Dear New Patient - Dr. Podell · Dear New Patient: Welcome. Enclosed is the New Patient General...

New Patient General History Questionnaire rev. Nov 2015 of 25

Dear New Patient: Welcome. Enclosed is the New Patient General History Questionnaire. Complete these pages as fully as you can, even if you are not sure of all the answers. If you have a single, straightforward health problem, you may skip the questions that are not relevant. However, problems for most of our patients are interrelated and relatively complex, so a full history is important. New patients cannot be seen without this information. New Patient visits are at least 1½ hours long, often more. Because of the time set aside for your initial visit and the time spent to review your case in advance, we require a $150.00 non-refundable deposit to hold your appointment. This deposit will be deducted from your initial visit fee. Upon receipt of the completed questionnaire and deposit in our Summit office, we will contact you to make your first appointment. If possible, please send or bring copies of previous laboratory or x-ray reports, especially if the results were abnormal. (Usually, the reports are enough. We do not need the actual x-ray films.) Any consultation letters, sleep study reports, and other medical information may also be helpful. The fee for the initial visit with Dr. Podell is $690.00. Payment is required at the time of service. This fee includes a comprehensive review of your medical history and a detailed explanation of treatment options and recommendations. The initial evaluation and treatment phase typically consists of a comprehensive initial visit and then two to three monthly follow up visits, costing $220.00 per visit. Further visits are on an as-needed basis. Dr Podell does not participate with any health insurance plans, including Medicare/Medigap programs. We will, however, provide you with a receipt that you can submit to your insurance plan (other than Medicare/Medigap) for possible reimbursement. Dr. Podell’s referrals for laboratory work, x-rays, etc. are typically covered by Medicare/Medigap since the providers of these services are usually Medicare participants. We have two locations in New Jersey: Our main office is located at 11 Overlook Road, Suite 140, Medical Arts Building II (MAC II), Summit, NJ 07901, Tel: 908-273.7770, Fax: 908-273-7788. Please use this address for all mailings. We also see patients at 53 Kossuth Street, Somerset, NJ 08873. We wish you well in your process of healing and look forward to working with you. Yours truly, Richard N. Podell, MD, MPH Clinical Professor Department of Family Medicine Rutgers-Robert Wood Johnson Medical School Beverly Licata, RN/Nurse Educator


Patient Information Last Name, First Name_____________________________________________ Date of Birth_______________ Street Address______________________________________________________ SSN___________________ City, State, Zip _______________________________________________Home Phone ( )______________ Email Address _________________________Work Phone ( )_____________ Cell ( )_______________ Sex: Male Female Marital Status: Married Single Widowed Divorced Separated Employer’s Name or School Name______________________________________________________________ Primary Care Physician________________________________________Phone ( )____________________ Pharmacy Name_____________________________________________Phone ( )____________________ Drug Allergies? No Yes If Yes, list names______________________________________________________ How did you hear about us? Doctor Radio Newspaper Friend Other_______________________________

Health Insurance Information (Primary) Health Insurance Provider__________________________________________________________________ Address________________________________________________________________________________ ID#______________________ Group#______________________ Plan Name or #____________________ Name of Insured ____________________________ Date of Birth_____________ SSN_________________ Patient’s Relationship to Insured: Self Spouse Child Other_____________________________________

Health Insurance Information (Secondary) Health Insurance Provider__________________________________________________________________ ID#______________________ Group#________________________ Name of Insured_____________________________ Date of Birth____________ SSN__________________ Patient’s Relationship to Insured: Self Spouse Child Other_____________________________________

Financial Responsibility (Person Financially Responsible for Patient Named Above)

Non-Medicare: I understand that Richard N. Podell, MD, does not participate with any health insurance and has "opted out" of Medicare. Payment is due at the time services are rendered. I agree to these payment terms and guarantee payment to Richard N. Podell, MD, for any services provided to the patient named above.

____________________________________________________________ __________________ ___________________ Signature of Guarantor Date SSN

Relationship to Patient: Self Spouse Child Other _______________________________ Medicare: I authorize the release of any information necessary to process medical claims for the patient named above and authorize that payment of Medicare benefits for these claims be made to our office. Also, I agree to promptly pay for any services not covered by Medicare and/or determined by Medicare to be my responsibility including any charges for Services and/or Laboratory Tests not covered or deemed “Not Reasonable and Necessary”).

____________________________________________________________ __________________ ___________________ Signature of Guarantor Date SSN

Relationship to Patient: Self Spouse Child Other _______________________________

For Practitioner Use Only

DATE

DX

MEDS


Your Name ________________________________________________________ Date ___________________

Date of Birth _________________ SSN ________________ Email Address ____________________________

Phone ( ) _____________________ Fax ( ) _____________________

Street Address _____________________________________________________________________________

City, State, Zip _____________________________________________________________________________

How did you hear of us? Doctor Internet Radio Newspaper Friend Other _________________________

Referral Information: Name ____________________________________ _______________________________

Street Address _____________________________________________________________________________

City, State, Zip _____________________________________________________________________________

Phone ( ) ______________________

Section I: Overview 1. My most important problems are in order of priority (e.g. fatigue, pain, sleep)

a. ___________________________________________________________________________________

b. ___________________________________________________________________________________

c. ___________________________________________________________________________________

d. ___________________________________________________________________________________

2. What have other doctors thought was the main cause or diagnosis?

_____________________________________________________________________________________

Do you agree? Circle one: Yes, largely Yes, partly No

3. What do you think is likely to be the main problem or diagnosis or treatment that might have been overlooked? Are there issues that you want to be especially sure that we focus on now?

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

a. Do you have any "hunches" about what kinds of diagnostic tests and/or treatments might be useful now?

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


4. Please comment on your most important current problems in the chart below. Severity is rated 0 (none) to 10 (most severe). Rate as many as are important, especially if the severity score is 5 or more.

Problem Severity

(0 to 10)

10=most severe

About When did this become a problem?

