Name: ___________________________________________ Age: ______ Sex: _____ Date: ______________ PART I Please list your 5 major health concerns in order of importance:1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________3. __________________________________________________________________________________________4. __________________________________________________________________________________________5. __________________________________________________________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Form

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feelingthatbowelsdonotemptycompletely LowerabdominalpainrelievedbypassingstoolorgasAlternatingconstipationanddiarrhea DiarrheaConstipationHard,dry,orsmallstoolCoatedtongueor“fuzzy”debrisontonguePasslargeamountoffoul-smellinggasMorethan3bowelmovementsdailyUselaxativesfrequently

Category II IncreasingfrequencyoffoodreactionsUnpredictablefoodreactionsAches,pains,andswellingthroughoutthebodyUnpredictableabdominalswellingFrequentbloatinganddistentionaftereating Abdominalintolerancetosugarsandstarches Category III IntolerancetosmellsIntolerancetojewelryIntolerancetoshampoo,lotion,detergents,etc.MultiplesmellandchemicalsensitivitiesConstantskinoutbreaks Category IV Excessivebelching,burping,orbloatingGasimmediatelyfollowingamealOffensivebreathDifficultbowelmovementSenseoffullnessduringandaftermealsDifficultydigestingfruitsandvegetables; undigestedfoodfoundinstools

Category VStomachpain,burning,oraching1-4hoursaftereatingUseantacidsFeelhungryanhourortwoaftereatingHeartburnwhenlyingdownorbendingforwardTemporaryreliefbyusingantacids,food,milk,or carbonatedbeveragesDigestiveproblemssubsidewithrestandrelaxationHeartburnduetospicyfoods,chocolate,citrus, peppers,alcohol,andcaffeine

Category VI RoughageandfibercauseconstipationIndigestionandfullnesslast2-4hoursaftereatingPain,tenderness,sorenessonleftsideunderribcageExcessivepassageofgas

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

Category VI (continued)Nauseaand/orvomitingStoolundigested,foulsmelling,mucouslike, greasy,orpoorlyformedFrequenturinationIncreasedthirstandappetite

Category VII Greasyorhigh-fatfoodscausedistressLowerbowelgasand/orbloatingseveralhours aftereatingBittermetallictasteinmouth,especiallyinthemorningBurpy,fishytasteafterconsumingfishoilsDifficultylosingweightUnexplaineditchyskinYellowishcasttoeyesStoolcoloralternatesfromclaycoloredto normalbrownReddenedskin,especiallypalmsDryorflakyskinand/orhairHistoryofgallbladderattacksorstonesHaveyouhadyourgallbladderremoved?

Category VIIIAcneandunhealthyskinExcessivehairlossOverallsenseofbloatingBodilyswellingfornoreasonHormoneimbalancesWeightgainPoorbowelfunctionExcessivelyfoul-smellingsweat

Category IX CravesweetsduringthedayIrritableifmealsaremissedDependoncoffeetokeepgoing/getstartedGetlight-headedifmealsaremissedEatingrelievesfatigueFeelshaky,jittery,orhavetremorsAgitated,easilyupset,nervousPoormemory/forgetfulBlurredvision

Category XFatigueaftermealsCravesweetsduringthedayEatingsweetsdoesnotrelievecravingsforsugarMusthavesweetsaftermealsWaistgirthisequalorlargerthanhipgirthFrequenturinationIncreasedthirstandappetiteDifficultylosingweight

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

PART IIIHowmanyalcoholicbeveragesdoyouconsumeperweek?Howmanycaffeinatedbeveragesdoyouconsumeperday?Howmanytimesdoyoueatoutperweek?Howmanytimesdoyoueatrawnutsorseedsperweek?Listthethreeworstfoodsyoueatduringtheaverageweek:Listthethreehealthiestfoodsyoueatduringtheaverageweek:PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Category XI CannotstayasleepCravesaltSlowstarterinthemorningAfternoonfatigueDizzinesswhenstandingupquicklyAfternoonheadachesHeadacheswithexertionorstressWeaknails

Category XIICannotfallasleepPerspireeasilyUnderhighamountofstressWeightgainwhenunderstressWakeuptiredevenafter6ormorehoursofsleepExcessiveperspirationorperspirationwithlittle ornoactivity

