7701 York Ave S, Suite 155| Edina, MN 55435 | Office Phone

2
New Patient Information
Forms
Name:
Age:
Address:
State:
Date:
City:
Zip:
Home Phone:
Cell Phone:
Email address:
Birth date:
Ht:
Wt:
Occupation:
Employer:
Bus. Phone:
Spouse’s name:
Employer:
Bus. Phone:
Who should we contact in case of an emergency?:
Phone:
Who is your primary care physician?
Phone:
Who should we thank for referring you?:
How did you hear about Restorative Health Solutions?:
Website | Referral | Health Lecture | Other:
Restorative Health Solutions | 7701 York Ave S, Suite 155| Edina, MN 55435 | Office Phone: 612-465-9250
www.restorativehealthsolutions.com | Email: [email protected]
1
Thank you for choosing Restorative Health Solutions. In our clinic we carefully examine all of the systems in
your body so that we may gather all the information necessary in order to best address your health and wellness.
Please be patient with all the paperwork we present to you. Please do not assume that any question is irrelevant
or unimportant to your case. We need you to carefully and honestly answer every question so that we may put
together the best approach to managing your case.
Your Reason for Coming to Restorative Health Solutions
Check as many that apply to you about your reason for visiting us today:
If yes, please indicate which
 Functional Medicine:
 Thyroid Testing
of the following you are
 Adrenal Testing
interested in:
 Allergy Testing
 Lifestyle Management



 Genetic Testing
 Weight loss/ Fitness

If yes, please indicate which
of the following you are
interested in:
 Concussion
 Testing
 Vertigo/dizziness
 Other?
 Chiropractic Care
 Functional Neurology
Neurotransmitter
Please describe your symptoms:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
When did your symptoms first occur?________________________________________________________________________________________
What makes them better? Worse?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Please rate the severity of your symptoms on a scale of 1-10?
0
No Pain
1
2
3
4
5
6
7
8
9
10
Worst Possible Pain
Restorative Health Solutions | 7701 York Ave S, Suite 155| Edina, MN 55435 | Office Phone: 612-465-9250
www.restorativehealthsolutions.com | Email: [email protected]
Have you seen anyone else for this condition? No. Yes. If yes, who?
If yes, what was the diagnosis? ______________________________________________________________________________________
What was the treatment? ___________________________________________________________________________________________
Have you lost work days for this condition? No. Yes. If yes, how much?
Have you tried any self-treatments for this condition?
What do you think is causing your present
health problem(s)?
On the diagram to the right, please mark the
following symptoms, if you are experiencing
them:
“//” for stabbing pain,
“B” for burning pain,
“D” for dull pain,
“A” for aching pain,
“N” or in areas where you have numbness
“T” in areas where you have tingling,
“St” in areas where you feel stiffness,
“Sw” in areas where you’ve had swelling,
“C” in areas where you have cramps,
Females only:
Is there any possibility that you are currently pregnant? No. Yes.
What was the date of your last menstrual period?
.
Doctor’s Notes:
Doctor’s Initials:
Past Health History and Family History
Please list all operations or surgeries you may have had with dates:
Please list any hospitalizations you may have had with dates:
Please list any major illness you have had with dates:
Have you had any recent infections, colds, or flu? No. Yes:
Please list any and all traumas or injuries you’ve ever had, with dates, from the simple to the serious:
Have you ever been diagnosed with a tumor, cancer, neoplasia, or dysplasia? No. Yes:
Have you ever been diagnosed with diabetes? No. Yes:
Have you ever been diagnosed with a cardiac (heart) condition, a blood vessel condition (like arteriosclerosis, atherosclerosis, or vasculitis),
or hypertension (high blood pressure)? No. Yes:
Have you ever had a stroke or heart attack? No. Yes:
Does anyone in your biological family (parent, grandparent, sibling, or child) have a history of heart disease, stroke, cancer, diabetes,
thyroid conditions, or other autoimmune disorders?
No. Yes, explain:
Does anyone in your biological family have a history of psychiatric diseases like depression, anxiety, schizophrenia, etc? No. Yes,
explain:
Does anyone in your biological family have a history of neuropathies (nerve diseases) or myopathies (muscle diseases)? No. Yes,
explain:
Does anyone in your biological family have a history of cancer? No. Yes, explain:
Does anyone in your biological family have a history of back or neck pain? No. Yes, explain:
Does anyone in your biological family have a history of any other known conditions? No. Yes, explain:
Doctor’s Notes:
Doctor’s Initials:
Social History
Please indicate your familial status? Single. Married. Divorced. Widowed.
