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Comprehensive Pa t i e n t Hi s t o r y In t a k e Fo r m An a l y s i s

Southeastern Center for Functional Medicine

Dr. Ronald Grisanti

2123 Old Spartanburg Road 348

Greer,SC 29650

8649057605

[email protected]

Report Date: 03-25-2018

Date Completed by Patient: 02-25-2018

Patient: Jane Doe

Date of Birth: 6/20/1957

Address: 2222 Old Spartanburg Road South Carolina

Home Phone: 8649057605

Work Phone:

Cell Phone:

Fax Number:

Email: [email protected]

Preferred mode of contact: Cell

Emergency Contact:

Marital Status: Married

Age: 60

Gender: Male

Number of Children: 2

Present Occupation: Boat Restorer

Present Job Duties: Use cleaning materials to clean and restore boats

Past Occupation(s): Car Restorer

Referred by: Referred by Mike Smith

Sample


Page: 2



Patient: Jane Doe


Ch i e f Co m p l a i n t s

1: Anxiety: have been suffering with anxiety for 20 years. I have seen several doctors who have prescribed multitudes of medication. Temporary relief

2: Thyroid issuses. Cold most of the time with fatigue

3: Insomnia-- I have a hard time falling asleep. I wake up several time each evening

4: Joint pain. This has been going on for at least 10 years.

Clinicians's Notes:

Sample


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Patient: Jane Doe


Pain Lo c a t i o n/Qu a l i t y

Location Aching Burning Numbness Sharp Shooting Stabbing Tingling

1. Head

2. Eye Rt.

3. Eye Lt.

4. Ear Rt.

5. Ear Lt.

10. Elbow Rt.

14. Hand Rt.

31. Lower back

Sample


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Patient: Jane Doe


Clinicians consulted for chief complaints listed:

1: Dr. Joseph Bulland

2: Dr. Sally Eston

Integrative medicine received for chief complaints listed:

1: Chiropractic

2: Acupuncture

3: Massage

4: Nutritional Therapy

5: Yoga

Diagnostic test(s) in past five years:

1: Chest X-ray

2: Mammogram

3: EKG

4: Colonoscopy

5: X-rays

6: Bone density test

7: Blood tests

Sample


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Patient: Jane Doe


Past Illnesses When

Immunizations When

Surgeries When

Gall Bladder removed in 1990

Hysterectomy partial removal 1995- ovaries still intact

Sample


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Patient: Jane Doe


Current Medications Duration

1: Acetaminophen - drug's generic name take periodically

2: Armour Thyroid (Thyroid Tablets) 8 years

3: Elavil (Amitriptyline) 10 years

Medication Allergies:

Sample


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Patient: Jane Doe


Current Supplementation Duration

Multi-vitamin 15 years

Probiotics 10 years

Vitamin C 5 years

Supplementation Adverse Reaction(s):

Sample


Page: 8



Patient: Jane Doe


History of Head Trauma: None

Alcohol Consumption: Yes, glass a wine once or twice a week

Smoker: No

Patient's recorded weight: 135

Patient's recorded height: 5'4

Exercise (days of the week): 3

Exercise Type: yoga and cardio

Primary Care Provider: Dr. Anthoney Secrito

Date of last physical examination: 1/5/2015

Date of last blood test: 1/5/2015

Blood type: O

Rh Factor: Positive

Did you have cesarean birth?: No

Were forceps used for your birth?: Yes

Sample


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Patient: Jane Doe


Fa m i l y Hi s t o r y

Mother: Uterine fibroids, Osteoporosis, Depression, Thyroid Disease

Father: Arthritis, High blood pressure

Sister:

Brother: Headache, Insomnia

Maternal Grandmother: Diabetes

Maternal Grandfather:

Paternal Grandmother:

Paternal Grandfather:

Sample


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Patient: Jane Doe


M a l e Me d i c a l Hi s t o r y

Sample


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Patient: Jane Doe


De n t a l Hi s t o r y

Teeth selected: 16, 17

mercury fillings

Note: Inquire about root canals, amalgam fillings, missing teeth, infections, cavities, broken teeth, impacted teeth, crowns, and abscessed teeth in the area(s) selected. In addition,

inquire about gum disease.

Clinicians's Notes:

Sample


Page: 12



Patient: Jane Doe


Chronological Past History as Recorded by the Patient

Birth to age 10: Healthy most of this time.

Age 11- 20: Had menstrual cramps almost my entire teens. I had constant headaches

Age 21 - 30: A lot of fatigue, depressed quite often

Age 31- 40: Had skiing accident. Broke my right foot. Had a difficulty with my second child.

Age 41- present: Spotty periods with periods of depression. Headaches

Mother had a difficult with my delivery. They required using forceps.

