New Patient Questionnaires

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New Patient Questionnaires

Welcome to Restoration Healthcare!

} First thing to know about us: We’re glad you’re here, and we’re currently accepting new patients from the Southern California area for initial doctor visits starting in March and April of 2022.

} Second thing to know about us: We use data and facts to help create your treatment plan, which is why we need your help in completing the attached New Patient Packet. Also, because we make it our business to stay up-to-date with the latest data and trends from the medical community at-large, we tend to update our protocols every 6 to 12 months.

} Third thing to know about us: We actively partner with you to discover and help you overcome chronic conditions that prevent you from living a long and healthy life. In other words, our approach to doctoring is different. We work to discover the underlying issues behind your pain or symptoms by working our way back to the point where we discover what prompted those symptoms in the first place. Then we work with you to make your life better.

The data gathered from the forms and questionnaires that follow are important for us to help you.

As you’ll see, we want you to tell us why you are here, what you’ve done to help yourself in the past, and what your medical and family history looks like. We also need you to complete a few questionnaires that will ultimately help us understand the genesis of your problem. Finally, we want you to tell us your story using the attached timeline.

} Fourth thing to know about us: Our staff plays a critical role in your care. They will help our doctors map out your plan of care, work with you to solve or overcome anything ‘financial’ that may seemingly get in the way of your treatment, manage your scheduling, and oversee the plan of how we are going to objectively measure your progress.

} Last thing to know about us: In most cases, 9 months is the amount of time for us to work together to get you back on track.

Before Getting Started

} If you are choosing us due to a new sports injury, please take the fast track: Complete all of Section I:

You and Your Medical History, and then skip ahead to Section IX: Orthopedic Localization Form.

} If you are here for Bio Identical Hormone Replacement only, Complete all of Section I: You and Your Medical History, and then go directly to Section V: Hormone Health Checklist for Women / Men.

List of questionnaires contained in our New Patient Packet:

Required: Required ONLY if Applicable:

• Metabolic Assessment ^• Chronic Illness Without a Diagnosis Symptom Checklist

• Brain Localization Form ^• Orthopedic Localization Form

• Heavy Metal Exposure Symptoms

• Hormones – Women / Men

• Medical Timeline – Plot out your medical history

• Future Scale

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SECTION I: “You and Your Medical Story”

General Information

Date:

First Name (legal name only): Last Name (legal name only): Age: Date of Birth: Email:

Address: City: State: Zip:

Phone (Home): (Cell): (Work):

Emergency Contact: Relationship:

Phone (Home): (Cell): (Work):

Genetic Background:

African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other:

When, where and from whom did you last receive medical or health care?

How did you hear about our practice?:

Clinic website RH website Other:

Social media (if yes, which one?):

Doctor referral (please share doctor’s name):

Referral from friend/family member (please share name):

Insurance and Pharmacy:

Insurance Carrier: Member ID:

Preferred Pharmacy Name: Pharmacy Phone:

Pharmacy Address:

Do we have your permission to link your Restoration Healthcare patient account with your Surescripts account at your pharmacy? (Surescripts handles the electronic transmission of prescriptions between healthcare organizations and pharmacies): Yes No

Education (what is your highest level of education):

Occupation (please tell us about your current occupation):

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1. I am suffering from the following:

A.

B.

C.

D.

E.

2. I have had the following treatment(s) over the last 12-18 months:

3. Using the table below, please tell us about any prior ultrasounds or scans you have had, such as mammograms, colonoscopy, MRIs, Pap smear, bone density, CTs, etc.:

Type of Imaging / Diagnostic Date Result (normal / abnormal)

 Please send all reports from mammograms, colonoscopy, MRIs, Pap smears, bone density, CTs, etc. — including your name and birthday — to: [email protected] (please send WITH this packet).

If you cannot send these files electronically, please mail them to: Restoration Healthcare; 18818 Teller Avenue, Suite 170; Irvine, CA 92612. Files may also be faxed to: (949) 535-2330.

4. Have you had any medical or lab testing done?:

 Please send all lab reports and related documentation — including your name and birthday — to:

[email protected] (please send WITH this packet). If you cannot send these files electronically, please mail them to: Restoration Healthcare; 18818 Teller Avenue, Suite 170;

Irvine, CA 92612. Files may also be faxed to: (949) 535-2330. (continued on next page )

SECTION I: “You and Your Medical Story”

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5. Past Medical History: (Check all that apply):

HIV Kidneys Liver Disease Lung Disease Bleeding Disorder Eating Disorder

Arthritis Alcohol Abuse Thyroid Disease Heart Valve Disorder Heart Disease Anemia Cancer Gallbladder Disorder Psychiatric Illness Drug Abuse

Other:

6. I estimate my % of the following in my daily diet:

Gluten Free – Dairy Free – Sugar Free –

7. I estimate that I consume the following number of alcoholic drinks per week:

8. I have the following food cravings:

9. My number of bowel movements per day is:

10. My bowel consistency is (loose, soft, hard):

11. Number (on average) of hours of sleep I get per night is:

12. Any snoring? (yes or no):

13. Wake up rested? (yes or no):

14. In regards to sex:

A). Interest (normal / no interest):

B). Ability (yes / no / some difficulty):

C). Any pain or dysfunction (yes / no):

D). My sexual activity level is best described as:

15. For women: when was your last menstrual cycle and describe (light, normal or heavy?):

16. I do the following exercise on a (daily / twice a week / three-times a week) basis:

17. I enjoy doing the following things for fun:

SECTION I: “You and Your Medical Story”

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18. Using the table below, please tell us about any of your known allergies

Type Reaction (nausea, rash, hives, etc.) Severity (mild, moderate, severe, fatal, unknown)

Any Allergy Testing Done? Yes No

 *Please send any results of allergy testing you have had done to: [email protected] (please send WITH this packet). If you cannot send these files electronically, please mail them to:

Restoration Healthcare; 18818 Teller Avenue, Suite 170; Irvine, CA 92612. Files may also be faxed to:

(949) 535-2330.

19. Do you smoke? Yes No (If yes, for how many years and how much?):

20. Living arrangements (house, apartment, who do you live with?):

21. Are you exposed to any potential environmental pathogens?:

22. Have you had any known exposures? (mold, heavy metals, tick bites, etc.):

23. Family History:

• Father: Current age? If he is deceased, at what age and how did he die?:

• Mother: Current age? If she is deceased, at what age and how did she die?:

SECTION I: “You and Your Medical Story”

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• Maternal and paternal grandparents: if deceased, at what ages and how did they die? (continued):

• If you have children, how many, what are their age(s) and gender?:

24. Family Medical History: (Check all that apply):

High Blood Pressure Nervous Breakdown Heart Trouble Cancer Strokes Anemia Obesity Kidney Disease Suicide Migraines Allergies Bleeding (abnormal)

Arthritis Epilepsy Syphilis

Patient’s First Name (print legal name only): Patient’s Last Name (print legal name only): Patient’s signature or legally authorized representative: Date:

SECTION I: “You and Your Medical Story”

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25. Please tell us about your current health challenges and issues, including any history of treatment (please feel free to elaborate… the text box below can handle up to 850 words)

SECTION I: “You and Your Medical Story”

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Rate your stress level on a scale of 1-10 during the average week?

(1 being the lowest, 10 being the highest)

How many alcoholic beverages do you consume per week?

How many times do you work out per week

How many caffeinated beverages do you consume per week?

How many times do you eat out per week?

How many times do you eat fish per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

1.

2.

3.

List the three healthiest foods you eat during the average week:

1.

2.

3.

Using the table below, please tell us about any medications you currently take.

Medication Dosage Brand Name Frequency Taken for

SECTION II: Metabolic Assessment Form

Date:

First Name (legal name only): Last Name (legal name only):

}

Part I

–

Instructions:

The purpose of this questionnaire is to identify difficulties you may be experiencing. Please, answer every question, do not skip any questions.

If needed, continue list onto next page

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SECTION II: Metabolic Assessment Form — Part I

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Using the table below, please tell us about any medications you currently take. (continued from previous page)

Medication Dosage Brand Name Frequency Taken for

Using the table below, please tell us about any supplements you currently take.

Supplement Dosage Brand Name Frequency Taken for

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}

Part II

– Please indicated with a check mark the appropriate number on all questions below.

Instructions:

The purpose of this questionnaire is to identify difficulties you may be experiencing. Please, answer every question, do not skip any questions. Follow the 0 to 3 key, and select, which best fits for all of your answers.

KEY

0 = I never / rarely have symptoms 1 = I often have symptoms

2 = I frequently have symptoms 3 = I most / always have symptoms

Category I 0 1 2 3

1. Feeling that bowels do not empty completely

2. Lower abdominal pain relieved by passing stool or gas 3. Alternating constipation and diarrhea

4. Diarrhea 5. Constipation

6. Hard, dry, or small stool

7. Coated tongue or “fuzzy” debris on tongue 8. Pass large amount of foul-smelling gas 9. More than 3 bowel movements daily 10. Use laxatives frequently

Please add up your totals from each column + Total overall score for Category I =

Category II 0 1 2 3

11. Increasing frequency of food reactions 12. Unpredictable food reactions

13. Aches, pains, and swelling throughout the body 14. Unpredictable abdominal swelling

15. Frequent bloating and distention after eating 16. Abdominal intolerance to sugars and starches

Please add up your totals from each column + Total overall score for Category II =

Category III 0 1 2 3

17. Intolerance to smells 18. Intolerance to jewelry

19. Intolerance to shampoo, lotions, detergents, etc.

20. Multiple smell and chemical sensitivities 21. Constant skin outbreaks

Please add up your totals from each column + Total overall score for Category II =

