Non-Patient Record Review - Beck Natural Medicine University

Slmptoms thalbother YouAllyear?Yes or NoWorsc outdoors?Yes or NoWhat elsemakes it worse?CommcntsNasal PollpsConstipationSweating SpellsHype ractivity/ADDInability to Think Cleartytoss of Sense of SmellHallucinationsInappropriateBeha'i,ior IIInabiliw to Ss'cat

List all doctors seen for your problems in the last 4 years. Add a separate sheet if neededDoctor'sNameYearExaminedSpecialty Tests Done MedicinesPrescribedDiagnosis orRecommendationsDid ItHelp?CommentsIal4568List your prirmry care physicianHas werlthing been done that can be to rule out correclable causes?What is missing?Have you been told there is nothing more that can be done?Have you been told you do not need tests that you think you do? Speci!.What have you and your insurance mmpany spent thus far?When were you last well?What moves, exposures, accidents,furnishings may have contributed?surgeries, dental work, infections, emotional stress, change ofjob, poor diet, antibiotics, newPlease give a history ofrvhen and how your symptoms began, and then how they progressed (feel free to add extra she€ts).Have you ever had tests to measure yotu (circle):Serum minerals RBC minerals traky gut Pesticides Fatty acids Mercury or other hea."ry metalsStool for Candida Detoxi-fication capability Other chemicals Other:

List sympLoms you knorv or suspcct (that are madc rvorse) from exposurc toLakesidcCountrysideAnimals. barn. havSpring, summer or fallDust or moldFoodsWork or schoolWood stove smokeCigarette smokePaintAir conditioningPollensLau,n morvingDampncssCold rveathcrHot rveatherWeather chansesPerfumeVCcsmeticsPolishes/CleansersFabric softenerDetergentsBeing overtiredCertain storesPlasticsCooking odorsSmokeFabricsChemicals (specify)FumesOdorsPaperNewsprintCertain buildingVMallsCleaning suppliesTraffuc exhaustParking garagesChristmas treesChalkWoolMenstrual preriodsOthcrsSymotomsCheck Applicable OneKno'rv SuspeclKnou, SuspectKnow SuspcctKnow SuspcctKnou' SuspcctKno'rv SuspectKnorv SuspcctKlorv SuspectKnorv SuspcctKnow SuspectKnorv SuspectKnorv SuspectKnorv SuspcctKnorv SuspeciKrorv SuspectKnorv SuspectKnorv SuspectKnow SuspectKnorv SuspectKnow SuspectKnow SuspectKnorv SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SusgrctKnow SuspectKnow SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnou, SuspectKnorv SuspectKnorv SuspcctKnorv _Knorr,_SuspcctSusp:c'-

When were you last well?Within two years of thc onset of your symptoms, drd you do any of the following.Change Jobs?Renovate your olTicc or home?Move to a new officc or home?Panel any rooms?Insulate any rooms?Carpet any rooms?Buy nerv furniture or bed?Install drop ceilings?Paint indoon?Sidc the housc?Change your heating system, stove- clothes drycr,or water heater?Used antibiotics?Used pesticide indoors or out?Have dental work done (fillings. root canals, etc)?Have emotional distrcss?YcsYesYesYesYesYesYcsYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoCheck OneNcve rNcvcrNcverNevcrNeve rNeverNeverNcvcrNeverNeve rNeverNcverNevcrNevcrNcvcrDo you have any gas utilities?Do you use alcohol?Do you use cigarettes?Do you drink coffee?Do you drink tea?Do you drink soft drinks?Do you pesticide your lawn or household plants?Do you wear numy dry+leaned clothes?Do you wear nnny polyester clothes?Do you we:tr many pennanent press clothes?Have you ever lived in a pesticided home?Have you ever lived in a urea foam formaldehydeinsulated (JIFI) home?Have you ever lived in a brand nerv home?Have you ever worked in a nerv office?YesYesYesYesYesYesYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNo-NoNoNeverNo,crNcverNeverNeverNeverNeverNeverNcverNeverNeverNeverNeverNeverlf your symptoms have been present all your life, rvhat lvorsens or provokes new symptoms?Give brand names (if able) for any of the following that you use:BlushFoundationLipstickMascaraHair conditionerShampooHairsprayAfter shavcDeodorantFabric softcnerSoapOthcr toiletrics

At any time in your life were you exposed to:Aerial spraying of pesticides?Strcet spraying or fogging ofpesticides?Pesticides at work?Pesticides in your home?YesYesYesYesCheck OneNoNoNo-NoYearsHow many antibiotic courses (average 5-10 days) have you had in your hfe?Any episodes rvhere you had antibiotrcs longer than a month or by intravenous route?flave you ever had worsening of symptoms after a root canal?Have you ever had a tooth extraction?How old were you for your first mercury filling?Horv many meals a week do you eat out of the house?Give 3 average (for you) brealdasts (include beverages for all meals and snacks below)l)2)3)Give 3 average (for you) mid-morning snacks:l)2)3)Give 3 average (for you) lunches:r)2)3)Give 3 average (for you) mid-afternoon snacls:l)2)3)Give 3 average (for you) dinners:l)2)-))Give 3 average (for you) bedtime snacls:r)2)3)What do you suspect is the cause of your qymptoms?Horv do your symptoms affect the rest of the family?When rvas your last complete medical examination? Plese include copy of itWhat rvas the conclusion - diagnosis?What rvas the rccommendation?What drugs rvere prescribcd rf any?

What books have you read regarding health?l0Which health newsletten do you read?What questions do you want to deal with?Do you have unresolved anger?What fears plague you the most?What ages drd you smoke?How often do you have alcohol?Have you ever used recreational drugs?What do you suspect is the major cause of your symptoms?