Greer,SC 29650 Sample - FMLogics.com · Comprehensive Patient H istory Intake Form A nalysis...
Transcript of Greer,SC 29650 Sample - FMLogics.com · Comprehensive Patient H istory Intake Form A nalysis...
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Southeastern Center for Functional Medicine
Dr. Ronald Grisanti
2123 Old Spartanburg Road 348
Greer,SC 29650
8649057605
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Address: 2222 Old Spartanburg Road South Carolina
Home Phone: 8649057605
Work Phone:
Cell Phone:
Fax Number:
Email: [email protected]
Preferred mode of contact: Cell
Emergency Contact:
Marital Status: Married
Age: 60
Gender: Male
Number of Children: 2
Present Occupation: Boat Restorer
Present Job Duties: Use cleaning materials to clean and restore boats
Past Occupation(s): Car Restorer
Referred by: Referred by Mike Smith
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 2
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Ch i e f Co m p l a i n t s
1: Anxiety: have been suffering with anxiety for 20 years. I have seen several doctors who have prescribed multitudes of medication. Temporary relief
2: Thyroid issuses. Cold most of the time with fatigue
3: Insomnia-- I have a hard time falling asleep. I wake up several time each evening
4: Joint pain. This has been going on for at least 10 years.
Clinicians's Notes:
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 3
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Pain Lo c a t i o n/Qu a l i t y
Location Aching Burning Numbness Sharp Shooting Stabbing Tingling
1. Head
2. Eye Rt.
3. Eye Lt.
4. Ear Rt.
5. Ear Lt.
10. Elbow Rt.
14. Hand Rt.
31. Lower back
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 4
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Clinicians consulted for chief complaints listed:
1: Dr. Joseph Bulland
2: Dr. Sally Eston
Integrative medicine received for chief complaints listed:
1: Chiropractic
2: Acupuncture
3: Massage
4: Nutritional Therapy
5: Yoga
Diagnostic test(s) in past five years:
1: Chest X-ray
2: Mammogram
3: EKG
4: Colonoscopy
5: X-rays
6: Bone density test
7: Blood tests
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 5
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Past Illnesses When
Immunizations When
Surgeries When
Gall Bladder removed in 1990
Hysterectomy partial removal 1995- ovaries still intact
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 6
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Current Medications Duration
1: Acetaminophen - drug's generic name take periodically
2: Armour Thyroid (Thyroid Tablets) 8 years
3: Elavil (Amitriptyline) 10 years
Medication Allergies:
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 7
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Current Supplementation Duration
Multi-vitamin 15 years
Probiotics 10 years
Vitamin C 5 years
Supplementation Adverse Reaction(s):
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 8
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
History of Head Trauma: None
Alcohol Consumption: Yes, glass a wine once or twice a week
Smoker: No
Patient's recorded weight: 135
Patient's recorded height: 5'4
Exercise (days of the week): 3
Exercise Type: yoga and cardio
Primary Care Provider: Dr. Anthoney Secrito
Date of last physical examination: 1/5/2015
Date of last blood test: 1/5/2015
Blood type: O
Rh Factor: Positive
Did you have cesarean birth?: No
Were forceps used for your birth?: Yes
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 9
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Fa m i l y Hi s t o r y
Mother: Uterine fibroids, Osteoporosis, Depression, Thyroid Disease
Father: Arthritis, High blood pressure
Sister:
Brother: Headache, Insomnia
Maternal Grandmother: Diabetes
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 10
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
M a l e Me d i c a l Hi s t o r y
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 11
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
De n t a l Hi s t o r y
Teeth selected: 16, 17
mercury fillings
Note: Inquire about root canals, amalgam fillings, missing teeth, infections, cavities, broken teeth, impacted teeth, crowns, and abscessed teeth in the area(s) selected. In addition,
inquire about gum disease.
Clinicians's Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 12
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Chronological Past History as Recorded by the Patient
Birth to age 10: Healthy most of this time.
Age 11- 20: Had menstrual cramps almost my entire teens. I had constant headaches
Age 21 - 30: A lot of fatigue, depressed quite often
Age 31- 40: Had skiing accident. Broke my right foot. Had a difficulty with my second child.
Age 41- present: Spotty periods with periods of depression. Headaches
Mother had a difficult with my delivery. They required using forceps.
