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Wellness Consultation Policies
Cancellation Policy: There is a $50 charge for cancellations of less than 24 hours or failure to show up for a scheduled appointment.
Email Policy: Email may be used for answering brief clarifying questions at your practitioner's discretion. If you are emailing about a
new or more detailed concern, you will be asked to schedule a phone or office consultation to ensure effective communication and
comprehensive care.
Costs of any laboratory tests are paid directly to the lab and do not include the fee for follow-up consultation to discuss the results.
Consultation Fees:
Practitioner 90 minutes 60 minutes 30 minutes 15 minutes
PharmD, DC, or ND $195 $145 $85 $30
Classical Homeopath, CCN, L.Ac., MS, RD, or RN N/A $110 $75 N/A
ACN, Ayurvedic, Certified Herbalist, NA, or LMT N/A $85 $55 N/A
Chiropractic Adjustment $40 per visit
HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment,
payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to
access and control your protected health information. “Protected health information” is information about you, including demographic
information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health
care services.
1. Uses and Disclosure of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are
involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the
operation of the physician’s practice and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related
services. This includes the coordination of management of your health care with a third party. For example, we would disclose your
protected health information, as necessary, to a home health agency that provides to you. For example, your protected health information
may be provided to a physician to whom you have been referred to ensure that physician has the necessary information to diagnose or
treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example,
obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health care plan to
obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of
your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training
of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected
health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration
desk where you will be asked to sign your name and indicated your physician. We may also call you by name in the waiting room when
your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you
of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include:
as Required By Law; Public Health Issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug
Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors; and Organ Donation; Research; Criminal
Activity; Military Activity and National Security; Workers’ Compensation; Inmates; Required Uses and Disclosures; Under the law, we must
make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine
our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless
required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an
action in reliance on the use or disclosure indicated in the authorization.
Your Rights: Following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the
following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part
of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part
of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want
the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use
and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to
use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have
the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e.
electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you
have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a
copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve
the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as
provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You
may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with
respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in
person or by phone at our Main Phone Number.
Privacy Notice Acknowledgement Form
The Federal Health Insurance and Portability and Accountability Act (HIPAA) regulates how health care providers may use and disclose
health information, and also requires that patients be notified of the provider’s privacy practices.
I, ___________________________ (Printed Name of Patient or Patient’s Representative ), acknowledge receipt of the “Privacy Notice
Acknowledgement Form” and “Wellness Consultation Policies”.
__________________________________________ ___________________Signature (Patient or Patient’s Representative) Date
Wellness Consultation Consent Form
I hereby understand, agree, and attest to the following:
1. I fully understand that the Wellness Consultant I am seeing in this office is not a physician, and I am not consulting for medical,
diagnostic, or treatment procedures. The appointments do not involve the diagnosing, prognosticating, treating or prescribing
of medicines or the treatment of disease, or any act which will constitute the practice of medicine in this state, for which a
license is required.
2. Since the Wellness Consultant is not a medical doctor or primary care physician, it is recommended that I continue services with
my primary care physician.
3. The services offered by the Wellness Consultant are at all times restricted to helping me gain a better understanding of ‘health’
(not disease), so that I will have greater self-awareness and be able to use a self-care plan for daily living.
4. The wellness plan offered (which may include discussion and or sale of nutritional supplements, nutrition and lifestyle
modifications, homeopathic remedies, vitamins, minerals, food grade herbs, and other dietary supplements) pertains to the
whole body concept of nutrition rather than addressing a specific ailment or condition.
5. The Wellness Consultant does not provide emergency or after-hours care. In the event of an emergency, I will dial 911 or
proceed to the nearest emergency room.
6. Laboratory testing may be conducted for screening purposes only and does not constitute a diagnosis of any medical condition.
It is my responsibility to follow up with a medical doctor if any of the lab results are abnormal.
7. Women who are pregnant or planning pregnancy must inform their Wellness Consultant, as this will likely alter the
recommendations that are made.
8. Since they are not prescribing physicians, the Wellness Consultants will not be able to advise me to discontinue or change doses
of my medications. I am advised to consult with my prescribing physician concerning any modifications of my pharmaceutical
medications.
9. Potential benefits of following a wellness plan include health optimization, symptomatic relief, and disease prevention. Potential
risks include rare allergic reactions, paradoxical reactions to supplements (example: valerian is a relaxing herb for most people,
but it is stimulating in some people), and drug-supplement interactions. Although there is a growing body of information
regarding such interactions, I understand that not all drug-supplement interactions are known at this time.
10. There are wide individual differences in response to a wellness plan, and no guarantees are made that I will gain any benefit nor
suffer any adverse consequences.