SECTION II: Metabolic Assessment Form

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Category IV 0 1 2 3 22. Excessive belching, burping, or bloating

23. Gas immediately following a meal 24. Offensive breath

25. Difficult bowel movements

26. Sense of fullness during and after meals

27. Difficulty digesting fruits and vegetables; undigested food found in stools

Please add up your totals from each column + Total overall score for Category IV =

Category V 0 1 2 3

28. Use of antacids

29. Stomach pain, burning, or aching 1– 4 hours after eating 30. Feel hungry an hour or two after eating

31. Heartburn when lying down or bending forward

32. Temporary relief by using antacids, food, milk, or carbonated beverages 33. Digestive problems subside with rest and relaxation

34. Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Please add up your totals from each column + Total overall score for Category V =

Category VI 0 1 2 3

35. Roughage and fiber cause constipation

36. Indigestion and fullness last 2 – 4 hours after eating 37. Pain, tenderness, soreness on left side under rib cage 38. Excessive passage of gas

39. Nausea and / or vomiting

40. Stool undigested, foul smelling, mucus-like, greasy, or poorly formed 41. Frequent urination

42. Increased thirst and appetite

Please add up your totals from each column + Total overall score for Category VI =

SECTION II: Metabolic Assessment Form

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Category VII 0 1 2 3 43. Abdominal distention after consumption of fiber, starches, and sugar

44. Abdominal distention after certain probiotic or natural supplements 45. Lowered gastrointestinal motility, constipation

46. Raised gastrointestinal motility, diarrhea 47. Alternating constipation and diarrhea 48. Suspicion of nutritional malabsorption 49. Frequent use of antacid medication

50. Have you been diagnosed with: Celiac Disease, Irritable Bowel Syndrome,Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome? Yes No Please add up your totals from each column +

Total overall score for Category VII =

Category VIII 0 1 2 3

51. Greasy or high-fat foods cause distress

52. Lower bowel gas and / or bloating several hours after eating 53. Bitter metallic taste in mouth, especially in the morning 54. Burpy, fishy taste after consuming fish oils

55. Difficulty losing weight 56. Unexplained itchy skin 57. Yellowish cast to eyes

58. Stool color alternates from clay colored to normal brown 59. Reddened skin, especially palms

60. Dry or flaky skin and / or hair

61. History of gallbladder attacks or stone 62. Have you had your gallbladder removed?

Please add up your totals from each column + Total overall score for Category VIII =

Category IX 0 1 2 3

63. Acne and unhealthy skin 64. Excessive hair loss 65. Overall sense of bloating 66. Bodily swelling for no reason 67. Hormone imbalances

68. Weight gain

69. Poor bowel function

70. Excessively foul-smelling sweat

Please add up your totals from each column + Total overall score for Category IX =

SECTION II: Metabolic Assessment Form

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Category X 0 1 2 3 71. Crave sweets during the day

72. Irritable if meals are missed

73. Depend on coffee to keep going / get started 74. Get light-headed if meals are missed

75. Eating relieves fatigue

76. Feel shaky, jittery, or have tremors 77. Agitated, easily upset, nervous 78. Poor memory / forgetful 79. Blurred vision

Please add up your totals from each column + Total overall score for Category X =

Category XI 0 1 2 3

80. Fatigue after meals

81. Crave sweets during the day

82. Eating sweets does not relieve cravings for sugar 83. Must have sweets after meal

84. Waist girth is equal or larger than hip girth 85. Frequent urination

86. Increased thirst and appetite 87. Difficulty losing weight

Please add up your totals from each column + Total overall score for Category XI =

Category XII 0 1 2 3

88. Cannot stay asleep 89. Crave salt

90. Slow starter in the morning 91. Afternoon fatigue

92. Dizziness when standing up quickly 93. Afternoon headaches

94. Headaches with exertion or stress 95. Weak nails

Please add up your totals from each column + Total overall score for Category XII =

SECTION II: Metabolic Assessment Form

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Category XIII 0 1 2 3 96. Cannot fall asleep

97. Perspire easily

98. Under a high amount of stress 99. Weight gain when under stress

100. Wake up tired even after 6 or more hours of sleep

101. Excessive perspiration or perspiration with little or no activity

Please add up your totals from each column + Total overall score for Category XIII =

Category XIV 0 1 2 3

102. Edema and swelling in ankles and wrist 103. Muscle cramping

104. Poor muscle endurance 105. Frequent urination 106. Frequent thirst 107. Crave salt

108. Abnormal sweating from minimal activity 109. Alteration in bowel regularity

110. Inability to hold breath for long periods 111. Shallow, rapid breathing

Please add up your totals from each column + Total overall score for Category XIV =

Category XV 0 1 2 3

112. Tired / sluggish

113. Feel cold— hands, feet, all over

114. Require excessive amounts of sleep to function properly 115. Increase in weight even with low-calorie diet

116. Gain weight easily

117. Difficult, infrequent bowel movements 118. Depression / lack of motivation

119. Morning headaches that wear off as the day progresses 120. Outer third of eyebrow thins

121. Thinning of hair on scalp, face, or genitals, or excessive hair loss 122. Dryness of skin and/or scalp

123. Mental sluggishness

Please add up your totals from each column + Total overall score for Category XV =

