we want to welcome you to lemont natural healthcare. our...

We want to welcome you to Lemont Natural Healthcare. Our mission is to improve your chronic health condition as much as possible and teach you how to manage your own health for the rest of your life. Please review our office policy before we enter our trusted doctor/patient relationship. Please initial after each point signifying that you understand:

1. What we offer is a holistic program, not medical therapy. This means that we may recommend labs tests that your medical doctor would not or did not order. These lab tests that we order can help determine the underlying causes of your health problems and evaluate the multiple systems of your body that interact together. Our bodies are a sum of these systems. These systems do not work independently. We then would balance your body with proven natural therapies based on these lab tests. The lab tests we order for you may or may not be covered by your insurance company. They do not understand holistic care and the reason why we order these tests. INITIALS: _______

2. Our office utilizes functional neurologic (brain balancing and therapy) and metabolic therapy (balancing your digestive, immune and hormone systems as well as dietary recommendations…what you should or should not eat), not medications. INITIALS: _______

3. It is very important that you fully understand the “why” behind what we do. For this reason we require that you watch our videos (posted on our website or on You Tube). We have made some short (2 to 3 minute introductory videos) and longer versions (30 to 45 minutes) that go into greater detail regarding our Holistic program for your condition. By initialing below, you are agreeing to watch the full length video. INITIALS: _______

4. In order for you to regain your health, there will be dietary changes, neurological and/or traditional exercises to be done as well as lifestyle changes. INITIALS: _______

5. Holistic therapy is not covered by insurance. This is their choice not ours. Typically Holistic therapy costs in our office range from $250-350 per month for up to 18 months if you chose to finance it. The exact cost of care and your options to pay for it will be explained in detail at your next appointment. It is very important that your spouse or significant other be with you during this appointment. They will be able to hear our program details, ask questions and they will be more informed to help support you while you are on our program. INITIALS: _______

Dr. Forzley has been in practice for 30 years utilizing metabolic therapy. Dr. Imber is one of only 9 board certified chiropractic functional neurologists in the state of Illinois. Our Neuro-Metabolic therapy program can drastically improve your health and get you back to enjoying your life.

I have read and fully understand all the above.

Signature: _________________________________ Date: _________

Sincerely,

Dr. Jeffrey E. Forzley Dr. Matthew J. Imber

1192 Walter St, Suite C Lemont, IL 60439

Phone: 630.257.0550 Fax: 630.257.0555

PATIENT INFORMATION www.LemontNaturalHealthcare.com

Home Phone: ______________________________________ Cell Phone: _______________________________________

E-‐mail Address: ________________________________________________________________________________________

Major Medical Insurance: PPO:______ HMO: ______ Medicare: ______ Medicaid: _______ None: ______

How did you hear about us? [ ] Internet, [ ] Newspaper ______________ (which ?), [ ] Other___________________

[ ] Facebook [ ] Website [ ] Personal Referral , whom may we thank? __________________________________

Date:______________________

Name: ___________________________________________________________________________________________ Last First Middle

Home Address: ____________________________________________________________________________________ Street Address Apt. / Condo Number

______________________________________________________________________________________________________________________________________ City State Zip Code

CONSENT TO NUTRITION EVALUATION / RECOMMENDATIONS I authorize Lemont Natural Healthcare to perform a nutrition / health analysis. No claims are made to diagnose, treat, cure or

prevent any specific disease or condition. X_________________________________________________________ _______________________________ Patient Name (Printed) Signature of Patient Date

CONSENT TO TREATMENT OF A MINOR (UNDER 18 YEARS OF AGE) I hereby authorize Lemont Natural Healthcare to evaluate and perform treatment for my _________________________,

named __________________________________, age________, and consent on his/her behalf. I am a legal guardian of this child.

X_____________________________________________________ ________________________ Guardian Name (Printed) Signature of Guardian Date

SSN#: _________-‐-‐-‐-‐_______-‐-‐-‐-‐__________

Age: _____ Birthdate: _____/_____ /_____ Weight ______lb. Height: ____’____”

Employer’s Name: __________________________________________ Occupation: _________________________

Address: _______________________________________________________________________________________

Marital Status: M S D W Name of Spouse:______________________ Phone ________________________

Emergency Contact Information

Name: _________________________________________________________________________________________ First Last

Relationship to you:_____________________________

Home Phone #:_________________________________ Mobile Phone #:_____________________________

DESCRIBE YOUR MAJOR HEALTH CONDITIONS / CONCERNS:

1.Conditions/Diagnosis:________________________________________________________________

Symptoms: _________________________________________________________________________

____________________________________________________________________________________

When did this start? __________________________________________________________________

Physician Seen: ______________________________________________ Date Seen_______________

Diagnosis: ____________________________________________________________________

Treatment: ___________________________________________________________________

Results: ______________________________________________________________________


Diagnosis: _____________________________________________________________________

Treatment: ____________________________________________________________________

Results: ______________________________________________________________________

Nutritional Supplements/Diet: _________________________________________________________

___________________________________________________________ Did it Help? YES NO

Other Treatment: ____________________________________________ Did it Help? YES NO


Symptoms: _________________________________________________________________________

____________________________________________________________________________________



Diagnosis: ____________________________________________________________________

Treatment: ___________________________________________________________________

Results: ______________________________________________________________________


Diagnosis: _____________________________________________________________________

Treatment: ____________________________________________________________________

Results: ______________________________________________________________________


___________________________________________________________ Did it Help? YES NO




Symptoms: _________________________________________________________________________

____________________________________________________________________________________



Diagnosis: ____________________________________________________________________

Treatment: ___________________________________________________________________

Results: ______________________________________________________________________


Diagnosis: _____________________________________________________________________

Treatment: ____________________________________________________________________

Results: ______________________________________________________________________


___________________________________________________________ Did it Help? YES NO



Symptoms: _________________________________________________________________________

____________________________________________________________________________________



Diagnosis: ____________________________________________________________________

Treatment: ___________________________________________________________________

Results: ______________________________________________________________________


Diagnosis: _____________________________________________________________________

Treatment: ____________________________________________________________________

Results: ______________________________________________________________________


___________________________________________________________ Did it Help? YES NO


PERSONAL HISTORY Please mark an “X” in front of any conditions you currently have or a “P” for previously had.

Muscle/ Joint __ Arthritis __ Bursitis __ Hernia __ Low Back Pain __ Neck Pain __ Stiff Neck __ Pain Between Shoulders __ Swollen Joints __ Fractures (Where and when?) ________________________________________ Pain / Numbness __ Shoulders __ Arms __ Elbows __ Hands __ Hips __ Legs __ Knees __ Feet Respiratory __ Asthma __ Chronic cough __ Difficulty breathing __ Wheezing __ Bronchitis __ Emphysema

Cardiovascular __ Arteriosclerosis __ Hardening of arteries __ Heart Attack __ High blood pressure __ Heart Disease __ Low blood pressure __ Pain over heart __ Poor circulation __ Pacemaker __ Rapid / Slow heartbeat __ Stroke Head __ Colds __ Deafness __ Dizziness __ Vertigo __ Dental decay __ Ear ache __ Ear ringing __ Enlarged glands __ Eye pain __ Failing vision __ Gum trouble __ Hay fever __ Hoarseness __ Light-‐headed __ Nose Bleeds __ Sinus infection __ Sore throat

General __ Allergies_________ __ Anxiety __ Convulsions __ Cancer (Where?) ___________________ __ Diabetes __ Dizziness __ Epilepsy __ Fainting __ Fatigue __ Headache __ Nervousness __ Loss of sleep __ Poor posture __ Sciatica __ Seizures __ Low Energy __ Spinal Curvature __ Swelling of ankles __ Thyroid issues __ Weight Loss (abnormal) __ Weight Gain (abnormal) Skin __ Acne __ Bruise easily __ Eczema __ Hives __ Itching __ Varicose veins

Genitourinary __ Bed-‐wetting __ Bladder infection __ Blood in urine __ Frequent urination __ Kidney infection __ Painful urination __ Prostate trouble Gastrointestinal __ Appendicitis __ Belching or gas __ Bloated abdomen __ Colitis __ Colon trouble __ Constipation __ Diarrhea __ Difficult Digestion __ Excessive hunger __ Gallbladder trouble __ Gallbladder Removed? __ Hemorrhoids __ Intestinal worms __ Liver trouble __ Nausea __ Pain over stomach __ Poor appetite __ Ulcers __ Vomiting __ Vomiting of blood

Misc. Conditions: __ Alcoholism __ Anemia __Autoimmune Disease __ Cold Sores __ Diabetes – I or II? __ Edema __ Fever blisters __ Goiter __ Gout __ Herpes __ Multiple Sclerosis __ Polio __ Rheumatic fever __ Scarlet fever __ Tuberculosis Women Only __ Cramps __ Fibrocystic breasts __ Excess menstrual flow __ Hot flashes __ Irregular cycle __ Lumps in breasts __ Menopause __ Miscarriage __ Painful menstruation __ Vaginal discharge Are you pregnant? Yes No If yes, how far along? _____ months?

