TABLE OF CONTENTS INTRODUCTION DIGESTION SUGAR HANDLING MUSCULOSKELETAL. Introduction I

Similar documents
INDEX. Copyright 2004

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

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

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

EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)

Initial Consultation

Functional Blood Chemistry & CBC Analysis

Patient Medical History

Medical History Form

LECOM Health Ophthalmology

06/09/2005 Medical history and intake form

Patient History Form

Patient Admittance Form

Nutrition Consultation Intake Form Please write or print clearly

Morris Medical Center, P.A.

WELLNESS HISTORY. Patient s Name: Date

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

Metabolic Assessment Form

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

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Welcome to About Women by Women

Who is filling out this intake form? Self Spouse Parent Guardian

Patient History Form

Family Naturopathic Clinic

1 Nutritional Reference Guide 2015 Dr. Todd Singleton

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Medical History Form

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

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

stoneburner acupuncture

J. B. Chapman Dr. Schussler's Biochemistry

Adams Memorial Hospital Decatur, Indiana EXPLANATION OF LABORATORY TESTS

Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:

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

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

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

Personal Health Profile. Address:

New Patient Intake Form

Patient Health History

LAKES INTERNAL MEDICINE

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

Mast Cell Activation Syndrome

Adult Health History Summary

NEW PATIENT QUESTIONNAIRE

OKANAGAN HEALTH & PERFORMANCE Inc.

MEDICAL HISTORY (To be filled in by patient)

Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.

what vitamins are what vitamins are for

Bodily Conditions Rooted in Hormone Imbalance

PEDIATRIC REGISTRATION FORM

Inner Balance Acupuncture

PATIENT MEDICAL HISTORY INTAKE FORM

Multiphasic Blood Analysis

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:

Client Questionnaire. Name: Date: Address: Phone: Height Weight Relationship Status Children: Occupation:

What do you believe is causing your most important health concern?

HEALTH PARTICIPATION CLIENT INTAKE FORM (Please Print) CLIENT INFORMATION

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

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

Blood Test Results Report

New Patient Intake Form

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Pure Health Natural Medicine

ENDOCRINE CONDITIONS ENDOCRINE EN-1

Clinical Herbal Medicine

Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?

New Patient Information

Medical History Form

Pre-Admission Testing Questionnaire

VIPUL M DESAI

Table 1 CDC Diagnostic Criteria for Chronic Fatigue Syndrome

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Evolve180 / Ideal Northwest Health Profile

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

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

Acupuncture Patient Health History

PATIENT INFORMATION FORM (WOMEN ONLY)

Pharmacy Prep. Qualifying Pharmacy Review

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

Creve Coeur Family Medicine, LLC

B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel

Ageless Acupuncture Patient Health History

Patient Name Date of Birth Age. Other phone ( ) . Other

ACUPUNCTURE INTAKE FORM

VASCULAR SURGERY PATIENT HEALTH HISTORY

For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.

THE OB/GYN CENTRE NEW PATIENT HISTORY

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

Headache Follow-up Visit Form

DEPARTMENT OF MEDICINE Outpatient Intake Form

Adult Health History

Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?

Transcription:

INTRODUCTION TABLE OF CONTENTS Introduction I DIGESTION Acid Indigestion D1 Excessive Appetite D9 Reduced Appetite D13 Biliary Insufficiency D19 Colitis D27 Constipation D33 Dry Mouth D39 Dysbiosis D43 Flatulence D51 Gastritis D55 Gum Disease D61 Halitosis D65 Ileitis D69 SUGAR HANDLING Blood Sugar Stabilization S1 Type II Diabetes S9 Healthy Hormone Diet S13 Sugar Control Diet S15 10 Guidelines for a Healthy Diet S17 Weight Management S19 MUSCULOSKELETAL Aerobic Endurance M1 Anaerobic Enhancement M7 Bone Healing M13 Bone Spurs M19 Carpel Tunnel M23 Degenerative Disc M27 Osteoarthritis M31 Osteoporosis M37

Athletic Nutrition M43 ENDOCRINE PMS EN3 Menstrual cramping EN4 Heavy menstrual flow (hemorrhage) EN4 Scanty menstrual flow EN5 Endometriosis EN5 Female libido EN5 Female infertility EN5 Morning sickness EN6 Pregnant or lactating females EN6 Lactation, dried up EN6 Postpartum depression EN7 Shrink uterus after pregnancy EN7 Varicose veins EN7 Vaginal tract dry EN8 Vaginal yeast EN8 Hot flashes EN8 Menopausal support EN9 Male libido EN9 Male fertility EN10 Benign prostrate hypertrophy EN10 Male erectile dysfunction EN10 Hypothyroid EN11 Hyperthyroid EN11 Hashimotos Thyroiditis EN11 Hypoadrenia EN12 Hyperadrenia EN12 Diabetes EN12 Hypoglycemia EN13 IMMUNE Chronic Immune Conditions Hepatitis, viral IM4 Hepatic sclerosis IM4 Free radical pathology/cancer IM4 Chemotherapy support program IM5 Acquired Immune Deficiency Syndrome (AIDS) IM6 Bladder irritation, chronic ( Leaky Bladder ) IM7 Lung congestion, chronic IM7