Sample


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Patient: Jane Doe


Patient Readiness

Willingness to make lifestyle changes: Yes

Patient expectations: I want to get to the root cause(s) of my health problems. I believe my primary doctor is only treating my symptoms and not looking for the cause(s)

Limitations recorded by patient: I am able to do most things just don't feel well

Immediate concerns: Anxiety, Thyroid issues, Joint pain

Future goals: Take a long vacation with my family

Sample


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Patient: Jane Doe


Signs a n d Symptoms

The patient reported the following present and past symptoms:

Symptom Present Past

Abdominal pain/cramps

Aching ankles, knees, wrists, or shoulders

Anger easily

Anxiety

Arthritis

Backaches

Bad breath (chronic)

Bitter taste in the mouth in the morning

Bleeding between periods/ frequent spotting

Bleeding, swollen gums

Bloating/Bloating and gas

Body odor

Brain fog/fatigue after eating

Breast soreness during menstrual period

Bruising easily

Bumps on the front thighs

Change in habits of bowel movements

Changes in hair texture and hair growth

Chapped dry lips

Chronic digestive symptoms (GERD, IBS, IBD)

Chronic intestinal infections (yeast/parasitic)

Chronic stress

Clothes dry-cleaned

Coated tongue (white, yellow or dark)

Constipation Sample


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Patient: Jane Doe





Constipation (chronic)

Decreased cognitive function (brain fog) most of the time

Depression

Difficult time concentrating

Difficult time managing stress

Difficult to sweat

Diminished Sex drive

Dizziness

Dizzy when getting up quick

Drink tap water

Dry mouth

Dry, rough, flaky skin

Easily startled

Excessive thirst

Exposed to toxins at home and workplace

Fever

Forgetfulness

Frequent ear infections

Frequent infections

Frequent mood swings

Frequent respiratory infections

Frequent urination

Frequent yeast infections/problems

Gallbladder removed

Generalized aches, sharp pains Sample


Page: 16



Patient: Jane Doe





Get short of breath easily

Have amalgam fillings

Headaches

Heaviness or tightness in the chest

Hemorrhoids

High cholesterol

Hives

Home pesticide treatments

Hormonal imbalance

Hot flashes

Indigestion

Insomnia

Irregular periods

Irritable before meal time

Itching

Leg cramps

Light-headed, especially when standing up

Loss of color in hair and skin

Low blood pressure

Low exercise tolerance

Lower bowel gas

Lyme Disease (If yes, check PRESENT)

Muscle pain

Muscles fatigue quickly

Nervousness Sample


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Patient: Jane Doe





Pain between shoulders

Palpitations/irregular, skipped heartbeat

Panic attacks

Partial hysterectomy

Periods of rapid heartbeats

PMS

Poor memory/memory loss

Quick to cry

Resist going to bed when tired

Sensitive to cold temperature

Sensitive to household cleaning products

Sensitive to MSG

Sensitive to room sprays and/or candles

Sensitive to tobacoo smoke

Sensitivity to light/noise

Sensitivity to perfumes/gasoline fumes/chemicals

Skin rashes

Skin tags

Slow to recover from surgery

Spider veins

Stressed-out most of the time

Tendency to startle easily

Thinning or loss of outside of eyebrows

Thyroid condition

Trouble falling and staying asleep Sample


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Patient: Jane Doe





Undigested food in stools

Unexplained hair loss

Varicose veins

Sample


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Patient: Jane Doe


En v i r o n m e n t a l Toxin Ex p o s u r e As s e s s m e n t

Item(s) Selected:

Use or make plastic shower curtains

Acrylic nail applications

Household cleaners that contain toxic chemicals

Eat fried foods

Exposure to pesticides

Eat foods with food additives

Use antiperspirants

Around or use herbicides

Work around sawdust

Live near a highway and/or railroad

Work around automobile exhaust

Enamelers

Flame retardants

Work with insulation for electrical wires

Work in or around metal fabricating

Paint strippers

Spray paints

Gardener

Aerosols

Household Member(s) Working with and/or Around Environmental Toxins: Yes

Have a whole house water filtration system: No

Home water supply: Public water

Clinicians's Notes:

Sample


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Patient: Jane Doe


Em o t i o n a l/Ps y c h o l o g i c a l As s e s s m e n t

Emotion(s) Selected:

Anger

Frustration

Anxiety

Nervousness

Fear

Resentment

Heartbreak

Feeling stuck in life

Worry

Negativity

Disappointment

Grief

Cloudy thinking

Hopelessness

Get agitated easily

Tend to be Shy

Clinicians's Notes:

Sample


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Patient: Jane Doe


Re p o r t e d Al l e r g i e s

Other food/substances:

Clinicians's Notes:

Sample


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Patient: Jane Doe


Di e t a r y Hi s t o r y An a l y s i s

Fo o d s consumed b y pat ien t t h r e e o r m o r e t imes p e r w e e k.