Checkmark if

substantially worse in the last year

Checkmark if worse in

recent months

Fatigue AND Poor Exercise Tolerance

Fatigue AND Decent Exercise Tolerance

Fatigue AND Uncertain Exercise Tolerance

Muscle Aches or Fibromyalgia

Joint Pain WITHOUT Joint Swelling

Joint Pain WITH Joint Swelling

Headache

Neck Pain

Sleep Problems

Depression or Loss of Enthusiasm

Anxiety and/or Stress

Concentration or Memory Problems

Weight Gain

Weight Loss

Dizziness or Low Blood Pressure

Heartburn, Reflux, GERD, Ulcers, Gastritis

Irritable Bowel, Gas, Bloating, Abdominal Pain

Constipation or Diarrhea (circle one)

Sinus, Nasal, or Allergy Problems

Food Allergy or Intolerance

Yeast (Candida) problem

Nutritional Problem

Fever

Enlarged Lymph Glands

Thyroid Problem

Other:


5. Please list ALL medications, vitamins, and supplements and if known, how much (pill size) and how often (timing/frequency) you take them. Write nutritional supplements on the back of this sheet if you need more space.

Medication name Pill Size (mg)

Dose timing/frequency

Date Started

Purpose

a. Important past medications AND why they were stopped (especially those for sleep, pain, depression, anxiety, or fatigue) ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Medicine Allergies ______________________________________________________________________

______________________________________________________________________________________

Medicines not Tolerated __________________________________________________________________

______________________________________________________________________________________

Are you concerned about possible side effects from any of your medicines? Circle: Yes No Please explain. _________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Did any of your important symptoms worsen within a few weeks of starting or changing the dose of a medicine? If so, please explain. ___________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

b. If you have ever been hospitalized or had an operation, indicate why and approximate dates:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________


c. Have you recently used marijuana, cocaine, LSD or other street drugs? Circle: Yes No

Have you ever had a substance or alcohol problem? Circle: Yes No

Is there a family history of alcohol or substance abuse? If so please explain. ________________________

______________________________________________________________________________________

______________________________________________________________________________________

6. Please describe the time and circumstances when the main problem(s) first appeared and/or worsened. Then briefly outline or tell the story of your illness.

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7. Are you currently working or in school? What do you do?

_________________________________________________________________________________________

_________________________________________________________________________________________

Do your current symptoms limit your effectiveness? Please explain. __________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________


8. Time Lines are useful to help understand the broad patterns of your life and their potential relationship to your health. Please list all events that are important to you—whether or not you think they might relate to your illness. Table 8a asks about life and health events during specific periods—from birth through to your current age. Table 8b provides space for more details and also allows you to emphasize different time scales—weeks, months, years, and/or decades. Please complete both tables on the next two pages.

a. Table 8a – Please tell us about all major life and health events

Period of Life or age

Life Events: Family/Relationship/Marriage/Birth;

Education/Job changes; Church/Social event; Psychosocial events—marriage, children significant losses, life-reversal;

Losses e.g. death of loved ones, divorce, abuse;

Home relocation or renovations; Other milestones, etc.

Health Events: Medical or Surgical Illness;

Hospitalizations; Major Allergic Events; Injuries/Accidents/Trauma; Periods of major depression/anxiety; Appearance, worsening or resolution of symptoms or health issues; Medicines or treatments that helped; Other health events

Birth to Age 5

Grade School Years

High School Years

College or Early Work Years

Early Career/ Marriage/ Pregnancy/

Early Family

Mid Career/

Teenage kids

Age 40-49

Age 50-59

Age 60+


b. Table 8b - Please include all events of importance, especially those that do or might relate to important illness. Use this

table to list more events and in more detail e.g. when first symptoms began, when next symptoms began, a treatment that helped, a treatment that made you worse, etc. You can also work in different time scales e.g. list multiple events that occurred during teenage years, and then another multiple set that occurred in the last few months. Please indicate approximately when each event happened. Try to be fairly consistent in the time units you use e.g. the number of years/months/weeks ago the event happened OR your approximate age when the event occurred, OR the approximate date of the event e.g. 1999, July 2008.

Approximate Timeframe When Event Occurred

Important Events (especially those that relate to the onset or ups and downs of any of your

important symptoms or illness)


9. Good Days/Bad Days/Average Days: Many people have a pattern of medium or average days (when their illness might be bad, but they get by), relatively bad days (when they are even worse than usual), and also relatively good days (when they can do more than usual). If this pattern applies to you, please complete this question. If your illness does not substantially limit your activities, please skip to question #10.

Average Days: In recent months, I typically experience medium or average days for about _____ days per month or _____ days per seven-day week. (You may give a range of days e.g. 3-5 days, or a number of days per month and/or per week.)

Give examples of activities/tasks you CAN do on an average or medium day:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Give examples of activities/tasks you CAN NOT do on an average or medium day:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Bad Days: In recent months, I typically experience bad days for about _____ days per month or _____ days per seven-day week. (You may give a range of days e.g. 3-5 days, or a number of days per month and/or per week.)

Give examples of activities/tasks you CAN do on a bad day:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Give examples of activities/tasks you CAN NOT do on a bad day:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Good Days: In recent months, I typically experience good days for about _____ days per month or _____ days per seven-day week. (You may give a range of days e.g. 3-5 days, or a number of days per month and/or per week.)

Give examples of activities/tasks you CAN still do on a good day:

_________________________________________________________________________________________

_________________________________________________________________________________________

________________________________________________________________________________

Give examples of activities/tasks you CAN NOT do even on a good day:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________


a. Horizontal vs Vertical Hours – In the chart below, estimate the number of hours you spend on each listed activity on an average day, bad day, and good day. Total hours for each day should add up to 24. We understand these are only estimates.

Horizontal and Vertical Activity Average day Bad day Good day

Lying down sleeping or trying to sleep/nap

Lying down but NOT sleeping or trying to sleep/nap

Sitting with feet elevated

Sitting with feet down or near the floor

Driving or being driven in a vehicle

Standing, moving around, or walking

Other (specify):

Total hours (should add to 24 for each day)

b. If you push too hard or overdo activities one day, how likely will the next day be a bad day?

Circle one: Almost always Often Occasionally Not often

10. Indicate how the following factors affect your major symptoms by marking B if they make you feel better, W worse, or U if you are unsure. If not relevant, leave blank.

Exercise ____ Sleep____ Food/Eating____ Alcohol____ Caffeine____ Salt____ Stress____ Season____ Sunlight____ Time of Day____ Heat____ Cold____ Humidity____

Barometric Pressure____ Other(specify)_______________ ____ Other(specify)_______________ ____

Section II: Specific Symptom Areas and Lifestyle Issues For each of the descriptions in Section II, mark X if it applies to you or answer the question as appropriate. Leave blank if it does not apply.

