Pathways to Health, Inc. David M. Marquis, DC, DACBN

Diplomate American Clinical Board of Nutrition

APPLICATION FORM

WELCOME TO OUR OFFICE. We specialize in assisting people to achieve their highest level of health through our Neurological, Brain-Based, and Metabolic corrective care programs. Our approach is very unique so we have very strict requirements in accepting new patients. In order to be seen I agree to: 1. Fill out the following information as thoroughly as possible and

understand the TERMS OF ACCEPTANCE on the last page of this Health Application so we can let you know if we can accept your case.

2. Watch the VIDEOS explaining ‘our type of care’.

I agree to the above terms, and understand that should I NOT have the paperwork completed to the best of my ability or should I NOT have watched the video, I may NOT be seen.

Signature __________________________________ Today’s Date _____________________________

PLEASE USE BLACK PEN (No Pencil, Please!)

PLEASE MAIL, EMAIL, FAX, OR BRING THIS PAPERWORK TO THE OFFICE ONE WEEK PRIOR TO YOUR SCHEDULED APPOINTMENT.

Email: pathwaystohealthag@gmail.com

Fax No. : 805-618-1496 Pathways to Health 880 Oak Park Blvd., Suite 202 Arroyo Grande, CA 93420

Office Phone: (805) 481-3499

HEALTH APPLICATION SURVEY

Name: _________________________________________________________ (Age) _______ Gender: M F

Home Address: __________________________________________________ Home Phone: ( ) _________________________

City, State, Zip: __________________________________________________ Work Phone: ( ) _________________________

Email Address: ___________________________________________________ Cell Phone: ( ) _________________________

Birth Date: ______ / ______ / _______ Marital Status: S M D W I Have a ‘significant other’ (circle one)

Height: ________________ Weight: _________________ Weight gain / loss in past 18 months: ______________________

Names of Children: ___________________________________________________________________ Ages: ____________________

Occupation: __________________________________________________ Employer Name: _______________________________

Spouse’s Name: __________________________ Work Phone: ( ) __________________ Cell Phone: ( ) ________________________

Spouse’s Employer: _________________________________________ Occupation: ____________________________________________

How were you referred to this office? __________________________________________________________________________________

PURPOSE OF THIS VISIT

Reason for this visit – Main Complaint:__________________________________________________________________________________

When did this condition begin? __________/_____/________ Did it begin: Gradual Sudden Progressive over time

What activities aggravate your symptoms? ____________________________________________________________________________

Is there anything, which has relieved your symptoms? � Yes � No Describe:__________________________________________________

Is this condition getting worse? � Yes � No Explain: ____________________________________________________________________

How often do you experience these symptoms throughout the day?: 100% 75% 50% 25% 10% Only with Activity

Does complaint(s) interfere with: __Work __Sleep __Hobbies __Daily Routine Explain: _____________________________________

Have you experienced this condition before? � Yes � No If so, please explain: _________________________________________________

Who have you seen for this? ______________________________________ What did they do? _________________________________

How did you respond? ____________________________________________________________________________________________

EXPERIENCE WITH DOCTORS

Have you seen a Medical Doctor for this condition? � Yes � No Who? __________________________ When? __________________

Type of Specialty: _________________________________ What was recommended?____________________________________________

How did you respond?_________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Did your previous doctor take X-Rays, MRI, or CT scan? � Yes � No Did you receive other diagnostic tests? � Yes � No

Type and results: ____________________________________________________________________ Please BRING a copy of the results

Have you received any Blood Analysis/Blood testing within the past 18 months? � Yes � No Please BRING a copy of the results.