How many children do you have? None. 1. 2. 3. 4. Other:
.
What do you do for a living?
. How many hours a week?
Do you have a second job?
. How many hours a week?
Describe your work environment:
How long have you been at this job?
What other jobs have you had in the past?
Describe your home life:
What is your highest level of education?
. What are your hobbies?
Do you exercise? No. Yes, then what type and how often:
Do you use any tobacco products? No. Yes, then what kind, how often, & how long:
Have you used tobacco products in the past? No. Yes, then what, how long, & when did you quit?
Do you drink alcoholic beverages? No. Yes, then what kind and how many a week:
Have you had alcohol problems in the past? No. Yes, then how long ago & for how long:
Do you drink caffeinated beverages? No. Yes, then what kind and how many a day:
Do you drink sodas? No. Yes, then how many a day:
Do you use recreational drugs? No. Yes, then how long ago & for how long::
Have you used recreational drugs in the past? No. Yes, then what type, when, & for how long:
Do you have any special dietary restrictions? No. Yes, then what type:
Are you sexually active? No. Yes. If yes have you ever been diagnosed with an STD or VD:
When did you last see a chiropractor?
. What were those visits for & how were the outcomes?
Why have you changed chiropractors?
Which diets have you done and how has each worked for you (Atkins, GAPS, gluten free, dairy free, Weight Watchers, etc.)?
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Doctor’s Notes:
Doctor’s Initials:
List all current medications, supplements, and dosages. Tell what you are taking each one for and if it is
working well for you or not.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
x.
y.
z.
2. List past medications, supplements you have taken and if they worked well for you or did not work for
you.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Doctor’s Notes:
Doctor’s Initials:
Health Goals
3. Do you think your condition can be cured or improved?
a.
4. What are you looking for in a health care practitioner?
a.
5. What do you feel is a reasonable amount of time to see changes with Dr. Warren and Dr. Paul?
a.
6. Is family/spouse supportive of you seeking care with Dr. Warren and Dr. Paul
a.
7. How has this condition negatively impacted your life?
a.
8. If you get better how will your life change?
a.
9. In order to improve your health, are you willing to significantly modify your diet?
a.
10. In order to improve your health, are you willing to significantly modify your lifestyle?
a.
11. In order to improve your health, are you willing to take several nutritional supplements each day?
a.
Doctor’s Notes:
Doctor’s Initials:
Review of Systems & Medical History:
1.
2.
3.
Are you currently experiencing any of the following symptoms, now or recently?
Chest pain
Jaw pain
Left arm pain
Shortness of breath
Excessive sweating without exertion
Pale skin or pallor
Blackouts
Swelling in your left arm
Lightheadedness
Please check off any of the below symptoms that you are be experiencing, now or recently?
Nausea
Vomiting
Difficulty with speaking
Dizziness or vertigo
Difficulty with swallowing
Disequilibrium or feeling unsteady
Double vision
Feeling like your are going to fall
Abnormal eye movements
Numbness
Abnormal sweating
Severe headache
Have you noticed any of the following?
Change in appetite
Unexplained weight loss
.
Unexplained weight gain
Recent fever
Recent fatigue
Please mark any of the below conditions that apply to you, past or present.
