ࡱ> OQLMN7 bjbjUU 0|7|7|lyyy8y,zɷh|| } } }}}}HJJJJJJ$1 Qn}}}}}n; } };;;} } }H;}H;~;nȦ }| p!\uy~Ч d 0ɷ)P);Welcome to our Office Thank you for choosing our offices. We look forward to working with you in partnership to achieve your health goals. On the following pages you will find several documents that need your attention. They are: Dr. OBryans credentials and Functional Medicine description Preparing for your first appointment A patient information sheet* Scheduling appointments* Fee schedule Financial policy* Our privacy policy A consent form* Acknowledgement receipt* An extensive written questionnaire* Seven day diet and activity log* Please read these documents carefully, fill them out accurately and provide signatures as indicated. You will need to bring the forms marked with an asterisk (*) with you to your first appointment. Please keep the other pages for your reference. As you will see, there is a lot of information provided to you about Dr. OBryans practice as well as a great deal of information to be provided by you. This is critical to the doctors assessment of your case. Dr. OBryans office is located at 736 Florsheim Drive, Suite 12, Libertyville, IL 60048. We can easily be reached from the I94 toll way if you exit at Townline Road (Route 60) heading west and turn north at Milwaukee Road (Route 21). Travel approximately 1 miles north on Milwaukee to Artaius. (Artaius is a stoplight street and there is a Walgreens on the northeast corner.) Turn right (east) on Artaius, follow the curve around until you reach Florsheim Drive. Turn left on Florsheim, and then immediately left again into the driveway on your left. Our building faces Florsheim Drive and the Libertyville Post Office. Our phone number is (847) 680-3100, fax number (847) 680-2026. Dr. OBryan sees patients every Tuesday and Thursday between 10:00 am 5:00 pm. Dr. Thomas OBryan Dr. Thomas OBryan was the Founding Director of Omnis Chiropractic Group in Glenview, Illinois. He is a graduate of the University of Michigan and the National College of Chiropractic. He is a Diplomat of the National Board of Chiropractic Examiners, a Board-Certified Diplomat of the American Clinical Board of Nutrition, and a Certified Clinical Nutritionist with the International and American Association of Clinical Nutritionists. He is a Certified Applied Kinesiologist. He is a member of the American Chiropractic Association, Price-Pottenger Foundation, the International Academy of Preventive Medicine and many other professional organizations. He is a practicing graduate of the Institute for Functional Medicines hallmark program, Applying Functional Medicine in Clinical Practice. Using tools of Applied Kinesiology, Laboratory and Functional Medicine, Dr. OBryans emphasis on diet and nutrition has given many patients with frustrating medical problems a game plan to follow in regaining their health. Dr. OBryan is listed in Whos Who in International Medicine, Outstanding Young Men in America, and the International Directory of Distinguished Leadership for Excellence in Education. He is a tri-athlete and has a second degree black belt in Aikido. Awarded Chiropractor of the Year, Dr. OBryan is the past President of the Chicago Chiropractic Society and a past Director of the Illinois Chiropractic Society. Dr. OBryan has practiced Functional Medicine for the past 23 years. What is Functional Medicine? Functional Medicine is defined as patient-centered, science-based health care that identifies and addresses the underlying triggers that cause disease and dysfunction. Its therapeutic goals are to reverse or prevent disease progression and enhance vitality. Functional Medicine is a field of health care that utilizes sophisticated assessment and testing to discover early indications of potential imbalances so that we may to intervene early improving ones overall health. The functional medicine health care approach recognizes that our bodies want to be well and that each individual patient is unique. What may work for some, may not work for others. Therefore, the therapeutic game plans used in Functional Medicine concentrate utilizing this premise while integrating knowledge from a wide range of academic and clinical disciplines. Its focus is to assess and intervene at root levels of metabolic imbalance - that is to identify the cause of an illness rather than focusing only on the illness. It aims to improve and optimize health at the psychological, biochemical or structural levels through therapies that restore, repair and rebuild that intrinsic balance. Its goal is to intervene before imbalances become later diseases utilizing intelligent and individualized combinations of treatments or protocols. Most chronic health conditions involve metabolic imbalances in one or more of these six categories: Nutritional Imbalances, Immune/Inflammatory Imbalances, Intestinal Dysfunction, Impaired Detoxification, Oxidative Stress and Endocrine Imbalance. The treatments and