Category XIII EdemaandswellinginanklesandwristsMusclecrampingPoormuscleenduranceFrequenturinationFrequentthirstCravesaltAbnormalsweatingfromminimalactivityAlterationinbowelregularityInabilitytoholdbreathforlongperiodsShallow,rapidbreathing

Category XIVTired/sluggishFeelcold―hands,feet,alloverRequireexcessiveamountsofsleeptofunctionproperlyIncreaseinweightevenwithlow-caloriedietGainweighteasilyDifficult,infrequentbowelmovementsDepression/lackofmotivationMorningheadachesthatwearoffasthedayprogressesOuterthirdofeyebrowthinsThinningofhaironscalp,face,orgenitals,orexcessive hairlossDrynessofskinand/orscalpMentalsluggishness

Category XVHeartpalpitationsInwardtremblingIncreasedpulseevenatrestNervousandemotionalInsomniaNightsweatsDifficultygainingweight

Category XVIDiminishedsexdriveMenstrualdisordersorlackofmenstruationIncreasedabilitytoeatsugarswithoutsymptoms

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

Category XVII IncreasedsexdriveTolerancetosugarsreduced“Splitting”-typeheadaches

Category XVIII (Males Only)UrinationdifficultyordribblingFrequenturinationPaininsideoflegsorheelsFeelingofincompletebowelemptyingLegtwitchingatnight

Category XIX (Males Only)DecreasedlibidoDecreasednumberofspontaneousmorningerectionsDecreasedfullnessoferectionsDifficultymaintainingmorningerectionsSpellsofmentalfatigueInabilitytoconcentrateEpisodesofdepressionMusclesorenessDecreasedphysicalstaminaUnexplainedweightgainIncreaseinfatdistributionaroundchestandhipsSweatingattacksMoreemotionalthaninthepast

Category XX (Menstruating Females Only)PerimenopausalAlternatingmenstrualcyclelengthsExtendedmenstrualcycle(greaterthan32days)Shortenedmenstrualcycle(lessthan24days)PainandcrampingduringperiodsScantybloodflowHeavybloodflowBreastpainandswellingduringmensesPelvicpainduringmensesIrritableanddepressedduringmensesAcneFacialhairgrowthHairloss/thinning

Category XXI (Menopausal Females Only)Howmanyyearshaveyoubeenmenopausal?Sincemenopause,doyoueverhaveuterinebleeding?HotflashesMentalfogginessDisinterestinsexMoodswingsDepressionPainfulintercourseShrinkingbreastsFacialhairgrowthAcneIncreasedvaginalpain,dryness,oritching

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Copyright©2012,DatisKharrazian.AllRightsReserved.SMGEMAF04(052212)

Rateyourstresslevelonascaleof1-10duringtheaverageweek:Howmanytimesdoyoueatfishperweek?Howmanytimesdoyouworkoutperweek?

Name: _____________________________________Age: ______ Sex: ________ Date:______________________

Neurotransmitter Assessment Form (NTAF)

Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

SECTION A• Is your memory noticeably declining? • Are you having a hard time remembering names and phone numbers? • Is your ability to focus noticeably declining? • Has it become harder for you to learn new things? • How often do you have a hard time remembering your appointments? • Is your temperament generally getting worse? • Is your attention span decreasing? • How often do you find yourself down or sad?• How often do you become fatigued when driving compared to in the past?• How often do you become fatigued when reading compared to in the past?• How often do you walk into rooms and forget why?• How often do you pick up your cell phone and forget why?

SECTION B• How high is your stress level? • How often do you feel you have something that must be done? • Do you feel you never have time for yourself? • How often do you feel you are not getting enough sleep or rest?• Do you find it difficult to get regular exercise?• Do you feel uncared for by the people in your life? • Do you feel you are not accomplishing your life’s purpose?• Is sharing your problems with someone difficult for you?

SECTION C SECTION C1 • How often do you get irritable, shaky, or have light-headedness between meals? • How often do you feel energized after eating? • How often do you have difficulty eating large meals in the morning? • How often does your energy level drop in the afternoon? • How often do you crave sugar and sweets in the afternoon?• How often do you wake up in the middle of the night?• How often do you have difficulty concentrating before eating?• How often do you depend on coffee to keep yourself going?• How often do you feel agitated, easily upset, and nervous between meals?