Almonds

Food/Substance Description: Almonds are a significant source of essential fatty acids, fiber, phytosterols, manganese, vitamin E, magnesium, and copper. One ounce of almonds

contains about 34 mg of phytosterol. Regular consumption of almonds is associated with reduced LDL cholesterol, and therefore may reduce the risk of cardiovascular disease. Almonds may alsoreduce the risk of colon cancer.

Other Considerations: (Note: Check for oxalate bioavailability) Source of oxalate.

Apples

Food/Substance Description: Apples are an excellent source of vitamin C, fiber, and a variety of phytochemicals, which include: quercetin, catechin, phloridzin, and chlorogenic acid.

Studies have linked apple consumption with reduced risk of certain cancers, cardiovascular disease, asthma, and diabetes. The phytochemicals are found mainly in the peel of the apple, andtherefore it is recommended to only consume organic apples.

Other Considerations: Conventional source is high in pesticide residue. Moderate cross-reactivity with latex allergy. Potential cross-reactivity with birch allergy.

Asparagus

Food/Substance Description: Asparagus is an excellent source of vitamins K, A, and C, potassium, protein, and folic acid. Asparagus is noted for its content of anti-inflammatorycompounds that can significantly inhibit COX2 enzymes and moderately inhibit COX1 enzymes.(Note: Avoid steaming, boiling, and baking methods of cooking. Sautéing or grilling is recommended).

Other Considerations: Moderate purine content. Conventional source is low in pesticide residue.

Avocado

Food/Substance Description: Avocado appears to serve as a functional food by containing substances that can decrease inflammation, lower blood cholesterol, decrease intestinal

glucose absorption (antihyperglycemic effects), and alleviate symptoms of benign prostatic hypertrophy.

Other Considerations: Potential cross-reactivity in individuals with latex allergy. Conventional source is low in pesticide residue.

Bananas

Food/Substance Description: Bananas are an excellent source of potassium and vitamin B6. Other significant nutrients include: vitamin C, fiber, magnesium, biotin, and vitamin B2.

Banana peels are a rich source of antioxidant flavonoids which include; gallocatechin, catechin, and epicatechin. The soluble and insoluble components of the fiber in banana can participate in ahypocholesterolemia effect, as well as normalize bowel function. It is recommended to use organic bananas if the peels are being consumed.

Other Considerations: Conventional source contains a low to moderate amount of pesticide residue. High cross-reactivity with latex allergy. Potential cross-reactivity with ragweed

allergy.

Beets

Food/Substance Description: Beet greens are an excellent source of vitamins A, C, B1, B2, B6, and K, magnesium, iron, potassium, copper, and calcium The root is an excellent source

of folic acid and a good source of fiber, potassium, and manganese. Beet root juice is known for its high content of inorganic nitrates, which has been demonstrated to decrease blood pressure byincreasing nitric oxide production in the body. Beets also stimulates the liver’s detoxification process.

Other Considerations: Significant dietary source of increasing urinary oxalate.

Sample


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Patient: Jane Doe




Blueberries

Food/Substance Description: Blueberries are a rich source of the antioxidant flavonoids called procyanidins and anthocyanins. Blueberries promote brain, urinary tract, eye, andcardiovascular health.

Other Considerations: Conventional source is high in pesticide residue.

Bottled Water

Food/Substance Description: Bottled water kept in a plastic container can absorb toxic chemicals that leach from the plastic. Heat exposure may cause an increase in the amount of

leaching. In addition, the source of the water may be in question.

Breakfast Cereals

Food/Substance Description:

Other Considerations: Inquire about which type is being consumed.

Broccoli

Food/Substance Description: Compounds found in broccoli demonstrate remarkable anticancer effects. Indole-3-carbinol and sulforaphane increase the excretion of a form of estrogen

known as 2-hydroxyestrone, which has been linked to breast cancer. Many antioxidants in broccoli include; carotenoids (lutein and zeaxanthin), tocopherols, ascorbic acid, and flavonoids (quercetinand kaempferol).

Other Considerations: Goitrogen ( May interfere with thyroid function.) Conventional source contains a low to moderate amount of pesticide residue.

Brown Rice (unrefined)

Food/Substance Description: Brown rice is good source of manganese, selenium, tryptophan, bran and gamma-oryzanol. Brown rice provides a significant amount of dietary fiber which

promotes normal bowel function and gastrointestinal health.