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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 13
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Patient Readiness
Willingness to make lifestyle changes: Yes
Patient expectations: I want to get to the root cause(s) of my health problems. I believe my primary doctor is only treating my symptoms and not looking for the cause(s)
Limitations recorded by patient: I am able to do most things just don't feel well
Immediate concerns: Anxiety, Thyroid issues, Joint pain
Future goals: Take a long vacation with my family
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 14
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Signs a n d Symptoms
The patient reported the following present and past symptoms:
Symptom Present Past
Abdominal pain/cramps
Aching ankles, knees, wrists, or shoulders
Anger easily
Anxiety
Arthritis
Backaches
Bad breath (chronic)
Bitter taste in the mouth in the morning
Bleeding between periods/ frequent spotting
Bleeding, swollen gums
Bloating/Bloating and gas
Body odor
Brain fog/fatigue after eating
Breast soreness during menstrual period
Bruising easily
Bumps on the front thighs
Change in habits of bowel movements
Changes in hair texture and hair growth
Chapped dry lips
Chronic digestive symptoms (GERD, IBS, IBD)
Chronic intestinal infections (yeast/parasitic)
Chronic stress
Clothes dry-cleaned
Coated tongue (white, yellow or dark)
Constipation Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 15
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Signs a n d Symptoms
The patient reported the following present and past symptoms:
Symptom Present Past
Constipation (chronic)
Decreased cognitive function (brain fog) most of the time
Depression
Difficult time concentrating
Difficult time managing stress
Difficult to sweat
Diminished Sex drive
Dizziness
Dizzy when getting up quick
Drink tap water
Dry mouth
Dry, rough, flaky skin
Easily startled
Excessive thirst
Exposed to toxins at home and workplace
Fever
Forgetfulness
Frequent ear infections
Frequent infections
Frequent mood swings
Frequent respiratory infections
Frequent urination
Frequent yeast infections/problems
Gallbladder removed
Generalized aches, sharp pains Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 16
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Signs a n d Symptoms
The patient reported the following present and past symptoms:
Symptom Present Past
Get short of breath easily
Have amalgam fillings
Headaches
Heaviness or tightness in the chest
Hemorrhoids
High cholesterol
Hives
Home pesticide treatments
Hormonal imbalance
Hot flashes
Indigestion
Insomnia
Irregular periods
Irritable before meal time
Itching
Leg cramps
Light-headed, especially when standing up
Loss of color in hair and skin
Low blood pressure
Low exercise tolerance
Lower bowel gas
Lyme Disease (If yes, check PRESENT)
Muscle pain
Muscles fatigue quickly
Nervousness Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 17
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Signs a n d Symptoms
The patient reported the following present and past symptoms:
Symptom Present Past
Pain between shoulders
Palpitations/irregular, skipped heartbeat
Panic attacks
Partial hysterectomy
Periods of rapid heartbeats
PMS
Poor memory/memory loss
Quick to cry
Resist going to bed when tired
Sensitive to cold temperature
Sensitive to household cleaning products
Sensitive to MSG
Sensitive to room sprays and/or candles
Sensitive to tobacoo smoke
Sensitivity to light/noise
Sensitivity to perfumes/gasoline fumes/chemicals
Skin rashes
Skin tags
Slow to recover from surgery
Spider veins
Stressed-out most of the time
Tendency to startle easily
Thinning or loss of outside of eyebrows
Thyroid condition
Trouble falling and staying asleep Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 18
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Signs a n d Symptoms
The patient reported the following present and past symptoms:
Symptom Present Past
Undigested food in stools
Unexplained hair loss
Varicose veins
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 19
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
En v i r o n m e n t a l Toxin Ex p o s u r e As s e s s m e n t
Item(s) Selected:
Use or make plastic shower curtains
Acrylic nail applications
Household cleaners that contain toxic chemicals
Eat fried foods
Exposure to pesticides
Eat foods with food additives
Use antiperspirants
Around or use herbicides
Work around sawdust
Live near a highway and/or railroad
Work around automobile exhaust
Enamelers
Flame retardants
Work with insulation for electrical wires
Work in or around metal fabricating
Paint strippers
Spray paints
Gardener
Aerosols
Household Member(s) Working with and/or Around Environmental Toxins: Yes
Have a whole house water filtration system: No
Home water supply: Public water
Clinicians's Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 20
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Em o t i o n a l/Ps y c h o l o g i c a l As s e s s m e n t
Emotion(s) Selected:
Anger
Frustration
Anxiety
Nervousness
Fear
Resentment
Heartbreak
Feeling stuck in life
Worry
Negativity
Disappointment
Grief
Cloudy thinking
Hopelessness
Get agitated easily
Tend to be Shy
Clinicians's Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 21
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Re p o r t e d Al l e r g i e s
Other food/substances:
Clinicians's Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 22
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Di e t a r y Hi s t o r y An a l y s i s
Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.
Almonds
Food/Substance Description: Almonds are a significant source of essential fatty acids, fiber, phytosterols, manganese, vitamin E, magnesium, and copper. One ounce of almonds
contains about 34 mg of phytosterol. Regular consumption of almonds is associated with reduced LDL cholesterol, and therefore may reduce the risk of cardiovascular disease. Almonds may alsoreduce the risk of colon cancer.