SECTION II: Metabolic Assessment Form

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Category XVI 0 1 2 3 124. Heart palpitations

125. Inward trembling

126. Increased pulse, even at rest 127. Nervous and emotional 128. Insomnia

129. Night sweats

Please add up your totals from each column + Total overall score for Category XVI =

Category XVII (Males Only) 0 1 2 3

130. Difficult urination or dribbling 131. Frequent urination

132. Pain inside of legs or heels

133. Feeling of incomplete bowel emptying 134. Leg twitching at night

135. Decreased libido

136. Decreased number of spontaneous morning erections 137. Decreased fullness of erection

138. Difficulty maintaining morning erections 139. Spells of mental fatigue

140. Inability to concentrate 141. Episodes of depression 142. Decreased physical stamina 143. Muscle soreness

144. Unexplained weight gain

145. Increase in fat distribution around chest and hips 146. Sweating attacks

147. More emotional than in the past

Please add up your totals from each column + Total overall score for Category XVII =

SECTION II: Metabolic Assessment Form

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Category XVIII (Menstruating Females Only) 0 1 2 3 148. Perimenopausal

149. Alternating menstrual cycle lengths

150. Extended menstrual cycle (greater than 32 days) 151. Shortened menstrual cycle (less than 24 days) 152. Pain and cramping during periods

153. Scanty blood flow 154. Heavy blood flow

155. Breast pain and swelling during menses 156. Pelvic pain during menses

157. Irritable and depressed during menses 158. Acne

159. Facial hair growth 160. Hair loss / thinning

Please add up your totals from each column + Total overall score for Category XVIII =

Category XIX (Menopausal Females Only) 0 1 2 3

161. How many years have you been menopausal? Years

162. Since menopause, do you ever have uterine bleeding? Yes No

163. Hot flashes 164. Mental fogginess 165. Disinterest in sex 166. Mood swings 167. Depression 168. Painful intercourse 169. Shrinking breasts 170. Facial hair growth 171. Acne

172. Increased vaginal pain, dryness, or itching

Please add up your totals from each column + Total overall score for Category XIX =

SECTION II: Metabolic Assessment Form

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SECTION III: Brain Region Localization Form

} 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.

KEY

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)

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 (liability) 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

Please add up your totals from each column + Total score =

Frontal Lobe Precentral and Supplementary Motor Areas (Areas 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

(continued on next page) Date:

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Frontal Lobe Broca’s Motor Speech Area (Areas 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

Parietal Somatosensory Area and Parietal Superior Lobule (Areas 3, 1, 2 and 7) 0 1 2 3 4 26. Notice word pronunciation and speaking fluency change at times

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

30. Hypersensitivities to touch or pain perception

Parietal Inferior Lobule (Areas 39 and 40) 0 1 2 3 4

31. Right / left confusion [L]

32. Difficulty with math calculations [L]

33. Difficulty finding words [L]

34. Difficulty with writing [L]

35. Difficulty recognizing symbols or shapes [R]

36. Difficulty with simple drawings [R]

37. Difficulty interpreting maps [R]

Temporal Lobe Auditory Cortex (Areas 41, 42) 0 1 2 3 4

38. Reduced function in overall hearing

39. Difficulty interpreting speech with background or scatter noise 40. Difficulty comprehending language without perfect pronunciation

41. Need to look at someone’s mouth when they are speaking to understand what they are saying 42. Difficulty in localizing sound

43. Dislike of left predictable rhythmic, repeated tempo and beat music [L]

44. Dislike of non-predictable rhythmic with multiple instruments [R]

45. Noticeable ear preference when using your phone; Check L= Left R= Right N= None ^L ^R ^None Please add up your totals from each column +

Total score =

Temporal Lobe Auditory Association Cortex (Area 22) 0 1 2 3 4 46. Difficulty comprehending meaning of spoken word [L]

47. Tend toward monotone speech without fluctuations or emotions [R]

SECTION III: Brain Region Localization Form

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Medial Temporal Lobe and Hippocampus 0 1 2 3 4 48. Memory less efficient

49. Memory loss that impacts daily activities

50. Confusion about dates, the passage of time, or place 51. Difficulty remembering events

52. Misplacement of things and difficulty retracing steps 53. Difficulty with memory of locations (addresses) 54. Difficulty with visual memory

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

56. Difficulty remembering faces

57. Difficulty remembering names with faces 58. Difficulty remembering words

59. Difficulty remembering numbers

60. Difficulty remembering to stay or be on time

Occipital Lobe (Areas, 17, 18, and 19) 0 1 2 3 4

61. Difficulty in discriminating similar shades of color 62. Dullness of colors in visual field

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

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

Cerebellum — Spinocerebellum 0 1 2 3 4

66. A need to hold the handrail or watch each step carefully when going down stairs 67. Feeling unsteady and prone to falling in the dark