Condition
Condition
Condition
Condition
Swollen or painful
joints
Neck pain or stiffness
Upper back pain or
stiffness
Mid back pain or
stiffness
Low back pain or
stiffness
Hip or pelvis pain
Foot or ankle pain
Leg pain
Knee pain
Shoulder pain
Elbow pain
Arm pain
Hand or wrist pain
Jaw pain or click (TMJ)
Chronic headaches
Sprain or strain
Trouble with prolonged
sitting or standing
Trouble with walking
Trouble with bending,
twisting, or lifting
Osteoporosis
Dislocated bones
Fractured bones
Bone infection
(osteomyelitis)
Herniated disc
Lumbago or lumbalgia
Scoliosis or other spinal
curvature
Difficulty walking
Osteoarthritis or DJD
Rheumatoid arthritis
Other arthritis
Gout
Ankylosing spondylitis
Auto accidents
Sports injuries
Machine accident
Accidental fall
Psychological issues
Nervousness
Depression
Irritability
Prostate problems
Erectile dysfunction
Premature ejaculation
Problems with sexual
libido or desire
Discharge from urethra
Gonorrhea
Bleeding disorder
Anemia
Allergies
The flu, how long ago
__________________
Anxiety
Feelings of
hopelessness
Phobias
HPV / genital warts
PMS problems
Menstrual problems
Breast discharge
Vaginal discharge
Breast lumps / soreness
Menopause
Vascular disease
Varicose veins
Autoimmune disease
A cold, how long ago
__________________
Panic attacks
Mood changes
PTSD
OCD
Syphilis
Kidney problems or
disease
Kidney stones
Difficulty urinating
Feelings of urgency to
urinate
Leg pain with walking
Blood clots / phlebitis
Frequent colds or flues
Alcoholism
Cancer
Work or social stress
Anger easy
Feelings of suicide
Eating disorders
Infrequent urination
Blood in urine
Frequent urination
Painful urination
Awaken to urinate
Bladder infections
Other STD / VD
Venous insufficiency
Bruise easily
HIV / AIDS
Other:
Doctor’s Notes:
Doctor’s Initials:
Condition
Migraines
Cluster headaches
Costen’s syndrome
Balance problems
Mental or emotional
disorder
Convulsions or epilepsy
Difficulty speaking
Difficulty swallowing
Losing time or blacking
out
Changes in skin
sensation
Muscle problems
Learning disability
Conduct disorder
Glaucoma
Dizziness
Motion sickness
Ear infections
Tinnitus
Sore throat
Pain in legs with
movement or activity
Heart palpations
(hearing racing heart)
Swelling in legs or feet
Congestive heart failure
Difficulty breathing
Chronic/frequent cough
COPD
Coughing up blood
Difficulty losing weight
Colon problems
Gall bladder trouble
Liver disease
Stomach/duodenal ulcer
Abdominal pain
Indigestion
Cirrhosis
Bloating
Craving sweets
Craving excessive salts
Pituitary disorder
Cold all the time
Dry skin
Change in hat size
Unexplained skin rash
Change in skin mole
Seborrhea
Acne
Condition
Trigeminal neuralgia or
Tic Doloreaux
Hypertension headache
Seizures
Neurological disease
Trouble concentrating
Difficulty swallowing
Trouble understanding
others
Stroke or CVA
Paralysis
Muscle weakness
Twitching muscles
Lost muscle tone
ADD or ADHD
Behavioral disorder
Macular degeneration
Vertigo
Unexplained giddiness
Ringing in ears
Sinus problems
Mouth sores
Heart attack
(myocardial infarct)
Irregular heart beats
Experience passing out
Skipped heart beats
Congenital heart disease
Shortness of breath
with activity
Short of breath at rest
Painful breathing
Hemorrhoids
Difficulty with control
of bowel movements
Nausea &/or vomiting
Digestive problems
Constipation
Diarrhea
Polyps
Diverticulitis
Hormonal issues
Thyroid disorder
Adrenal disorder
Hot all the time
Trouble with sleep
Change in glove size
Itching
Change in nails
Eczema
Dermatitis
Condition
Tension headaches
Pain in your face
Temporal arteritis
Trouble sleeping
Difficulty with focus
Loss of memory
Fainting spells
Tire easily
Mini-stroke or TIA
Blurred vision
Double vision
Muscle cramping
Tremors (shaking)
Abnormal movements
Dyslexia
Asperger’s syndrome
Cataracts
Unsteadiness
Difficult with balance
Earaches
Nose bleeds
Bleeding gums
Arrhythmia
Heart murmur
Atherosclerosis /
arteriosclerosis
Dizzy or light-headed
with exercise
Wheezing
Asthma
Coughing up mucus
Pneumothorax
Difficulty swallowing
Gall bladder stones
Intestinal issues
Heartburn
Gastric ulcers
Excessive belching
Digestive issues
Celiac Disease (Sprue)
Irritable bowel syndrm.
