CHIRO-MED.Excellence in Chiropractic Medicine

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CHIRO-MED.Excellence in Chiropractic Medicine \~32()0 WI--:ST MAl STREE',V 1480 NORTH CRU~N MOUNT RD. 11I':U,EVILLE, IL 62226 O'FALLON, IL 62269 () I1<-135-3200 lux 618-235-3282 (j IIHi22-2222 1'(1.'< 618-624-8 57 E-Ill,li I: chiromed I@aol.colll E-mail: chiromcdofulloncnsbcglobal.net www.chiromedltd.com Health Profile Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight-loss plan. A client may be advised to seek medical advice based on his or her health profile, General Last Name: First Name: Address: Apt/Unit # City: State: Zip: Phone: Cell: E-mail: ------------- --------- Date of Birth: Age: Profession: Whom may we thank for referring you? Weight Ibs. Weight 1 year ago: Ibs. Min. Adult Weight lbs at age Maximum Weight: lbs. at age Height Do you exercise? 0 Yes If yes, what kind? How often? Have you been on a diet before? 0 Yes If yes, please specify which diet and why you think it didn't work for you (e.q. too rigid, too much cooking involved, etc.): On a scale of 1 to 10, how committed are you to losing fat on this program? (10 being the highestlevelofcommitmenij:

Familv Life: What is your marital status? M SOW Number of children: -------,-.,... Ages:. Do you have children? Medical Information: ( Please list any phy~icians you see"and Hi~ir specialty: Allergies: Do you have any food allergies? If so, please list Do you have any medication allergies? If so, pleas~ list List all medications for allergies on back sheet. Cardiovascular Function: Have you had a cardiovascular event? 0 Yes (if no, check box and skip to next section) If so, please specify: Howlongago? Are you taking any medication? 0 Yes List all medications for cardiovascular function on back sheet. Do you have a history of arrhythmia 0 Yes Have you been diagnosed with Congestive Heart Failure (CHF) 0 Yes Colon Function: o Crohn's disease Do you have: 0 Irritable Bowel 0 Colitis 0 Diarrhea 0 Diverticulosis? 0 Constipation Are you taking any medication? 0 Yes List all medications for colon function on back sheet. Diabetes: Do you have diabetes? 0 Yes (if no, check box and skip to next section) If so, which type? o Type I - insulin dependent (insulin injections only) o Type II - non-insulin dependent (diabetic pills) o Type II - insulin dependent (diabetic pills and insulin) ; Is your blood sugar level monitored? 0 Yes If so, by whom? 0 Myself 0 Physician o Other (specify): Are you taking any medication? 0 Yes List all medications for diabetes on back sheet. Do you tend to be hypoglycemic? 0 Yes

Emotional Evaluation: Do any of the following apply to you? (if no, skip to next section) o Depression 0 Anxiety.0 Panic Attacks LJ Bulimia (or history of) 0 Anorexia (or history of) If so, are you underthe care of a p~y?iciap(?d Yes If so, are you taking any medication? 0 Yes List all medications for emotional conditions on back sheet. General: Do you have Parkinson's disease? 0 Yes Do you have Cancer? 0 Yes Are you in Cancer remission? 0 Yes If so, please specify and indicate for how long: If so, are you under the care of a physician? D' Yes Are you generally fatigued or have low energy? 0 Yes Are you pregnant? 0 Yes Are you breastfeedinq? 0 Yes Do you get cold easily? [j Yes Do you have cold hands/feet? 0 Yes Do you have other health problems? If so, please specify: If so, are you under the care of a physician? Are you taking any medications for any of the above? List all medications for the above on back sheet. Hvpertension: Do you have high blood pressure? 0 Yes If so, do you have your blood pressure checked? If so, are you under the care of a physician? If so, are you taking any medication? List all medications for hypertension on back sheet. (if no, check box and skip to next section) Inflammatorv Conditions: Do any of the following apply to you? (if no, skip to next section) o Migraines 0 Fibromyalgia 0 Rheumatoid Arthritis 0 Lupus Osteoarthritis Chronic Fatigue Syndrome 0 Psoriasis o Other autoimmune or inflammatory condition: If so, are you taking any medication? 0 Yes List all medications for inflammatory conditions on back sheet.

Kidnev Function: Have you been diagnosed with kidney disease? 0 Yes Are you taking any medication? 0 Yes List all medications for kidney function on becic sheet. Have you ever had *idney Stones?'. 0 Yes Have you ever had Gout? 0 Yes (if no, check box and skip to next section) Liver Function: Do you have liver problems? 0 Yes (if no, check box and skip to next section) If so, please specify: --------------------------------------------------------------- No Are you taking any medication? 0 Yes List all medications for liver function on back sheet. No If so, are you taking any medication? 0 Yes List all medications for liver function on back sheet. Muscular/Skeletal Conditions: In which areas do you have aches or pains: o Neck 0 Back 0 Knees 0 Other How often do you take Ibuprofen or other pain reducing medications for the above? List all medications for muscular/skeletal conditions on back sheet. Do you have arth ritis? If so, where? Are you under the care of a physician for your aches and pains? 0 Yes Do you feel your weight has damaged or "worn down" any of your joints? 0 Yes Ovarian/Breast Function: Check off the situations that apply to you currently: o Irregular Periods 0 Menopause 0 Fibrocystic Breasts o Painful Periods 0 Hysterectomy 0 Heavy periods o Amenorrhea 0 Uterine Fibroma 0 Cancer (uterus, breast) If so, are you taking any medication? 0 Yes List all medications for ovarian/breast function on back sheet. Please indicate the date of your last menstrual cycle: Stomach /Digestive Function: Do you have: 0 Acid Reflux 0 Gastric Ulcer 0 Heartburn 0 Celiac Disease? If so, are you taking any medication? 0 Yes List all medications for stomach/digestive function on back sheet. Thvroid Function: Do you have thyroid problems? 0 Yes If so, are you taking any medication? 0 Yes List all medications for thyroid function on back sheet. (if no, check box and skip to next section)

Are you currently taking Vitamins, Herbs or Supplements? Vitamin, Herb or Supplement Name 1. 2. ------- ' s..f Reason -------~--------~-~----------------------- 4. 5. ---------------------------------------- Eating Habits: (please be as honest as possible so that we may better help you) Breakfast Do you have breakfast every morning? 0 Yes 0 Never. Do you have a snack before lunch? 0 Never Lunch Do you have lunch every day? 0 Never Do you have a snack before dinner? 0 Never Dinner Do you have dinner every day? 0 Never Do you eat a snack at night? 0 Never

Other: Do you prefer: 0 Sweet foods 0 Salty foods 0 Fatty foods Are you a vegetarian? 0 Yes How many glasses of water do you drink per day? How many cups of coffee do you drink per-day? glasses cups Do you smoke? \.'.. "0 Yes If yes, how many packs per day? for how many yrs? Do you drink alcohol? 0 Yes If yes, what, how much, and how often? CASH Scale: Compulsions or Cravings/Appetite/Satiety/Hunger Score each item on a 0-10 numbering scale. Each feeling represents a different part of the brain and different neurotransmitters Compulsions/Cravinqs Feeling or urge to eat when not hungry. You are full. There is no food in sight. You get an urge to eat which cannot be repressed. 0----'-1-----2-----3-----4-----5-----6-----7 -----8-----9-----10 Never occurs Constant Appetite Feeling of hunger stimulated by sight, sounds, smells, or social cues. You recently ate and feel full. You walk into a room. There is food everywhere. It looks and smells good. Everyone is having fun. You: 0-----1-----2 -----3-----4-----5-----6-----7 -----8-----9-----10 Never eat more Always eat more Satiety A feeling of fullness acquired during eating. When you eat, you usually: 0-----1-----2-----3-----4-----5-----6-----7 -----8-----9-----10 Leave food on plate one plate only second's thirds Hunger That feeling of a pain or ache in your stomach when really empty. This is a true pain or discomfort. 0-----1-----2-----3-----4-----5-----6-----7 -----8-----9-----10 Never hungry Constant hunger

You must take vitamins and minerals while you are on the Chiro-Med Weight Loss Program. If you stop taking them, you may experience undesirable side effects. (Client's initials) If you are taking medications, are you interested in getting off of any or all of your prescription medications? 0 Yes 0 NOr,~ If you have health problems not indicated on this health profile, please consult your physician. Obesity affects entire families. program? 0 Yes Do you have any family members who could benefit from this Please list all medications which you take on back side of this page. Signature: Date: ------- The signatory client hereby recognizes the veracity of the information provided herein and that he/she has made an informed decision to go on the Chiro-Med Weight Loss Program. You must talk to Dr. Laux prior to starting this diet if you have a history of any of the following: History of a cardia-vascular event: (i.e. heart attack, stroke, aneurysm, by-pass, stent surgery, history of having cardiac arrhythmia including havea pace-maker) History of or current active cancer; including skin cancers Pregnant female (note from OB/GYN ONLY) Breast-feeding female (note from PEDIATRICIAN ONLY) Severe Liver Disease Severe Kidney Disesase Diagnosis or history of Congestive Heart Failure (CHF) Patients currently on Lithium therapy Patients with a diagnosis of Parkinson's Disease Strict Vegan lifestyle

Allergies: MEDICATIONS Please list all medications taken for the following: Inflammatory conditions: Cardiovascular function: Kidney function: Colon function: ------------------- Liver function: Diabetes: -------------- Muscular/skeletal conditions: ~ Emotional conditions: Ovarian/breast function: General medications: ----------- Stomach/digestive function: Hyperiension: Thyroid function: [] Photo First Appointment Weight, o BMI Vitals Blood Pressure o Pulse For Office Use Only Photo Weight. o BMI Final Appointment Vitals Blood Pressure o Pulse H/f you follow the program it works. It's the easiest diet I've ever been on." -Mark Wachtel (lost 227 Ibs. in 50 weeks)

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