therapies used in our office include only those in which good science and/or clinical experience have demonstrated results. To be considered as consistent with the principles of Functional Medicine a treatment method must fulfill four criteria. They are: First do no harm Improve symptoms as well as the overall function and quality of life Help to convert the underlying causes of the disorder Improve the long-term prognosis for the patient Although this approach depends to some degree on extensive laboratory testing as well as a range of therapies directed at the underlying causes, the most important therapy is the time and care taken with each patient at every visit. There are few shortcuts to this approach; it simply takes time to be this thorough. We strongly feel it is time well spent. Patient Information Sheet Please fill in the following. This information is confidential and will help us serve you better. In some cases, it may be necessary for us to reach you before or immediately after a scheduled appointment (i.e. the doctor is running late, a change in appointment time, contact you regarding test results, etc.) Patient Name: Date: Address: City: State: Zip: Home Phone: Work Phone: Work Days/Hours: Cell Phone: Email Address: Home Fax Number: Work Fax Number: Birth date: Age: Sex: M / F Social Security #: Parent/Guardian Name (if applicable): Emergency Contact: Relationship: Phone Number: Employer Name: Occupation: Employer Address: City: State: Zip: Insurance Company: Insurance Phone Number: Group #: ID #: Insurance Company Mailing Address: Insureds Name: Whom May We Thank for Referring You to our Office? What have you heard about our office?_____________________________________________________ ____________________________________________________________________________________ How to Prepare for your First Appointment Congratulations on taking your first step toward achieving your health goals. We are very committed to helping you in that process. New patient appointments are usually scheduled in the morning and will last approximately 1 hours with the doctor. There are often other tests ordered that may require additional time. Please plan on spending at least 2 3 hours here. To most effectively utilize that time, please prepare in advance and note the following simple steps. Please arrive 30 minutes prior to your scheduled appointment time. Bring your completed detailed questionnaire with you or arrive approximately 90 minutes before your scheduled appointment to complete the questionnaire here. Plan to provide a urine sample upon arrival. Please wear comfortable clothing as all new patients will be given a Vitality and Longevity Assessment. This is a simple test that measures lean body and fat mass, total body water levels, basal metabolic rate and cellular nutrient and cellular toxicity statuses among other things. As a result, please: Have nothing to eat for at least 5 hours prior to your arrival (minimum amounts of water are ok). Do not drink coffee or alcohol for at least 12 hours prior to your arrival. Do not exercise for at least 12 hours prior to your arrival You will most likely receive a great deal of information and education about ways to enhance your health. We understand that sometimes that information being presented all at once can be overwhelming. To help you remember what was discussed, the doctors recommendations and other information, your session will usually be audiotaped. There is only one copy of that tape and it is given to you at the conclusion of your appointment. (If you would rather not have the session taped, please notify the doctor.) Please always feel free to take notes during the session as well. Please bring with you any medications and vitamin/mineral supplements you are currently taking. Please bring your completed diet activity log. Please bring any reports, x-rays, MRIs, etc you currently have regarding your condition. Please note: It is not uncommon for a first appointment to cost anywhere between $250 - $1,200 and in some cases more, when you take into account the doctors fees and the laboratory fees. All expenses (other than the basic $250 examination fee) are solely at your discretion. After spending about an hour with Dr. OBryan reviewing your symptoms and medical history, you will choose which tests being recommended to perform. The costs are dependent on the extent of the case and the types of laboratory tests ordered. You will have an opportunity to discuss any concerns you may have in this area with the doctor during your appointment. However, please rest assured that only those tests that are absolutely necessary are ordered. And, the information received from doing these tests is critical in the diagnosis and management of your care. Hopefully, in a very short time, you will see that you are making an investment in your future. And through that investment you will see better, more healthful days ahead. Scheduling Appointments As