1. Chronic Fatigue Syndrome Criteria (Ann Int Med 1994; 121:953-9)

New onset, persistent or relapsing, debilitating fatigue___ Does not resolve with rest____

No previous history of similar symptoms____ Persists at least 6 months ____

Substantial reduction of previous activity ____

Severe symptoms began: Suddenly____ Gradually____ Not sure____

Chronic Fatigue Syndrome Additional Criteria – “Official” diagnosis requires at least 4 or more of the following being present for more than six months. Please indicate if you have experienced any of the following symptoms for SIX months or more:

Impaired memory or concentration____ Frequent sore throat____

Painful/tender lymph nodes esp. neck or armpit____ New or different headaches____

Muscle pain (myalgia) WITH marked weakness____ Muscle pain WITHOUT marked weakness____

Unrefreshing sleep____ Sleeping too much____ Sleeping too little____

Multi-joint pain WITHOUT joint swelling____ Multi-joint pain WITH joint swelling____

Substantial increase in activity or exertion is likely to cause a prolonged increase of fatigue and/or pain____

Such post-exertional flare up of symptoms often may last for 24 hours or more____

a. If you feel worse after physical activity, indicate all that apply: Immediately after____ After several hours____ Both early and late____ Not sure____ Doesn’t apply; I don’t exercise____

If you often feel worse for many hours or longer after physical activity, please describe a specific, recent example of what activity you did, what was the result, and for how long after did you feel bad.

______________________________________________________________________________________

______________________________________________________________________________________


Compared to before you became ill, which of the following activities, if any, have you had to substantially reduce in frequency or duration because of your illness? (Please complete this section if you have major limitations, whether the main cause is fatigue, pain, or any other cause. If not limited, skip this question.)

Shopping for food___ Carrying groceries___ Shopping at the mall___ Cleaning the house___

Cooking/cleaning up___ Visiting friends___ Visiting family___ Work at a job___ School___

Volunteering___ Exercise___ if so, what type of exercise____________________________________

Other___ If so, please specify___________________________________________________________

Comments: _________________________________________________________________________

b. Often people have more than one kind of fatigue. Mark V next to the types of fatigue you find very important and mark M next to the types you find to be moderately important. Otherwise, leave blank.

Feeling “weak”___ Being actually weak in terms of acute strength___

Having poor stamina for doing things___ If so, provide an example______________________________

Feeling sleepy/wanting to sleep___ Feeling dizzy/off-balance/vertigo/light-headed___

Feeling “spacey”___ Difficulty concentrating/memory problems___ Loss of enthusiasm___

Other______________________________________________________________________________

c. Indicate if there are other potentially related symptoms:

Light-headed/faint/dizzy/vertigo/off-balance___ worse when standing___ Irritable bowel/gas___

Constipation___ Diarrhea___ Blood in stool___ Anxiety___ Panic___ Vaginal discharge___

Breathless or disordered breathing___ Alcohol problem in your history or in family___

Comments:_________________________________________________________________________

d. Indicate how the following factors substantially affect the severity of your fatigue by marking B if the factor makes it better or W for worse. Leave blank if there is little or no effect.

Physical exertion___ Mental exertion___ Sleep___ food/eating___ Alcohol___ Caffeine___

Salt___ Hydration___ Stress___ Heat___ Cold___ Time of day___ Day of week___

Menstrual pattern___ Season of year___ Humidity___ Air pollution___ Sunlight___

Exposure to chemicals/smells___ Barometric pressure___ Specify other___ ___________________

Comments:_________________________________________________________________________

e. Indicate the constancy or variability of your fatigue and related symptoms by marking one of the following:

Present almost every day, week, and month for most all of the day___

Mostly present but can be largely absent for hours___ days___ weeks___ months___

Occurs occasionally or intermittently or some other pattern___ If so, please explain ______________________________________________________________________________________________________________________________________________________________________

f. What treatments, activities, or other things have been significantly helpful for reducing or improving your fatigue? (Include medicines, sleep, exercise, nutrients, relaxation therapies, etc) ____________________________________________________________________________________________________________________________________________________________________________

2. Muscle Ache/Pain Related Symptoms

Your age when significant muscle pain began______

Onset was: Gradual___ Sudden___ Describe:_________________________________________________

Current status: Severe___ Moderate___ Mild___ Which joints swell, if any?________________________

Are your muscles often very sore to the touch?____ If so, where mainly?______________________

Does moderate exercise worsen pain?____ Reduce pain?____ Have no effect?____

Is your pain worse at night?____

Do you often feel stiff in the morning?____ If so, for how many hours after you wake?____

What effect does morning activity have on stiffness? Reduces it____ Increases it____ Has no effect____

Do you often have night sweats?____

Have you had x-rays, CT scans, or MRIs of any of the painful areas?____ If so, what did they show?____________________________________________________________________________________


_________________________________________________________________________________________ If you have chest pain does your chest pain often worsen with exertion? Yes____ No____ Not sure____ If you have chest pain does it often worsen when you breathe? Yes____ No ___ Not Sure____

Refer to the diagram below showing a front and back view of a human body. Show your area(s) of frequent or chronic pain by shading the corresponding areas on the diagram. Then on the chart below the diagram, find the area(s) you have shaded and indicate the severity by marking x for mild pain, xx for moderate pain, and xxx for severe in the appropriate severity column(s). If you have pain on both the left and right side, mark both the left and right side columns. Leave both the diagram and chart blank if you do not have frequent or chronic pain.

Shaded area of chronic or frequent pain

Severity level for Left side

Severity level for Right side

Shaded area of chronic or frequent pain

Severity level

Jaw Front of Head

Shoulder Back of Head

Chest Front of Neck

Upper Back Back of Neck

Mid Back Upper Spine

Lower Back Middle Spine

Abdomen Lower Spine

Upper Arm

Lower Arm

Hand/Wrist

Hip

Upper Leg

Buttocks

Knee

Lower Leg

Ankle/Foot


Mark P if you have a personal history or F if you have a family history with any of the following. Leave blank if it does not apply.

