*It is extremely important that you list the pharmacy’s fax number
*It is extremely important that you list the pharmacy’s fax number.
*Note: If Discover is your primary card, please provide another card (i.e., MC or Visa) for transactions (i.e., supplement orders, etc.) that we may need to process. Some pharmacies do not accept Discover
If you had a magic wand and could help your child in three ways, what would they be?
Please list current and ongoing problems in order of priority:
Diseases/Diagnosis/Conditions (Check appropriate box and provide date of onset)
Check box if yes and provide date.
Please attach a copy of all Lab testing that have been performed.
List Family Members:
Resources for emotional support:
Menstrual History
Mother’s Past Pregnancies
Please indicate the approximate age in months for the following milestones: (example: walking 14 months):
Current Medications
Previous Medications: Last 10 years
Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy)
Check family members that apply
Please provide age if still alive
Please provide age if Deceased.
Check family members that apply:
Please list child’s reaction to immunization (Change in stools, crying, seizures, irritability, fever, rash, poor sleep etc.)
Age 0-2 Months
Age 2-4 Months
Age 4-6 Months
Age 6-9 Months
Age 9-12 Months
Age 12-15 Months
Age 15-18 Months
Age 18-24 Months
Other
List type and amount of activity daily(school, therapies, play etc.):
Please check appropriate box
Bedding: Synthetic, down, feather, cotton, organic
Type: Crib, Junior bed, Adult bed
Flooring(circle): Carpet wall to wall, Area rug, Wood, Glued down, Synthetic padding, carpet throughout house.
Is your child sensitive to any of the following?
Please check all current symptoms occurring or present in the past 6 months.
Rate on a scale of: 5 (very willing) to 1 (not willing)
In order to improve your child’s health, how willing is the patient in:
Rate on a scale of: 5 (very confident) to 1 (not confident at all)
Rate on a scale of: 5 (very supportive) to 1 (very unsupportive)
Rate on a scale of: 5 (very frequent contact) to 1 (very infrequent contact)
It is important to keep an accurate record of your child’s usual food and beverage intake as a part of the treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.
The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness and helps track your child’s progress over time. Rate each of the following symptoms based upon your child’s health profile for the past 30 days. If you are taking after the first time, record your child’s symptoms for the last 48 hours ONLY.
POINTSCALE 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe
2 = Occasionally have, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe
Key to Questionnaire: Add individual scores and total each group. Add each group scores and give a grand total. Optimal is less than 10 • Mild Toxicity: 10-50 • Moderate Toxicity: 50-100 • Severe Toxicity: over 100
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