Breakfast (List foods):___________________________________________________________________ Lunch (List foods):______________________________________________________________________ Dinner (List foods): _____________________________________________________________________ Snacks (List foods):_____________________________________________________________________ Drinks (List): _____________________________________________________________________ How much pure water do you drink per day? ________oz Water source: Tap Bottled Filtered Filter Type: _____________________ Sleep: Hours per night ____ Difficulty falling asleep? Yes No Rested when you awake? Yes No Do you awaken during the night? Yes No If yes, can you fall right back asleep? Yes No Do you work a midnight shift? Yes No Do you exercise? Yes No Exercise Type: Aerobic Weights Yoga Other:____________ Exercise Frequency:_____/times per week Alcohol Use: Yes No Type: Wine Beer Hard Liquor Drinks per week? ________ Tobacco Use: Current? Yes No How many years? ___________ Type: Cigarettes (Packs per day? ____) Cigars Pipe Chewing Tobacco In the past? Yes No How many total years? ______ When did you quit? _____________ Stress Level: (none) 0 1 2 3 4 5 6 7 8 9 10 (high) Energy Level: (none) 0 1 2 3 4 5 6 7 8 9 10 (high)

PERSONAL HISTORY (Cont.)

Dental History: Do you have gingivitis? Yes No How many fillings do you have? ____________________ How many are silver / amalgam fillings? ____ Have you had any silver / amalgam fillings removed? Yes All No How many crowns do you have? ___________ How many root canals have you had? _______________

Vaccination history: Childhood vaccines? Yes No Flu vaccines: Currently receive? Yes No How many years? ________________ Tetanus vaccines: Yes No Date of last one? _______________________

List all current medications taken: __________________________________________________________ ______________________________________________________________________________________ List all nutritional supplements taken: _______________________________________________________ ______________________________________________________________________________________ Surgeries and the year performed: __________________________________________________________ ______________________________________________________________________________________

Were you breastfed? Yes No For how long? _____________________ Have you been tested for allergies? Yes No Do you have any allergies? Yes No Food Allergies (list):______________________________________________________________________ Seasonal Allergies (list):___________________________________________________________________ Other Allergies (list):_____________________________________________________________________ Allergy Test Type: Skin Blood Electro-‐Dermal Muscle Testing / AK Have you been exposed to: Toxic Chemicals Mold Via… Work Hobbies Home Type: __________________________________________________________________________________

Why do you think your previous treatments failed? _____________________________________________ _______________________________________________________________________________________ Do you think you can improve? _____________________________________________________________ _______________________________________________________________________________________ What emotional experiences are affecting your health? _________________________________________ _______________________________________________________________________________________ What is your purpose / motivation in life? _____________________________________________________ _______________________________________________________________________________________ What do you miss the most that your health condition is preventing you from doing? _________________ _______________________________________________________________________________________ What do you think is a realistic time to get better? ______________________________________________ _______________________________________________________________________________________ What specific improvements do you want? ____________________________________________________ _______________________________________________________________________________________ Is your family supportive of you seeking holistic therapy? ________________________________________ _______________________________________________________________________________________ Comments: _____________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________

Lemont Natural Healthcare HIPPA NOTICE OF PRIVACY PRACTICES

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. This Notice of Privacy Practices described how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice and any other required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose your protected health information in the following situations without your authorization; these situations include: as Required By Law, Public Health issues as Required By Law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. We may use or disclose, as needed, your protected health information in order to support the business activities of your physicians’ practice. We may also call you by name in the Reception Area when your physician is ready to see you. We may also call you by name while under the care and treatment of our office. We may use or disclose your protected health information, as necessary to contact you to remind you of your appointment. Other Permitted and Required Uses and Disclosures will be made only with your consent, Authorization or opportunity to object unless required by law. You may revoke this Authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights: Following is a statement of your rights with respect to your protected health information: You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.