Cheese (low-fat)

Food/Substance Description: Cheese is a good source of tryptophan, calcium, iodine, phosphorous, selenium, and protein. Cow and goat cheese contain lactose, however the content

is considerably lower that cow's milk or goat's milk. The amount of lactose present in cheese depends upon the age and hardness of the cheese. The more aged and harder cheeses contain loweramounts of lactose. Inquire about which type and variety of cheese is consumed (i.e. milk, goat, soy – natural or processed).

Other Considerations: Common food allergen. Non-Organic is high in pesticides and other toxins, including DDT and PCBs. Contains low amounts of lactose.

Chicken

Food/Substance Description: Chicken is a good source of protein, niacin, selenium, pyridoxine, and phosphorous.

Other Considerations: Moderate purine content. May contain arsenic. Non-organic sources may contain antibiotics and/or growth hormones.

Chocolate

Food/Substance Description: Chocolate contains fats, protein, carbohydrates, caffeine, magnesium, calcium, iron and B2. In addition, chocolate contains a significant amount of

phytochemicals called flavonoids. These flavonoids are potent antioxidants and protect against LDL oxidation. Chocolate also provide a significant amount of arginine which is required for theproduction of nitric oxide, a vasodilator. (Note: Dark semisweet chocolate is recommended due to its high flavonoid content). Chocolate consumption will raise urinary oxalate excretion and can lead tostone formation.

Other Considerations: Significant dietary source of increasing urinary oxalate. Contains phenylethylamine. Potential migraine inducer.

Sample


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Patient: Jane Doe




Corn

Food/Substance Description: Corn is a good source of vitamins B1 and B5, magnesium and folic acid. Corn is deficient in niacin and the amino acids lysine and tryptophan. Corn is

significant source of lutein and zeaxanthin, and therefore contributes to eye health.

Other Considerations: Conventional source is low in pesticide residue. Potential food allergen.

Diet Soda

Food/Substance Description: These beverages contain artificial sweeteners. The additives present in diet soda may be associated with hives, asthma, and/or skin rash.

Other Considerations: May contain: benzoic acid or sodium benzoate. May contain tartrazine and/or FD&C yellow number 5.

Energy Drinks

Food/Substance Description: One of the main active ingredients in energy drinks is caffeine. Inquiry about which type, how much, how often, and the time of day this product is

consumed.

Fast Food



Fried Foods

Food/Substance Description: Frying modifies the foods and the oil used during cooking.The oil will deteriorate through oxidation and hydrogenation, especially when reused. This

process causes a loss of unsaturated fats and an increase of trans fats. In addition, the food will absorb the degraded oil products which can cause adverse health effects. It is recommended to usedolive or sunflower oil for frying, if you must, and not to reuse the oil. These oils are less prone to oxidation.

Kidney Beans

Food/Substance Description: Kidney beans are a good source of molybdenum, fiber, protein, folic acid, magnesium, iron, copper, and phosphorous. The bioactive components in

kidney beans can bind bile acids which can lower cholesterol. Research indicates that the lectins found in kidney beans have anti-cancer properties against certain lymphomas. Kidney beans maycontain pesticide residue.

Other Considerations: Inquire about conventional or organic source.

Navy Beans

Food/Substance Description: Navy beans are a good source of protein, fiber, folic acid, magnesium, iron, and phosphorous. The fiber contained in navy beans assists in lowering

cholesterol and helps regulate blood sugar level.

Other Considerations: (Note: Check for oxalate bioavailability) Moderate purine content.

Oatmeal

Food/Substance Description: Oat bran is a source of beta-glucans which can bind bile acids in the gastrointestinal tract and thereby lower total cholesterol. About 3 grams per may help

to lower total cholesterol by 8 to 23 percent. In addition, whole oats contain dietary polyphenols which have ant-inflammatory and anti-proliferative properties. Oats are a good source of manganeseand selenium. Oats are not safe for all individuals with celiac disease. Oats are often grown or processed with other cereals leading to cross-contamination with wheat, barley or rye. Currently, thereare also very few known producers of pure gluten-free oats in North America. Although oats appear to be safe in the vast majority of individuals with celiac disease, there is evidence that, in someindividuals, the protein in oats (avenins) can trigger an immune response similar to gluten. Oats are not safe for all individuals with celiac disease.

Other Considerations: Gluten containing food.

Sample


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Patient: Jane Doe




Oranges

Food/Substance Description: Oranges contain vitamin C, flavonoids and carotenoids. Hesperetin is a cholesterol lowering flavanoid is found in a number of citrus juices. It appears toreduce cholesteryl ester mass and inhibit apoB secretion by up to 80%. Hesperetin may have antioxidant, anti-inflammatory, anti-allergic, hypolipidemic, vasoprotective and anticarcinogenic action.

Pasta (gluten containing)


Other Considerations: Gluten containing food.