Other Considerations: (Note: Check for oxalate bioavailability) Source of oxalate.
Apples
Food/Substance Description: Apples are an excellent source of vitamin C, fiber, and a variety of phytochemicals, which include: quercetin, catechin, phloridzin, and chlorogenic acid.
Studies have linked apple consumption with reduced risk of certain cancers, cardiovascular disease, asthma, and diabetes. The phytochemicals are found mainly in the peel of the apple, andtherefore it is recommended to only consume organic apples.
Other Considerations: Conventional source is high in pesticide residue. Moderate cross-reactivity with latex allergy. Potential cross-reactivity with birch allergy.
Asparagus
Food/Substance Description: Asparagus is an excellent source of vitamins K, A, and C, potassium, protein, and folic acid. Asparagus is noted for its content of anti-inflammatorycompounds that can significantly inhibit COX2 enzymes and moderately inhibit COX1 enzymes.(Note: Avoid steaming, boiling, and baking methods of cooking. Sautéing or grilling is recommended).
Other Considerations: Moderate purine content. Conventional source is low in pesticide residue.
Avocado
Food/Substance Description: Avocado appears to serve as a functional food by containing substances that can decrease inflammation, lower blood cholesterol, decrease intestinal
glucose absorption (antihyperglycemic effects), and alleviate symptoms of benign prostatic hypertrophy.
Other Considerations: Potential cross-reactivity in individuals with latex allergy. Conventional source is low in pesticide residue.
Bananas
Food/Substance Description: Bananas are an excellent source of potassium and vitamin B6. Other significant nutrients include: vitamin C, fiber, magnesium, biotin, and vitamin B2.
Banana peels are a rich source of antioxidant flavonoids which include; gallocatechin, catechin, and epicatechin. The soluble and insoluble components of the fiber in banana can participate in ahypocholesterolemia effect, as well as normalize bowel function. It is recommended to use organic bananas if the peels are being consumed.
Other Considerations: Conventional source contains a low to moderate amount of pesticide residue. High cross-reactivity with latex allergy. Potential cross-reactivity with ragweed
allergy.
Beets
Food/Substance Description: Beet greens are an excellent source of vitamins A, C, B1, B2, B6, and K, magnesium, iron, potassium, copper, and calcium The root is an excellent source
of folic acid and a good source of fiber, potassium, and manganese. Beet root juice is known for its high content of inorganic nitrates, which has been demonstrated to decrease blood pressure byincreasing nitric oxide production in the body. Beets also stimulates the liver’s detoxification process.
Other Considerations: Significant dietary source of increasing urinary oxalate.
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 23
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Di e t a r y Hi s t o r y An a l y s i s
Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.
Blueberries
Food/Substance Description: Blueberries are a rich source of the antioxidant flavonoids called procyanidins and anthocyanins. Blueberries promote brain, urinary tract, eye, andcardiovascular health.
Other Considerations: Conventional source is high in pesticide residue.
Bottled Water
Food/Substance Description: Bottled water kept in a plastic container can absorb toxic chemicals that leach from the plastic. Heat exposure may cause an increase in the amount of
leaching. In addition, the source of the water may be in question.
Breakfast Cereals
Food/Substance Description:
Other Considerations: Inquire about which type is being consumed.
Broccoli
Food/Substance Description: Compounds found in broccoli demonstrate remarkable anticancer effects. Indole-3-carbinol and sulforaphane increase the excretion of a form of estrogen
known as 2-hydroxyestrone, which has been linked to breast cancer. Many antioxidants in broccoli include; carotenoids (lutein and zeaxanthin), tocopherols, ascorbic acid, and flavonoids (quercetinand kaempferol).
Other Considerations: Goitrogen ( May interfere with thyroid function.) Conventional source contains a low to moderate amount of pesticide residue.
Brown Rice (unrefined)
Food/Substance Description: Brown rice is good source of manganese, selenium, tryptophan, bran and gamma-oryzanol. Brown rice provides a significant amount of dietary fiber which
promotes normal bowel function and gastrointestinal health.
Cheese (low-fat)
Food/Substance Description: Cheese is a good source of tryptophan, calcium, iodine, phosphorous, selenium, and protein. Cow and goat cheese contain lactose, however the content
is considerably lower that cow's milk or goat's milk. The amount of lactose present in cheese depends upon the age and hardness of the cheese. The more aged and harder cheeses contain loweramounts of lactose. Inquire about which type and variety of cheese is consumed (i.e. milk, goat, soy – natural or processed).