Have you seen a Chiropractor before? � Yes � No Who? __________________________________ When? _____________________

Reason for visits: _________________________How did you respond? ____________________________ FAMILY HEALTH HISTORY

List any health history issues in your family: Arthritis, Rheumatoid Arthritis, Juvenile RA, Lupus, Diabetes I or II, Hashimotos,

Sarcodosis, Psoriasis, Celiac, Crohns, Gout, Cancer, Heart Disease Who? ___________________________________________________

Are your parents still living, healthy, and if not healthy, please explain details with their ages. Also share any other details on family history you

can share: ___________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Date: _______________

Family History

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NARRATIVE OF CURRENT PROBLEM SHARE YOUR STORY IN YOUR OWN WORDS. A DETAILED NARRATIVE OF THE SEQUENCE OF EVENTS, TREATMENTS ATTEMPTED, AND RESULTS, EVERYTHING LEADING TO TODAY IS NEEDED: ___________________________________________________________________________________________________________________

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HEALTH LIFESTYLE Do you exercise? Yes No How often? 1X 2X 3X 4X 5X per week other: ___________________________________________

What activities? Running Jogging Weight Training Cycling Yoga Pilates Swimming _________________________________________

Do you smoke? Yes No How much? _____________________________________________________________________________

Do you drink alcohol? Yes No How much / week? ____________________________________________________________________

Do you drink coffee? Yes No How many cups / day? _________________________________________________________________

Do you take any supplements (i.e. vitamins, minerals, herbs –PLEASE BRING ALL THESE, IN THEIR BOTTLES, WITH YOU TO

YOUR APPOINTMENT) ___________________________________________________________________________________________

BRAIN AND CERVICAL: Do you currently experience: (please write ‘past’ if you did experience this but are not currently)

! Confusion / Brain Fog ! Memory Loss /Forgetfulness ! Depression / Sadness ! Emotional swings ! Anger / Frustration ! Unclear Thinking ! Mixing up data ! Difficult speech / can’t find words ! Procrastination / Disorganized ! OCD or early OCD symptoms

! Attention deficit / Focus issues ! Early Dementia issues ! Difficult / Dislike social situations ! Anxious / Panic Attacks ! Phobias / Addictions ! Neck Pain, soreness, achy ! Pain into your shoulders/arms/hands ! Numbness/tingling in arms/hands ! Hearing disturbances ! Weakness in grip

! Headaches ! Dizziness ! Visual disturbances ! Coldness in hands ! Thyroid conditions ! Sinusitis ! Allergies/Hay fever ! Recurrent colds/Flue ! Low Energy/Fatigue ! TMJ/Pain/Clicking

HEART / LUNGS / DIGESTIVE Do you currently experience: (please write ‘past’ if you did experience this but are not currently)

! Heart Palpitations ! Heart Murmurs ! Tachycardia ! Heart Attacks/Angina ! Recurrent Lung Infections/Bronchitis

! Asthma / Wheezing ! Shortness Of Breath ! ANY history of Auto-Immune Ds ! Fatigue between meals ! Rashes / Skin / Nail changes

! Mid / Upper Back Pain ! Pain Into Your Ribs/Chest ! Indigestion/Heartburn ! Reflux / Ulcers

! Nausea / Vomiting ! Diabetes / Insulin resistance ! Hypoglycemic symptoms ! Tired/Irritable after eating or when

you haven’t eaten for a while

SPINAL CORD: Do you currently experience: (please write ‘past’ if you did experience this but are not currently)

! Pain into your hips/legs/feet ! Numbness/tingling in your legs/feet ! Coldness in your legs/feet ! Muscle cramps in your legs/feet ! Constipation / Diarrhea

! Weakness/injuries in your hips/knees/ankles ! Recurrent bladder infections ! Frequent/difficulty urinating ! Menstrual irregularities/cramping (females) ! Sexual dysfunction

! Low back pain

Please list any health conditions not mentioned: ___________________________________________________________________________ Please list any medications currently taking and their purpose: ________________________________________________________________ ___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Please list all past surgeries: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Please list all previous accidents and falls: ________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How supportive is your Spouse/Family/Significant other to you seeking care? (be very specific) ____________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Is there anything that you eat or drink that makes you feel better or worse?______________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What have you been diagnosed with from prior doctors? _____________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What is YOUR idea of a ‘perfect’ doctor? __________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you willing to make strict dietary changes and possibly take supplements necessary for your recovery? Yes No How have others been affected by your health condition?

a. No one is affected b. Haven’t noticed any problem c. They tell me to do something d. People avoid me

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

a. Job b. Kids c. Future ability d. Marriage e. Self-esteem f. Sleep g. Time h. Finances i. Freedom