SECTION C2 • How often do you get fatigued after meals? • How often do you crave sugar and sweets after meals? • How often do you feel you need stimulants, such as coffee, after meals? • How often do you have difficulty losing weight? • How much larger is your waist girth compared to your hip girth? • How often do you urinate?• Have your thirst and appetite increased?• How often do you gain weight when under stress?• How often do you have difficulty falling asleep?

SECTION 1• Are you losing interest in hobbies?• How often do you feel overwhelmed? • How often do you have feelings of inner rage? • How often do you have feelings of paranoia? • How often do you feel sad or down for no reason? • How often do you feel like you are not enjoying life?

• How often do you feel you lack artistic appreciation? • How often do you feel depressed in overcast weather? • How much are you losing your enthusiasm for your favorite activities? • How much are you losing your enjoyment for your favorite foods? • How much are you losing your enjoyment of friendships and relationships? • How often do you have difficulty falling into deep, restful sleep? • How often do you have feelings of dependency on others? • How often do you feel more susceptible to pain? • How often do you have feelings of unprovoked anger? • How much are you losing interest in life?

SECTION 2• How often do you have feelings of hopelessness? • How often do you have self-destructive thoughts? • How often do you have an inability to handle stress?• How often do you have anger and aggression while under stress? • How often do you feel you are not rested, even after long hours of sleep? • How often do you prefer to isolate yourself from others?• How often do you have unexplained lack of concern for family and friends? • How easily are you distracted from your tasks? • How often do you have an inability to finish tasks? • How often do you feel the need to consume caffeine to stay alert? • How often do you feel your libido has been decreased? • How often do you lose your temper for minor reasons?• How often do you have feelings of worthlessness?

SECTION 3• How often do you feel anxious or panicked for no reason? • How often do you have feelings of dread or impending doom? • How often do you feel knots in your stomach? • How often do you have feelings of being overwhelmed for no reason?• How often do you have feelings of guilt about everyday decisions?• How often does your mind feel restless? • How difficult is it to turn your mind off when you want to relax?• How often do you have disorganized attention? • How often do you worry about things you were not worried about before? • How often do you have feelings of inner tension and inner excitability?

SECTION 4• Do you feel your visual memory (shapes & images) has decreased? • Do you feel your verbal memory has decreased? • Do you have memory lapses? • Has your creativity decreased? • Has your comprehension diminished? • Do you have difficulty calculating numbers? • Do you have difficulty recognizing objects & faces? • Do you feel like your opinion about yourself has changed? • Are you experiencing excessive urination? • Are you experiencing a slower mental response?

Copyright © 2011, Datis Kharrazian. All Rights Reserved. SMGENTAF04(110211)

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 3

Copyright © 2011, Datis Kharrazian. All Rights Reserved. SMGENTAF04(110211)

Atropine

Ipratropium

Scopolamine

Tiotropium

Mecamylamine

Hexamethonium

Nicotine (high doses)