Other Considerations: Common food allergen. Non-Organic is high in pesticides and other toxins, including DDT and PCBs. Contains low amounts of lactose.
Chicken
Food/Substance Description: Chicken is a good source of protein, niacin, selenium, pyridoxine, and phosphorous.
Other Considerations: Moderate purine content. May contain arsenic. Non-organic sources may contain antibiotics and/or growth hormones.
Chocolate
Food/Substance Description: Chocolate contains fats, protein, carbohydrates, caffeine, magnesium, calcium, iron and B2. In addition, chocolate contains a significant amount of
phytochemicals called flavonoids. These flavonoids are potent antioxidants and protect against LDL oxidation. Chocolate also provide a significant amount of arginine which is required for theproduction of nitric oxide, a vasodilator. (Note: Dark semisweet chocolate is recommended due to its high flavonoid content). Chocolate consumption will raise urinary oxalate excretion and can lead tostone formation.
Other Considerations: Significant dietary source of increasing urinary oxalate. Contains phenylethylamine. Potential migraine inducer.
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 24
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Di e t a r y Hi s t o r y An a l y s i s
Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.
Corn
Food/Substance Description: Corn is a good source of vitamins B1 and B5, magnesium and folic acid. Corn is deficient in niacin and the amino acids lysine and tryptophan. Corn is
significant source of lutein and zeaxanthin, and therefore contributes to eye health.
Other Considerations: Conventional source is low in pesticide residue. Potential food allergen.
Diet Soda
Food/Substance Description: These beverages contain artificial sweeteners. The additives present in diet soda may be associated with hives, asthma, and/or skin rash.
Other Considerations: May contain: benzoic acid or sodium benzoate. May contain tartrazine and/or FD&C yellow number 5.
Energy Drinks
Food/Substance Description: One of the main active ingredients in energy drinks is caffeine. Inquiry about which type, how much, how often, and the time of day this product is
consumed.
Fast Food
Food/Substance Description:
Other Considerations: Inquire about which type is being consumed.
Fried Foods
Food/Substance Description: Frying modifies the foods and the oil used during cooking.The oil will deteriorate through oxidation and hydrogenation, especially when reused. This
process causes a loss of unsaturated fats and an increase of trans fats. In addition, the food will absorb the degraded oil products which can cause adverse health effects. It is recommended to usedolive or sunflower oil for frying, if you must, and not to reuse the oil. These oils are less prone to oxidation.
Kidney Beans
Food/Substance Description: Kidney beans are a good source of molybdenum, fiber, protein, folic acid, magnesium, iron, copper, and phosphorous. The bioactive components in
kidney beans can bind bile acids which can lower cholesterol. Research indicates that the lectins found in kidney beans have anti-cancer properties against certain lymphomas. Kidney beans maycontain pesticide residue.
Other Considerations: Inquire about conventional or organic source.
Navy Beans
Food/Substance Description: Navy beans are a good source of protein, fiber, folic acid, magnesium, iron, and phosphorous. The fiber contained in navy beans assists in lowering
cholesterol and helps regulate blood sugar level.
Other Considerations: (Note: Check for oxalate bioavailability) Moderate purine content.
Oatmeal
Food/Substance Description: Oat bran is a source of beta-glucans which can bind bile acids in the gastrointestinal tract and thereby lower total cholesterol. About 3 grams per may help
to lower total cholesterol by 8 to 23 percent. In addition, whole oats contain dietary polyphenols which have ant-inflammatory and anti-proliferative properties. Oats are a good source of manganeseand selenium. Oats are not safe for all individuals with celiac disease. Oats are often grown or processed with other cereals leading to cross-contamination with wheat, barley or rye. Currently, thereare also very few known producers of pure gluten-free oats in North America. Although oats appear to be safe in the vast majority of individuals with celiac disease, there is evidence that, in someindividuals, the protein in oats (avenins) can trigger an immune response similar to gluten. Oats are not safe for all individuals with celiac disease.
Other Considerations: Gluten containing food.
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 25
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Di e t a r y Hi s t o r y An a l y s i s
Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.
Oranges
Food/Substance Description: Oranges contain vitamin C, flavonoids and carotenoids. Hesperetin is a cholesterol lowering flavanoid is found in a number of citrus juices. It appears toreduce cholesteryl ester mass and inhibit apoB secretion by up to 80%. Hesperetin may have antioxidant, anti-inflammatory, anti-allergic, hypolipidemic, vasoprotective and anticarcinogenic action.
Pasta (gluten containing)
Food/Substance Description:
Other Considerations: Gluten containing food.