previously mentioned, we are very committed to helping you achieve your health goals. We believe strongly in that partnership. We will respect your time and ask that you respect ours. Our scheduling procedures are unique in the healthcare field. We do not overbook. We schedule a very limited number of patients a day. Because of this, a missed appointment or a cancellation impacts on us much more than on an office that overbooks. With that in mind, a missed or cancelled appointment with less than a 2 business day advanced notice will be charged at the regular office visit rate ($150.00). In addition, we can only accommodate late arrivals by offering what ever is left of your appointment time. Again, however, the regular office visit rate will apply regardless of time spent with the doctor. Please note you will be responsible for payment as most insurance carriers will not cover missed/cancelled appointments. Appointments are usually 1 hour, except the new patient appointment, which is usually 1 hours. After the initial visit, when no additional tests are required we will do our best to accommodate telephone consultations for our long distance patients. I have read, understand and agree to the above. Name (please print) Signature Date Fee Schedule New Patient Functional Examination: $250.00 - $400.00 Existing Patient: $150.00 - $210.00 Interpretation & Management: $45.00 -$150.00 Of test results, billed for each cycle of lab tests Missed or Cancelled Appointments: $150.00 Without 48 hours notice Previous Test Reviews: $30.00 - $185.00 In office, by phone or e-mail Phone Consults: $50.00 - $250.00 Special Reports: $75.00 - $175.00 Letters to insurance carriers, other reports, etc. Laboratory Tests: As per individual lab Billed separately and directly from the lab Email Consults: $45.00 - $185.00 Email Consults As you are well aware, email greatly increases effective communication. This is especially true when it comes to a physician like Dr. OBryan who communicates and monitors patients all over the country. Of obvious great benefit, you are able to keep in constant contact, you dont have to travel to see the doctor and often you can get responses in a more timely manner than if you had to set up an appointment. Dr. OBryan is at the leading edge of medicine and continues to invest in new technology. However, he can spend as much as 5 hours a day emailing patients. As a result, we have no choice but to charge for this service. All appointments are charged based on the following criteria: Time spent Nature of the problem (Existing, New, Recurring, Confirmatory) Number of Diagnosis or Management Options (Minimal, Limited, Multiple, Extensive) Amount and/or Complexity of Data to be Reviewed (Minimal or None, Limited, Moderate, Extensive) Risk of Complications (Minimal, Low, Moderate, High) Type of Decision Making (Straightforward, Low Complexity, Moderate Complexity, High Complexity) Payment is expected at time of service. Financial Policy Payment is expected for all services at the time the care is provided in our office. Although many of our patients have health insurance that covers most or part of these services, we do not accept payment directly from health insurance companies. We provide a detailed receipt - complete with diagnoses, at the time of service. It is your responsibility to submit it to your insurance company for reimbursement. This allows us to keep our fees at a reasonable level while continuing to provide high-quality, natural healthcare. However, there can be separate additional charges for any laboratory tests that are ordered by Dr. OBryan (i.e. blood work, stool or urine analysis, etc.). In most cases, the laboratories can bill your insurance company for you. But some also offer a discount for those patients who pre-pay. Please note: Some insurance companies consider nutritional (vitamins and diet) recommendations to be preventative healthcare and will not reimburse for these products or services. Clearly, we do not share this view and current science validates our approach to healthcare as not only preventative but also therapeutic. Therefore we can in no way guarantee that any insurance company will cover any services, tests, supplements, etc. Each company, policy and individual case is different. If you have any questions regarding what will be covered, we recommend that you discuss this directly with your insurance carrier. We accept payment by cash, check or credit card (VISA or MasterCard only). I have read, understand and agree to the above. Patient Name (please print) Signature of Patient or Guardian Date Patient Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The office of Dr. Thomas OBryan & Associates (referred to hereafter as the or this office) is committed to protecting your personal medical information. The creation of a record detailing the care and services you receive helps this office to provide you with quality healthcare and complies with this offices medical retention requirements. This notice applies to the medical records maintained by this office and it specifically details the way in which your medical information may be used and disclosed to third parties. This notice also details your individual rights regarding your medical records. This form must be signed and dated before your treatment begins. 