Trimethaphan

Pralidoxime

Atracurium

Cisatracurium

Doxacurium

Metocurine

Mivacurium

Pancuronium

Xanax®

Lexotanil®

Lexotan®

Librium®

Klonopin®

Valium®

ProSom®

Rohypnol®

Ambien CR®

Sonata®

Lunesta®

Imovane®

Flumazenil

Echothiophate

Isoflurophate

Organophosphate Insecticides

Organophosphate-containing nerve agents

Thorazine®

Prolixin®

Trilafon®

Compazine®

Mellaril®

Stelazine®

Vesprin®

Nozinan®

Depixol®

Navane®

Fluanxol®

Clopixol®

Mirapex®

Sifrol®

Requip®

Wellbutrin XL®

Stablon®

Coaxil®

Tatinol®

Effexor®

Pristiq®

Meridia®

Serzone®

Dalcipran®

Desipramine

Duloxetine

Elavil®

Endep®

Tryptanol

Trepiline®

Asendin®

Asendis®

Defanyl®

Demolox®

Moxadil®

Anafranil®

Norpramin®

Pertofrane®

Marplan®

Aurorix®

Manerix®

Moclodura®

Nardil®

Adeline®

Eldepryl®

Remeron®

Zispin®

Avanza®

Paxil®

Zoloft®

Prozac®

Celexa®

Lexapro®

Luvox®

Cipramil®

Emocal®

Seropram®

Cipralex®

Fontex®

Dapoxetine

Donepezil

Galantamine

Rivastigmine

Tacrine

THC

Carbamate Insecticides

Rocuronium

Succinylcholine

Tubocurarine

Vecuronium

Hemicholinium

Dalmane®

Ativan®

Loramet®

Sedoxil®

Dormicum®

Serax®

Restoril®

Halcion®

Acuphase®

Haldol®

Orap®

Clozaril®

Zyprexa®

Zydis®

Seroquel XR®

Geodon®

Solian®

Invega®

Abilify®

Prothiaden®

Adapin®

Sinequan®

Tofranil®

Janamine®

Gamanil®

Aventyl®

Pamelor®

Opipramol®

Vivactil®

Rhotrimine®

Surmontil®

Azilect®

Marsilid®

Iprozid®

Ipronid®

Rivivol®

Zyvox®

Zyvoxid®

Seromex®

Seronil®

Sarafem®

Fluctin®

Faverin®

Seroxat

Aropax®

Deroxat®

Rexetin®

Paroxat®

Lustral®

Serlain®

Edrophonium

Neostigmine

Physostigmine

Pyridostigmine

Norset®

Remergil®

Axit®

*Please refer to prescribing physician for nutritional interactions with any medications you are taking.

Medication History*

Please check any of the following medications you have taken in the past or are currently taking.

Norepinephrine and Dopamine Reuptake Inhibitors (NDRI)

Dopamine Receptor Agonists

D2 Dopamine Receptor Blockers (antipsychotics)

GABA Antagonist Competitive Binder

Cholinesterase Inhibitors (irreversible)

Agonist Modulators of GABA Receptors (nonbenzodiazepines)

Selective Serotonin Reuptake Enhancers (SSREs)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Tricylic Antidepressants (TCAs)

Monoamine Oxidase Inhibitors (MAOIs)Noradrenergic and Specific Sertonergic Antidepressants (NaSSAas)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Cholinesterase Inhibitors (reversible)

Acetylcholine Receptor Antagonists Antimuscarinic Agents

Acetylcholine Receptor Antagonists Ganglionic Blockers

Acetylcholinesterase Reactivators

Acetylcholine Receptor Antagonists Neuromuscular Blockers

Agonist Modulators of GABA Receptors (benzodiazepines)

NEW PATIENT QUESTIONNAIRE

Name: Date: Address

Cell Work Birthdate F M PhoneAge Marital Status S M D W #Kids Email Emergency Contact Name & Number Please describe any problem you are currently experiencing or have experienced in the past to help us get a better understanding of your health history. For example, if you now, or as a child, frequently were ill with ear infections please write that in the ears/nose/throat section below. Again please be as detailed as possible as this form is VERY IMPORTANT to us. We need to know as much about you as possible in order to properly evaluate and treat your condition. 1. WHOLE BODY HEAD: (concussions, stroke, headaches, dizziness, etc. EARS/NOSE/THROAT: (ear infections, inner ear problems, nose bleeds, frequent strep infections, difficulty swallowing, loss of hearing, smelling or taste etc.) EYES: (corrective lenses, dryness, double/blurry vision, etc.) THYROID: (hyper/hypothyroidism? Medication for this?) ARMS/LEGS: (pain, skin disorders, abnormal weakness, loss of limbs/fingers/toes-briefly explain how loss occurred, etc.) ABDOMINAL/REPRODUCTIVE AREA: (nausea, ulcers, kidney stones, ovarian cancer, prostate problems, diabetes, bladder control, any cancers, etc.) LUNG/HEART: (difficulties breathing, asthma, heart attacks, angina, stroke, rapid/slow heart rate, pacemaker, etc.){circle} BLOOD: (anemia, etc.)