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

a. Family health problems b. Heart disease c. Cancer d. Diabetes e. Arthritis f. Fibromyalgia g. Depression h. Chronic Fatigue i. Need surgery

How has your health condition affected your job, relationships, finances, family, or other activities? _______________________________________________________________________________________ _______________________________________________________________________________________ What has that cost you? (time, money, happiness, freedom, sleep, promotion, etc.) _______________________________________________________________________________________ _______________________________________________________________________________________ What are you most concerned with regarding your problem? ______________________________________ _______________________________________________________________________________________ Where do you picture yourself being in the next 5 years if this problem is not taken care of? _______________________________________________________________________________________ _______________________________________________________________________________________ What would be different/better without this problem? Please be specific. _______________________________________________________________________________________ _______________________________________________________________________________________ What do you desire most to get from working with Dr. Marquis?___________________________________________ _______________________________________________________________________________________ What one thing would you like to be able to do that your current health is preventing you from doing? ________________________________ _______________________________________________________________________________________

Please list anything else we should know that would help us assess your case: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I attest to the previous being true and complete to the best of my ability. I understand that care with Dr. Marquis may or may not be appropriate for my case and desire to consult with him regarding my condition to determine for myself. I also understand that there is a Consultation/Case Review fee, which may not include any treatment. ________________________________________________ _______________________________ Signature Date

MAKE SURE TO VIEW THE VIDEO PRIOR TO APPOINTMENT TIME.

CHECK OUT MORE INFORMATION AT: www.drdavidmarquis.com

Here are my rules for acceptance: 1. If you are a smoker, I am going to ask that you stop smoking. If you are unable to see yourself doing this, this will not be the right program for you. 2. I will ask you to make certain lifestyle changes (i.e. diet). If you are unwilling to make the necessary changes that I will ask, then this will not be the program for you. 3. Insurance does NOT cover my treatment program. Why? I am out of network with insurance companies. The reason I do this is simple: I will NOT let an insurance company dictate how I will treat and manage my patients. You have been through the insurance loop...and you are still looking for answers. There is a reason why the typical medical model has failed you. I am free to get you better, AS FAST AS POSSIBLE!!! If you want to rely on your health insurance to get you better, this will not be the program for you. 4. Costs related to our comprehensive approach vary depending on the case and time needed to treat. However, if you can afford $150-$250 a month, you can afford to be under our care. A bigger question you must ask is this, “Can I afford to NOT be in this program?” We have flexible payment options to make this very affordable. The real question is...can YOU afford not to get better? 5. If you are married or have a significant other, I REQUIRE that they attend your 2 initial office visits. This is not for my benefit but yours. I find that when a patient has the support of their spouse or significant other, their life will be changed quicker! Again, this is a REQUIREMENT. This is your health, and everyone’s support is needed. Thank you for reading through this information. I pride myself in helping change those people’s lives who have lost hope, or who are frustrated at the way the typical medical model has pushed them around. If you are ready for a life changing health program, my office will be the place for you!

Owner

Typewritten Text

8

© 2013 Datis Kharrazian. All Rights Reserved. SMGEBFAF32(082013)

Brain Function Assessment Form™ (BFAF)Name: _____________________________________ Age: ______ Sex: ________ Date:_____________________

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

SECTION 1• A decrease in attention span 0 1 2 3

• Mental fatigue 0 1 2 3

• Difficulty learning new things 0 1 2 3

• Difficulty staying focused and concentrating for extended periods of time 0 1 2 3

• Experiencing fatigue when reading sooner than in the past 0 1 2 3

• Experiencing fatigue when driving sooner than in the past 0 1 2 3

• Need for caffeine to stay mentally alert 0 1 2 3

• Overall brain function impairs your daily life 0 1 2 3

SECTION 2• Twitching or tremor in your hands and legs

when resting 0 1 2 3

• Handwriting has gotten smaller and more crowded together 0 1 2 3

• A loss of smell to foods 0 1 2 3

• Difficulty sleeping or fitful sleep 0 1 2 3

• Stiffness in shoulders and hips that goes away when you start to move 0 1 2 3

• Constipation 0 1 2 3

• Voice has become softer 0 1 2 3

• Facial expression that is serious or angry 0 1 2 3

• Episodes of dizziness or light-headedness upon standing 0 1 2 3

• A hunched over posture when getting up and walking 0 1 2 3

SECTION 3 • Memory loss that impacts daily activities 0 1 2 3

• Difficulty planning, problem solving, or working with numbers 0 1 2 3

• Difficulty completing daily tasks 0 1 2 3

• Confusion about dates, the passage of time, or place 0 1 2 3

• Difficulty understanding visual images and spatial relationships (addresses and locations) 0 1 2 3