Psoriasis____ Crohn’s disease or ulcerative colitis____ Rheumatoid arthritis____ Lupus____

Spinal arthritis____ Ankylosing spondylitis____ Sjoegren’s Syndrome (dry eyes)____

Hashimototo’s thyroiditis___ Grave’s disease____ Other thyroid problem___

Other auto-immune or immune related illness____ Comments:_________________________________________________________________________

If your pain significantly limits your activities, please be sure you have answered the Good days/Bad days/ Average Days questions in Section I #9 (page 9) as it applies to the effects of increased activity on your pain.

a. If your pain significantly limits your activities, indicate when: Immediately after____

After several hours____ Both early and late____ Not sure____ Doesn’t apply; I don’t exercise____

If you often feel worse for many hours or longer after physical activity, please describe a specific recent example of what activity you did, how it made you feel, and for how long after did you feel bad.

______________________________________________________________________________________

______________________________________________________________________________________

b. Compared to before you became ill, which of the following activities have you had to substantially reduce in frequency or duration?

Shopping for food___ Carrying groceries___ Shopping at the mall___ Cleaning the house___

Cooking/cleaning up___ Visiting friends___ Visiting family___ Work at a job___ School___

Volunteering___ Exercise___ if so, what type of exercise____________________________________

Other___ If so, please specify___________________________________________________________

Comments: _________________________________________________________________________

Please note, the next set of questions duplicate previous questions related to fatigue. Please answer both sets if both fatigue and pain limit your activities.

Indicate how the following factors substantially affect the severity of your pain by marking B if the factors make it better or W for worse. Leave blank if there is little or no effect.

Physical exertion___ Mental exertion___ Sleep___ food/eating___ Alcohol___ Caffeine___

Salt___ Hydration___ Stress___ Heat___ Cold___ Time of day___ Day of week___

Menstrual pattern___ Season of year___ Humidity___ Air pollution___ Sunlight___

Exposure to chemicals/smells___ Barometric pressure___ Specify other___ ___________________

Comments:_________________________________________________________________________

Indicate the effects of the following “quick relief” medicines for your muscle aches by marking VG if it helped pain a lot, L if it helped but only a little, NC if there was no change, and W if it made it worse. Leave blank if you have not tried it.

Aspirin or Ibuprofen____ Celebrex or Vioxx (Cox-2 anti-inflammatories)____

Tylenol____ Codeine____ Prednisone/Steroid____ Percodan/Percoset____

Other narcotic pain medicines ____ _________________________________________________________

Ultram (tramadol)____ Lidocaine (Lidoderm) patch____ Voltaren Gel____

Other (please specify)____ ________________________________________________________________

Which of the following test resulted in abnormal findings? Leave blank if normal or not done.

Sed rate____ CRP____ Lyme test____ ANA____ Rheumatoid factor____ Latex____ CPK____

HLA B-27____ SSA/SSO____

3. Family History

a. Circulatory - Do you have a family history of: High blood pressure___ High cholesterol/triglycerides___ Diabetes___ Heart Attack, Stroke, or Arterial disease of the leg before age 60___


b. Neurochemical - Do you have a family history of: Major depression___ Manic depressive illness___

Major anxiety___ Panic anxiety___ Alcoholism or drug abuse___ Suicide attempt or success___

Attention deficit___ Obsessive-compulsive disorder___ Schizophrenia___

c. Cancer - Do you have a family history of: Breast cancer___ Colon or rectal cancer___

Melanoma/Skin cancer___ Prostate cancer___ Stomach Cancer___ Other________________________

4. Exercise

I can comfortably walk: less than ¼ mile___ ¼ mile___ ½ mile___ 1 mile___ greater than 1 mile___

If you cannot comfortably walk one mile, indicate all of the main limiting factors: Weakness___ Joint pain___

Short of breath___ Muscle pain___ Chest pressure or pain___ Rapid heart___ Other__________________

My preferred form of current exercise is: Walking___ Treadmill___ Swimming___ Warm water pool___

Indoor bike___ Other(s)_____________________________________________________________________

During or shortly after I exercise, I usually: Feel worse___ Better___ About the same___ Not sure___

A few hours later I usually feel: Better___ Worse___ About the same___ Not sure___

The next day I usually feel: Better___ Worse___ About the same___ Not sure___

Exercise causes me to feel: Abnormal chest pain or pressure___ Mental cloudiness___ Calf pain___

Other ____________________________________________________________________________________

Comment:_________________________________________________________________________________

5. Sleep Problems

About what time do you usually go to bed? _______________________

About what time do you actually fall asleep? _______________________

Is initially falling asleep often a problem? _______________________

Do you wake often during the night? _______________________

About what time do you get up in the morning? _______________________

Subtracting interruptions, about how many hours do you actually sleep? __________

Do you usually need an alarm clock to wake up? _______________________

Do you usually sleep more than 45 minutes longer on weekends or holidays? ______

When you wake in the morning do you feel you have rested well? _______________

Do you take naps more than once a week? _______________________

If you take naps, do these refresh you? _______________________

Are you sleeping much less than when you were last feeling well? ______________

Do you ever fall asleep inappropriately, for example:

At work/school? ______________________

While driving? ______________________

With other people? ______________________

Watching TV? ______________________

Do you or did you take sleeping aides more than once a week? ________________

State the name(s) of sleeping aides used and mark H if they have helped, NC if no change, or W if it made you worse. __________________________ _____

__________________________ _____

__________________________ _____

__________________________ _____

Have you ever had an overnight sleep study? ____________________

If yes, was the study normal? Yes____ No____ Not sure____ (Please provide us a copy of the report.)

