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Microsoft word - confidential hormone evaluation.doc

d ess:________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Alle Please describe the allergic reaction you experienced and when it occurred? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Ove Please check all products that you use occasionally or regularly. Check all that apply. Combination product (cough+cold reliever)(e.g.: Triaminic DM®) Sleep aids (e.g.: Excedrin PC®, Unisom®, Sominex®, Nytol®) Antidiarrheals (e.g.:Imodium®, Pepto Bismol®, Kaopectate®) Laxatives/stool softeners (e.g.: Doxidan®, Correctol®, etc.) Diet aids/weight loss products (e.g.: Dexatril®) Cough suppressant (e.g.: Robitussin DM®) Acid blockers (e.g.: Tagamet HB®, Pepcid C®, Zantac 75®) Antihistamine product (e.g: Chlor-Trimeton®) Other (please list)___________________________________ ______ Decongestant product (e.g: Sudafed ®) ______________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 t : Please identify and list the products you are using: vitamins (e.g.: multiple or single vitamins such as B complex, E, C, beta carotene) minerals (e.g: calcium, magnesium, chromium, colloidal minerals, various single minerals) herbs (e.g: Ginseng, Ginkgo Biloba, Echinacea, other herbal medicinal teas, tinctures, remedies, etc.) enzymes (e.g: digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) nutrition/protein supplements (e.g: shark cartilage, protein powers, amino acids, fish oils, etc.) others (glucosamine, etc.) None a es: Please check all that apply to you. Heart disease (e.g.: Congestive Heart Failure) High cholesterol or lipids (e.g.: Hyperlipidemia) High blood pressure (e.g.: Hypertension) Lung condition (e.g.: asthma, emphysema, COPD) Other: Please list: _______________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Li ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Bone Size: Have you ever used oral contraceptives? No Yes Any problems? No Yes If YES, describe any problem(s). ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 - Family member(s) ___________________________________ - Family member(s) ___________________________________ Fibrocystic breast - Family member(s) ___________________________________ Breast Cancer - Family member(s) ___________________________________ - Family member(s) ___________________________________ - Family member(s) ___________________________________ - Family member(s) ___________________________________ Since you first began having periods, have you ever had what YOU would consider to be abnormal cycles? If YES, please explain (such as age when this occurred, symptoms….) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ When was your last period? _______________________________________________ How many days did it last? _______________________________________________ Do you have, or did you ever have Premenstrual Syndrome (PMS)? No Yes If YES, explain symptoms and rate severity: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Ple ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Ple ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809 25 Cabot Street Beverly, MA 01915 978-524-4800 fx 978-524-4809

Source: http://custommedicine.com/CONFIDENTIAL%20HORMONE%20EVALUATION.pdf

Microsoft word - ford, wayne adam.doc

Information researched and summarized by Shanna Woodson, Whitnee Young, & Christina Nolin Life Event 12/03/1961 Fell off step and hit his head; bled a lot Youth Not close to parents, got in trouble with the law Moved in with father, Calvin Eugene “Gene” Ford (went back and forth Stayed with family friend after having troubles at home Father remarried, greatly upsetting

Wr report 2/00 (eng)

alcohol. The disulfiram reaction manifestsnutritional status. Some modification in itself by headaches, nausea, vomiting, chestinteractions could increase or decrease drugaction and/or contribute to dietary deficienciesassociations will minimize or avoid such is of particular importance in the managementof patients receiving medications. The chronicuse of drugs requires close monitoring of

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