1. This office may use and/or disclose your medical information consistent only with valid consent granted by you for the purposes of: Treatment In order to provide you with the healthcare you require, this office will provide your medical information to those healthcare professionals, whether they are part of this offices staff or not, directly involved in your care so that they may understand your medical condition and needs. Payment In order to get paid for services provided, this office will provide your medical information, directly or through a billing service, to appropriate third-party payers, pursuant to their billing payment requirements. For example, this office may need to tell your insurance plan about a treatment you are going to receive so that it can be determined whether or not your plan may cover the treatment. Health Care Operations In order to gain an overall view of various elements of this offices operations, individual medical information may be collected, complied or disseminated. For example, this office may utilize your medical information in order to evaluate the performance of our personnel in providing care to you. 2. This office may use and/or disclose your medical information, without written consent, in the following instances: Communication Barriers If, due to substantial communication barriers or an inability to communicate, this office has been unable to obtain consent and this office determines, exercising its professional judgment, that your consent to receive treatment is clearly inferred from the circumstances. Involvement in Care or Payment In accordance with applicable laws, disclosure may be made to your family members, other relatives, close personal friends and/or any other person identified by you, of such information that is relevant to the persons involvement with your care or payment related to your healthcare. Notification In order to notify or assist in the notification of a family member, a personal representative or another person responsible for your care, of your location or general condition. Required by Law When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law. Threat to Health and/or Safety If it is necessary to prevent or lessen serious and imminent threat to the health and/or safety of a person or the public, in accordance with applicable laws. Appointment Reminders, Treatment Alternatives, and Health Related Benefits In order to provide you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. Public Health Risks In order to prevent or control disease, injury and disability and report child abuse or neglect. Lawsuits and Disputes In order to comply with a court or administrative order in connection with a lawsuit or dispute. 3. Your Individual Rights You have the right to: Revoke any authorization and/or consent, in writing, at any time To request revocation, please submit a written request to this office. Request restrictions on certain uses and/or disclosures as provided by law However, this office is not obligated to agree to any requested restrictions. To request a restriction, please submit a written request to this office. In your written request you must inform this office of what information you want to limit, whether you want to limit this offices use or disclosure, or both, and to whom you want the limits to apply. If this office agrees to your request, we will comply with the request unless the information is needed in order to provide you with emergency treatment. Receive confidential communications of protected health information as required by law To request confidential communications; you must make your request in writing to this office. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted. Inspect and copy protected health information as provided by law This right includes access to medical and billing records. To inspect and copy health care information, please submit a written request to this office. This office can charge you a fee for the costs of copying, mailing or other supplies associated with your request. This office may deny you access to medical information, but you have the right to have this denial reviewed as will be set forth more fully in the written denial notice. Amend incorrect or incomplete protected information as provided by law To request an amendment, please submit a written request to this office. You must provide a reason that supports your request for the amendment(s). This office may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the office (unless the individual or entity that created the information is no longer available), if the information is not part of the medical information maintained by the office, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. To complain to this office if you believe your privacy rights have been violated To file a complaint, please contact this office. All complaints must be in writing. Have your questions about your rights answered You may contact this office. 