If not entirely normal, what was the result?_________________________________________________

Have you ever been diagnosed with:

Sleep Apnea____ Upper airway resistance____ Periodic leg movement disorder____

Idiopathic hypersomnia____ Other______________________________________________________


a. Sleep Observation – Is there someone who could observe you and your breathing while you are asleep for 30 minutes? If so, ask them to provide answers to the following questions:

Is snoring: Rare____ Mild____ Moderate____ Severe____

Does breathing often stop for 10 seconds or longer? _______________________________

Is there difficulty breathing, snorting, or struggling for breath? _______________________________

Is there often muscle twitching or jerking during sleep? _______________________________

Do you toss and turn a lot? _______________________________

Do you sleep quietly, hardly moving at all? _______________________________

Do you often wake with a headache? _______________________________

Do you often wake with muscle aches? _______________________________

6. Nutritional/Gastrointestinal/Food Allergy

a. Diet

How do you rate your diet? Excellent____ Good____ Fair____ Poor____

Comments:_____________________________________________________________________________

Indicate how many times in an average week you eat: Green leafy vegetables(excluding lettuce)____

Yellow vegetables (carrot/squash/sweet potato)____ Berries____ Fruit____ Fish____ Yogurt____

Milk/cheese____ Ice cream____ Chocolate____ Beef/pork____ Chicken/turkey____

Salad dressing or vegetable oil____ Soy____ Nuts/beans/seeds____

Indicate how many times a week you: Eat at home____ Eat in a restaurant____ Skip breakfast____

Skip lunch____ Skip dinner____

Do you consciously try to reduce the intake of any of the following? Sugars____ Other carbohydrates____

Artificial sweeteners____ Caffeine____ Alcohol____ Protein____ Why?_________________________

______________________________________________________________________________________

How much do you restrict your fat intake? Mildly____ Moderately____ Severely____ Not at all____

Show how the following make you feel by marking B for better and W for worse: Sugar____ Starch____

Alcohol____ Caffeine____ Milk products____ Fatty foods____ Organic food____ Yeast____

Additives____ Wheat/gluten____ Chocolate____ Garlic/onion____ spices____ Deli meats____

MSG____ Artificial sweeteners____

Are there specific foods you feel you “almost can’t live without”? If so, please specify.

____________________________________________________________________________________________________________________________________________________________________________

Please specify any foods you avoid because you suspect you are allergic or do not tolerate.

____________________________________________________________________________________________________________________________________________________________________________

Have you ever been tested for food allergies?____ If so, what kind of test?__________________________

What were the results?________________________________________

Are these results generally consistent with your experience?___________________________________

b. Caffeine

Indicate how many cups/glasses per day you drink of: Coffee____ Decaffeinated drinks____ Tea____

Herbal tea____ Cola drinks____ Other soft drinks____

If you drink caffeinated drinks regularly, have you ever abstained completely for two or more days since you have been ill?____ If so, what happened?____________________________________________________

If you omit caffeine, do you think you would likely develop? Headache____ Muscle ache____

Mental cloudiness____ Severe fatigue____ Don’t know; haven’t tried____


c. Alcohol

Indicate how many portions a day you typically have: Whiskey___ Wine____ Beer____ Other______

Do you or anyone else suspect you have a drinking problem? __________

d. Hypoglycemia

Do you suspect you might have hypoglycemia? _________________

Do you often have increased symptoms:

3 or 4 hours after eating? _________________

If your meal is late? _________________

If you eat too much sugar or starch? _________________

If so, list your symtoms________________________________________________________________

Do you often have increased symptoms within one hour of eating?_____________

If so, list your symptoms_______________________________________________________________

Do you find that snacking helps? _________________

If so, when? _________________

e. Candida (Yeast) Syndrome (controversial and unproved)

Do you often have vaginal yeast infections? _________________

Do you often have intestinal gas, bloating, diarrhea, or constipation? ___________

Do your symptoms worsen when you eat a high sugar or high carb diet? ________

Do symptoms improve when reducing sugar, bread, or starch? _______________

Do symptoms worsen when you drink alcohol? _________________

Indicate if you have often taken:

Antibiotics____ Estrogen hormones or birth control pills____ Cortisone/prednisone_____

Have you or a health care professional suspected that you have a yeast or candida problem?_____

If so, when, by whom, and what test?______________________________________________

Have you tried at least 2 months of a Candida yeast diet? _____________________________

If so, did it help?____ Cause no change?____ Make you worse?____

Have you tried a medicine for yeast (e.g. Nystatin, Diflucan)?____

If so, did it help?______________________________________________________________

f. Other G.I.

Indicate if you often have any of the following:

Diarrhea (multiple or loose stools)____ Constipation____ Abdominal gas/bloating____

Blood in your stool____ Very dark tarry stool____

If so, what factors do you suspect of contributing to these symptoms?_________________________

Indicate if you often take: Fiber pills or extra fiber____ Stool softeners____ Laxatives____

If so, did it help?____ Cause no change?____ Make you worse?____

Do you often have excess acid symptoms, gastritis, esophagitis, heartburn, or esophageal reflux?______

If you have ever been tested for Helicobacter bacteria (H. Pylorus),

Was the test positive?_____ Were you treated?______

Have you ever had intestinal parasites, worms, ameba, giardia, or other intestinal infection?___________

7. Environmental Health

Indicate how much the following factors affect you by marking M for moderately and S for severely. Leave blank if it does not affect you.

Noise____ Heat/humidity____ Lights____ Odors/Smells____ Computers____ Others being ill____

Tobacco/indoor pollution____ Occupational chemicals____ Cold____ Repetitive tasks____ Posture____ Comments:_________________________________________________________________

How old is your home? ____________

Is it often: Damp____ Moldy____ Dry____ Very dusty____

Do you have: Air conditioning units____ Central A/C____ A/C in your bedroom_____


Mold: Have you ever been exposed to a moldy environment? e.g. high humidity _______________

Flood or water leak in your home or at work, obvious mold in the walls or in your bathroom? _________

If yes, was mold exposure likely in the period when you first became ill or when your illness worsened?_____

Do you tend to be worse in the fall when leaves are on the ground, but before it gets very cold? _________

Any other potential mold exposures? _________________________________________________________

Does your bedroom have:

Carpet___ Area carpet___ Wall to wall carpet___ Central air filter___ Portable filter___

Section III: Physical Illness For each of the descriptions in Section III, mark X if it applies to you or answer the question as appropriate. Leave blank if it does not apply.

