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: [email protected]
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!
© 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