4. Office Rights and Requirements This office: Is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected information. Is required to abide by the terms of this notice. Reserves the right to change the terms of this notice and to make the new notice provisions effective for all protective information that it maintains. Will give to you, and you will be required to sign, a receipt for any revised notice. Will not retaliate against you for filing a complaint. 5. This original notice is in effect as of 10/1/02. Patient Consent Form Name:________________________________________ Date of Birth:_____________________________________ Through the use of this consent form, I authorize Dr. Thomas OBryan & Associates to perform the following: (Items 1 and 2 must be checked before treatment begins.) ____1. Conduct an evaluation and receive treatment from Dr. Thomas OBryan & Associates. ____2. To exchange/release personal information with those health care professionals treating/practicing on site, who are directly involved in the care of my dependent(s) or myself so they may understand my/his/her medical condition and needs. ____3. To release information pertaining to an auto or personal injury accident to attorneys office, insurance agencies, workman compensation organizations, etc. ____4. To receive from or release to (if the healthcare professional is not located on site): Name of person, Doctors name, Organization, Attorneys office or Institution Address (for above) Phone Number Fax Number The following information: _____Patient History _____Behavioral Report _____Medical Records _____Teachers Report _____Education/Academic Records _____Verbal Exchange _____Psychological Evaluation _____Other Information _____Neurological Evaluation Specify other reason___________________ _____X-Rays/MRIs, etc. ___________________________________ If you do not consent to the above use and/or disclosure of your personal health information, then this office will not treat you. I have read and understand the foregoing notice and all of my questions have been answered to my complete satisfaction and in a way I can understand. ______________________________________ _______________________________________ Name of Patient (please print) Signature of Patient ______________________________________ _______________________________________ Name of Guardian/Parent (if individual is a minor) Signature of Parent/Guardian ______________________________________ _______________________________________ Relationship to Patient Date Signed RELEASE IS VALID FOR DURATION OF THE PATIENTS CARE IN THIS OFFICE Acknowledgement Receipt of Patient Privacy Notice As required by the Health Insurance Portability and Accountability Act of 1996 regulation, I hereby acknowledge that I have received a copy of Dr. Thomas OBryans Patient Privacy Notice and Consent Form effective 10/02. In addition, I am aware that Dr. OBryan has included a provision that HE reserves the right to change the terms of the privacy notice and to make the new notice provisions effective for all protected health information that it maintains. Your requests: _____ I wish to file a request for restriction of my protected health information (i.e. information is only to be released to me in person). Please describe: __________________________________________________________________________ _____ I wish to file a request for alternative communications of my protected health information (including whether or not it is ok to leave messages on voicemail or with a person regarding test results, appointments, returning calls). Please describe and leave alternative phone number: __________________________________________________________________________ _____ I wish to object to the following in the notice of privacy practices. Please describe: __________________________________________________________________________ _____ I wish that my protected health information be released to my insurance carrier upon a written request. _____ I wish that my protected health information NOT be released to my insurance carrier upon a written request. _____ No special communication restrictions for my protected health information are necessary. __________________________________________________________________________ By signing below, I certify that I have received and reviewed this notice and all of my questions have been answered to my satisfaction in language that I can understand. I also understand that this office is not required to honor any changes/requests to the Patient Privacy Notice. ______________________________________ _______________________________________ Name of Patient (please print) Signature of Individual ______________________________________ _______________________________________ Name of Guardian/Parent (if individual is a minor) Signature of Parent/Guardian ______________________________________ _______________________________________ Relationship to Patient Date Signed New Patient Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends significantly on your ability to respond thoughtfully and accurately to the questions posed in the written questionnaire as well as by the doctor during your consultation. The doctor will review this questionnaire with you during your initial consultation and your confidentiality will be strictly maintained. Please carefully consider each of the questions as your answers will enhance the doctors efficiency and will provide for a more effective use of your consultation time. There are usually a few questions, which you will not know the answers to. If so, simply leave these blank for the time being and proceed from there. If you need more room for a particular question, please use the back or add additional sheets. Thank you for your time in advance. 1. How did you hear about our clinic? 2 . Please state your primary reason for attending our clinic. If this involves a specific health condition, please describe it in detail. List the very first time that you noticed the condition and describe carefully any factors that you suspect may have played a role in its onset and perpetuation. Please list every detail possible and give the Doctor the opportunity to distinguish what may or may not be relevant to your case. 3. Please outline on the diagram the area of your discomfort. Mark the areas on this body where you feel the described sensations using appropriate symbols. Please include all affected areas and mark areas of radiation. Numbness = ------- Pins & Needles = 00000 Burning = xxxxx Aching= ***** Stabbing = /////// Other = ##### Pain Chart   Right Left Right Left 4. Is your health currently getting better, worse, or staying the same? How do you know? Were there any precipitating events? 5. What are the most significant measures, which you have taken to date to improve your state of health? 6. Please list the 5 most significant stressful events in your life, from the most recent to the most distant. Are any of these situations continuing to impact on your life? If so, please indicate these clearly. A. B. C. D. E. 7. Are you currently working with a professional counselor, psychologist, social worker, psychiatrist, pastor or therapist? ________________________________ Which? Have you in the past?_________________________ When? 8. Do you have a medical doctor? _________________ Who? Address: ___________________________________ Phone Number: Have you consulted this medical doctor regarding the aforementioned condition(s)? If so, when?________________________________ If not, why not? Please explain his/her diagnosis, therapy and result. 9. Have you consulted other practitioners before? __________When? Have you consulted this practitioner regarding the aforementioned condition(s)? If so, when?________________________________ If not, why not? Please explain his/her diagnosis, therapy and result. 10. Do you consult any other healthcare professional on a regular basis? (Dentist, Optometrist, Licensed Acupuncturist, Massage Therapist, etc.) Please provide details. 11. Please list all of your secondary health concerns/conditions of which you are aware of, whether you feel they are related to your primary reason for attending our clinic or not. 12. Please list any and all drugs/medications which you are presently using or have used in the past and what they are/were being used for. Please reflect carefully as your current health state may relate directly to the treatment of a past health problem. Also, please indicate who prescribed these for you and how he/she determined your specific needs and dosages. 13. Do you supplement your diet with vitamins or minerals? _________ please list the brand name, content, potencies, (if possible, bring these with you on your first appointment). Also, please indicate who prescribed these for you and how he/she determined your specific needs and dosages. 