1. Hidden Infections and Allergies

a. Nose/Sinus

Have you had a sinus infection in the last 4 months or more than 2 sinus infections in the last year? _____

Do you have chronic nasal stuffiness, post nasal drip or hoarse voice? _____________

Do you often have yellow or green mucus from your nose, lungs, or throat? _____________

Do you often have a sinus type pressure over, under, or between your eyes? _____________

Do you have a sore throat more than once every 8 weeks? _____________

Have you ever had a sinus CT scan or x-ray? _________________ Results:__________________

Do you seem to react with allergies? _________________If so, what kind?_____________

Are you exposed to high doses of unusual chemicals as well as indoor or outdoor air pollutants? _________

Is your work or home environment:

Poorly ventilated? _________________

Exceptionally dry? _________________

Humid? _________________

Did any changes in your work or household environment precede the worsening of your health? _________

Do you develop symptoms when exposed to environmental chemicals or odors? _____________________

b. Asthma/Bronchitis

Is this a concern? __________________

Do you often:

Wheeze? __________________

Cough? __________________

Feel chest tightness? __________________

Have abnormal shortness of breath? __________________

Does exercise make it worse? __________________

Does cold air make it worse? __________________

Do you often cough mucus from your lungs? __________________

Is it clear? __________________

Is it yellow? __________________

Is it green? __________________

Have you ever had a lung function test or been told you have asthma, emphysema, or any other lung disease? _________________

Have you had a chest x-ray within the last 5 years? _____ Results: _______________________________

Do you currently smoke tobacco? _________________

If not, have you ever smoked regularly? _________________

If you have smoked regularly, for about how many years? __________

c. Urine/Prostate

Do you often have burning or pain when you pass urine? _________________________

Do you have difficulty starting urination? _________________________

Do you have slow urine flow? _________________________

Do you ever spill urine accidentally (incontinence)? _________________________


Have you ever had kidney stones? _________________________

Do you have diabetes or a blood sugar problem? _________________________

For women only, do you have more than one urine infection per year? ______________

For men only, have you ever had urine infections? _________________________

Comments:_______________________________________________________________________

d. Lyme Disease

Have you ever had or been told that you had Lyme Disease? Yes____ No____ Not sure____

Have you had bull’s eye type rash that grew over several weeks/months before disappearing? ____

Have you ever had an abrupt weakness on one or both sides of your face (Bell’s Palsy)? ____

Are you often exposed to ticks? ________

Has a doctor ever diagnosed or treated you for:

Lyme Disease? ________

Bebesiosis? ________

Mycoplasma? ________

Other chronic infection? ________ Comments:_________________________________________________________________________

e. Fever and Other Infections

Do you often feel warm? ________

Do you have chills? ________

When you feel warm what is your actual temperature range? ________

Have you ever had hepatitis? ________

Do you have any AIDS risk factors or abnormal tests? ________

Have you had close exposure to someone with tuberculosis (T.B.), a positive skin test, or signs of T.B. on a chest x-ray? ________

2. Hormones

a. PMS/Menstrual

Do important symptoms get markedly worse in the week or two before your period and improve substantially once you have had your period? ________

If yes, specify symptoms _____________________________________

Do you have menstrual cramps or related symptoms that are severe enough to disturb your feeling of well-being or daily function? ________

Do you have vaginal bleeding other than at your period? ________

Are you taking contraceptives or other measures to avoid pregnancy? Yes____ No____

b. Perimenopause

Do you have: Mood swings____ Hot flashes____ Night sweats_____

c. Menopause

Are hot flashes or night sweats very bothersome? ________

Have you had a hysterectomy? ________

Which symptoms, if any, improved or worsened after menopause? _________________________________

d. Thyroid

Have you ever been told that your thyroid is abnormal? _______

Have you ever been on thyroid medicines? _______

Do you have any swelling in the lower neck? _______

Did you ever receive x-ray treatments to the neck? _______

Do you have a family history of thyroid disease? _______

Are you intolerant of: Cold_______ Heat_______

Is your body temperature less than 97° before you get out of bed? ______

Do you feel hyper? _______


Have you experienced:

Rapid heart rate? _______

Weight gain or loss? _______

Sweats? _______

Anxiety? _______

e. Other

Do you have any discharge from your nipples? _______

Has anyone told you that you have low adrenals? _______

Do you have excess hair growth on face or body? _______

3. Heart/Blood Pressure

Do you often feel light-headed or have a rapid heart rate when:

You stand up quickly? _______

You stand still for 10 or more minutes? _______

Do you tend to have: Low blood pressure_______ High blood pressure_______

Do you have:

Chest tightness, pressure or pain, or any distress/abnormality when you exert yourself/exercise? _____

Calf or leg pain when you walk? _______

Mitral Valve Prolapse? _______

Other murmurs or heart valve problems? _______

Frequent extra or skipped heart beats/palpitations? _______

Have you ever had a(n):

Heart attack or angina? _______

Heart catheterization? _______

Angioplasty or heart surgery? _______

Stroke or near-stroke (TIA)? _______

About what level are your levels for: Total cholesterol______ LDL______ HDL______

Trigylcerides______ Homocysteine_______

Have you ever had a(n): EKG______ Exercise stress test_____ Echocardiogram_______

If so, were any of the results abnormal? ________________________________

Do you need antibiotics before seeing a dentist? _______

4. Headache

Do you have a headache more than once weekly? _______

Are your headaches:

Severe enough to reduce activity? _______

On one side of the head at a time? _______

Preceded by “aura”? _______

With nausea? _______

Waking you from sleep? _______

Worse on waking in the morning? _______

When you have headaches, are you unusually sensitive to:

Bright lights? _______

Loud noises? _______

Smells? _______

Are your headaches related to:

Stress? _______

Posture/position? _______

Nasal sinus congestion? _______

Muscle tension? _______

Medicines? _______

Caffeine? _______

Food? _______


Do you have pain in your jaw? _______

Do you grind your teeth at night? _______

Does your jaw lock or not open widely? _______

How often do you take headache medicine? _____________________________________

Do you drink caffeine or take pills with caffeine daily? _______

Section IV: Neurochemical Balance and Emotional Health For each of the descriptions in Section IV, mark X if it applies to you or answer the question as appropriate. Leave blank if it does not apply.

During the last 3 months have you been under severe emotional stress? Yes____ No____ Not sure____

If yes, what do you think are the most important contributors?__________________________________

___________________________________________________________________________________

If you are under the care of a therapist, please state who you are seeing, why, and whether it is helping?