• Difficulty finding words when speaking 0 1 2 3

• Misplacement of things and inability to retrace steps 0 1 2 3

• Poor judgment and bad decisions 0 1 2 3

• Disinterest in hobbies, social activities, or work 0 1 2 3

• Personality or mood changes 0 1 2 3

SECTION 4• Reduced function in overall hearing 0 1 2 3

• Difficulty understanding language with background or scatter noise 0 1 2 3

• Ringing or buzzing in the ear 0 1 2 3

• Difficulty comprehending language without perfect pronunciation 0 1 2 3

• Difficulty recognizing familiar faces 0 1 2 3

• Changes in comprehending the meaning of sentences, written or spoken 0 1 2 3

• Difficulty with verbal memory and finding words 0 1 2 3

• Difficulty remembering events 0 1 2 3

• Difficulty recalling previously learned facts and names 0 1 2 3

• Inability to comprehend familiar words when read 0 1 2 3

• Difficulty spelling familiar words 0 1 2 3

• Monotone, unemotional speech 0 1 2 3

• Difficulty understanding the emotions of others when they speak (nonverbal cues) 0 1 2 3

• Disinterest in music and a lack of appreciation for melodies 0 1 2 3

• Difficulty with long-term memory 0 1 2 3

• Memory impairment when doing the basic activities of daily living 0 1 2 3

• Difficulty with directions and visual memory 0 1 2 3

• Noticeable differences in energy levels throughout the day 0 1 2 3

SECTION 5• Difficulty coordinating visual inputs

and hand movements, resulting in an inability to efficiently reach for objects 0 1 2 3

• Difficulty comprehending written text 0 1 2 3

• Floaters or halos in your visual field 0 1 2 3

• Dullness of colors in your visual field during different times of the day 0 1 2 3

• Difficulty discriminating similar shades of color 0 1 2 3

© 2013 Datis Kharrazian. All Rights Reserved. SMGEBFAF32(082013)

Brain Function Assessment Form™ (BFAF)

SECTION 9• A decrease in movement speed 0 1 2 3

• Difficulty initiating movement 0 1 2 3

• Stiffness in your muscles (not joints) 0 1 2 3

• A stooped posture when walking 0 1 2 3

• Cramping of your hand when writing 0 1 2 3

SECTION 6• Difficulty with detailed hand coordination 0 1 2 3

• Difficulty with making decisions 0 1 2 3

• Difficulty with suppressing socially inappropriate thoughts 0 1 2 3

• Socially inappropriate behavior 0 1 2 3

• Decisions made based on desires, regardless of the consequences 0 1 2 3

• Difficulty planning and organizing daily events 0 1 2 3

• Difficulty motivating yourself to start and finish tasks 0 1 2 3

• A loss of attention and concentration 0 1 2 3

SECTION 10• Abnormal body movements (such as twitching legs) 0 1 2 3

• Desires to flinch, clear your throat, or perform some type of movement 0 1 2 3

• Constant nervousness and a restless mind 0 1 2 3

• Compulsive behaviors 0 1 2 3

• Increased tightness and tone in specific muscles 0 1 2 3

SECTION 7• Hypersensitivities to touch or pain 0 1 2 3

• Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall 0 1 2 3

• Frequently bumping into the wall or objects 0 1 2 3

• Difficulty with right-left discrimination 0 1 2 3

• Handwriting has become sloppier 0 1 2 3

• Difficulty with basic math calculations 0 1 2 3

• Difficulty finding words for written or verbal communication 0 1 2 3

• Difficulty recognizing symbols, words, or letters 0 1 2 3

SECTION 11• Difficulty with balance, or balance that is

noticeably worse on one side 0 1 2 3

• A need to hold the handrail or watch each step carefully when going down stairs 0 1 2 3