Peanuts
Food/Substance Description: Peanuts are a good source of protein, tocopherols, magnesium, phosphorous, manganese, folic acid, biotin, thiamine and niacin. The fungus, Aspergillusflavus, can grow on peanuts. This fungus produces a carcinogenic substance called aflatoxin. Proper storage of peanuts is required to prevent the growth of this fungus.
Other Considerations: (Note: Check for oxalate bioavailability) Goitrogen ( May interfere with thyroid function.) Common food allergen.
Quinoa
Food/Substance Description: Quinoa is a seed that is high in protein, especially lysine and methionine, and includes all of the essential amino acids. It’s also a good source of iron andcopper. Quinoa is also a low allergenic food.
Safflower Oil
Food/Substance Description: Safflower oil contains the essential fatty acids, linolenic and linoleic acids, which may be beneficial in lowering cholesterol and reducing the risk of heart
disease. Safflower seed oil can act as a blood thinner. Safflower may cause an allergic reaction in individuals allergic to ragweed and related plants.
Other Considerations: Potential cross-reactivity with ragweed allergy.
Salad Dressings (commercial/bottled)
Food/Substance Description: This product generally contain a host of additives.
Other Considerations: Inquire about which type is being consumed.
Snack Foods (chips, pretzels, etc.)
Food/Substance Description:
Other Considerations: May contain sulfites. May contain gluten.
Soft Drinks (soda)
Food/Substance Description: These beverages contain significant amount of refined sugar. The additives present in soda may be associated with hives, asthma, and/or skin rash).
Other Considerations: May contain tartrazine and/or FD&C yellow number 5. May contain: benzoic acid or sodium benzoate.
Soybeans/soy products
Food/Substance Description: Soy contains a high amount of protein (low in methionine and tryptophan), essential fatty acids, phytosterols, lecithin, isoflavones and protease inhibitors.
One protease inhibitor called Bowman-Birk inhibitor, is particularly effective in suppressing carcinogenesis. Phytosterols can block the absorption sites of cholesterol, thereby exhibiting a cholesterol-lowering effect. Soy protein has been shown to lower total cholesterol and LDL-C levels. Individuals with estrogen-sensitive breast cancer and thyroid dysfunction should limit their intake of soyproducts. Soy foods contain both oxalate and phytate in varying amounts. Soy foods that contain more phytate that oxalate may be beneficial for individuals with kidney stones or persons with a highrisk of kidney stone formation.
Other Considerations: Goitrogen ( May interfere with thyroid function.) Moderate purine content. (Note: Check for oxalate bioavailability) Contains a significant amount of oxalates .Common food allergen.
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 26
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Di e t a r y Hi s t o r y An a l y s i s
Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.
Sweet Potatoes
Food/Substance Description: Sweet potatoes are a good source of carotenoids (alpha-carotene and beta-carotene). Packed with important vitamins like A, C and B6, sweet potatoes
have good antioxidant properties. They're also an excellent source of dietary fiber, potassium and iron. Sweet potatoes may help stabilize blood sugar. Hemoglobin A1c may improve after three to fivemonths of regular ingestion. (Note: Sweet potatoes do not belong to the nightshade family of vegetables.)
Other Considerations: Conventional source is low in pesticide residue. Contains a significant amount of oxalates . (Note: Check for oxalate bioavailability)
Turkey
Food/Substance Description: Turkey is a good source of protein, selenium, niacin, pyridoxine, and phosphorous.
Other Considerations: Moderately high purine containing food.
Wheat (bulgur)
Food/Substance Description: Bulgar is a variety of wheat and should be avoided in individuals with celiac disease and gluten sensitivity.
Other Considerations: Common food allergen. Gluten containing food.
White Potatoes
Food/Substance Description: Potatoes are a good source of vitamins C and B6, potassium, and dietary fiber. Most of the nutrients, fiber, and protein are found in the skins. (Note: Avoid
any potato that has a discoloration, in particular a green tint.)
Other Considerations: Nightshade (solanine/chaonine containing food) Conventional source is high in pesticide residue. Potential cross-reactivity in individuals with latex allergy.
White Rice
Food/Substance Description: White rice is put through a milling and polishing process resulting in a loss of the bran, germ, and most of the nutrients. It is estimated that the processing ofrice results in a 70-90% loss of B vitamins, as well as a loss of phosphorous, iron and manganese.
Yogurt
Food/Substance Description: Yogurt is a good source of calcium, protein, phosphorous, iodine, and vitamins B2 and B12. The health benefits from consuming yogurt include: enhancing
immune function, improved milk tolerance, enhanced gastrointestinal function, and cholesterol lowering. Regular intake of yogurt (with certain probiotics) can effectively suppress H. pylori infection.
Other Considerations: Lactose containing food. Common food allergen.