68. Prone to sway to one side when walking or standing 69. Recent clumsiness in hands

Cerebellum — Cerebrocerebellum 0 1 2 3 4

70. Recent clumsiness in feet or frequent tripping

71. A slight hand shake when reaching for something at the end of movement 72. Episodes of dizziness or disorientation

SECTION III: Brain Region Localization Form

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Cerebellum — Vestibulocerebellum 0 1 2 3 4 73. Back muscles that tire quickly when standing or walking

74. Chronic neck or back muscle tightness 75. Nausea, car sickness, or sea sickness

76. Feeling of disorientation or shifting of the environment 77. Crowded places cause anxiety

78. Slowness in movements

Basal Ganglia Direct Pathway 0 1 2 3 4

79. Stiffness in your muscles (not joints) that goes away when you move 80. Cramping of hands when writing

81. A stooped posture when walking 82. Voice has become softer

83. Change in facial expression that leads people to frequently ask if you are upset or angry 84. Uncontrollable muscle movements

Basal Ganglia Indirect Pathway 0 1 2 3 4

85. Intense need to clear your throat regularly, or contract a group of muscles 86. Obsessive compulsive tendencies

87. Constant nervousness and restless mind 88. Dry mouth or eyes

Autonomic Reduced Parasympathetic Activity 0 1 2 3 4

89. Difficulty swallowing supplements or large bites of food 90. Slow bowel movements and tendency for constipation 91. Chronic digestive complaints

92. Bowel or bladder incontinence resulting in staining your underwear 93. Tendency for anxiety

SECTION III: Brain Region Localization Form

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SECTION III: Brain Region Localization Form

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Autonomic Increased Sympathetic Activity 0 1 2 3 4

94. Easily startled 95. Difficulty relaxing

96. Sensitive to bright or flashing lights 97. Episodes of racing heart

98. Difficulty sleeping

99. Have you ever been diagnosed with a seizure disorder?

Epileptiform Activity Yes No

100. Have you ever been diagnosed with epilepsy?

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

102. Have you ever experienced sudden muscle stiffness and rigidity throughout your body?

103. Have you ever experienced sudden muscle jerks throughout your body?

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

105. Have you ever been told that you stare into space while you’re lip smacking chewing, or fidgeting?

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

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

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

109. Do you ever experience sudden involuntary head rotation with your eyes moving forcefully to one side?

110. Do you ever experience sudden involuntary shifts in your eyes to the side or upward?

111. Do you ever experience sudden vocalization of random words or notice a sudden inability to speak?

112. 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?

113. Do you ever experience a ringing sensation in your ears (tinnitus), sounds, or voices spontaneously?

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

115. Do you ever experience flashing lights, stars, or jagged lines in your visual field?

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SECTION IV: Heavy Metal Exposure Symptoms Questionnaire

}

Instructions:

Please rate the following symptoms from “0” to “10” (“0” = no symptoms, “10” = high level of symptoms). Rate these as true as possible. Do not over exaggerate. Do not underestimate.

Please do not over think.

Symptoms 0 1 2 3 4 5 6 7 8 9 10

1. Depression / Mood changes 2. Headache

3. Diminished cognitive performance 4. Diminished reaction time

5. Diminished visual motor performance 6. Dizziness

7. Fatigue 8. Forgetfulness

9. Impaired concentration 10. Increased nervousness 11. Irritability

12. Lethargy 13. Malaise 14. Weakness

Patient’s signature or legally authorized representative:

Date:

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SECTION V: Hormone Health Checklist For Women

}

Instructions:

Please rate and check the following symptoms from “Never-1,” “Mild-2” “Moderate-3”

to “Severe-4.” Rate these as true as possible. Do not over exaggerate. Do not underestimate.

Please do not over think.

Symptoms Never Mild Moderate Severe

1. Impaired concentration 2. Fatigue

3. Memory Loss 4. Mental confusion

5. Decreased sex drive / libido 6. Sleep problems

7. Mood changes / Irritability 8. Tension

9. Migraine / severe headaches 10. Difficult attaining sexual climax 11. Bloating

12. Weight gain 13. Breast tenderness 14. Vaginal dryness 15. Hot flashes 16. Night sweats

17. Dry and wrinkled skin 18. Hair falling out 19. Cold all the time

20. Swelling all over the body 21. Joint pain

Family History Yes No Relationship

22. Heart disease 23. Diabetes 24. Osteoporosis 25. Alzheimer’s disease 26. Breast cancer Date:

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SECTION V: Hormone Health Checklist For Men

}

Instructions:

Please rate and check the following symptoms from “Never-1,” “Mild-2” “Moderate-3”

to “Severe-4.” Rate these as true as possible. Do not over exaggerate. Do not underestimate.

Please do not overthink.