• Episodes of dizziness 0 1 2 3

• Nausea, car sickness, or seasickness 0 1 2 3

• A quick impact after consuming alcohol 0 1 2 3

• A slight hand shake when reaching for something 0 1 2 3

• Back muscles that tire quickly when standing or walking 0 1 2 3

• Chronic neck or back muscle tightness 0 1 2 3

SECTION 8• Difficulty swallowing supplements

or large bites of food 0 1 2 3

• Bowel motility and movements slow 0 1 2 3

• Bloating after meals 0 1 2 3

• Dry eyes or dry mouth 0 1 2 3

• A racing heart 0 1 2 3

• A flutter in the chest or an abnormal heart rhythm 0 1 2 3

• Bowel or bladder incontinence, resulting in staining your underwear 0 1 2 3

Brain Health and Nutrition Assessment Form™ (BHNAF)

© 2013 Datis Kharrazian. All Rights Reserved. SMGEBHNAF34(082013)

Name: _____________________________________ Age: ______ Sex: ________ Date:_____________________

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

SECTION 1• Low brain endurance for focus and concentration 0 1 2 3

• Cold hands and feet 0 1 2 3

• Must exercise or drink coffee to improve brain function 0 1 2 3

• Poor nail health 0 1 2 3

• Fungal growth on toenails 0 1 2 3

• Must wear socks at night 0 1 2 3

• Nail beds are white instead of pink 0 1 2 3

• The tip of the nose is cold 0 1 2 3

SECTION 2• Irritable, nervous, shaky, or light-headed between meals 0 1 2 3

• Feel energized after meals 0 1 2 3

• Difficulty eating large meals in the morning 0 1 2 3

• Energy level drops in the afternoon 0 1 2 3

• Crave sugar and sweets in the afternoon 0 1 2 3

• Wake up in the middle of the night 0 1 2 3

• Difficulty concentrating before eating 0 1 2 3

• Depend on coffee to keep going 0 1 2 3

SECTION 3• Fatigue after meals 0 1 2 3

• Sugar and sweet cravings after meals 0 1 2 3

• Need for a stimulant, such as coffee, after meals 0 1 2 3

• Difficulty losing weight 0 1 2 3

• Increased frequency of urination 0 1 2 3

• Difficulty falling asleep 0 1 2 3

• Increased appetite 0 1 2 3

SECTION 4• Always have projects and things that need to be done 0 1 2 3

• Never have time for yourself 0 1 2 3

• Not getting enough sleep or rest 0 1 2 3

• Difficulty getting regular exercise 0 1 2 3

• Feel that you are not accomplishing your life’s purpose 0 1 2 3

SECTION 8• Grain consumption leads to tiredness 0 1 2 3

• Grain consumption makes it difficult to focus and concentrate 0 1 2 3

• Feel better when bread and grains are avoided 0 1 2 3

• Grain consumption causes the development of any symptoms 0 1 2 3

• A 100% gluten-free diet Yes or No

SECTION 7• Brain fog (unclear thoughts or concentration) Yes or No

• Pain and inflammation Yes or No

• Noticeable variations in mental speed Yes or No

• Brain fatigue after meals 0 1 2 3

• Brain fatigue after exposure to chemicals, scents, or pollutants 0 1 2 3

• Brain fatigue when the body is inflamed 0 1 2 3

SECTION 6 • Difficulty digesting foods 0 1 2 3

• Constipation or inconsistent bowel movements 0 1 2 3

• Increased bloating or gas 0 1 2 3

• Abdominal distention after meals 0 1 2 3

• Difficulty digesting protein-rich foods 0 1 2 3

• Difficulty digesting starch-rich foods 0 1 2 3

• Difficulty digesting fatty or greasy foods 0 1 2 3

• Difficulty swallowing supplements or large bites of food 0 1 2 3

• Abnormal gag reflex Yes or No

SECTION 5• Dry and unhealthy skin 0 1 2 3

• Dandruff or a flaky scalp 0 1 2 3

• Consumption of processed foods that are bagged or boxed 0 1 2 3

• Consumption of fried foods 0 1 2 3

• Difficulty consuming raw nuts or seeds 0 1 2 3

• Difficulty consuming fish (not fried) 0 1 2 3

• Difficulty consuming olive oil, avocados, flax seed oil, or natural fats 0 1 2 3

Brain Health and Nutrition Assessment Form™ (BHNAF)

© 2013 Datis Kharrazian. All Rights Reserved. SMGEBHNAF34(082013)

INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers.

