7 CEDAR GROVE LANE, SUITE 38MARC J. CONDREN, M.D., C.N.S. SOMERSET, NEW JERSEY 08873

(732) 469-2133

Thank you for your interest in our medical practice. We specialize in using natural approaches to healing. Our goal is to help you to achieve the highest possible level of good health. Our approach is to integrate the techniques utilized in Nutritional and Anti-Aging Medicine with the advantages of regular modern medicine.

THE SERVICES WE OFFER INCLUDE: Diet recommendations for improving your health Individualized prescription of nutritional supplements. Food allergy testing. Hormone level testing (and treatment using natural hormones):

thyroid hormones adrenal hormones, including DHEA and cortisol levels female sex hormones, for both menstruating and post-menopausal women testosterone levels

Candida albicans (yeast) overgrowth assessment and treatment. Heavy metal testing and treatment. Relaxation training for management of stress and emotional problems. Exercise recommendations: For general health and for home physical therapy rehabilitation. Plus others. (Call if you are looking for a specific service not mentioned above)

The questionnaires enclosed in this pack are designed to obtain general information about your health history, current symptoms, and diet. If you wish to become a patient of our medical practice, please provide the information requested on the enclosed sheets and return the pack to us. We will then contact you to schedule a medical evaluation. Your medical evaluation is done over the first two office visits. This includes taking your medical history, doing a physical examination, obtaining samples for the recommended laboratory testing, and beginning a nutritional supplement program. Your diet will be analyzed, and a session scheduled to discuss your specific dietary recommendations in detail.

Attention is paid to the lifestyle influences that are important for maximizing good health and treating common chronic health conditions. It is important that you are motivated to make changes in how you eat and that you will allow some time in your life for other health-promoting activities. We hope to provide the education and support necessary to help you in your goal of achieving and maintaining good health!

If you desire more information about our medical practice, please call our office. If needed, a free, brief (10 minute) introductory meeting with Dr. Condren may be scheduled to help you decide about becoming a new patient.

PATIENT INFORMATION FORM

NAME:_______________________________________________ SOCIAL SECURITY #:_______________________FIRST MI LAST

HOME STREET ADDRESS:________________________________________________________________________

CITY:__________________________________________STATE:________ ZIP CODE:_______________________

HOME PHONE:__________________________________ WORK PHONE:___________________________

OCCUPATION:_____________________________________________________________________________________

EMPLOYED BY:____________________________________________________________________________________

EMPLOYERS ADDRESS:____________________________________________________________________________

MARITAL STATUS: Single Married Divorced Widow/Widower

EDUCATIONAL LEVEL:_____________________________________

HOW DID YOU FIND OUT ABOUT OUR MEDICAL PRACTICE?______________________________________________

WHO IS RESPONSIBLE FOR PAYMENT FOR SERVICES RENDERED?_______________________________________

PLEASE READ THE FINANCIAL POLICY ON THE NEXTPAGE AND THEN SIGN THE STATEMENT BELOW

I understand and agree that I am responsible for immediate payment of fees for medical services rendered to me by Dr. Condren. I have read and understand the financial policy outlined on the reverse side of this form.

__________________________________________________ DATE:_________________Signature (Parent, for minor)

DO YOU WANT OUR OFFICE TO SUBMIT INSURANCE CLAIMS TO YOUR INSURANCE COMPANY FOR MEDICAL SERVICES RENDERED?

YES NOIf yes, make sure that you complete the insurance verification form, unless you have Medicare coverage

FINANCIAL POLICY

PAYMENT FOR SERVICES IS DUE AT THE TIME SERVICES ARE RENDERED.

For your convenience, our office accepts debit cards and Visa/MasterCard.

Returned checks are subject to an additional $20 fee. Charges may also be made for appointments canceled without advance notice.

The payment arrangements and fees for all of the laboratory tests done in the office are determined by the laboratories. Due to current New Jersey State law, Dr. Condren can not have a financial relationship with any laboratory.