14. Indicate whether there is any history of the following conditions in your family (siblings, parents, grandparents, aunts, uncles, first cousins and children) and note whether mother or fathers side of the family. Use the following key to mark as appropriate: M=Mother, F=Father, B=Brother, S=Sister, GM=Grandmother, GF=Grandfather, A=Aunt, U=Uncle, C=Cousin Heart Disease ______ Asthma ______ Wheat/Gluten Sensitivity Cancer ______ Allergies ______ Dairy Sensitivity Diabetes ______ Psoriasis ______ Celiac Disease Osteoarthritis ______ Eczema ______ Miscarriages Ankylosing Spondilitis ______ Mental Illness ______ Thyroid Disease Rheumatoid Arthritis ______ Parkinsons disease ______ Drug Abuse Multiple Sclerosis ______ Muscular Dystrophy ______ Autoimmune Disorders Alzheimers ______ Crohns Disease ______ Genetic Disorders _______ Other Conditions:______________________________________________________________________ 15. Check the intake of the following and note how often they are consumed. Intake Times per Day Times per Week _____ Coffee ____________ _____________ _____ Tea ____________ _____________ _____ Alcohol ____________ _____________ _____ Cigarettes ____________ _____________ _____ White Sugar ____________ _____________ _____ Chocolate ____________ _____________ _____ Soda Pop ____________ _____________ _____ Fast Food ____________ _____________ 16. Did your mother have any health problems during pregnancy (i.e. morning sickness, nausea, high blood sugar, high blood pressure, any medications used at that time)? (Please look into that if possible). Please explain. 17. Was your birth process natural or was there medical intervention, (i.e. C-Section, Forceps, Epidural, Anesthesia, etc.)? Please explain. 18. Were you separated from your mother for any medical or other reason during the first six months after birth?___________ for approximately how long and why? 19. Were you breast-fed within the first 10 hours after birth? 20. Were you breast-fed at all? 21. Were you fed anything other than breast milk during your first 6 months of life? If so, which foods? 22. Were you a colicky baby?_______ until what age? 23. Did you require any medical attention, hospitalization or medication as an infant (before age 2)? As a child (age 2 years to 10 years)? Please explain. 24. Did you have any childhood allergies that you have grown out of? _______ If so, please explain in detail. 25. Have you had any surgery? ________ If so, please list all surgeries, their approximate dates, why they were performed, and if you feel they were successful. 26. Have you had any illnesses other than the ordinary self-limiting childhood diseases of the measles, mumps and chicken pox? __________ If so, please explain. 27. Did you get vaccinations as a child? _________ If so, which ones and when? 28. Have you ever had worm or parasite infections?_________ Have you suspected either? If yes, please explain. 29. Have you ever had scarlet or rheumatic fever? 30. Did you grow up in a city, suburban, agricultural/rural area or near an industrial area? If so, please explain how long you were there and if possible any known hazards? 31. Did you grow up near electric wires or a utility transformer site? ________If so, approximately how close to your home and for how long did you live there? 32. Was your home growing up heated with heating oil, a gas furnace, wood burning stove or radiators? How is your home heated today? Has your home been checked for radon?________ What was the result? _____________How old is your home? _________ How long have you lived there? Have you lived near new construction or in a new construction home? ________ For how long? Does your home have a wood porch? 33. Have you ever been diagnosed as having: HIV/AIDS ______ Asthma ______ Celiac Disease Cancer ______ Allergies ______ Food Allergies Diabetes ______ Thyroid disease ______ Food Sensitivities Arthritis ______ Mono or Epstein Barr ______ Multiple Sclerosis ______ Crohns Disease ______ Muscular Dystrophy ______ Hepatitis ______ Auto-immune Disorders ______ Clinical Depression ______ Alzheimers ______ Other Conditions (that may be pertinent to your recent state of health): 34. Have you ever had a disease condition involving your bones, joints, muscles, ligaments or tendons? ____ Please explain. 35. Have you had any bad sprains or broken bones due to accidents or sports? _______ How many? _______ Please explain. 36. Have you ever had spinal X-Rays, CAT Scans or MRIs done?_______ When, where, why? Were any abnormalities found? (Please bring with you any reports and actual x-rays you may have regarding this). 37. Have you ever had any other tests done? (i.e. bone scan, ultrasound, stress tests, EMG nerve tests, blood work, stool analysis, etc.) _____ What were the reasons for the tests? Were any abnormalities found? (Please bring with you any reports and actual test results you may have regarding these). 38. Have you ever had any infections or inflammations? (i.e. tonsillitis, bladder or ear infection, vaginitis, colitis, sinusitis, yeast overgrowth, mastitis, dental abscess, etc.) Please explain. 39. What do you feel is your weakest body system and why? (i.e. heart, kidney, lungs, digestion, etc.) 40. Have you had any respiratory disorders? (i.e. pneumonia, bronchitis, asthma, sinus infections, etc.) 41. How many times each year do you have a cold, sinusitis, the flu, sore throat, swollen glands or bronchitis? How long do they usually last? __________ Do you often relapse? __________ Are they severe enough to affect your lifestyle (i.e. require medication, time off work, stay in bed etc.)? 