Functional Neurology Seminars LP © 2016 Dr. Datis Kharrazian and Dr. Brandon Brock

Page 1

NAME: DATE:

Brain Region Localization Form

0 = I never have symptoms (0% of the time)1 = I rarely have symptoms (Less than 25% of the time)2 = I often have symptoms (Half of the time)3 = I frequently have symptoms (75% of the time)4 = I always have symptoms (100% of the time)

KEY:

Frontal lobe Prefrontal, Dorsolateral and Orbitofrontal (Areas 9, 10, 11, and 12)

0 1 2 3 4

1. Difficulty with restraint and controlling impulses or desires

2. Emotional instability (lability)

3. Difficulty planning and organizing

4. Difficulty making decisions

5. Lack of motivation, enthusiasm, interest and drive (apathetic)

6. Difficulty getting a sound or melody out of your thoughts (Perseveration)

7. Constantly repeat events or thoughts with difficulty letting go

8. Difficulty initiating and finishing tasks

9. Episodes of depression

10. Mental fatigue

11. Decrease in attention span

12. Difficulty staying focused and concentrating for extended periods of time

13. Difficulty with creativity, imagination, and intuition

14. Difficulty in appreciating art and music

15. Difficulty with analytical thought

16. Difficulty with math, number skills and time consciousness

17. Difficulty taking ideas, actions, and words and putting them in a linear sequence

Frontal Lobe Precentral and Supplementary Motor Areas (Area 4 and 6)

0 1 2 3 4

18. Initiating movements with your arm or leg has become more difficult

19. Feeling of arm or leg heaviness, especially when tired

20. Increased muscle tightness in your arm or leg

21. Reduced muscle endurance in your arm or leg

22. Noticeable difference in your muscle function or strength from one side to the other

23. Noticeable difference in your muscle tightness from one side to the other

Frontal Lobe Broca’s Motor Speech Area (Area 44 and 45)

0 1 2 3 4

24. Difficulty producing words verbally, especially when fatigued

25. Find the actual act of speaking difficult at times

26. Notice word pronunciation and speaking fluency change at times

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3,1,2 and 7)

0 1 2 3 4

27. Difficulty in perception of position of limbs

28. Difficulty with spatial awareness when moving, laying back in a chair, or leaning against a wall

29. Frequently bumping body or limbs into the wall or objects accidently

30. Reoccurring injury in the same body part or side of the body

31. Hypersensitivities to touch or pain perception

Brain Region Localization Form

0 = I never have symptoms (0% of the time)1 = I rarely have symptoms (Less than 25% of the time)2 = I often have symptoms (Half of the time)3 = I frequently have symptoms (75% of the time)4 = I always have symptoms (100% of the time)

KEY:INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers.

Functional Neurology Seminars LP © 2016 Dr. Datis Kharrazian and Dr. Brandon BrockPage 2

Parietal Inferior Lobule (Area 39 and 40)

0 1 2 3 4

32. Right/left confusion

33. Difficulty with math calculations

34. Difficulty finding words

35. Difficulty with writing

36. Difficulty recognizing symbols or shapes

37. Difficulty with simple drawings

38. Difficulty interpreting maps

Temporal Lobe Auditory Cortex (Areas 41, 42)

0 1 2 3 4

39. Reduced function in overall hearing

40. Difficulty interpreting speech with background or scatter noise

41. Difficulty comprehending language without perfect pronunciation

42. Need to look at someone’s mouth when they are speaking to understand what they are saying

43. Difficulty in localizing sound

44. Dislike of left predictable rhythmic, repeated tempo and beat music

45. Dislike of non-predictable rhythmic with multiple instruments

46. Noticeable ear preference when using your phone

right, left, no preference

Temporal Lobe Auditory Association Cortex (Area 22)

