer the questions on this form as they relate to the person being evaluated. Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand: We do not treat symptoms, illness, conditions or diseases. This is not a treatment for allergies, this does not diagnose allergies or relieve allergies A symptom is an attempt by your body to tell you something. We identify substances that may cause stress on the body and work to reduce substance specific stress using a combination of Low Level Light Therapy, Acupoint Stimulation, Homeopathy, Nutrition and Energetic Information to help bring the body back into balance We do not use drugs in this program. There is no single method that will work for everyone but this integrative approach can help increase your core level energy, boost your immune system and help your body better deal with substance stressors leading to a higher quality of life Just because certain substances are considered healthy or safe, this does not mean they are appropriate, healthy or safe for you. Your diet and environment consists of everything you eat, drink, rub on your skin, or inhale Our procedures are safe, non-invasive and painless. If you suffer from anaphylaxis, we recommended you consult your primary care physician for medical treatment appropriate for you. If you believe you suffer from allergies, we recommend you consult with your general practitioner, immunologist or board certified allergist before seeking alternative care. Candida Questionnaire and Score Sheet This questionnaire is designed for adults and the scoring system isn't appropriate for children. It lists factors in your medical history which promote the growth of Candida Albicans (Section A), and symptoms commonly found in individuals with yeastconnected illness (Sections B and C). For each "Yes" answer in Section A, circle the Point Score in that section. Total your score and record it on the line at the end of the section. Then move on to Sections B and C and score as directed. Filling out and scoring this questionnaire should help you and your physician evaluate the possible role of Candida in contributing to your health problem. It will not provide an automatic "Yes" or "No" answer. 15 BioLight Technologies 1
2 Section A: History Point Score 1. Have you taken tetracycline's (or other antibiotics) for 2 months (or longer)? Have you, at any time in your life, taken other "broad spectrum" antibiotics (Including Keflex, ampicillin, amoxicillin, Ceclor, Bactrim, and Septra *) for respiratory, urinary or other infections (for 2 months or longer, or in shorter courses 4 or more times in a 1-year period? Have you, at any time in your life, been troubled by persistent vaginal problems or had 3 or more episodes of vaginitis in a year? Have you been pregnant 2 or more times? Have you been pregnant 1 time? Have you taken birth control pills for more than 2 years? For 6 months to 2 years? Have you taken prednisone, Decadron or other cortisone-type drugs for more than 2 weeks? For 2 weeks or less? Does exposure to perfumes, insecticides, fabric shop odors and other chemicals provoke... Moderate to severe symptoms? Mild symptoms? 8. Are your symptoms worse on damp, muggy days or in moldy places? 9. Have you had persistent athlete's foot, "jock itch", or other chronic fungous infections of the skin or nails? Have such infections been... Severe or persistent? Mild to moderate? 10. Do you crave sugar? Do you crave breads? Do you crave alcoholic beverages? Does tobacco smoke really bother you? A... *Such antibiotics kill off "good germs" while they're killing off those which cause infection. 15 BioLight Technologies 2
3 Section B: Major Symptoms For each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is mild,... score 3 points. If a symptom is moderate,... score 6 points. If a symptom is severe or disabling,... score 9 points. Add total score for this section and record it on the line at the end of this section. 1. Fatigue or lethargy. 2. Feeling of being "drained" 3. Poor memory 4. Feeling "spacey " or "unreal" 5. Depression 6. Numbness, burning or tingling 7. Muscle aches 8. Muscle weakness or paralysis 9. Pain and/or swelling in joints 10. Abdominal pain 11. Constipation 12. Diarrhea 13. Bloating 14. Troublesome vaginal discharge 15. Persistent vaginal burning or itching 16. Prostatitis 17. Impotence 18. Loss of sexual feeling 19. Endometriosis. Dysmenorrhea 21. Premenstrual tension 22. Spots in front of eyes 23 Erratic Vision Point Score B BioLight Technologies 3
4 Section C: Other Symptoms For each symptom which is present, enter the appropriate figure in the Point Score column: If a symptom is mild,... score 1 points. If a symptom is moderate,... score 2 points. If a symptom is severe or disabling,... score 3 points. Add total score for this section and record it on the line at the end of this section. *While the symptoms in this section occur commonly in patients with yeast-connected illness, they also occur commonly in patients who do not have Candida. 1. Drowsiness 2. Irritability or jitteriness 3. Incoordination 4. Inability to concentrate 5. Frequent mood swings 6. Headache 7. Dizziness / loss of balance 8. Pressure above ears...feeling of head swelling and tingling 9. Itching 10. Other rashes 11. Heartburn 12. Indigestion 13. Belching and intestinal gas 14. Mucus in stools 15. Hemorrhoids 16. Dry mouth 17. Rash or blisters in mouth 18. Bad breath 19. Joint swelling or arthritis. Nasal congestion or discharge 21. Postnasal drip 22. Nasal itching Point Score 15 BioLight Technologies 4
5 23. Sore or dry throat 24. Cough 25. Pain or tightness in chest 26. Wheezing or shortness of breath 27. Urgency or urinary frequency 28. Burning on urination 29. Failing vision 30. Burning or tearing eyes 31. Recurrent ear infections 32. Fluid in ears 33. Ear pain or deafness 34. Tubes in ears 35. Other symptoms: C... GRAND TOTAL SCORE (Add up Total Score for Sections A, B, and C)... Evaluation: (Note that the scoring will be different for females and males since seven questions apply exclusively to women, while only two apply exclusively to men.) If your point score is over 180 in women (and 140 in men), Candida almost certainly plays a role in causing your health problems. If your point score is over 1 in women (and 90 in men), Candida probably plays a role in causing your health problems. If your point score is 60 to 1 for women (and 40 to 90 in men), Candida possibly plays a role in causing your health problems. If your point score is less than 60 for women (and 40 for men), Candida is less apt to be playing a significant role in causing your health problems. 15 BioLight Technologies 5
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Patient History Questionnaire
Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency
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
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
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
ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you
ACUPUNCTURE SPECIFIC INTAKE FORM
ACUPUNCTURE SPECIFIC INTAKE FORM A naturopathic 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
New Patient Questionnaire
- - Toda y 's Date: Primary Care Provider's Name: Was a consultation recommended? Primary Clinic: Referring provider's name (if different): Please answer the following questions to facilitate the diagnosis