Have you ever been diagnosed with any of the following? The patient has a history of the following conditions: Glaucoma

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PALMETTO PHYSICAL MEDICINE 10 FINANCIAL BOULEVARD ANDERSON, SC 29621 PHONE (864) 437.8930 FAX (864) 309.8004 Have you ever been diagnosed with any of the following? Palpitation/Flutter Feelings Edema/Swelling Insomnia Racing Heart/Tachycardia Chest Pain Shortness of Breath Headaches Hypertension Deviated Septum Insulin Dependent Diabetes Hypoglycemia Mucosa Disorder The patient has a history of the following conditions: Coronary Artery Disease Glaucoma Heart Valve Disease Dysrhythmias Are you currently being treated for any medical conditions? Yes No If so, by whom are you being treated? Where are you being treated? What are you being treated for? Past Hospitalizations: None List Below Date: 1 Notes:

Past Surgical History: None Appendectomy Cardiovascular Procedure Cervical Spine Hysterectomy Joint Replacement Prostate Gall Bladder Lumbar Spine Carpal Tunnel Shoulder Thoracic Spine Thyroid Hip Gastro-Intestinal Hernia Knee Other: What is your daily/weekly intake of the following? How Much? Do you drink alcohol? Yes No Do you drink caffeine? Yes No Have you ever been hospitalized, under medical care, or checked into rehab for alcohol or drug treatment? If you answered yes, please explain: Yes No Explain: Are you currently pregnant, or do you think that you might be pregnant at this time? No, I am definitely not pregnant at this time. Yes, I am definitely pregnant. There is a possibility that I may be pregnant at this time. Are you breastfeeding? Yes No 2

MEMORANDUM FOR RECORD What, exactly, is your goal? Why is that your goal? Why is it an issue? What are you doing to get there? What are you willing to do to (insert goal here)? Identified Fat Storing Triggers: Have you ever Detoxed your body? Yes No If so, what was used? Result? Do you currently exercise? Yes No If so, how many times per week on average? What types of exercise do you do? Do you currently take any of the following supplements? Magnesium MSM Collagen Vitamin B Vitamin D Do you have any of the following problems with your weight? Inability to Lose Weight: 3

Food Cravings: Binge Eating: Water Retention: Do you have any of the following Digestive symptoms? Constipation: Diarrhea: Reflux or Heartburn: Bloating: Gas: Nausea or Vomiting: Stomach Pains or Cramping: Do you have any of the following problems with your Head or Ears? Migraines: Headaches: Earaches: Ear Infection: Ringing in Ears: Do you have any of the following problems with your Eyes or Throat? Itchy Eyes: Watery Eyes: Sore Throat: Persistent Canker Sores: 4

Do you have any of the following Sinus/Respiratory symptoms? Stuffy or runny nose: Asthma: Chest Congestion: Chronic Cough: Wheezing: Frequent Sneezing: Do you have any of the following Skin Disorders? Eczema: Dermatitis: Excessive Sweating: Rashes: Hives: Nail Fungus: Do you have any of the following problems with your Emotional/Mental state of mind? Depression: Anxiety: Mood Swings: Irritability: Poor Concentration: 5

Do you have any of the following other symptoms? Joint Pain: Arthritis: Swelling/Edema: Chest Pains: Muscle Aches: Do you have any of the following problems with your Energy? Fatigue: Hyperactivity: Lethargy: Restlessness: Insomnia: Females Only: Actively trying to conceive or not using birth control Pregnant Using birth control Hysterectomy HOW ARE YOU SUPPRESSING FAT BURNING HORMONES? Consume Caffeine Eat Carbohydrates Eat/Drink Sugar Consume Artificial Sweetener 6

Eat Non Organic / All Natural Foods Drink Alcohol Eat Out Experience Stress / Emotional Baggage Lack Sleep (get less than 7 hours per night) Skip Meals 7

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