Night sweats
Decreased energy
Frequent urination
Hair loss
Increased sex drive
Under a lot of stress
Change in hair pattern
Bruise easy
Psoriasis
Skin cancer
Condition
Sinus headaches
Cervicogenic headaches
Other type of headache
Recent incoordination
Head seems heavy/tired
Head or arms feel tired
Loss of consciousness
Concussions
Head injury
Persistent headache
Spontaneous movement
Weak muscles of face
Numbness or tingling
Excessive sweating
Autism (PDD or ASD)
Bedwetting
Retinopathy
Pain with coughing or
sneezing
Hearing loss
Difficulty swallowing
Hoarseness
High cholesterol
High blood pressure
(hypertension)
Scarlet fever
Rheumatic fever
Other heart disease
Emphysema
Bronchitis
Snoring
Other lung problems
Hepatitis
More than 3 bowel
movements a day
Less than 1 bowel
movement a day
Excessive gas
Blood in stool
Ulcerative colitis
Crohn’s disease
Diabetes
Hyperthyroidism
Hypothyroidism
Excessive thirst
Decreased sex drive
Change in skin color
Shingles
Herpes
Warts
Other skin disorder
Doctor’s Notes:
Doctor’s Initials:
Metabolic Assessment Formtm
Name:
___________________________________________ Age: ______ Sex: _____
Date: ____________________
PART I
Please list your 5 major health concerns in order of importance:
1. ____________________________________________ 4. ___________________________________________
2. ____________________________________________ 5. ___________________________________________
3. ____________________________________________
PART II
Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
Category I Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
Category II
0 1 2 3
Increasing frequency of food reactions
0 1 2 3
Unpredictable food reactions
0 1 2 3
Aches, pains, and swelling throughout the body
0 1 2 3
Unpredictable abdominal swelling
0 1 2 3
Frequent bloating and distention after eating
0 1 2 3
Abdominal intolerance to sugars and starches
Category III 0 1 2 3
Intolerance to smells
0 1 2 3
Intolerance to jewelry
0 1 2 3
Intolerance to shampoo, lotion, detergents, etc
0 1 2 3
Multiple smell and chemical sensitivities
0 1 2 3
Constant skin outbreaks
Category IV
0 1 2 3
Excessive belching, burping, or bloating
0 1 2 3
Gas immediately following a meal
0 1 2 3
Offensive breath
0 1 2 3
Difficult bowel movements
0 1 2 3
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables;
0 1 2 3
undigested food found in stools
Category V
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or
carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus,
peppers, alcohol, and caffeine
Category VI
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucus like,
greasy, or poorly formed
Frequent urination
Increased thirst and appetite
© 2014 Datis Kharrazian. All Rights Reserved.
SMGEMAF04(121614)Version 2
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
1
1
2
2
3
3
0
1
2
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
Category VII
Abdominal distention after consumption of
fiber, starches, and sugar
Abdominal distention after certain probiotic
or natural supplements
Lowered gastrointestinal motility, constipation
Raised gastrointestinal motility, diarrhea
Alternating constipation and diarrhea
Suspicion of nutritional malabsorption
Frequent use of antacid medication
Have you been diagnosed with Celiac Disease,
Irritable Bowel Syndrome, Diverticulosis/
Diverticulitis, or Leaky Gut Syndrome?
Category VIII
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours
after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to
normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
0
1
2
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Yes
No
0
1
2
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
1
1
1
1
Yes
Category IX
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category X Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Category XI
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
2 3
2 3
2 3
2 3
No
Category XII
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
Category XIII
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little
or no activity
Category XIV
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing
Category XV
Tired/sluggish
Feel cold―hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive
hair loss
Dryness of skin and/or scalp
Mental sluggishness
Category XVI
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
1
2
3
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XVI (Cont.)
Night sweats
Difficulty gaining weight
0
0
1
1
2
2
3
3
Category XVII (Males Only)
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XVIII (Males Only)
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
Category XIX (Menstruating Females Only)
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning
0
0
0
0
0
0
0
0
0
Yes
Yes
Yes
Yes
1
1
1
1
1
1
1
1
1
Category XX (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching
_______ years
Yes No
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PART III
How many alcoholic beverages do you consume per week?
Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day?
How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out 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:
List the three healthiest foods you eat during the average week:
PART IV
Please list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
© 2014 Datis Kharrazian. All Rights Reserved.
SMGEMAF04(121614)Version 2
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Neurotransmitter Assessment Form™ (NTAF)
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 A
• Is your memory noticeably declining?
• Are you having a hard time remembering names
and phone numbers?
• Is your ability to focus noticeably declining?