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 27
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Pa t i e n t Hi s t o r y Tr iphasic An a l y s i s Su m m a r y
PHASE 1A – Suspected Environmental Toxin Exposure(s)
Suspected Environmental Illness
Low Medium High
Inquire about household members working with and/or around environmental toxins.
Clinician’s Notes:
Inquire about home water quality
Clinician’s Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 28
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 1B –Suspected Environmental Toxin Exposure Analysis Based on Symptom Survey
Biotoxin Symptom Analysis
(Biotoxins are natural toxic substances produced by organism. e.g. mold)
Low Medium High
Phthalates/Parabens Exposure
Low Medium High
Chlorinated Pesticides
Low Medium High
PCBs
Low Medium High
Volatile Organic Compounds
Low Medium High
Organophosphates
Low Medium High
Bisphenol A
Low Medium High
Heavy Metal Toxicity
Low Medium High
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 29
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 2A – Suspected Nutritional Deficiency(s) Based on Signs and Symptoms
Essential Fatty Acids
Vitamin B1
Vitamin B12
Vitamin B2
Vitamin B6
Vitamin C
Vitamin D
Vitamin E
PHASE 2B – Drug Induced Nutrient Depletion
Glutathione
Coenzyme Q-10
Vitamin B2
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 30
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 2C – Possible Adverse Food Reaction(s) (see Reported Allergy section)
Food Selected Allergen Selected
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 31
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 2D – Suspected Gluten Sensitivity/Celiac Disease
Low Medium High
Phase 2E – Digestive System Assessment
Low Medium High
Food Allergies
Gastric Reflux
Gastric/Duodenal MucosalErrosion
Hypochlohydra/PancreaticInsuffiency
Small Intestine Dysfunction
Liver/GallbladderDysfunction
Large Intestine Dysfunction
IntestinalHyperpermeability/BowelToxicity
Additional Patient Comments:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 33
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Abdominalpain/cramps
1 1 1 1 1Medications/Acute abdominal pain needs
immediate attention.
Aching ankles,knees, wrists, orshoulders
1 1 1Monoarticular: infection-avascular
necrosis-trauma/Polyarticular:inflammatory conditions
Anger easily 1 1 1
Anxiety 1 1 1 1 1 1 Substance abuse
Arthritis 1 1 1 1
Backaches 1 1 1 1 1Neuromusculoskeletal disease/
abdonimal aorticaneurysm/endometriosis/vitamin D
Bitter taste in themouth in themorning
1 1GERD, certain medications, dental
issues, sinus conditions
Bleeding betweenperiods/ frequentspotting
1 1 1
Cervical cancer, uterine fibroids,cervicitis, vaginal dryness, IUD use,
miscarriage, ectopic pregnancy,anticoagulants
Bloating/Bloatingand gas
1 1 Stomach cancer
Brain fog/fatigueafter eating
1 1 1 1
Breast sorenessduring menstrualperiod
1
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 35
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Bruising easily 1 1 1 1 1
Autoimmune disease, certainmedications, thrombocytopenia, loss of
collagen, illness that affect bloodcoagulation
Bumps on the frontthighs
1 1 1 1 Malabsorption
Changes in hairtexture and hairgrowth
1 1 Psoriasis, chemotherapy, color treatment
Chronic stress 1 1 1
Clothes dry-cleaned
1
Coated tongue(white, yellow ordark)
1 1 1 Intestinal dysbiosis, high level of toxins
Constipation 1 1 1 1 1Lack of physcial activity, colon cancer,
certain medication, nervous systemdisorders
Constipation(chronic)
1 1 1 1 1 1 1 1
Decreasedcognitive function(brain fog) most ofthe time
1 1
Depression 1 1 1 1 1
Difficult timeconcentrating
1 1 1 1 Stress, sleep apnea, head traumaSample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 37
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Difficult timemanaging stress
1
Difficult to sweat 1 1 Hypothalamus dysfunction
Diminished Sexdrive
1 1 1 1 1Certain medications, substance abuse,
relationship issues
Dizziness 1 1 1 1Certain medications, brain lesion, ear
disorder, MS, seizures
Dizzy when gettingup quick
1 Postural orthotic tachycardia syndrome
Drink tap water 1
Dry, rough, flakyskin
1 1 1 1
Easily startled 1
Excessive thirst 1 1
Loss of fluids, excessive exercise, burns,infections, heart disease, liver disease,
kidney disease, diabetes mellitus,diabetes insipidus
Exposed to toxinsat home andworkplace
Frequent infections 1 1 1 1 1 1
Frequent colds or flu indicate an immunesystems dysfunction due to excessivebody burden of toxins, gastrointestinaldysfunction, adrenal dysfunction and/or
liver dysfunction.Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 39
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Frequent moodswings
1 1 Neurotransmitter imbalance
Frequent urination 1 1 1