0 1 2 3 4

47. Difficulty comprehending meaning of spoken word

48. Tend toward monotone speech without fluctuations or emotions

Medial Temporal lobe and Hippocampus

0 1 2 3 4

49. Memory less efficient

50. Memory loss that impacts daily activities

51. Confusion about dates, the passage of time, or place

52. Difficulty remembering events

53. Misplacement of things and difficulty retracing steps

54. Difficulty with memory of locations (addresses)

55. Difficulty with visual memory

56. Always forgetting where you put items such as keys, wallet, phone, etc.

57. Difficulty remembering faces

58. Difficulty remembering names with faces

59. Difficulty with remembering words

60. Difficulty remembering numbers

61. Difficulty remembering to stay or be on time

Occipital Lobe (Area, 17, 18, and 19)

0 1 2 3 4

62. Difficulty in discriminating similar shades of color

63. Dullness of colors in visual field

64. Difficulty coordinating visual inputs and hand movements, resulting in an inability to efficiently reach out for objects

66. Floater or halos in visual field

Brain Region Localization Form

0 = I never have symptoms (0% of the time)1 = I rarely have symptoms (Less than 25% of the time)2 = I often have symptoms (Half of the time)3 = I frequently have symptoms (75% of the time)4 = I always have symptoms (100% of the time)

KEY:INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to 4 key, and select which best fits for all of your answers.

Functional Neurology Seminars LP © 2016 Dr. Datis Kharrazian and Dr. Brandon Brock

Page 3

Cerebellum - Spinocerebellum 0 1 2 3 4

67. Difficulty with balance, or balance that is worse on one side

68. A need to hold the handrail or watch each step carefully when going down stairs

69. Feeling unsteady and prone to falling in the dark

70. Proness to sway to one side when walking or standing

Cerebellum - Cerebrocerebellum 0 1 2 3 4

71. Recent clumsiness in hands

72. Recent clumsiness in feet or frequent tripping

73. A slight hand shake when reaching for something at the end of movement

Cerebellum - Vestibulocerebellum 0 1 2 3 4

74. Episodes of dizziness or disorientation

75. Back muscles that tire quickly when standing or walking

76. Chronic neck or back muscle tightness

77. Nausea, car sickness, or sea sickness

78. Feeling of disorientation or shifting of the environment

79. Crowded places cause anxiety

Basal Ganglia Direct Pathway 0 1 2 3 4

80. Slowness in movements

81. Stiffness in your muscles (not joints) that goes away when you move

82. Cramping of hands when writing

83. A stooped posture when walking

84. Voice has become softer

85. Facial expression changed leading people to frequently ask if you are upset or angry

Basal Ganglia Indirect Pathway 0 1 2 3 4

86. Uncontrollable muscle movements

87. Intense need to clear your throat regularly or contract a group of muscles

88. Obsessive compulsive tendencies

89. Constant nervousness and restless mind

Autonomic Reduced Parasympathetic Activity

0 1 2 3 4

90. Dry mouth or eyes

91. Difficulty swallowing supplements or large bites of food

92. Slow bowel movements and tendency for constipation

93. Chronic digestive complaints

94. Bowel or bladder incontinence resulting in staining your underwear

Autonomic Increased Sympathetic Activity

0 1 2 3 4

95. Tendency for anxiety

96. Easily startled

97. Difficulty relaxing

98. Sensitive to bright or flashing lights

99. Episodes of racing heart

100. Difficulty sleeping

Epileptiform Activity Yes / No

Have you ever been diagnosed with a seizure disorder? Yes / No

Have you ever been diagnosed with epilepsy? Yes / No

Have you ever been told that you seemed frozen, absent, or tuned out at times without any recollection of the event?

Yes / No

Have you ever experienced sudden muscle stiffness and rigidity throughout your body? Yes / No

Have you ever experienced sudden muscle jerks throughout your body? Yes / No

Have you ever experienced a total loss of your muscle tone that lead to loss of control of your muscles or a fall?