• Has it become harder for you to learn new things?
• How often do you have a hard time remembering
your appointments?
• Is your temperament generally getting worse?
• Is your attention span decreasing?
• How often do you find yourself down or sad?
• How often do you become fatigued when driving
compared to in the past?
• How often do you become fatigued when reading
compared to in the past?
• How often do you walk into rooms and forget why?
• How often do you pick up your cell phone and forget why?
section b
• How high is your stress level?
• How often do you feel you have something that
must be done?
• Do you feel you never have time for yourself?
• How often do you feel you are not getting enough
sleep or rest?
• Do you find it difficult to get regular exercise?
• Do you feel uncared for by the people in your life?
• Do you feel you are not accomplishing your
life’s purpose?
• Is sharing your problems with someone difficult for you?
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section C
section C1
• How often do you get irritable, shaky, or have
light-headedness between meals?
• How often do you feel energized after eating?
• How often do you have difficulty eating large
meals in the morning?
• How often does your energy level drop in the afternoon?
• How often do you crave sugar and sweets in the afternoon?
• How often do you wake up in the middle of the night?
• How often do you have difficulty concentrating
before eating?
• How often do you depend on coffee to keep yourself going?
• How often do you feel agitated, easily upset, and nervous
between meals?
section C2
• How often do you get fatigued after meals?
• How often do you crave sugar and sweets after meals?
• How often do you feel you need stimulants, such as
coffee, after meals?
• How often do you have difficulty losing weight?
• How much larger is your waist girth compared to
your hip girth?
• How often do you urinate?
• Have your thirst and appetite increased?
• How often do you gain weight when under stress?
• How often do you have difficulty falling asleep?
section 1
•
•
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•
•
Are you losing interest in hobbies?
How often do you feel overwhelmed?
How often do you have feelings of inner rage?
How often do you have feelings of paranoia?
How often do you feel sad or down for no reason?
How often do you feel like you are not enjoying life?
© 2013, Datis Kharrazian. All Rights Reserved.
SMGENTAF04(031513)
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• How often do you feel you lack artistic appreciation?
• How often do you feel depressed in overcast weather?
• How much are you losing your enthusiasm for your
favorite activities?
• How much are you losing your enjoyment for
your favorite foods?
• How much are you losing your enjoyment of
friendships and relationships?
• How often do you have difficulty falling into
deep, restful sleep?
• How often do you have feelings of dependency
on others?
• How often do you feel more susceptible to pain?
• How often do you have feelings of unprovoked anger?
• How much are you losing interest in life?
section 2
• How often do you have feelings of hopelessness?
• How often do you have self-destructive thoughts?
• How often do you have an inability to handle stress?
• How often do you have anger and aggression while
under stress?
• How often do you feel you are not rested, even after
long hours of sleep?
• How often do you prefer to isolate yourself from others?
• How often do you have unexplained lack of concern for
family and friends?
• How easily are you distracted from your tasks?
• How often do you have an inability to finish tasks?
• How often do you feel the need to consume caffeine to
stay alert?
• How often do you feel your libido has been decreased?
• How often do you lose your temper for minor reasons?
• How often do you have feelings of worthlessness?
section 3
• How often do you feel anxious or panicked for no reason?
• How often do you have feelings of dread or
impending doom?
• How often do you feel knots in your stomach?
• How often do you have feelings of being overwhelmed
for no reason?
• How often do you have feelings of guilt about
everyday decisions?
• How often does your mind feel restless?
• How difficult is it to turn your mind off when you
want to relax?
• How often do you have disorganized attention?
• How often do you worry about things you were
not worried about before?
• How often do you have feelings of inner tension and
inner excitability?
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section 4
• Do you feel your visual memory (shapes & images)
has decreased?
• Do you feel your verbal memory has decreased?
• Do you have memory lapses?
• Has your creativity decreased?
• Has your comprehension diminished?
• Do you have difficulty calculating numbers?
• Do you have difficulty recognizing objects & faces?
• Do you feel like your opinion about yourself
has changed?
• Are you experiencing excessive urination?
• Are you experiencing a slower mental response?
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
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Medication History*
Please check any of the following medications you have taken in the past or are currently taking.