Peanuts

Food/Substance Description: Peanuts are a good source of protein, tocopherols, magnesium, phosphorous, manganese, folic acid, biotin, thiamine and niacin. The fungus, Aspergillusflavus, can grow on peanuts. This fungus produces a carcinogenic substance called aflatoxin. Proper storage of peanuts is required to prevent the growth of this fungus.

Other Considerations: (Note: Check for oxalate bioavailability) Goitrogen ( May interfere with thyroid function.) Common food allergen.

Quinoa

Food/Substance Description: Quinoa is a seed that is high in protein, especially lysine and methionine, and includes all of the essential amino acids. It’s also a good source of iron andcopper. Quinoa is also a low allergenic food.

Safflower Oil

Food/Substance Description: Safflower oil contains the essential fatty acids, linolenic and linoleic acids, which may be beneficial in lowering cholesterol and reducing the risk of heart

disease. Safflower seed oil can act as a blood thinner. Safflower may cause an allergic reaction in individuals allergic to ragweed and related plants.

Other Considerations: Potential cross-reactivity with ragweed allergy.

Salad Dressings (commercial/bottled)

Food/Substance Description: This product generally contain a host of additives.


Snack Foods (chips, pretzels, etc.)


Other Considerations: May contain sulfites. May contain gluten.

Soft Drinks (soda)

Food/Substance Description: These beverages contain significant amount of refined sugar. The additives present in soda may be associated with hives, asthma, and/or skin rash).

Other Considerations: May contain tartrazine and/or FD&C yellow number 5. May contain: benzoic acid or sodium benzoate.

Soybeans/soy products

Food/Substance Description: Soy contains a high amount of protein (low in methionine and tryptophan), essential fatty acids, phytosterols, lecithin, isoflavones and protease inhibitors.

One protease inhibitor called Bowman-Birk inhibitor, is particularly effective in suppressing carcinogenesis. Phytosterols can block the absorption sites of cholesterol, thereby exhibiting a cholesterol-lowering effect. Soy protein has been shown to lower total cholesterol and LDL-C levels. Individuals with estrogen-sensitive breast cancer and thyroid dysfunction should limit their intake of soyproducts. Soy foods contain both oxalate and phytate in varying amounts. Soy foods that contain more phytate that oxalate may be beneficial for individuals with kidney stones or persons with a highrisk of kidney stone formation.

Other Considerations: Goitrogen ( May interfere with thyroid function.) Moderate purine content. (Note: Check for oxalate bioavailability) Contains a significant amount of oxalates .Common food allergen.

Sample


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Patient: Jane Doe




Sweet Potatoes

Food/Substance Description: Sweet potatoes are a good source of carotenoids (alpha-carotene and beta-carotene). Packed with important vitamins like A, C and B6, sweet potatoes

have good antioxidant properties. They're also an excellent source of dietary fiber, potassium and iron. Sweet potatoes may help stabilize blood sugar. Hemoglobin A1c may improve after three to fivemonths of regular ingestion. (Note: Sweet potatoes do not belong to the nightshade family of vegetables.)

Other Considerations: Conventional source is low in pesticide residue. Contains a significant amount of oxalates . (Note: Check for oxalate bioavailability)

Turkey

Food/Substance Description: Turkey is a good source of protein, selenium, niacin, pyridoxine, and phosphorous.

Other Considerations: Moderately high purine containing food.

Wheat (bulgur)

Food/Substance Description: Bulgar is a variety of wheat and should be avoided in individuals with celiac disease and gluten sensitivity.

Other Considerations: Common food allergen. Gluten containing food.

White Potatoes

Food/Substance Description: Potatoes are a good source of vitamins C and B6, potassium, and dietary fiber. Most of the nutrients, fiber, and protein are found in the skins. (Note: Avoid

any potato that has a discoloration, in particular a green tint.)

Other Considerations: Nightshade (solanine/chaonine containing food) Conventional source is high in pesticide residue. Potential cross-reactivity in individuals with latex allergy.

White Rice

Food/Substance Description: White rice is put through a milling and polishing process resulting in a loss of the bran, germ, and most of the nutrients. It is estimated that the processing ofrice results in a 70-90% loss of B vitamins, as well as a loss of phosphorous, iron and manganese.

Yogurt

Food/Substance Description: Yogurt is a good source of calcium, protein, phosphorous, iodine, and vitamins B2 and B12. The health benefits from consuming yogurt include: enhancing

immune function, improved milk tolerance, enhanced gastrointestinal function, and cholesterol lowering. Regular intake of yogurt (with certain probiotics) can effectively suppress H. pylori infection.

Other Considerations: Lactose containing food. Common food allergen.

Sample


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Patient: Jane Doe


Pa t i e n t Hi s t o r y Tr iphasic An a l y s i s Su m m a r y

PHASE 1A – Suspected Environmental Toxin Exposure(s)

Suspected Environmental Illness

Low Medium High

Inquire about household members working with and/or around environmental toxins.