Yes / No

Have you ever been told that you stare into space while you’re lip smacking, chewing, or fidgeting that you are not aware of?

Yes / No

Do you ever experience sudden emotional responses such as anxiety, sadness, cry, or laugh for no real reason?

Yes / No

Do you ever experience sudden racing heart rate, sudden loss of bladder function, intestinal spasm, respiration, sweating, or any other sudden changes of function?

Yes / No

Do you ever experience sudden involuntary muscle contractures or jerks in any individual parts of your limbs or face?

Yes / No

Do you ever experience sudden involuntary head rotation and your eyes move forcefully to one side? Yes / No

Do you ever experience sudden involuntary shift in your eyes to the side or upwards? Yes / No

Do you ever experience sudden vocalization of random words or notice a sudden inability to speak? Yes / No

Do you ever experience any spontaneous sensations of tingling, pins and needles” numbness, coldness, burning or other random sensations in any region of your body?

Yes / No

Do you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously? Yes / No

Do you ever experience spontaneous perception of smells such as burning rubber, foul smells, or other odors without finding the source of the odor?

Yes / No

Do you ever experience flashing lights, stars, or jagged lines in your visual field? Yes / No

Brain Region Localization Form

Functional Neurology Seminars LP © 2016 Dr. Datis Kharrazian and Dr. Brandon Brock

Page 4

SIGNATURE: DATE:

INSTRUCTIONS:The purpose of this questionnaire is to identify difficulties that you may be experiencing. Please select yes or no.

Medication HistoryMedication HistoryPlease circle any of the following medication you have been or are currently taking.

Acetylcholine Receptor Antagonist – Antimuscarinic AgentsAcetylcholine Receptor Antagonist – Antimuscarinic AgentsAtropine, Ipratopium, Scopolamine, Tiotropium

Acetylcholine Receptor Antagonist - Ganlionic BlockersAcetylcholine Receptor Antagonist - Ganlionic BlockersMecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan

Acetylcholinesterase ReactivatorsAcetylcholinesterase ReactivatorsPralidoxime

Acetylcholine Receptor Antagonist - Neuromuscular Blockers Acetylcholine Receptor Antagonist - Neuromuscular Blockers Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine, Vecuronium, Hemicholine

Agonist Modulator of GABA Receptor (benzodiazpines)Agonist Modulator of GABA Receptor (benzodiazpines)Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum, Megadon, Serax , Restoril, Halcion

Agonist Modulator of GABA Receptors (nonbenzodiazpines)Agonist Modulator of GABA Receptors (nonbenzodiazpines)Ambien, Sonata, Lunesta, Imovane

Cholinesterase Inhibitors (irreversible)Cholinesterase Inhibitors (irreversible)Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents

Cholinesterase Inhibitors (reversible)Cholinesterase Inhibitors (reversible)Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine,Carbamate Insecticidses

Dopamine Reuptake InhibitorsDopamine Reuptake InhibitorsWellbutrin (Bupropion)

Dopamine Receptor Agonists Dopamine Receptor Agonists Mirapex, Sifrol, Requip

D2 Dopamine Receptor Blockers (antipsychotics)D2 Dopamine Receptor Blockers (antipsychotics)Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol, Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify

GABA Antagonist Competitive binder GABA Antagonist Competitive binder Flumazenil

Monoamine Oxidase Inhibitor (MAOI)Monoamine Oxidase Inhibitor (MAOI)Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid

Noradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa)Noradrenergic and Specifi c Sertonergic Antidepressants (NaSSaa)Remeron, Zispin, Avanza, Norset, Remergil, Axit

Selective Serotonin Reuptake InhibitorSelective Serotonin Reuptake InhibitorPaxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil, Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine

Selective Serotonin Reuptake EnhancersSelective Serotonin Reuptake EnhancersStablon, Coaxil, Tatinol

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine

Tricylic Antidepresseants (TCAs)Tricylic Antidepresseants (TCAs)Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil

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

SMGEP

QNTA

F04(1009).INDD

All Rights Reserved. Copyright © 2008, Datis Kharrazian