Noradrenergic and Specific Serotonergic
Antidepressants (NaSSAs)
 Remeron®
 Zispin®
 Avanza®
 Norset®
 Remergil®
 Axit®
Tricyclic Antidepressants (TCAs)
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Elavil®
Endep®
Tryptanol®
Trepiline®
Asendin®
Asendis®
Defanyl®
Demolox®
Moxadil®
Anafranil®
Norpramin®
Pertofrane®
Thadentm
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Prothiaden®
Adapin®
Sinequan®
Tofranil®
Janamine®
Gamanil®
Aventyl®
Pamelor®
Opipramol®
Vivactil®
Rhotrimine®
Surmontil®
Norpramin®
Monoamine Oxidase Inhibitors (MAOIs)

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
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
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Marplan®
Aurorix®
Manerix®
Moclodura®
Nardil®
Adeline®
Eldepryl®
Azilect®

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Marsilid®
Iprozid®
Ipronid®
Rivivol®
Propilniazida®
Zyvox®
Zyvoxid®
Dopamine Receptor Agonists
 Mirapex®
 Sifrol®
 Requip®
Norepinephrine–Dopamine
Reuptake Inhibitors (NDRIs)
Paxil®
Zoloft®
Prozac®
Celexa®
Lexapro®
Esertia®
Luvox®
Cipramil®
Emocal®
Seropram®
Cipralex®
Fontex®
Priligy®
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Serotonin-Norepinephrine
Reuptake Inhibitors (SNRIs)
 Effexor®
 Pristiq®
 Meridia®
 Serzone®
 Dalcipran®
 Cymbalta®
Selective Serotonin
Reuptake Enhancers (SSREs)
 Stablon®
 Coaxil®
Thorazine®
Prolixin®
Trilafon®
Compazine®
Mellaril®
Stelazine®
Vesprin®
Nozinan®
Depixol®
Navane®
Fluanxol®
Clopixol®
Acetylcholine Receptor Agonists
 Urecholine®
 Evoxac®  Salagen®
 AtroPen®  Scopace® Isopto®
 Nicotone
 Atrovent®
 Spiriva®
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Acuphase®
Haldol®
Orap®
Clozaril®
Zyprexa®
Zydis®
Seroquel XR®
Geodon®
Solian®
Invega®
Abilify®
 Inversine®  Hexamethonium
 Nicotine (high doses)  Arfonad®
Acetylcholine Receptor Antagonists
(neuromuscular blockers)

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Tracrium®
Nimbex®
Nuromax®
Metubine®
Mivacron®
Pavulon®
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Zemuron®
Anectine®
Tubocurarine®
Norcuron®
Hemicholinium-3®
Acetylcholinesterase Reactivators
 Protopam®
GABA Antagonist Competitive Binder
Cholinesterase Inhibitors (reversible)
 Romazicon®
Agonist Modulators of GABA Receptors
(benzodiazepines)
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Xanax®
Lexotanil®
Lexotan®
Librium®
Klonopin®
Valium®
 Prosom®
 Rohypnol®
 Magadon®
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Dalmane®
Ativan®
Loramet®
Sedoxil®
Dormicum®
Serax®
 Restoril®
 Halcion®
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Aricept®
 Enlon®
Razadyne®
 Prostigmin®
Exelon®
 Antilirium®
Cognex®
 Mestinon®
THC
Carbamate insecticides
Cholinesterase Inhibitors (irreversible)

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 Tatinol®
© 2013, Datis Kharrazian. All Rights Reserved.
SMGENTAF04(031513)
Ambien CR®
Sonata®
Lunesta®
Imovane®
Acetylcholine Receptor Antagonists
(ganglionic blockers)
 Wellbutrin XL®
D2 Dopamine Receptor Blockers
(antipsychotics)
Seromex®
Seronil®
Sarafem®
Fluctin®
Faverin®
Seroxat®
Aropax®
Deroxat®
Rexetin®
Paroxat®
Lustral®
Serlain®

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Acetylcholine Receptor Antagonists
(antimuscarinic agents)
Selective Serotonin
Reuptake Inhibitors (SSRIs)

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Agonist Modulators of GABA Receptors
(non-benzodiazepines)
*Please refer to prescribing physician for nutritional interactions with any medications you are taking.
Echothiophate
Isoflurophate
Organophosphate insecticides
Organophosphate-containing nerve agents
Notice of HIPAA Privacy Practices
This notice describes how personal health information about you may be used and disclosed and how you can receive
access to this information. Please review it carefully.