If you have any questions or concerns about the above information, or any uncertainty regarding potential health insurance coverage for our services, please don't hesitate to call and discuss them with us. We are here to help you.

FEE SCHEDULE

The fees written below are the full charges for each procedure listed.

New patient medical evaluation: $200 includes history taking, physical examination, and laboratory testing recommendations

Regular medical office visit: $100

Extended medical office visit (35-60 minutes): $150-$200

Diet counseling session: $35

Relaxation session: $35

Phlebotomy (blood drawing): $20

Lung function testing (spirometry): $35

ELISA/ACT food allergy test: $350 (must be paid in full when blood sample drawn)

We recommend this test for anybody with medical diseases that are promoted by having a “leaky gut”, or to anyone who is interested in having food allergy testing. Examples of medical conditions for which this test is recommended include: environmental allergies, asthma, eczema, psoriasis, "irritable" and inflammatory bowel disease, and auto-immune diseases (such as rheumatoid arthritis and multiple sclerosis).

NEW PATIENT PACK

PLEASE LIST BELOW YOUR MAIN HEALTH CONCERNS:(Use the other side of the page if necessary)

Have you consulted other physicians for any of these concerns? Yes NoIf yes, please indicate what tests have been done to diagnose your problems and write in the names & specialties of thephysicians who have evaluated and treated you in the space below. (Use back of page if necessary)TESTS DONE:

MRI scan Endoscopy UltrasoundCT scan Sigmoidoscopy or colonoscopy X-ray testEKG Skin allergy testing BiopsiesOTHER tests: please list here

Please check the following services that are of particular interest to you:

Dietary analysis and recommendations Candida (yeast) testing and treatment Nutritional supplement recommendations Relaxation training Food allergy testing Heavy metal testing and treatment Hormone level testing and treatment Exercise recommendations The BodyTalk System™ therapy OTHER - please list here:

MEDICAL INFORMATION FORM

Name:__________________________________________________________Date of Birth:____________________________ Age:__________Last complete physical exam was done in what year?_____________

MEDICATIONS: List all prescription and over-the-counter medications you take WITH THE DOSES.

____________________________________________________________________________________________

____________________________________________________________________________________________

MEDICAL ILLNESSES: Check in the first column if you have or had any of the following.Check in the second column if a close blood relative has (or had).

Self Relative Self Relative____ ____ High cholesterol ____ ____ Stroke____ ____ Heart disease ____ ____ Cancer____ ____ High blood pressure ____ ____ Liver disease, hepatitis, jaundice____ ____ Diabetes ____ ____ Gallbladder disease____ ____ Eczema or hives ____ ____ Pneumonia____ ____ Psoriasis ____ ____ Infectious mononucleosis____ ____ Asthma ____ ____ Lyme's disease____ ____ Stomach problems or ulcer ____ ____ Kidney disease____ ____ Irritable bowel disease ____ ____ Glaucoma, cataracts____ ____ Fibrocystic breast disease ____ ____ Broken bones, fractures____ ____ Thyroid disease, goiter ____ ____ Herniated vertebral disk____ ____ Uterine fibroids ____ ____ Rheumatic fever____ ____ Endometriosis ____ ____ Epilepsy, seizures ____ ____ Prostate Disease ____ ____ Phlebitis____ ____ Arthritis ____ ____ Drug abuse____ ____ Anemia ____ ____ Alcoholism

ALLERGIES: List anything you are allergic to and what your reaction is to it.Check here if there are allergy problems in your blood relatives.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OPERATIONS AND HOSPITALIZATIONS: Please list below all operations plus reasons for being admitted to a hospital, and the year they occurred. Do not include normal pregnancies. If none, check here .