_________________________________________________________________________________________ _________________________________________________________________________________________

Please provide the relationships and ages of the individuals that live with you: ___________________________

_________________________________________________________________________________________

What is the attitude of those closest to you regarding you and your illness? _____________________________

_________________________________________________________________________________________

On a scale from 0 (hopeless/pessimistic) to 10 (hopeful/optimistic), rate your attitude toward your illness ______

1. Stress/Anxiety

Has there been increased stress in your life?_____

If yes, why?_________________________________________________________________________

___________________________________________________________________________________

Do you feel nervous, jittery, or anxious more often than you like?_____

If yes, why?_________________________________________________________________________

___________________________________________________________________________________

Circle all that apply to you:

a. Physical muscle tension or activity: Jumping, Trembling, Muscle-tightness, Heaviness or aching, Fidgeting, Restless, East to startle

b. Symptoms of over-activation: Sweating, Heart-pounding, Cold or clammy hands, Dry mouth, Light-headed, Numbness, Tingling, Hot or cold spells, Frequent urination, Diarrhea, Stomach discomfort, Lump in throat, Flushing, Paleness, Breathless

c. Fears: Worry, Fearful expectation about self or family, Fear of losing control or having an accident, Specific phobias or fears such as being alone, open spaces, closed spaces, automobiles, bridges, heights

d. Hyper alertness: To threats or troubles in the environment, To symptoms or functions of your body, On-edge, Irritable, Impatient, Difficulty sleeping

Have you ever had a “panic attack”?____

If so, do you have them more than once a month?___________________________________________

Do you spend much time or energy anticipating or worrying about your next episode of symptoms or illness? ________________________________________________________________________


2. Depression

Do you often experience or feel:

Loss of enthusiasm or interest in your usual activities? _______________

Depressed, sad, or blue? _______________

Loss of appetite? _______________

Increased appetite? _______________

Weight loss? _______________

Weight gain? _______________

Life seems not worth living? _______________

Have you ever seriously considered suicide? _______________ Have you thought of suicide recently? _______________

Explain:____________________________________________________________________________ ____________________________________________________________________________

Have you ever actually tried to harm yourself in any way? ________________

Have there been important reverses in personal/family/finance? ________________

Have you had an increased use of alcohol, drugs, or caffeine? ________________

Have you had an increased use in mood altering medicines? ________________

Have you been seriously depressed? ________________

Have you ever taken medicines for depression? ________________

If yes, which ones and did they help?_________________________________________________

Is depression or fatigue usually worse in the winter and better in the spring or on vacations to warm climates?

_________________________________________________________________________________________

3. Manic/Depressive (Bipolar) Disorder

Are there periods during which you are abnormally super-productive or manic? _______________________

Has anyone ever suggested that you might be “hypomanic” or have bipolar depression? ________________

4. Post-Traumatic Stress

Has there been major physical or emotional trauma any time in your life such as loss of a loved one, divorce, physical abuse/violence, sexual abuse (rape or incest), a serious accident or illness, etc? If so, please explain.

__________________________________________________________________________________________________________________________________________________________________________________

Do disturbing thoughts, dreams, or images related to past events recur frequently? _______________________

5. Obsessive-Compulsive Traits

Do thoughts often intrude that you cannot keep out? ______________

Do you feel compulsive impulses to perform hand-washing, counting, throat-clearing, touching or making noises,

or other acts or actions? ______________

Do you have recurring tics or twitches? ______________

6. Hyperventilation Syndrome

Do you often:

Feel lightheaded or dizzy? ______________

Feel numbness/tingling? ______________

Have spasm or cramps on hands or forearms? ______________

Feel short of breath? ______________

Have frequent sighing? ______________

Have a sense that you can’t take a full breath in? ______________

Feel short of breath with mild exertion? ______________

Feel “spacey”? ______________


7. Attention Deficit Disorder

Have you had great difficulty focusing or concentrating since childhood or teenage years? ____________

Have you had an unusually short attention span? ____________

Have you or others thought you might be hyperactive or have Attention Deficit Syndrome? ____________

Have you ever been treated with or benefited from Ritalin, Dexedrine, or other stimulant medicines? _________

8. Pavlovian Conditioning

Did your problem begin or increase markedly after a major illness, stress, or accident? ______________

Do direct or indirect reminders of difficult or traumatic episodes or periods tend to trigger your symptoms? _____

Once your symptoms begin, do you become more frightened, upset, or tend to panic? ______________

Do you spend time or energy anticipating or worrying about your next episode of symptoms or illness? _______

Do you have a powerful or vividly imaginative mind or creativity in art, music, dance, or literature? __________

Can you produce interesting or detailed fantasies, daydreams, or changes of mood with thoughts or mental imagery? ______________

9. Thought Disorders

Illogical thoughts____ Hallucinations____ History of psychosis or schizophrenia____

Paranoid thoughts____ Erratic or highly variable moods____

10. Type “A” Personality Trait

Do you usually feel impatient, rushed, or time pressured? ______________

Are you often hostile or angry? ______________

11. Associated with Low Serotonin

Craving for sugar or starch____ Depression worse in winter____ PMS____ Decreased sweating____

Intolerant of heat____ Low grade fever____ Feel chronically stressed____ Often depressed____

Are you now or have you recently been in counseling or therapy? ____ If so, please provide contact information for this therapist: Name______________________________________________________________________

Complete Address__________________________________________________________________________

_________________________________________________________________________________________Telephone____________________________________


Section V: Review of Symptoms, Treatments and Diagnostic Tests

1. Review of Current Symptoms – Mark MI if your symptoms are Mild, O for Moderate, and S for severe in the

blank space next to the symptom(s) that apply to you. Leave blank if it does not apply.

Constitutional: Mouth: Joints:

Fatigue Sores/fissures Ache/pain

Weight change Herpes/frequent cold sores Stiff

Fever/chills/sweats Gum/tooth problems Swelling

Appetite change Tongue problem Thyroid:

Abnormal thirst Lungs/Heart: Mass or lump in neck

Difficulty sleeping Cough Cold or heat intolerance

Light-headed Wheezing History of x-ray to neck

Eyes: Shortness of breath Feel hyper or sluggish

Vision Hyperventilation G.U. and Hormonal (Female):

Tearing Phlegm/mucus/bronchitis Severe menstrual cramps

Itching Chest pain or exertion Severe PMS

Feel heavy Other chest pain or distress Menstrual irregularity

Allergic shiners Rapid/slow palpitations Herpes

Ears: Irregular heart rate/rhythm Frequent vaginal discharge

Itching Ankle swelling Yeast or Candida infection

Hearing problem Calf pain on exercise Painful or difficult urination

Blocked ears Sore tender legs Pressure/urgency/itching

Sensitive to sound High blood pressure Vaginal rash

Ringing in ears Gastrointestinal: Sexual problem

Dizziness/vertigo Nausea G.U. (Male):