This Notice of HIPAA Privacy Practices describes how we may use and disclose your protected health information to
carry out treatment, payment or health care operations, and for other purposes that are permitted or required by law.
It also describes your rights to access and control of your personal medical information. "Pro“ected health information”
includes demographic information and is information about you that may identify you and relates to your past, present,
or future physical or mental health or condition and related health care services.
We are required by law to:
• Make sure that medical information that identifies you is kept private;
• Give you this Notice of our legal duties and privacy practices with respect to medical information about you; and
• Follow the terms of the Notice that is currently in effect.
Who Will Follow This Notice: This notice applies to Restorative Health Solutions and all other health care and
service providers that provide services such as billing and marketing.
How we may use and disclose personal health information about you: Your protected health information may be used
and disclosed by your physician, our office staff and others outside of our office that are involved in your care and
treatment for the purpose of providing health care services to you, to pay your health care bills, to support the
operation of Restorative Health Solutions, and any other use required by law.
The follow categories describe different ways that we use and disclose personal health information. Not every use or
disclosure in each category will be listed.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. For example, we share medical information about you in order to coordinate different
needs like lab work and x-rays. Your protected health information may also be provided to another physician to whom
you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: We may use and disclose your medical information about you so that the treatment and services you receive
at Restorative Health Solutions may be billed to and payment may be collected from you, an insurance company or
third party.
Healthcare Operations: We may use and disclose your protected health information in order to support Restorative
Health Solutions’ business activities. We may disclose information to doctors, technicians, or interns for review and
learning purposes.
We may remove information that identifies you from this set of medical information so others may use it to study health
care and health care delivery without learning who the specific patients are.
We may use and disclose your medical information to tell you about health related benefits, services, or wellness classes
that may be of interest to you.
We may release medical information about you to individuals you designate as a care giver. We may also give
information to someone who helps pay for your care.
Under certain circumstances we may use and disclose medical information about you for research purposes.
We will disclose medical information about you when required to do so by federal, state, or local law.
We may disclose medical information about you for public health activities. We may use and disclose medical
information about you to agencies when necessary to prevent a serious threat to your health and safety or the health
and safety of the public or another person. These activities generally include the following:
•
•
•
To Prevent or control disease, injury, or disability;
To report child abuse or neglect;
To notify the appropriate government authority if we believe a patient has been the victim of abuse,
neglect, or domestic violence. We will only make this disclosure when required or authorized by law.
We may disclose medical information to a health agency for activities authorized by law. These oversight activities
include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the health care system, government programs, and compliance with other laws.
If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or
administrative order. We may also disclose medical information about you in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute.
We may release medical information about you if asked to do so by a law enforcement official in response to a court
order, subpoena, warrant, summons or similar process.
We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify
a deceased person or determine the cause of death.
Your Rights Regarding Medical Information About You:
You have the right to inspect and copy medical information that may be used to make decisions about your care. If you
feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information.
We may deny or accept your request.
Signature below is only acknowledgment that you have received this Notice of our HIPAA Privacy Practices.
Print Patient’s Name:
Print Your Name:
Relation to Patient:
Signature:
Date:
Informed Consent to Chiropractic Treatment and Care
Patient’s Name:
I request and consent to the performance and procedures which are within the scope of chiropractic including,
but not limited to, physical examination, chiropractic adjustments, various modes of physical therapy including
laser therapy and a TENS unit, nutritional therapy, and neurological therapy. These procedures may be
performed by the doctor stated above or any doctor legally representing Restorative Health Solutions PA.
I have had an opportunity to discuss with the doctor of chiropractic named above the nature and purpose
of chiropractic adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that there are some risks to chiropractic treatment, including, but not limited to,
fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and
explain all risks and complications, and I wish to rely on the doctor to exercise
judgment during the course of the procedure which the doctor feels at the time, based upon the facts then
known, is in my best interest.
I have read, or have read to me, the above consent. I have also had an opportunity to ask questions about its
content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the
entire course of treatment for my present condition and for future conditions(s) for which I seek treatment.
Signature of Patient or Patient’s Representative
Print Name of Patient’s Representative
Relationship or Authority of Representative
7701 York Ave S., Suite 155 |Edina, MN 55435 | www.restorativehealthsolutions.com
[email protected] | Phone: 763-316-4264| Fax: 952-303-3403