THE FOLLOWING QUESTIONS HAVE TO DO WITH BRAIN STEM FUNCTION: HIGH IML Are you sensitive to light or have blurring vision? Y N Have you experienced an increase in sweating? Y N Do you have trouble sleeping, continuously waking up during the night or trouble getting to sleep? Y N Have you experienced an increase in pulse or heart rate, or had heart palpitations? Y N Do you have a history of urinary tract infections? Y N Have you experienced visual changes before migraine headaches? Y N Do you have, or have you had bedsores or lesions? Y N LOW IML Do you fatigue easily? Y N Do you have cold hands or feet? Y N Do you experience frequent urination or are you unable to control urinary or bowel movements? Y N Do you have episodes of fainting or hypoxia? Y N For the next several questions please answer briefly and give the dates each began to the best of your knowledge and if you can think of what contributed to it. 1. Any history of fainting/loss of consciousness? Y N 2. Noticeable changes in your handwriting? Y N 3. Changes in sexual function? Y N 4. Are you more irritable or angry? Y N 5. Episodes of depression or anxiety? Y N 6. Problems with equilibrium, loss of balance, tripping, dropping things, etc? Y N 7. Difficulty scanning pages while reading a book? Y N 8. Difficulty adding or subtracting? Y N 9. Difficulty moving your eyes? Or double vision? Y N

10. Difficulty expressing what you would like to say? Y N 11. Any changes in speech? Y N 12. Any changes in sensation? Y N 13. Any changes in memory? Y N 14. Any changes in hearing? Y N 15. Excess dryness or wetness of the eyes or nose? Y N 2. FULL DESCRIPTION (DETAILED) OF WORK ACTIVITIES What do you do? What are your duties? How many hours per week do you work? Do you do a lot of lifting or twisting at work? 3. LIFESTYLE Hobbies/Activities/Exercise. Diet (List briefly the types of foods you generally eat.) Rate your salt/sugar/fat consumption. (Mark each: Low/Moderate/High) Salt L M H Sugar L M H Fat L M H What type of vitamins/supplements? History of diets? Any changes? 1. How have you taken care of your health in the past?

Medications Routine Medical Exercise Nutrition/Diet Holistic Care Vitamins Chiropractic Other (please specify):

2. How did the previous method(s) work out for you?

Bad results Did not get worse Some results Did not work very long Great results Still trying Nothing changed Confused

3. How have others been affected by your health condition?

No one is affected Haven’t noticed any problem They tell me to do something People avoid me

4. What are you afraid this might be (or beginning) to affect (or will affect)?

Job Sleep Kids Time Future ability Finances Marriage Freedom Self-esteem

5. Are there health conditions you are afraid this might turn into?

Family health problems Fibromyalgia Heart disease Depression Cancer Chronic Fatigue Diabetes Need surgery Arthritis

How has your health condition affected your job, relationships, finances, family, or other activites? Please give 3 examples: What has that cost you ? (time, money, happiness, freedom, sleep, promotion, etc.) Give 3 examples: What most concerns you regarding your problem? Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? Please be specific:

What would be different/better without this problem? Please be specific: What do you most desire from working with us? What is that worth to you? Is there anything that would hold you back from beginning care? If I accept you for care and you needed to be here 1-2 times per week, would that be a present problem? Yes No If I accept you for care and require you to make certain lifestyle changes (i.e. diet), would that be a problem? Yes No Our specialized care requires out of pocket expenses: would that be a problem for you? Yes No Please list goals YOU would like to accomplish after beginning care at our office: 6 Month Goals: 12 Month Goals:

NEUROLOGICAL ASSESSMENT FORM Patient Name _______________________________________ Date __________________