Year Operation or illness

OVER

FAMILY HISTORY: For each member of your family indicate their present state of health.(Health)

List names below Good Fair Poor Dead Medical problemsFather:Mother:Brothers/Sisters:

Spouse:Child:Child:Child:Child:

SUPPLEMENTS: Please list all nutritional supplements (such as vitamins, minerals, herbs, and other preparations) that you currently take on a daily basis and the amounts of each that you take.

____________________________________________________________________________________________FOR OFFICE USE ONLYEX: BFB: D&N:

Name:_________________________________

REVIEW OF SYSTEMS FORM

If you are experiencing (especially within the past year) any of the following symptoms or medical problems, rate its frequency, intensity, and duration as defined below. Leave blank if you do not experience it.

Frequency (FREQ) Scale:1 = Occurs about every 2-3 months or less2 = Occurs about once or twice a month3 = Occurs about 1-2 times a week4 = Occurs about 3-5 times a week5 = Occurs every day or is always present

Intensity (INT) Scale: Rate on a numerical scale from 1 = mild to 5 = severe.

How Long: Enter approximately how long it has been present in your lifetime in months (M) or years (Y).

FREQINT HOW LONG FREQINT HOW LONG

GENERAL: Tiredness, Fatigue LUNGS: Wheezing Trouble falling asleep Short of breath Trouble staying asleep Dry Cough Family-related stress Cough up mucus Work-related stress Cough up blood Difficulty concentrating CIRCULATION: Chest pains Mental fogginess; poor clarity Chest tightness or pressure Difficulty with memory Racing or irregular heart beat Cravings for sugary foods Leg cramps Cravings for salty foods Ankles or feet swell Eyes sensitive to light Fluid retention Depression Cold hands and/or feet Trouble relaxing Varicose veins Tend to worry DIGESTIVE: Nausea Tend to feel irritable or angry Vomiting Tend to feel cold easily Heartburn Unusual hunger or thirst Upper abdominal pain Loss of appetite Lower abdominal painHEAD: Headaches Diarrhea (loose, watery BM's) Sneezing Constipation Sinus congestion Tan, beige, or yellow BM's Nasal congestion Blood in BM's or rectum Post-Nasal Drip Excess gas Ear ache Abdominal bloating Eyes water or itch Hemorrhoids Decreased taste sense Black stools Bad or bitter taste in mouth URINARY: Pain with urination Bad breath Hard to stop or start urine stream White or yellow coat on tongue Brown or bloody urine Mucus in throat Sore tongue MALES ONLY: Prostate pains Sore or swollen gums Weak flow of urine Nose bleeds Discharge from penis Dark circles under eyes

PLEASE TURN THE PAGE OVER TO COMPLETE THIS FORM

FREQ INT HOW LONGFEMALES ONLY: Heavy menses Vaginal discharge or burning Cramps with menses Premenstrual SymptomsSKIN: Dry in cold weather Acne Bruises easily ItchyMUSCLES/BONES: Back pain Sciatic pain down legs Joint swelling Joint pain/aching Muscles ache Cramps Muscle weaknessNEURO: Dizziness Fainting Convulsion/seizures

Please record the average number of how many times per year you have the following problems:

TIMES/YEARMigraine headachesHead coldsViral "flu" infectionsSinus infectionsSore throatsBronchitisUrinary tract infections

Please place a check in the box preceding each statement if it applies to you:

Smoke cigarettes OR Quit smoking about ______ years ago Recent weight gain or loss Consume more than 2-3 alcoholic drinks a week Get symptoms of being sick from consuming small or moderate amounts of alcohol Consume more than 1 cup of coffee a day Overly sensitive to the effects of caffeine on your body Occasionally engage in recreational drug usage Frequently take antibiotics for more than 2 weeks a year Have taken antibiotics continuously for more than 1 month in the past Have had multiple episodes of athlete's foot rash Get symptoms of being sick from exposure to cleaning chemicals, perfumes, paint or gas fumes, or pollution