42. Do you take medication for the above? _______ If so, what kind? 43. Is your libido (sexual drive) Low, Normal, High (please circle one)? 44. Have you ever had any venereal disease or genital herpes? ______ Did you receive treatment? If so, what kind? 45. Have you ever fainted, blacked out or had a seizure or convulsion? ______ Please explain. 46. Do you get dizzy or light-headed if you stand up too quickly? (Please circle one) Never, Rarely, Occasionally (2x per week), Often (4x per week), Daily 47. Do you find that you can crave stimulants (coffee, pop, sweets, etc.) afterexertion (exercise, physical work, a high stress period, demanding mental work,or a cold or flu)? 48. Do you wear a medical alert bracelet or tag?________ For what condition(s)? 49. Are you aware of having any allergies to foods, drugs, or inhalants? How do you react? Please list all and describe in detail. 50. Have you recently lost or gained a lot of weight? Do you know why? 51. What direction do you see your health and body function moving in the next five years? 52. Where would you like to see your health and body function moving toward in the next five years? 53. Are you willing to devote the time and energy into making that happen? 54. FOR WOMEN ONLY: Have you ever been pregnant? ________________ How many times? _________________How many live births?______________ Any miscarriages? ________________Have you had any trouble getting pregnant? _______________ Please explain._________________________________________________ What was the date of your last menstrual period?_____________________________________________ Are you using any birth control method?_________________ If so, which?________________________ Do you have a history of fibroids or cysts?___________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 1. Signs of Fatty Acid Deficiency Place a 1, 2 or 3 next to all signs or symptoms that apply: 1 = Mild 2 = Moderate 3 = Severe Dry Skin Use of lotion for dryish skin Dry, rough patches on elbows Dry, cracked heels Dandruff Dry eyes Dry, frizzy or unmanageable hair Frequent urination Increased thirst Bumps or chicken skin on backs of arms Soft, brittle or easily frayed fingernails Allergies Difficulty with attention or focus Hyperactivity Aggression or hostility Irritability Depression General learning problems Poor memory Reading difficulty Heart rhythm problems Joint inflammation Fatigue Total 2. Trans Fatty Acid Intake Place a 1, 2 or 3 next to each question based on which best describes your dietary intake of the following foods: 0 = Never 1 = Less than once a month 2 = Once a month 3 = Weekly French fries Chicken nuggets Potato chips Corn chips/tortilla chips Fish burgers (deep fried) Doughnuts Pastries Candy Margarine Cake Cookies Shortening Deep fried mushrooms Puffed cheese snacks Total 3. Omega-3 Fatty Acid Intake Place a 1, 2 or 3 next to each question based on which best describes your dietary intake of the following foods: 0 = Never 1 = Less than once a month 2 = Once a month 3 = Weekly Salmon Cod (Atlantic) Haddock Snapper Sea Scallops Mackerel Herring Sardines Anchovies Bluefin Tuna Eggs Krill Caviar Trout, rainbow Flax oil/meal Fish oil Chia seeds Walnuts (English, Black) Pumpkin seeds Brazil nuts Candlenut Butternut Total Scoring Your Brain Fatty Acid Profile Section Your Score 1 _________ 2 _________ 3 _________ Interpretation Below is a quick interpretation of your results. Section 1 Signs of Fatty Acid Deficiency Less than 4 = Good 5 10 = Strong evidence of fatty acid imbalance > 10 = Very strong evidence of fatty acid imbalance Section 2 Trans Fatty Acid Intake Less than 4 = Good, the lower the number the better 5-10 = Probably too many trans fats for optimum brain health > 10 = Far too many trans fats for optimum brain health Section 3 Omega-3 Fatty Acid Intake Less than 5 = Far too many Omega-3 for brain health 5 10 = Modest intake, but probably not ideal for brain health > 10 = Better > 20 = Excellent Seven-Day Diet & Activity Log Patient Name: Please take the time to complete the following survey carefully, as accurately and honestly as possible. Please enter the time an activity is begun, what activity (i.e. ate breakfast, had snack, slept), the type of food consumed (i.e. frozen, canned, fresh/raw, cooked, fast food, etc.) or the activity that was done, and the amount (for food enter the weight in ounces if possible or estimate, for other activities enter the amount in minutes/hours). Please include all foods and beverages consumed for this seven-day period. If an activity was skipped (i.e. lunch, please indicate by writing none in the time field) Be sure to mention all fast foods, oils and any condiments used (i.e. mayo, mustard, ketchup, salad dressing, relish, etc.). Please also complete the activity/exercise and relaxation portions at the bottom. Please list the type of exercise or activity, its duration and your pulse rate before, during and after the activity, if possible. 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