Clinician’s Notes:

Inquire about home water quality


Sample


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Patient: Jane Doe


PHASE 1B –Suspected Environmental Toxin Exposure Analysis Based on Symptom Survey

Biotoxin Symptom Analysis

(Biotoxins are natural toxic substances produced by organism. e.g. mold)

Low Medium High

Phthalates/Parabens Exposure

Low Medium High

Chlorinated Pesticides

Low Medium High

PCBs

Low Medium High

Volatile Organic Compounds

Low Medium High

Organophosphates

Low Medium High

Bisphenol A

Low Medium High

Heavy Metal Toxicity

Low Medium High

Sample


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Patient: Jane Doe


PHASE 2A – Suspected Nutritional Deficiency(s) Based on Signs and Symptoms

Essential Fatty Acids

Vitamin B1

Vitamin B12

Vitamin B2

Vitamin B6

Vitamin C

Vitamin D

Vitamin E

PHASE 2B – Drug Induced Nutrient Depletion

Glutathione

Coenzyme Q-10

Vitamin B2

Sample


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Patient: Jane Doe


PHASE 2C – Possible Adverse Food Reaction(s) (see Reported Allergy section)

Food Selected Allergen Selected

Sample


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Patient: Jane Doe


PHASE 2D – Suspected Gluten Sensitivity/Celiac Disease

Low Medium High

Phase 2E – Digestive System Assessment

Low Medium High

Food Allergies

Gastric Reflux

Gastric/Duodenal MucosalErrosion

Hypochlohydra/PancreaticInsuffiency

Small Intestine Dysfunction

Liver/GallbladderDysfunction

Large Intestine Dysfunction

IntestinalHyperpermeability/BowelToxicity

Additional Patient Comments:

Sample


Page: 33



Patient: Jane Doe


PHASE 3A: Systems Dysfunction Assessment (SDA)

Abdominalpain/cramps

1 1 1 1 1Medications/Acute abdominal pain needs

immediate attention.

Aching ankles,knees, wrists, orshoulders

1 1 1Monoarticular: infection-avascular

necrosis-trauma/Polyarticular:inflammatory conditions

Anger easily 1 1 1

Anxiety 1 1 1 1 1 1 Substance abuse

Arthritis 1 1 1 1

Backaches 1 1 1 1 1Neuromusculoskeletal disease/

abdonimal aorticaneurysm/endometriosis/vitamin D

Bitter taste in themouth in themorning

1 1GERD, certain medications, dental

issues, sinus conditions

Bleeding betweenperiods/ frequentspotting

1 1 1

Cervical cancer, uterine fibroids,cervicitis, vaginal dryness, IUD use,

miscarriage, ectopic pregnancy,anticoagulants

Bloating/Bloatingand gas

1 1 Stomach cancer

Brain fog/fatigueafter eating

1 1 1 1

Breast sorenessduring menstrualperiod

1

Sample


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Patient: Jane Doe



Bruising easily 1 1 1 1 1

Autoimmune disease, certainmedications, thrombocytopenia, loss of

collagen, illness that affect bloodcoagulation

Bumps on the frontthighs

1 1 1 1 Malabsorption

Changes in hairtexture and hairgrowth

1 1 Psoriasis, chemotherapy, color treatment

Chronic stress 1 1 1

Clothes dry-cleaned

1

Coated tongue(white, yellow ordark)

1 1 1 Intestinal dysbiosis, high level of toxins

Constipation 1 1 1 1 1Lack of physcial activity, colon cancer,

certain medication, nervous systemdisorders

Constipation(chronic)

1 1 1 1 1 1 1 1

Decreasedcognitive function(brain fog) most ofthe time

1 1

Depression 1 1 1 1 1

Difficult timeconcentrating

1 1 1 1 Stress, sleep apnea, head traumaSample


Page: 37



Patient: Jane Doe



Difficult timemanaging stress

1

Difficult to sweat 1 1 Hypothalamus dysfunction

Diminished Sexdrive

1 1 1 1 1Certain medications, substance abuse,

relationship issues

Dizziness 1 1 1 1Certain medications, brain lesion, ear

disorder, MS, seizures

Dizzy when gettingup quick

1 Postural orthotic tachycardia syndrome

Drink tap water 1

Dry, rough, flakyskin

1 1 1 1

Easily startled 1

Excessive thirst 1 1

Loss of fluids, excessive exercise, burns,infections, heart disease, liver disease,

kidney disease, diabetes mellitus,diabetes insipidus

Exposed to toxinsat home andworkplace

Frequent infections 1 1 1 1 1 1

Frequent colds or flu indicate an immunesystems dysfunction due to excessivebody burden of toxins, gastrointestinaldysfunction, adrenal dysfunction and/or