Symptoms Never Mild Moderate Severe

1. Decline in general well being 2. Fatigue

3. Joint pain / muscle ache 4. Excessive sweating 5. Sleep problems

6. Increased need for sleep 7. Irritability

8. Nervousness 9. Anxiety

10. Depressed mood

11. Exhaustion / lacking vitality

12. Declining mental ability / focus / concentration 13. Feeling you have passed your peak

14. Feeling burned out / hit rock bottom 15. Decreased muscle strength

16. Weight gain / belly fat / inability to lose weight 17. Breast development

18. Shrinking testicles 19. Rapid hair loss

20. Decrease in beard growth 21. New migraine headaches 22. Decreased desire / libido 23. Decreased morning erections

24. Decreased ability to perform sexually 25. Infrequent of absent ejaculations 26. No results from E.D. medications

Family History Yes No Relationship

27. Heart disease 28. Diabetes 29. Osteoporosis 30. Alzheimer’s disease 31. Prostate cancer Date:

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Antecedents

In the space below, please do your best to tell us about your parents’ health status and the state of their environment before you were conceived and during the pregnancy that resulted in you.

Mediators / Perpetuators

Using the space below, please share your ideas related to the root cause of your current health issues. Everything is fair game so please don’t hold back or leave anything out!

SECTION VI: Functional Medicine Timeline

Date:

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SECTION VI: Functional Medicine Timeline

(continued)

Triggers or Triggering Events

Using the space below, please tell us about what you think kicked off the current episode of your health situation(s).

Signs, Symptoms, or Diseases Reported

Using the space below, please tell us what the first signs were of your health issue and/or how it was diagnosed by another doctor prior to you coming to see us at Restoration Healthcare.

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SECTION VII: Chronic Illness without Diagnosis

}

Instructions:

Think about how you have been feeling over the previous month and how often the following has bothered you. Check the number you feel best applies to you.

Section A: Symptoms ^Never Sometimes Most of the time All of the time

1. Unexplained fevers, sweats, chills or flushing 0 1 2 3

2. Unexplained weight loss or gain 0 1 2 3

3. Fatigue, tiredness 0 1 2 3

4. Unexplained hair loss 0 1 2 3

5. Swollen glands 0 1 2 3

6. Sore throat 0 1 2 3

7. Testicular pain / Pelvic pain 0 1 2 3

8. Unexplained menstrual irregularity 0 1 2 3

9. Unexplained breast milk production, breast pain 0 1 2 3

10. Irritable bladder or bladder dysfunction 0 1 2 3

11. Sexual dysfunction / loss of libido 0 1 2 3

12. Upset stomach 0 1 2 3

13. Change in bowel function (constipation or diarrhea) 0 1 2 3

14. Chest pain or rib soreness 0 1 2 3

15. Shortness of breath / cough 0 1 2 3

16. Heart palpitations, pulse skips, heart block 0 1 2 3

17. History of heart murmur or valve prolapse 0 1 2 3

18. Joint pain or swelling 0 1 2 3

19. Stiffness of the neck or back 0 1 2 3

20. Muscle pain or cramps 0 1 2 3

21. Twitching of the face or other muscles 0 1 2 3

22. Headaches 0 1 2 3

23. Neck cracks or neck stiffness 0 1 2 3

24. Tingling, numbness, burning or stabbing sensations 0 1 2 3

25. Facial paralysis (Bell’s Palsy) 0 1 2 3

26. Eyes / vision — double, blurry 0 1 2 3

27. Ears / hearing — buzzing, ringing, ear pain 0 1 2 3

28. Increased motion sickness, vertigo 0 1 2 3

(continued on next page ) Date:

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Section B Yes No 39. You have had a tick bite with rash or flu-like symptoms. 3 Points 0 Points 40. You have had a tick bite, an Erythema migrains or undefined rash, followed by flu-like symptoms. 5 Points 0 Points 41. You live in what is considered a Lyme endemic area. 2 Points 0 Points 42. You have a family member diagnosed with Lyme and /or tick-bourne infections. 1 Points 0 Points

43. You experience migratory muscle pain. 4 Points 0 Points

44. You experience migratory joint pain. 4 Points 0 Points

45. You experience tingling / burning / numbness that migrates and / or comes and goes. 4 Points 0 Points 46. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia. 3 Points 0 Points 47. You have received a prior diagnosis of a non-specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis). 3 Points 0 Points 48. You have had a positive Lyme test (ELISA, Western Blot, PCR). 3 Points 0 Points

Totals =

Please add up your points from Section B: _____________

+ Score from Section A: _____________

A + B = : _____________

Please add up your totals from each column, then add up the 4 column totals.

This is your first score.