Autoimmune IM7 Myasthenia gravis IM9 Lou Gehrig s Disease (ALS) IM9 Airborne allergies IM10 Food allergies IM10 Fibromyalgia IM10 Lymph adenopathy, chronic (swollen lymph nodes) IM11 Non-Chronic Immune Conditions Colds and flu IM11 Sinus congestion IM12 Sore throat IM12 Chest cold- lung congestion IM13 Lymph glands swollen IM13 Herpes simplex I or II, shingles, chicken pox (active outbreak) IM14 Herpes or shingles virus (dormant) IM14 Stomachache or food poisoning IM14 Bladder irritation or infection IM15 CARDIOVASCULAR Angina C1 Arrhythmia C5 Arteriosclerosis C11 Atherosclerosis C17 Cholesterol C23 Homocystine C29 Hypertension C33 Congestive heart failure C41 Cardiac Support, Maintenance C41 Arrhythmia s, alternative support C41 Angina, alternative support C42 Oral Chelation C42 Peripheral vascular disease C43 Hypertension, alternative support C43 RENAL AND BLADDER Kidney support RB2 Kidney stones RB2 Bladder infections RB3 Leaky bladder RB3 Interstitial cystitis RB3

DETOXIFICATION Gastrointestinal detoxification (Upper GI) DT5 Gastrointestinal detoxification (Lower GI) DT5 Liver detoxification DT6 Gallbladder flush DT6 Heavy metals detoxification DT7 Chemical detoxification DT8 NEUROLOGICAL AND PSYCHOLOGICAL Alzheimer s NP2 Memory failing ( sometimers ) NP2 Anxiety NP3 Depression NP3 Seasonal sadness NP3 Nerve pain (sciatica/trigeminal neuritis) NP4 Raynaud s Syndrome NP4 Parkinson s Syndrome NP5 Amyotrophic lateral sclerosis (ALS or Lou Gehrig s Disease) NP6 Dyslexia NP6 Nerve injuries NP6 Stroke prevention (occlusive stroke) NP7 Stroke prevention (hemorrhagic stroke or aneurysm) NP7 PEDIATRIC ADD/ADHD PD2 Allergy to cows milk PD2 Allergies, Food PD3 Alternating constipation/diarrhea PD3 Asthma PD3 Bed-wetting PD4 Blue baby PD4 Breastfeeding PD4 Breast milk decreased PD5 Bronchitis for infants PD5 Childhood diseases PD5 Colic PD6 Constipation PD6 Cradle Cap PD6 Croup PD6 Crying (constant) PD7

Diarrhea PD7 Ear ache PD7 Eyes weak PD8 Fever PD8 Growing pains PD8 Hay fever PD8 Increase mental function PD9 Loss of appetite PD9 Mononucleosis PD10 Mouth ulcer PD10 Overweight PD10 Pneumonia PD11 Rheumatic fever PD11 Small Stature PD11 Sore Throat PD12 Strep Throat PD12 Thrush PD12 Tonsillitis PD12 Toothache PD12 Vomiting PD13 Whooping Cough PD13 Worms PD13 BLOOD CHEMISTRY Albumin Decreased BC1 Alkaline Phosphatase High BC1 Anemia (Low Red Blood Count) BC2 Bands, High BC2 Basophils High BC2 Bilirubin High, Direct BC3 Bun High BC3 Serum Calcium High BC3 Serum Calcium Low BC4 Cholesterol High BC4 Cholesterol Low BC4 Creatinine High BC4 C Reactive Protein High BC5 Eosinophils High BC5 Glucose High BC5 Glucose Low BC6 Hematocrit High BC6 Hematocrit Low BC6

Hemoglobin Low BC6 Hyperchromatosis BC6 LDH (Lactate Dehydrogenase), Elevated Liver Enzymes BC6 LDH (Lactate Dehydrogenase), Elevated Cardiac Enzymes BC7 LDH (Lactate Dehydrogenase) Elevated Lung Enzymes BC7 LDH (Lactate Dehydrogenase) Elevated Muscle Enzymes BC7 LDH (Lactate Dehydrogenase) Elevated Kidney Enzymes BC7 Lymphocytes High BC7 Lymphocytes Low BC8 Monocytes High BC8 Monocytes Low BC8 Neutrophils Low BC8 Neutrophils High BC9 Platelet Count Low BC9 SED Rate High BC9 SGOT Elevated BC9 Total Protein High BC10 Total Protein Low BC10 Triglycerides High BC10 Urea High BC10 Uric Acid High BC10 White Blood Cell Count Low (leukopenia, chronic immune challenge) BC11 White Blood Cell Count High (leukocytosis, transient immune challenge) BC11 White Blood Cell Count High (leukocytosis, transient immune challenge) BC12 PRODUCT INGREDIENTS ADHS through Remedy #10 P-1through P-66

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback