NeuroSolutions Initial Intake Name Date Home Address Home Phone Cell Phone Email Address Emergency Contact & Phone Height Weight How did you hear about NeuroSolutions? What is/are your main problem(s)/symptom(s) prompting your request for a consultation? How long have you had this problem for? After you first noticed the symptoms, did they increase significantly within two months, or gradually (longer than two months)? Are your symptoms getting worse, better, or staying the same? Do your symptoms relapse and remit (come and go)? If so, describe Have any of your family members had similar symptoms? 1
Where in your body did your symptoms first originate? Have you had any regular exposure to chemicals or heavy metals (i.e. pesticides, mercury in fish, etc.)? What makes your symptoms feel better? What makes your symptoms feel worse? When are your symptoms most problematic? What have you tried thus far to improve your condition? Describe any balance/mobility difficulties you have Do you have a pacemaker? Yes No Do you have any neck and/or low back discomfort? If yes, please explain How would you rate the average severity over the last two weeks of your most problematic symptom? No discomfort 0 1 2 3 4 5 6 7 8 9 10 Worst discomfort Possible When your symptom is at its worst, how would you rate it? No discomfort 0 1 2 3 4 5 6 7 8 9 10 Worst discomfort Possible How is your condition impacting your life? What would you like to do, that you are unable to do? What is your desired goal from care? What would realizing this mean to you? On a scale from 0 to 10, how committed are you to resolving your condition? 0 1 2 3 4 5 6 7 8 9 10 2
Have you ever been tested/evaluated for: Diabetes No Yes Results Anytime of autoimmune disease/dysfunction No Yes Results B12, B6, and/or Copper levels No Yes Results Heavy metal or chemical toxicity No Yes Results Plantar Fasciitis No Yes Results Morton s Neuroma No Yes Results HIV No Yes Results CIDP No Yes Results Spinal Stenosis No Yes Results Degenerative disc disease/bulging disc/herniated disc No Yes Results Cancer (any type) No Yes Results Vasculitis No Yes Results List all current diagnoses not mentioned above List all surgeries you have previously had and the year you had it Please list the prescription drugs you are currently taking, or attach a list Name Dose (MG or IU) Times Daily Have you ever taken chemotherapy drugs? If so, which ones, what doses, when you started and stopped taking them. List all Nutritional Supplements (vitamins, herbs, homeopathics, etc.) and the doses 3
Describe your exercise habits (how often, for how long, and what type(s)) How many servings of refined carbohydrates (i.e. pasta, soda, candy, bread, etc.) do you have per day on average? How many servings of vegetables do you have per day on average? How much water do you drink on average per day? Do you drink tap water? Yes No Do you use pesticides or any other chemicals in your home? Yes No Do you regularly eat fish? Yes No Do you use cosmetics, nail polish, perfume, hair spray etc.? Yes No Do you smoke? Yes No If so, how much? Do you drink alcohol? Yes No If so, how much on average per week? Please give name, address, and office phone of your primary care physician/family doctor When were you last seen there May we send them updates on your treatment/condition Yes No List all allergies (or sensitivities) to medicines, foods, and other items 4
Guide to answer the following questions. Circle one for each line. 0 = Never, 1 = Rarely, 2 = Occasional, 3 = Often, 4 = Frequently. HEAD HEART Headaches 0 1 2 3 4 Skipped Heartbeats 0 1 2 3 4 Dizziness 0 1 2 3 4 Rapid heartbeat 0 1 2 3 4 Pressure 0 1 2 3 4 Chest Pain 0 1 2 3 4 Faintness 0 1 2 3 4 BLADDER / OTHER MIND Frequent or urgent urination 0 1 2 3 4 Poor Memory 0 1 2 3 4 Leaky bladder 0 1 2 3 4 Confusion 0 1 2 3 4 Frequent illness 0 1 2 3 4 Difficulty making decisions 0 1 2 3 4 SKIN Stuttering 0 1 2 3 4 Acne 0 1 2 3 4 Slurred speech 0 1 2 3 4 Hives, rashes, dry skin 0 1 2 3 4 Learning Disability 0 1 2 3 4 Hair loss 0 1 2 3 4 Poor coordination 0 1 2 3 4 Flushing 0 1 2 3 4 EYES Excessive sweating 0 1 2 3 4 Watery itchy eyes 0 1 2 3 4 JOINTS / MUSCLE Swollen, reddened 0 1 2 3 4 Pain or aches in joints 0 1 2 3 4 Dark Circles under eyes 0 1 2 3 4 Rheumatoid Arthritis 0 1 2 3 4 Blurred or tunnel vision 0 1 2 3 4 Osteoarthritis 0 1 2 3 4 EARS Stiffness/limited movement 0 1 2 3 4 Itchy Ears 0 1 2 3 4 Muscle pain or aches 0 1 2 3 4 Ear aches, infections 0 1 2 3 4 Frequent back pain 0 1 2 3 4 Drainage from ear 0 1 2 3 4 Weak or tired feeling 0 1 2 3 4 Ringing or hearing loss 0 1 2 3 4 WEIGHT NOSE Binge eating or drinking 0 1 2 3 4 Stuffy nose 0 1 2 3 4 Craving certain foods 0 1 2 3 4 Sinus Problems 0 1 2 3 4 Excessive weight 0 1 2 3 4 Hay Fever 0 1 2 3 4 Compulsive eating 0 1 2 3 4 Sneezing attacks 0 1 2 3 4 Water retention 0 1 2 3 4 Excessive mucous 0 1 2 3 4 Under weight 0 1 2 3 4 MOUTH / THROAT EMOTIONS Chronic coughing 0 1 2 3 4 Mood swings 0 1 2 3 4 Gagging 0 1 2 3 4 Anxiety/Fear/Nervousness 0 1 2 3 4 Need to clear your throat 0 1 2 3 4 Anger/Irritability 0 1 2 3 4 Swollen tongue, gums 0 1 2 3 4 Depression 0 1 2 3 4 DIGESTIVE Sense of despair 0 1 2 3 4 Nausea or vomiting 0 1 2 3 4 Lethargy/Fatigue 0 1 2 3 4 Diarrhea 0 1 2 3 4 ENERGY Constipation 0 1 2 3 4 Fatigue or sluggishness 0 1 2 3 4 Gas, bloating 0 1 2 3 4 Hyperactivity 0 1 2 3 4 LUNGS Restlessness 0 1 2 3 4 Chest congestion 0 1 2 3 4 Difficulty getting to sleep 0 1 2 3 4 Asthma, bronchitis 0 1 2 3 4 Difficulty staying asleep 0 1 2 3 4 Shortness of breath 0 1 2 3 4 Difficulty breathing 0 1 2 3 4 5