This is your score from Section A: _____________

}

Instructions:

Please check off each “yes” answer to with the following questions:

Section A: Symptoms continued ^Never Sometimes Most of the time All of the time

29. Lightheadedness, poor balance, difficulty walking 0 1 2 3

30. Tremors 0 1 2 3

31. Confusion, difficulty thinking 0 1 2 3

32. Difficulty with concentration or reading 0 1 2 3

33. Forgetfulness, poor short-term memory 0 1 2 3

34. Disorientation; getting lost, going to wrong places 0 1 2 3

35. Difficulty with speech or writing 0 1 2 3

36. Mood swings, irritability, depression 0 1 2 3

37. Disturbed sleep — too much, too little, early awake 0 1 2 3

38. Exaggerated symptoms or worsening hangovers from alcohol 0 1 2 3 Totals =

SECTION VII: Chronic Illness without Diagnosis

(continued)

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SECTION VII: Chronic Illness without Diagnosis

(continued)

Section C

Section D

Lastly, if you rated a ‘3’ in Section A for ALL of the following symptoms, give yourself 5 points:

Fatigue

Forgetfulness, poor short-term memory

Joint pain or swelling

Tingling, numbness, burning or stabbing sensations

Disturbed sleep – too much, too little, early awake

Only give yourself these 5 points if you rated “3” for ALL of the above symptoms.

Final scoring:

0 – 20 = Tick borne illness not likely 21 – 45 = Tick borne illness possible 46 & above = Tick borne illness highly likely

1.

Thinking about your overall physical health, how many days during the past 30 days was your physical health not good?

2.

You have had a tick bite with rash or flu-like symptoms 0 – 5 Days = 1 point

6 – 12 Days = 2 points 13 – 20 Days = 3 points 21 – 30 Days = 4 points

Please, give yourself 5 points and add it to the final score after Section C

This is your final score = _____________

Please add up your points from Section C: _____________

+ Score from Section A + B: _____________

A + B + C = : _____________

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SECTION VIII: Orthopedic Localization Form

}

Instructions:

The purpose of this questionnaire is to identify difficulties that you may be experiencing.

Please answer every question, do not skip any questions and select with a checkmark which best fits for all of your answers.

Section I: Symptoms ^{Yes No} PAIN LEVEL:

0 1 2 3 4 5 6 7 8 9 10

1. Do you have pain in your spine?

2. Do you have pain in your arms?

3. Do you have pain in your legs?

4. Do you have pain over your abdomen / torso?

Symptoms continued Yes No PAIN LEVEL

0 – 3 4 – 6 7 – 10

5. Do you have weakness in your back? Mild Moderate Severe

6. Do you have weakness in your shoulders? Mild Moderate Severe

7. Do you have weakness in your hips or glutes? Mild Moderate Severe

8. Do you have weakness in your arms? Mild Moderate Severe

9. Do you have weakness in your legs? Mild Moderate Severe

10. Do you have weakness in your feet? Mild Moderate Severe

11. Do you have weakness on one side of the body? Mild Moderate Severe

12. Do you have cramping? Mild Moderate Severe

13. Do you get weak with exercises or movement? Mild Moderate Severe 14. Do your muscles cramp and freeze with movement? Mild Moderate Severe 15. Do you have a loss in muscle size? Where? ^Mild Moderate Severe 16. Have your noticed your muscles jumping?Where? ^Mild Moderate Severe

17. Do you have weakness in your face? Mild Moderate Severe

18. Do you have problems talking? Mild Moderate Severe

19. Do you have problems swallowing? Mild Moderate Severe

20. Do you have sensory loss or pain down your arm? Mild Moderate Severe 21. Do you have sensory loss or pain down your leg? Mild Moderate Severe 22. Do you have sensory loss on one side of the body? Mild Moderate Severe 23. Do your have sensory loss over your shoulders? Mild Moderate Severe 24. Do you have sensory loss with one arm or portion of the arm? ^Mild Moderate Severe

25. Do you have sensory loss with one or both hands or a single finger? If so, which areas: ^Mild Moderate Severe 26. Do you have bowel or bladder control issues? Mild Moderate Severe

(continued on next page ) Date:

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Symptoms continued Yes No PAIN LEVEL

0 – 3 4 – 6 7 – 10

28. Do you have pain or sensory loss over your hips? Mild Moderate Severe 29. Do you have pain or sensory loss in one or both legs? Mild Moderate Severe 30. Do you have sensory loss in your feet or a portion of your foot? If so, where?: ^Mild Moderate Severe 31. Do you have sensory loss in your face? If so, where?: ^Mild Moderate Severe

32. Do you have high arches? Mild Moderate Severe

33. Do you have hammertoes? Mild Moderate Severe

Gait ^{Yes No} _{0 – 3} ^{PAIN LEVEL}_{4 – 6} _{7 – 10}

34. Do you fall? How often? ^Mild Moderate Severe 35. Do you have a hard time standing on your toes or heels? Mild Moderate Severe

36. Do you fall to one side? Mild Moderate Severe

37. Do you walk with your legs wide apart? Mild Moderate Severe

38. Do you waddle when you walk? Mild Moderate Severe

39. Do you have a hard time going up or down stairs? Mild Moderate Severe 40. Is an arm or both arms tight or spastic? Mild Moderate Severe

41. Is a leg or both legs spastic? Mild Moderate Severe

42. Do your feet slap when you walk? Mild Moderate Severe

43. Do you have to high step when you walk? Mild Moderate Severe

44. Do you shuffle when you walk? Mild Moderate Severe

45. Is it hard to start walking? Mild Moderate Severe

46. Is it hard to turn if you stop walking? Mild Moderate Severe

SECTION VIII: Orthopedic Localization Form

(continued)

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SECTION IX: Mold History Questionnaire

Indoor dampness and mold (fungal growth) are common problems in California and around the world. In fact, studies reveal 85 percent of residential and commercial buildings in the U.S. have experienced water damage, while 45 percent currently are water damaged. When a building has suffered water damage, the likelihood of mold is significantly increased, and if there’s mold in your home, you may have a mold-related illness.

By answering the following questions, you’ll help us understand what your mold-related exposure may be. Please answer each question as best you can. At the end, feel free to share any additional details we may not have asked about below.

1. Regardless of whether you live in a freestanding home, apartment building, or condominium, what year was it built?

2. Does your residence smell musty? Yes No

3. How about mold… is mold visible anywhere inside your residence? Yes No

4. Does your home, apartment, or condominium have a crawlspace or basement? Yes No If yes, is crawlspace or basement damp or does it smell musty? Yes No

If the building has a crawlspace, is it covered with vapor barrier? Yes No Do Not Know If there is a vapor barrier, is it intact? Yes No Do Not Know

If there is a vapor barrier, is it taped together and brought up to the sidewalls of the foundation?

Yes No Do Not Know

5. If your house, apartment, or condominium includes a basement:

Is the basement finished? Yes No Is there carpet? Yes No

Is water pooling? Yes No

6. Is there any standing water inside or around the outside of your house, apartment, or condominium?

Yes No

7. Does the area your house, apartment, or condominium slope down toward your residence or away from it?

Toward Away N/A

8. If your house, apartment, or condominium has downspouts, are they connected to gutters?

Yes No

9. If your house, apartment, or condominium has gutters, do they overflow during heavy downpours?

Yes No Do Not Know

10. Do any of the windows in your house, apartment, or condominium leak (i.e., allow water to enter the residence when it’s raining)? Yes No

11. Does the roof of your house, apartment, or condominium have any leaks? Yes No Do Not Know

continued on next page Date:

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SECTION IX: Mold History Questionnaire

(continued)

12. If you know what the humidity is inside your house, apartment, or condominium, please note it here:

13. Do any of the windows in your house, apartment, or condominium collect condensation?

Yes No

14. What percent of your living space is covered by carpeting?

How old is the carpeting in the residence?

15. Are water stains present on any of the ceilings, flooring, or walls in your house, apartment, or condominium?

Yes No

16. Does the flooring sag in any of the rooms of your house, apartment, or condominium? Yes No 17. Do you have a dryer inside your house, apartment, or condominium, does it vent to the outdoors?

Yes No

18. If your bathrooms have vents, do they vent to the outside of the residence and not into insulation in the attic or other spaces? Yes No Do Not Know

19. Are others in your house, apartment, or condominium frequently sick? Yes No

20. Not including where you live now, have you ever lived in a house, apartment, or condominium had confirmed or suspected issues related to mold or water damage? Yes No

21. If your home, apartment, or condominium has standalone air conditioning units or mini splits (heating and cooling systems that allow you to control the temperatures in individual rooms or spaces), please shine a light into the unit(s) without disassembling them and describe what’s inside with respect to mold, accumulating water, accumulating dust, etc.

22. Finally, using the space below, please tell us anything else you feel may help us understand your exposure to mold. For example, if you spend time in an office, school, restaurant, or other environment where you suspect mold is present, please tell us about that below in as much detail as possible:

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SECTION X: The Future Scale

Date:

} Directions:

Read each item carefully. Using the scale shown below, please select the number that best describes YOU and put that number in the box provided.

1. = Definitely False 2. = Mostly False 3. = Somewhat False 4. = Slightly False

} Scoring:

Agency — please add together the scores for items 2, 9, 10, and 12:

Pathway — please add together the scores tally for items 1, 4, 6, and 8:

The Future Scale Questionnaire ^{Scale 1–8}

1. I can think of many ways to get out of a jam.

2. I energetically pursue my goals.

3. I feel tired most of the time.

4. There are lots of ways around any problem.

5. I am easily downed in an argument.

6. I can think of many ways to get the things in life that are important to me.

7. I worry about my health.

8. Even when others get discouraged, I know I can find a way to solve the problem.

9. My past experiences have prepared me well for my future.

10. I’ve been pretty successful in life.

11. I usually find myself worrying about something.

12. I meet the goals that I set for myself.

5. = Slightly True 6. = Somewhat True 7. = Mostly True 8. = Definitely True