FOR FEMALES ONLY: In menopause (have had no periods) since _________ (year) Have had more than 2 vaginal yeast infections in my life Take over-the-counter or prescription drugs for menstrual cramps May skip a month (or more) in menstrual cycle Have the following premenstrual symptoms (please check) for _______ days before my periods:

Breast tenderness or pain Fluid retention or weight gain Easily irritated or angered; moody Depression Cramps Headaches Abdominal bloating Constipation or diarrhea

NUTRITIONAL QUESTIONAIRE

Do you believe that what you eat may strongly affect your health and/or how you feel? yes no

Our focus of treatment is on dietary interventions to promote the body’s ability to heal itself. Are you willing to make major changes in your diet?

yes no

Have you already made healthy changes to your diet? yes no If yes, please describe the changes:

Please estimate the number of servings per day or week that you drink or eat the following foods:

FOOD SERVING SIZENUMBER OF SERVINGS

PER DAY OR PER WEEKWater 8 oz. glassesCooked Vegetables ½ cupSalad 1 cupFruit Juices 8 oz.Fresh Fruit One piece or ½ cupBread One piece of breadCrackers 4 oz.Processed Breakfast Cereals 1 cupPasta 1 cupWhole Grains (i.e., oats, rice) 1 cup cookedDried Beans (legumes) ½ cup cookedEggs 1 eggFish 3 oz.Poultry 3 oz.Beef 3 oz.Pork 3 oz.Cheese 2 oz.Yogurt ½ cupMilk 8 oz. glassesCoffee, Regular 8 oz. cupsCoffee, Decaf 8 oz. cupsRegular Tea 8 oz. cupsHerbal Teas 8 oz. cupsSoda/Soft Drinks 12 oz.Candy 1 barCake One 2” pieceIce Cream/Frozen Yogurt ½ cupCookies One 2” cookie

Alcohol8 oz. glass of wine12 oz. beer1 oz. hard liquor

How many times a week do you eat deep-fried foods, such as potato chips, French fries,or fried chicken? _____ times a week

OVER

Please rate the quality of your diet: Excellent ____ Good ____ Fair ____ Poor ____

How many times do you eat during the day (meals and snacks)? ____

What percentage of your meals are prepared at home? _____%

What percentage of your meals are eaten out? _____%

Please rate the level of your cooking skills: Excellent ____ Good ____ Fair ____ Poor ____

Please rate on a scale of 1-10 how much you enjoy cooking: (10 = very much; 1 = hate it) ____

Do you have to watch what you eat to avoid gaining weight? yes no

Do you have to watch what you eat to avoid losing weight? yes no

Do any foods seem to irritate you in any way? yes no Please name the food and describe the problem.

What foods do you have a craving for?

What foods do you dislike?

Do you feel your diet is excessive in some respect? yes no Please describe:

Do you feel your diet is deficient in some respect? yes no Please describe:

Please feel free to write in any further notes or information that you feel is important.

INSURANCE VERIFICATION FORM

Complete this form if you want the office to submit claims to your insurance company.This form does not need to be completed if you wish us to submit claims to Medicare.

Call your insurance company to complete this form (unless you already know all of the answers).

Name of insurance company:_________________________________________________________

Name of person who gave you the information:___________________________________________

Ask the following questions:

1. Does my policy provide benefits for ANY MEDICAL DOCTOR that I choose to see? YES NO

2. Does my policy provide benefits for ANY LABORATORY that I choose to use? YES NO

IF NO, what laboratory must I use? ______________________________________

3. Does my policy cover outpatient medical office visits and diagnostic tests? Are there any limits to my coverage? YES NOPlease describe any coverage limits: (Be as specific as possible)________________________________________________________________________________________________________________________________________________________________________________________________

4. What is the address of the office where the claims are to be sent?____________________________________________________________________________________________________________________________________

5. Individual policy? YES NO OR Group Policy: YES NO

Identification number:_______________________ Group Policy number:_______________________

Name policy is under:_______________________________________________

Employee's Company Name:______________________________________________________________