Diabetes mellitus, diabetes insipidus,certain medications, sickle cell anemia,caffeine, alcohol, prostate conditions,
pregnancy
Frequent yeastinfections/problems
1 1
Gallbladder removed 1 1 Consider bile salts supplementation
Generalized aches,sharp pains
1 1 1 1Certain medications, stenuous exercise,
viral/bacterial infections
Get short of breatheasily
1 1 1 1 1 1 1 Respiratory diseases
Have amalgamfillings
1 Mercury toxicity
Headaches 1 1 1 1Qualify headache cause [i.e. primary or
secondary]
High cholesterol 1 1 1
Home pesticidetreatments
1
Hormonal imbalance 1 1 1 1
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 41
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Hot flashes 1 1 1
Insomnia 1 1 1 1 1Hormonal imbalance, certain
medications, pre-existing conditions
Irregular periods 1 1 1 1 1
Hormonal imbalance, certainmedications, eating disorders, excessiveexercise, excessive weightloss or gain,
illness
Itching 1 1 1
Loss of color inhair and skin
1 1 1 Autoimmune disease
Low bloodpressure
1 1 1 1 1
Low exercisetolerance
1 1 1High oxidative stress, pulmonary
conditions, mitochondrial dysfunction, highbody burden of environmental toxins
Muscle pain 1 1 1 1
Certain medications, environmentaltoxins, stenusou exercise, infections,
autoimmune disease, nutritionaldeficiencies
Muscles fatiguequickly
1 1 1 1
Nervousness 1 1 1 1
Pain betweenshoulders
1Referred pain from the stomach, heart, or
thoracic spine
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 43
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Palpitations/irregular,skipped heartbeat
1 1 1 1 1 1 1
Certain medications, anxiety,hypertension, diabetes, hyperthyroidism,
heart disease, electrolyte imbalacne,substance abuse
Panic attacks 1 1 1 1Thyroid diease, adrenal dysfunction,
dietary choices
Periods of rapidheartbeats
1 1 1 1 1Certain medications, heart disease,fever, alcohol, eletrolyte imbalance,
allergies, caffeine
PMS 1 1 1 1 1 1Candidiasis, thryoid dysfunction, GIdysfunction, hormonal imbalance,
nutritional deficiencies, diet
Poor memory/memory1 1 1 1 1 1 1 1
Mold, oxidative stress, blood sugarloss
1 1 1 1 1 1 1 1dysregulation, environmnetal toxins
Quick to cry 1 1 1 1 1
Resist going to bedwhen tired
1
Sensitive to coldtemperature
1 1 1 1 Metabolic disorders
Sensitive to householdcleaning products
1 1
Sensitive to MSG 1 1
Sensitive to roomsprays and/or candles
1 1
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 45
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Sensitive to tobacoosmoke
1 1
Sensitivity tolight/noise
1 1 1
Inflammation of the iris or uvea, cornealabbrasion, coneal ulcer, certain
medications, migraines, eye disease,vitamin A deficiency, hormonal imbalance
Sensitivity toperfumes/gasolinefumes/chemicals
1 1 1
Skin tags 1Insulin resistance, diabetes, skin irritation,
virus
Spider veins 1 1Prolonged standing, hormonal imbalance,
oral contraceptive use, heredity,overweight, history of clots, liver disease
Stressed-out mostof the time
1 1
Tendency to startleeasily
Sleep disorder, fatigue, psychologicaldisorder
Thinning or loss ofoutside of eyebrows
1
Thyroid condition 1 1 1 1
Trouble falling andstaying asleep
1
Undigested food instools
1
The following conditions are associatedwith undigested food in the stool: a need
to digestive support (HCl and/orpancreatic enzyme) and not chewing food
well.Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 47
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3A: Systems Dysfunction Assessment (SDA)
Unexplained hairloss
1 1 1 1 Check for fungal infection
Varicose veins 1 1 1Obesity, inflammatory disease,
heavy lifing, pregnancy, constipation,prolonges standing, lower fiber diet
Percentage: 26% 22% 21% 10% 29% 17% 18% 22% 33% 39% 21% 30% 12% 11% 6% 26% 25% 30% 30%
Total Symptom Burden Score: 253
Clinician’s Notes:
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 48
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
PHASE 3B: Dental Energetic/Meridian Analysis
Tooth Organs Joints Vertebrae Endocrine Systems Sensory Muscles Sinus
16 Heart, Small Intestine
Hand and Elbow, Plantarside of Foot, Sacroiliac,Toes, Ulnar side of theShoulder
C1, C2, C7, T1, T5,T6, T7, S1, S2
Anteriorpituitary
Central Nervous,Limbic
Inner Ear,Tongue
Trapezius
17 Heart, Ileum, Jejunum
Hand and Elbow, Plantarside of Foot, Sacroiliac,Toes, Ulnar side of theShoulder
C1, C2, C7, T1, T5,T6, T7, S1, S2
Energy Exchange,Peripheral Nerves
Middle/ExternalEar, Tongue
Psoas
Patient's Notes:
Clinician’s Notes:
Signature: ________________________ Date: _________________
Sample
Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s
Page: 49
Report Date: 03-25-2018
Date Completed by Patient: 02-25-2018
Patient: Jane Doe
Date of Birth: 6/20/1957
Recommended Lab Testing based on PHASE 3A: Systems Dysfunction Assessment (SDA) above.
