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Y O U R K E Y T O L I F E L O N G H E A L T H A N D V I T A L I T Y
iMMunizatiOn
Did you have any of the following reactions? Please give approximate date if you don’t have specific. “Bowel” means any bowel symptom such as diarrhea, “Swelling” means Diphtheria-pertussis-tetanus
DPT 1
DPT 2
DPT 3
DPT 4
DPT 5
Adult Diphtheria-Tetanus
Pediatric Diphtheria- Tetanus
h influenza type B
Hib 1
Hib 2
Hib 3
Hib 4
Oral pOliO Vaccine
OPV 1
OPV 2
OPV 3
OPV 4
OPV 5
Polio Vaccine Injection
Polio Vaccine Injection 1
Polio Vaccine Injection 2
Polio Vaccine Injection 3
Polio Vaccine Injection 4
Polio Vaccine Injection 5
Measles-MuMps-ruBella
MMR 1 xxx
MMR 2
hepatitis-B Vaccine
HBV 1
HBV 2
HBV 3
HBV 4
MiscellaneOus
Varivax (Chicken Pox)
Tine Test
Other:
MeDicatiOn Or suppleMent
Please check all that apply.
suBstances affectinG
central nerVOus systeM
Clozaril (clozapine)
Haldol
Prolixin
Risperdal
Seroquel
Stelazine
Thorazine
Zyprexa
Antihistamine
Clonidine
Cogentin
Deanol (deaner, DMAE)
Dextromethorphan
Lithium
Naltrexone
St John’s wort
Anafranil
Depakene for behavior
Depakene for seizures
Depakote for behavior
Depakote for seizures
Dilantin
Felbatol
Gabitril
Keppra
Klonopin
Lamictal
Luvox
Mysoline
Neurontin
Paxil
Phenobarbital
Tegretol
Topamax
Trileptal
Valium
Zarontin
Zonegran
Adderal
Prozac
Zoloft
Amphetamine
MeDicatiOn Or suppleMent (cOntinueD)
suBstances affectinG
Cylert
Dexedrine, Dextroamphetamine
Fenfluramine
Focalin
Ritalin
Buspar
Chloral hydrate
Valium
Desipramine
Mellaril
Tofranil
antiBiOtics
Bactrim (Septra)
Biochoice
Bismuth
Colostrum
Diflucan
DiGestiVe flOra
Humatin
Lamisil
Yodoxin
Bethanecol
DIGESTION
Digestive enzymes
Pepsid
Peptidase Enzymes
Probiotics
DetOXificatiOn
DMPS
DMSA (succimer, Chemet)
Reduced glutathione (transderm)
Reduced glutathione IV
Reduced glutathione oral
B6 & Magnesium
Brain child supplements
Folic Acid
Melatonin
Multivitamin high potency
Multivitamin regular potency
MeDicatiOn Or suppleMent (cOntinueD)
suBstances affectinG
nutritiOn anD MetaBOlisM
Super Nu Thera
Ultra Clear Sustain
Vitamin B3 (Niacin)
Vitamin B6
5 HPT
Alpha Keto Glutarate
Amino Acid Mix
Deanol
Dimethylglycine (DMG)
DMG
Glutamine
SAMe (SAM, Samyr)
TMG
Tryptophan
Tyrosine
Calcium
Magnesium
Manganese
Selenium
Zinc
Human Growth Factor
IV Immune Globulin
Kutapressin
Oral Immune globulin
Secretin IV
Secretin transdermal
Steroids
TTFD
DHA rich oils
EPA rich oils
Omega 6 rich oils
Omega brite
Cod liver oil
Flax Oil
Alka Gold
Carbatrol
Tranxene
Famvir
Valtrex
Zovirax
Actos
syMptOM scOre sheet
For monitoring progress: Record the main problems in the Symptom column. Enter the date and rank
according to ratings below. Put a “P” for problems that were present only in the past. Put an “L” to mark lab tests of importance. I will paste these symptoms, and a distil ation of the x’d in the laboratory data questionnaire on next page, into the record we will use to track progress. Rank = (0= Absent, 3= mild, 6= Moderate, 9=severe, 12= incapacitating.) past /lab
laBOratOry Data
eValuatiOn/test
24 hour urine amino acidsAmino acid screenBlood chemistry screenBlood countBlood test for fatty acidsBlood test for food allergiesCAT scanColonoscopyDMSA loading studyEEGFolic acidFragile X chromosome studyHair elementsImmune profileIntestinal permeabilityLiver Detoxification profileMRIOrganic acids quantitative – fungal/bacterial metabolitesOrganic acids quantitative – metabolismOrganic acids screenPET scanPinworm prepPlasma amino acidsPlasma or serum zincRBC elementsSerum Ferritin (iron stores)Serum methylmalonic acidSerum Vitamin ASmall bowel biopsyStool cultureStool parasitesThyroid ProfileUric acid test (blood or urine)Urinary PeptidesUrine elementsUrine Kryptopyrrole past anD present prOfessiOnals
Who made the initial diagnosis of autism/other disorder? _____________________________________________ When? ______________________

Source: https://www.vitaminportfolio.com/Content/resources/New%20Pediatric%20Patient%20Addendum.pdf

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Bankart Repair Post-Op Instructions Missouri Orthopaedic Institute Bankart Repair Post-Operative Instructions Seth L. Sherman, M.D. Tamara L Young, ATC, OTC, M.Ed Department of Sports Medicine Ø Anesthetic drugs used during surgery may cause nausea for the first 24 hours. If nausea is encountered, drink only clear liquids and light food (jello, soups, dry crackers, toast).

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CHAPTER 12 NUISANCES (a) MISCELLANEOUS PROVISIONS (b) ABATEMENT PROCEDURES (c) SPECIAL PROVISIONS RELATING TO JUNK (d) VIOLATIONS Nebraska Statutes For statutory provisions authorizing cities to declare and abate nuisances, see R.R.S. §§ 16-230, 18-1720. (a) GENERAL PROVISIONS 12-1-1. Definitions. As used in this chapter, the following terms shall have the followi

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