HIPPA – Page 2 You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care of\or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer person. Signature below is only acknowledgement that you have received and read this Notice of our Privacy Practices: Print Name: ___________________________________ Date: _____________________________ Signature: __________________________________________________________ or Signature of Legal Representative: ____________________________________________ Relationship: __________________________________________ (e.g. Attorney-In-Fact, Guardian, Parent if Minor)

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)

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NEUROLOGICAL ASSESSMENT FORM NAME: ______________________________________________________ DATE:______________

1. Are you left or right handed?……………………………………………………………………………….. Right Left

2. Have you had a head injury?………………………………………………………………………………. Yes No

3. Do you currently experience or have a past history of vertigo or balance disorders?……………..… Yes No

4. Do you have any ringing or pressure in your ears? …………………………………………………….. Yes No

5. Do you experience nausea? ………………………………………………………………………………. Yes No

6. Do you find that your balance is getting worse? ………………………………………………………… Yes No

7. Do you have difficulties walking down stairs?………………………………………………………….… Yes No

8. Do you find yourself searching for words frequently when you speak?……………………………..… Yes No

9. Have you noticed your ability to concentrate is getting worse? ...………………………………...…… Yes No

10. Do you get lost often or have a hard time with directions?…………………………………………...… Yes No

11. Do quick flashes of light on TV or loud noises bother you? ……………………………………….…… Yes No

12. Do you feel like you need to wear sunglasses outside?………………………………………………… Yes No

13. Has your handwriting changed in recent years? ………………………………………………………… Yes No

14. Do you have a hard time swallowing? ……………………………………………………………………. Yes No

15. Do to gag easily?……………………………………………………………………………………………. Yes No

16. Do you experience blurriness in you vision or have double vision? …………………………………... Yes No

o CIRCLE ALL THAT APPLY: Blurriness, Double Vision

17. Do you have any changes in smell or smell foul things that are not present?………………………... Yes No

18. Do you have any difficulty with taste or taste things differently than what you are eating? ………… Yes No

19. Have you noticed clumsiness in hand coordination? …………………………………………………… Yes No

o Which hand? CIRCLE: Right, Left

20. Do you have difficulty with short-term memory? ………………………………………………………… Yes No

21. Have you been told you have or noticed any memory loss of past events?………………………….. Yes No

22. Have you noticed uneven sweating or temperature on one side of your body?……………………… Yes No

23. Do you have any tightness, weakness or instability in your back or neck?…………………………… Yes No

o CIRCLE ALL THAT APPLY: Back, Neck

24. Do you have tightness or feelings of weakness in you arms/hands or legs/feet?……………………. Yes No

o CIRCLE ALL THAT APPLY: Arms/hands, Legs/feet

25. Do you ever have any numbness or tingling in your arms/hands, legs/feet or face?………………... Yes No

o CIRCLE ALL THAT APPLY: Arms/hands, Legs/feet, Face

26. Do you have any difficulty with falling asleep or staying asleep?……………………………………… Yes No

o CIRCLE ALL THAT APPLY: Falling asleep, Staying asleep

27. Do you get motion sickness easily (car sick or sea sick)? ……………………………………………... Yes No

28. Do you ever experience flashes of light in you visual fields?…………………………………………… Yes No

29. Do you ever experience dry eyes or mouth?…………………………………………………………….. Yes No

o CIRCLE ALL THAT APPLY: Eyes, Mouth

30. Do you ever experience increased tearing or salivation?………………………………………………. Yes No

o CIRCLE ALL THAT APPLY: Tearing, Salivation

31. Do you ever have slurred speech?………………………………………………………………………... Yes No

32. Have you noticed any drooping of your eyelids or facial muscles?……………………………………. Yes No

o CIRCLE ALL THAT APPLY: Eyelids, Facial Muscles

33. Do you ever notice increased heart rate or pulse during the day? ……………………………………. Yes No

34. Have you ever experienced or been diagnosed with arrhythmia (fluctuating heart rate)? …………. Yes No

35. Do you experience Deja Vu? ……………………………………………………………………………… Yes No

36. Does driving cause you fatigue, headaches or any other symptoms?………………………………… Yes No

o CIRCLE ALL THAT APPLY: Fatigue, Headaches, Other Symptoms

37. Does working on a computer cause you fatigue, headaches or other symptoms? …………………. Yes No

o CIRCLE ALL THAT APPLY: Fatigue, Headaches, Other Symptoms

38. Have you lost your interest in hobbies and functions you used to enjoy? ……………………………. Yes No

39. Do you have a hard time motivating yourself to engage in activities?………………………………… Yes No

40. Do you ever have a fluttering of the eye or noticed you are blinking frequently? ……………………. Yes No

41. Do you have difficulty distinguishing right and left?……………………………………………………… Yes No

Patient Signature:__________________________________________________________ Date: ________________

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