liver dysfunction.Sample


Page: 39



Patient: Jane Doe



Frequent moodswings

1 1 Neurotransmitter imbalance

Frequent urination 1 1 1

Diabetes mellitus, diabetes insipidus,certain medications, sickle cell anemia,caffeine, alcohol, prostate conditions,

pregnancy

Frequent yeastinfections/problems

1 1

Gallbladder removed 1 1 Consider bile salts supplementation

Generalized aches,sharp pains

1 1 1 1Certain medications, stenuous exercise,

viral/bacterial infections

Get short of breatheasily

1 1 1 1 1 1 1 Respiratory diseases

Have amalgamfillings

1 Mercury toxicity

Headaches 1 1 1 1Qualify headache cause [i.e. primary or

secondary]

High cholesterol 1 1 1

Home pesticidetreatments

1

Hormonal imbalance 1 1 1 1

Sample


Page: 41



Patient: Jane Doe



Hot flashes 1 1 1

Insomnia 1 1 1 1 1Hormonal imbalance, certain

medications, pre-existing conditions

Irregular periods 1 1 1 1 1

Hormonal imbalance, certainmedications, eating disorders, excessiveexercise, excessive weightloss or gain,

illness

Itching 1 1 1

Loss of color inhair and skin

1 1 1 Autoimmune disease

Low bloodpressure

1 1 1 1 1

Low exercisetolerance

1 1 1High oxidative stress, pulmonary

conditions, mitochondrial dysfunction, highbody burden of environmental toxins

Muscle pain 1 1 1 1

Certain medications, environmentaltoxins, stenusou exercise, infections,

autoimmune disease, nutritionaldeficiencies

Muscles fatiguequickly

1 1 1 1

Nervousness 1 1 1 1

Pain betweenshoulders

1Referred pain from the stomach, heart, or

thoracic spine

Sample


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Patient: Jane Doe



Palpitations/irregular,skipped heartbeat

1 1 1 1 1 1 1

Certain medications, anxiety,hypertension, diabetes, hyperthyroidism,

heart disease, electrolyte imbalacne,substance abuse

Panic attacks 1 1 1 1Thyroid diease, adrenal dysfunction,

dietary choices

Periods of rapidheartbeats

1 1 1 1 1Certain medications, heart disease,fever, alcohol, eletrolyte imbalance,

allergies, caffeine

PMS 1 1 1 1 1 1Candidiasis, thryoid dysfunction, GIdysfunction, hormonal imbalance,

nutritional deficiencies, diet

Poor memory/memory1 1 1 1 1 1 1 1

Mold, oxidative stress, blood sugarloss

1 1 1 1 1 1 1 1dysregulation, environmnetal toxins

Quick to cry 1 1 1 1 1

Resist going to bedwhen tired

1

Sensitive to coldtemperature

1 1 1 1 Metabolic disorders

Sensitive to householdcleaning products

1 1

Sensitive to MSG 1 1

Sensitive to roomsprays and/or candles

1 1

Sample


Page: 45



Patient: Jane Doe



Sensitive to tobacoosmoke

1 1

Sensitivity tolight/noise

1 1 1

Inflammation of the iris or uvea, cornealabbrasion, coneal ulcer, certain

medications, migraines, eye disease,vitamin A deficiency, hormonal imbalance

Sensitivity toperfumes/gasolinefumes/chemicals

1 1 1

Skin tags 1Insulin resistance, diabetes, skin irritation,

virus

Spider veins 1 1Prolonged standing, hormonal imbalance,

oral contraceptive use, heredity,overweight, history of clots, liver disease

Stressed-out mostof the time

1 1

Tendency to startleeasily

Sleep disorder, fatigue, psychologicaldisorder

Thinning or loss ofoutside of eyebrows

1

Thyroid condition 1 1 1 1

Trouble falling andstaying asleep

1

Undigested food instools

1

The following conditions are associatedwith undigested food in the stool: a need

to digestive support (HCl and/orpancreatic enzyme) and not chewing food

well.Sample


Page: 47



Patient: Jane Doe



Unexplained hairloss

1 1 1 1 Check for fungal infection

Varicose veins 1 1 1Obesity, inflammatory disease,

heavy lifing, pregnancy, constipation,prolonges standing, lower fiber diet

Percentage: 26% 22% 21% 10% 29% 17% 18% 22% 33% 39% 21% 30% 12% 11% 6% 26% 25% 30% 30%