SDA Recommended Lab Testing %
Adrenal Dysfunction Labrix (www.labrix.com) 39%
Thyroid DysfunctionTSH, total T4, free T4, total T3, free T3, Reverse T3, Thyroid Antibody, Thyroid Peroxidase. Iodine loading test. ReviewFMUMAP for comprehensive evaluation for thyroid
33%
Psychological Disorder Cognitive behavioral therapy (CBT), Emotional Freedom Technique (EFT) 30%
Mycotoxins
Complement C4a (Labcorp:004330), Complement C3a, Transforming growth factor beta one (TGF b-1), MelanocyteStimulating Hormone (MSH ), Matrix Metalloproteinase-9 (MMP-9)- Online VCS Screening Testhttp://www.survivingmold.com/store1/online-screening-test. If any of the above are positive recommend RealTimeLabMycotoxin Test (https://www.realtimelab.com), HLA-DR genetic testing, MARCoNS testing(http://www.microbiologydx.com)
30%
Reproductive HormoneDysfunction
Dutch Hormone Testing (https://dutchtest.com) 30%
Liver/GallbladderDysfunction
ALT, ALP, AST, Bilirubin, Albumin, Total Protein, GGT. Detoxification component of the Organic Acids (Genova).Hepatitis Profile, MTHFR testing
29%
Dietary Factors Spectracell, ION Test (Genova) 26%
Cardiovascular DiseaseHeart Scan (Calcium Score), CardioIQ, CardioION (Genova), Rule out Chlamydia pneumoniae IgG & IgMAntibodiesTest Code:903103, Rule out H.Pylori
26%
Environmental ToxinExposure
QuickSilver Tri-Mercury Test, Quicksilver Total Toxic Blood Profile, Toxic Effects Core (Genova), GPL-Tox: Toxic Non-metal Chemical Profile (Great Plains Lab), Glyphosate Test (Great Plains Lab)
25%
Kidney Dysfunction BUN, creatinine, Glomerular Filtration Rate(GFR) 22%
Nutritional Deficiencies ION Test (Genova), NutrEval (Genova) 22%
Anemia Ferritin, Iron, Total Iron Binding Capacity, Transferrin and Transferrin Saturation, CBC with differential and platelet count 21%
Blood Sugar Dysfunction Hemogloblin A1c, Organic Acids (Genova) 21%
Small/Large IntestineDysfunction
GI Effects, BioHealth SIBO Test using Lactulose, Dysbiosis component of the Organic Acids (Genova) 18%
Digestive EnzymeInsufficiency
GI Effects -Pancreatic Elastase (Genova) 17%
Immune SystemDysfunction
CD57, cytokine testing, Immunoglobulins IgA, IgE, IgG, IgM, Quantitative Serum (002295) 12%
InflammationTH1 and TH2 Cytokine Test| Basic Panel, TH1 and TH2 Cytokine Test| Advanced Test Panel,http://www.truehealthlabs.com
11%
Food Allergy (Dunwoody) Dietary Antigen and Environmental Allergen Exposure Profiles 10%
Infection
CD57 Panel (HNK1) LabCorp: 505026, Lyme Testing (iGeneX), HLA-DR genetic testing, Coxsackie A7, A9, A16 andA24 IgG and IgM/Test Number: 163295, Parovirus B19 IgM/IgG/Test Number: 163303, CMV (Cytomegalovirus)IgG/IgM/Test Number: 096727/Test Number: 006494, HHV 6 IgG/IgM Antibodies/Test Number: 138529/Test Number:161075 Epstein Barr Virus (EBV) (IgM, IgG), EBV Early Antigen Ab, IgG, EBV Ab VCA, IgG, EBV Nuclear Antien Ab,IgG, EBV Ab VCA, IgM. Epstein Barr Virus Profile (EBV) - Full Diagnostic Profile/Number: 216655, Human HerpesVirus Type 6 IgM
6%Sample