1. Are you left or right handed? Right Left

2. Have you had a head injury? YES NO

3. Have you noticed your ability to concentrate is getting worse? YES NO

4. Does driving cause you fatigue, headaches, or any other symptoms? (circle) YES NO

5. Does working on a computer cause you fatigue, headaches, or other symptoms? YES NO

6. Have you lost your interest in hobbies and functions that you used to enjoy? YES NO

7. Do you have any changes in smell or smell foul things that are not present? YES NO

8. Do you have difficulty with taste or taste things differently than what you are eating? YES NO

9. Do you have difficulty with short-term memory? YES NO

10. Have you been told or noticed any memory loss of past events? YES NO

11. Do you experience Déjà vu? YES NO

12. Do you ever experience flashes of light in your visual field? YES NO

13. Do you get lost often or have a hard time with directions? YES NO

14. Do you currently experience or have a past history of vertigo or balance disorders? YES NO

15. Noticed clumsiness in hand coordination? Which Hand? Right / Left (circle) YES NO

16. Do you find that your balance is getting worse? YES NO

17. Do you have any tightness, weakness, or instability in your back or neck? (circle) YES NO

18. Do you ever have slurred speech? YES NO

19. Do you have difficulty with math problems, or remembering numbers? YES NO

20. Do you find yourself searching for words frequently when you speak? YES NO

21. Do you get motion sickness easily (car sick or sea sick)? YES NO

22. Have you ever experienced or been diagnosed with arrhythmia (fluctuating heart rate)? YES NO

23. Do you have difficulty distinguishing right and left? YES NO

24. Do you feel like you need to wear sunglasses outside? YES NO

25. Do you have any difficulty with falling asleep or staying asleep? YES NO

26. Noticed uneven sweating or temperature on one side of your body? YES NO

27. Do quick flashes of light on TV or loud noises bother you? YES NO

28. Do you have a hard time motivating yourself to engage in activities? YES NO

29. Do you experience blurriness in your vision or double vision? (circle) YES NO

30. Do you have a hard time swallowing? YES NO

31. Do you gag easily? YES NO

32. Do you experience nausea? YES NO

33. Do you ever experience dry eyes or mouth? (circle) YES NO

34. Do you ever experience increase tearing or salivation? (circle) YES NO

35. Noticed any drooping of your eyelids or facial muscles? (circle) YES NO

36. Has your handwriting changed in recent years? YES NO

37. Do you ever have fluttering of the eye or noticed you are blinking frequently? YES NO

38. Do you ever have any numbness or tingling in your hands, legs, or face? (circle) YES NO

39. Do you have difficulties walking down stairs? YES NO

40. Do you have any ringing or pressure in the ears? YES NO

41. Do you ever notice increased heart rate (tachycardia) or pulse during the day? YES NO

42. Do you have any tightness, or feelings of weakness in your hands or legs? (circle) YES NO

Patient Signature_______________________________________________ Date _________________

Lawrence Chiropractic Center 1342 Auburn Road ~ Suite 114 ~ Dacula, Ga 30019 Tel: 770-237-5534 ~ Fax: 770-237-5532 www.lawrencechiropracticcenter.com

Patient Name_____________________________________________________________

ASSIGNMENT OF INSURANCE BENEFITS

I authorize and direct that payment be made directly to:

Natalie A. Lawrence, D.C.

1342 Auburn Rd. Suite 114

Dacula, Ga 30019

For any and all insurance benefits or reimbursement for services rendered by her which

amounts would otherwise be payable to me under any insurance or pre-paid health plan.

Date______________________________ X_________________________________ Patient/Guardian

RELEASE OF INFORMATION

I authorize the release of any information concerning my health and health care services

to my insurance companies, pre-paid health plan, attorney, medical doctor, and/or

Medicare.

Date______________________________ X________________________________ Patient/Guardian

PAYMENT AGREEMENT

I understand that there is no guarantee that my insurance companies or pre-paid health

plan will cover or pay for all of my charges. Not withstanding denial, reduction of

benefits, or failure to pay for any reason, I understand that I am responsible for all

remaining charges.

Date_______________________________ X__________________________________ Patient/Guardian

NOTICE OF PRIVACY PRACTICES

I acknowledge that there is a posting of the NOTICE OF PRIVACY PRACTICES in the

office for my information and perusal and that I may request a copy of this notice if I so

desire.

Date______________________________ X__________________________________ Patient/Guardian

Lawrence Chiropractic Center 1342 Auburn Road ~ Suite 114 ~ Dacula, Ga 30019 Tel: 770-237-5534 ~ Fax: 770-237-5532

RECORDS RELEASE

TO:

I HEREBY AUTHORIZE YOU TO RELEASE TO LAWRENCE

CHIROPRACTIC CENTER ANY INFORMATION REGARDING THE

RESULTS OF DIAGNOSTIC TESTING, LABORATORY TESTING AND/OR

RADIOLOGICAL REPORTS (CT, MRI AND X-RAY) RENDERED TO ME

DURING THE PERIODS FROM __________TO_________.

WE ASK THAT YOU FAX ALL INFORMATION TO OUR OFFICE.

PATIENT NAME__________________________________

SOCIAL SECURITY NUMBER______________________

DATE OF BIRTH__________________________________

_____________ _____________________

DATE SIGNATURE

_____________ _____________________

DATE WITNESS