Nose/Throat: Belching/bloating gas Difficulty voiding

Stuffed/runny nose Passing gas Prostate problem

Postnasal drip Heartburn/Stomach pain Lump on testes

Sore throat Diarrhea Sexual problem

Tight/swollen throat Constipation Herpes

Hoarse voice Cramps or aches Neuropsychiatric:

Trouble swallowing Rectal pain or itching Headache

Skin: Blood or black stool Depression/apathy

Itching Worms or parasites Anxiety/irritable

Flushing Muscles: Hyperactive

Rashes Tight/stiff Learning disability

Hives Ache/sore/pain “Brain fog”/difficulty concentrating

Dry/rough skin Neck Mood swings

Acne Low back Suicidal

Nail/hair problem Shoulder/upper back Homicidal

Lymph Nodes: Extremities Faints/blackouts

Swollen/tender Weakness Seizures/convulsions

Numbness or tingling

Others: please list below


2. Treatments You Have Tried – Mark H if the treatment has helped you, W if it is has made you worse, NC for no change, or U if uncertain in the space next to the applicable treatment(s). Leave blank if you have not tried it.

Nutritional Treatments: Mind/Body Therapies: Neurochemical Medicines:

Hypoglycemia diet Deep breathing Tricyclic anti-depressants

Low sugar/carbs Relaxation tapes SSRIs

No MSG/Nutrasweet Prayer Zoloft/Setraline

Candida diet Meditation Effexor

Multivitamin/mineral Heart math Wellbutrin

Vitamin B-12 shots Counseling Elavil/Amitryptiline

Fish oil Music Prozac/Fluoxetine

Primrose or Borage Oil Hypnosis Luvox/Celexa

ENADA Better sleep Cymbalta or Savella

L-Carnitine Body Work: Pamelor/Nortyptiline

CDP-Choline Massage therapy Paxil

Tryptophan Pool therapy Remeron Food allergy elimination diet Trigger Point injection Desyrel/Trazadone

Low fat diet Acupuncture Lithium

No artificial colors or flavors Physical therapy Nardil/MAO inhibitors

Increase vegetables/fruit Walk/jog Sleep Medicines:

IV vitamins Manual trigger point therapy Restoril

Other vitamins Chiropractic Ambien (zolpidem)

Flax oil Weights Sonata (zaleplon)

N-Acetyl Cysteine Stretching Klonopin

Lipoic acid Hormonal Treatments: Halcion (triazolam)

Acetyl-L Carnitine T3 Thyroid/Cytomel Sinemet/Dopamine

Phosphatidyl Serine Estrogen Antihistamines/Benadryl

Tyrosine Growth hormone Nerve/Pain Stabilizing Medicines:

Off wheat/gluten Cortisol/Prednisone Neurontin/Gabapentin

Off milk products Thyroid/Synthroid or Levoxyl Lyrica

Organic diet Testosterone Guaifenesin

Reduce caffeine Armour (Natural) thyroid Aricept/Galantamine

Magnesium Progesterone Dextromethorphan

Zinc Melatonin Amantadine

Primrose oil DHEA Anti-Anxiety:

Glutathione Blood Pressure Raising Tactics: Valium/Diazepam

Bioflavanoids Salt/water Ativan/Lorazepam

Coenzyme Q10 Proamatine Buspar

Lactobacillus/Acidophilus Jobst stockings Respiradol/Abilify

Herbal Therapies: Florinef Seroquel

St. John’s Wort Beta blockers/Propranalol Pain Medications:

Valerian Licorice Aspirin/Ibuprofen

Ginkgo Epogen Codeine

Black Cohosh/Remifemin Antibiotics: Percocet/Percodan

Echinacea Anti-virals e.g. Valtrex Other NSAIDs e.g. Relafen

Ginseng Kutapressin Cox-2 inhibitors (Celebrex, Vioxx, etc)

Other Anti-bacterials e.g. Penicillin Oxycontin or morphine

Muscle Relaxants: Gamma Globulin Ultram

Flexeril Other antibiotic ______________ Methadone

Soma (carisoprodol) Stimulant-like Medicines: Oxycodone

Zanaflex (tizanidine) Ritalin Other: please list below

Seroquel Phentiramine/Adipex

Baclofen Provigil or Nuvigil

Straterra


3. Diagnostic Tests- For all tests that you have done, please provide us with the reports. In the Results column, mark N if the test results were normal, A if abnormal, and U for uncertain. In the Year column note the approximate year the test was most recently done. Leave both spaces blank if the test was not done.

Results- N,A, or U Year Results- N,A, or U Year

Basic Tests: Nutrition:

CBC Homocysteine

Liver tests Vitamin B-12

SMA-6 (kidney, potassium) Food allergies

PSA (men only) Amino acid analysis

Thyroid Essential fatty acids

Blood sugar Magnesium

Urinalysis Zinc

Mammogram Candida tests

Inflammatory/Autoimmune: Organic acid analysis

Sed Rate Anti-gluten (wheat) antibodies

CRP G.I: ANA Upper G.I. x-ray

CPK (Muscle Enzyme) Upper G.I. endoscopy

Rheumatoid factor Small bowel x-ray

Infections: Stool test for blood

Lyme Test Colonoscopy

HIV antibodies Sigmoidoscopy

Hepatitis antibodies Helicobacter (H. Pylorus)

Mycoplasma Neurology/Psychology:

HHV-6 C.T. brain

Chest x-ray C.T. cervical spine

Sinus C.T. scan or MRI Psychological consult

T.B. test Sleep observation (at home)

Chlamydia Hyperventilation test

IgG/IgA Antibody tests MRI of brain

Endocrine: Neurology consult

Glucose tolerance test EEG

HBA1C Sleep observation (in lab)

Cortisol Heart /Lung:

Estrogen EKG

Prolactin Exercise stress test

Insulin level Thallium stress test

DHEAS Echocardiogram

Growth hormone Lung function tests

Testosterone CT scan of heart (E.B.T)

Other: Other:

Other: Other:

Dear New Patient - Dr. Podell · Dear New Patient: Welcome. Enclosed is the New Patient General...

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