Total Symptom Burden Score: 253


Sample


Page: 48



Patient: Jane Doe


PHASE 3B: Dental Energetic/Meridian Analysis

Tooth Organs Joints Vertebrae Endocrine Systems Sensory Muscles Sinus

16 Heart, Small Intestine

Hand and Elbow, Plantarside of Foot, Sacroiliac,Toes, Ulnar side of theShoulder

C1, C2, C7, T1, T5,T6, T7, S1, S2

Anteriorpituitary

Central Nervous,Limbic

Inner Ear,Tongue

Trapezius

17 Heart, Ileum, Jejunum

Hand and Elbow, Plantarside of Foot, Sacroiliac,Toes, Ulnar side of theShoulder

C1, C2, C7, T1, T5,T6, T7, S1, S2

Energy Exchange,Peripheral Nerves

Middle/ExternalEar, Tongue

Psoas

Patient's Notes:


Signature: ________________________ Date: _________________

Sample


Page: 49



Patient: Jane Doe


Recommended Lab Testing based on PHASE 3A: Systems Dysfunction Assessment (SDA) above.

SDA Recommended Lab Testing %

Adrenal Dysfunction Labrix (www.labrix.com) 39%

Thyroid DysfunctionTSH, total T4, free T4, total T3, free T3, Reverse T3, Thyroid Antibody, Thyroid Peroxidase. Iodine loading test. ReviewFMUMAP for comprehensive evaluation for thyroid

33%

Psychological Disorder Cognitive behavioral therapy (CBT), Emotional Freedom Technique (EFT) 30%

Mycotoxins

Complement C4a (Labcorp:004330), Complement C3a, Transforming growth factor beta one (TGF b-1), MelanocyteStimulating Hormone (MSH ), Matrix Metalloproteinase-9 (MMP-9)- Online VCS Screening Testhttp://www.survivingmold.com/store1/online-screening-test. If any of the above are positive recommend RealTimeLabMycotoxin Test (https://www.realtimelab.com), HLA-DR genetic testing, MARCoNS testing(http://www.microbiologydx.com)

30%

Reproductive HormoneDysfunction

Dutch Hormone Testing (https://dutchtest.com) 30%

Liver/GallbladderDysfunction

ALT, ALP, AST, Bilirubin, Albumin, Total Protein, GGT. Detoxification component of the Organic Acids (Genova).Hepatitis Profile, MTHFR testing

29%

Dietary Factors Spectracell, ION Test (Genova) 26%

Cardiovascular DiseaseHeart Scan (Calcium Score), CardioIQ, CardioION (Genova), Rule out Chlamydia pneumoniae IgG & IgMAntibodiesTest Code:903103, Rule out H.Pylori

26%

Environmental ToxinExposure

QuickSilver Tri-Mercury Test, Quicksilver Total Toxic Blood Profile, Toxic Effects Core (Genova), GPL-Tox: Toxic Non-metal Chemical Profile (Great Plains Lab), Glyphosate Test (Great Plains Lab)

25%

Kidney Dysfunction BUN, creatinine, Glomerular Filtration Rate(GFR) 22%

Nutritional Deficiencies ION Test (Genova), NutrEval (Genova) 22%

Anemia Ferritin, Iron, Total Iron Binding Capacity, Transferrin and Transferrin Saturation, CBC with differential and platelet count 21%

Blood Sugar Dysfunction Hemogloblin A1c, Organic Acids (Genova) 21%

Small/Large IntestineDysfunction

GI Effects, BioHealth SIBO Test using Lactulose, Dysbiosis component of the Organic Acids (Genova) 18%

Digestive EnzymeInsufficiency

GI Effects -Pancreatic Elastase (Genova) 17%

Immune SystemDysfunction

CD57, cytokine testing, Immunoglobulins IgA, IgE, IgG, IgM, Quantitative Serum (002295) 12%

InflammationTH1 and TH2 Cytokine Test| Basic Panel, TH1 and TH2 Cytokine Test| Advanced Test Panel,http://www.truehealthlabs.com

11%

Food Allergy (Dunwoody) Dietary Antigen and Environmental Allergen Exposure Profiles 10%

Infection

CD57 Panel (HNK1) LabCorp: 505026, Lyme Testing (iGeneX), HLA-DR genetic testing, Coxsackie A7, A9, A16 andA24 IgG and IgM/Test Number: 163295, Parovirus B19 IgM/IgG/Test Number: 163303, CMV (Cytomegalovirus)IgG/IgM/Test Number: 096727/Test Number: 006494, HHV 6 IgG/IgM Antibodies/Test Number: 138529/Test Number:161075 Epstein Barr Virus (EBV) (IgM, IgG), EBV Early Antigen Ab, IgG, EBV Ab VCA, IgG, EBV Nuclear Antien Ab,IgG, EBV Ab VCA, IgM. Epstein Barr Virus Profile (EBV) - Full Diagnostic Profile/Number: 216655, Human HerpesVirus Type 6 IgM

6%Sample

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