11. While I may experience immediate benefits from the wellness plan, I understand that the most effective results will occur when I
make a long-term commitment to rebuild my health, which will likely involve some lifestyle modifications.
___________________________________________________ _________________________________________________
Signature of Client or Client’s Representative: Printed Name of Client or Client’s Representative:
Phone Number:(__________)_________-_______________ Date: ____________________________
Referred By: _______________________________________
Janet R. Perry, MA
Wellness [email protected]
512.585.1320
As a wellness consultant I am able to provide you with information that may assist you in
making health care decisions. This information is provided for purposes of education only.
I am not a medical doctor and do not diagnose or treat medical conditions. You are advised to
seek the opinion of your health care provider in regard to any information we may discuss.
Name_______________________________________________________________________
Address_____________________________________________________________________
City, State & Zip_______________________________________________________________
Home Phone_________________________Cell Phone________________________________
Email_______________________________________________________________________
DOB___________________ Age______ Sex________ Height__________ Weight__________
Partner's Name________________________________________________________________
Employer__________________________________Occupation_________________________
Primary Care Physician_____________________________ Phone_______________________
Physician Address_____________________________________________________________
City, State & Zip_______________________________________________________________
Emergency Contact Name & Phone________________________________________________
Signature____________________________________________Date_____________________
SYMPTOM SURVEY FORM
Patient Doctor Date
INSTRUCTIONS: Fill in only the circles which apply to you. Leave blank if you don't have the problem. * Fill in the circle marked 1 for MILD symptoms (occur once or twice a year). * Fill in the circle marked 2 for MODERATE symptoms (occur several times a month). * Fill in the circle marked 3 for SEVERE symptoms (you are aware of it almost constantly).
Leave circles BLANK if they don't apply to you!
GROUP ONE
1 Acid foods upset 8 Gag easily 15 Appetite reduced
2 Get chilled often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meal
6 Keyed up - fail to calm
7 Cut heals slowly
9 Unable to relax; startles easily
10 Extremities cold, clammy
11 Strong light irritates
12 Urine amount reduced
13 Heart pounds after retiring
14 "Nervous" stomach
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach often
GROUP TWO
21 Joint stiffness on arising 29 Digestion rapid 37 "Slow starter"
22 Muscle-leg-toe cramps at night
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen, puffy
27 Indigestion soon after meals
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
38 Get "chilled" infrequently
39 Perspire easily
40 Circulation poor, sensitive to
cold
41 Subject to colds, asthma,
bronchitis
28 Always seems hungry; feels
"lightheaded" often
36 Constipation, diarrhea
alternating
GROUP THREE
Eat when nervous 49 Heart palpitates if meals missed
or delayed
53 Crave candy or coffee in
afternoons Excessive appetite
Hungry between meals
Irritable before meals
Get "shaky" if hungry
Fatigue, eating relieves
"Lightheaded" if meals delayed
50 Afternoon headaches
51 Overeating sweets upsets
52 Awaken after few hours sleep -
hard to get back to sleep
54 Moods of depression - "blues"
or melancholy
55 Abnormal craving for sweets
or snacks
42
43
44
45
46
47
48
GROUP FOUR
56 Hands and feet go to sleep
easily, numbness
63 Get "drowsy" often 68 Bruise easily, "black and blue"
spots
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 High altitude discomfort
60 Opens windows in closed
rooms
61 Susceptible to colds and fevers
62 Afternoon "yawner"
64 Swollen ankles, worse at night
65 Muscle cramps, worse during
exercise; get "charley horses"
66 Shortness of breath on exertion
67 Dull pain in chest or radiating
into left arm, worse on exertion
69 Tendency to anemia
70 "Nose bleeds" frequent
71 Noises in head, or "ringing in
ears"
72 Tension under the breastbone,
or feeling of "tightness", worse
on exertion
1 2 3 1 2 3 3 2 1
1 2 3 1 2 3 1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
Vegetarian: Yes No
!!Birth Date / / Approx Weight
!SYMPTOM SURVEY FORM - PAGE 2
GROUP FIVE
73 Dizziness 83 Feeling queasy; headache
over
eyes
91 Sneezing attacks
74 Dry skin
75 Burning feet
76 Blurred vision
84 Greasy foods upset
85 Stools light colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to
watery
92 Dreaming, nightmare type bad
dreams
93 Bad breath (halitosis)
94 Milk products cause distress
95 Sensitive to hot weather
96 Burning or itching anus
GROUP SIX
98 Loss of taste for meat 101 Coated tongue 104 Mucous colitis or "irritable
bowel" 99 Lower bowel gas several hours
after eating
100 Burning stomach sensations,
eating relieves
102 Pass large amounts of
foul-smelling gas
103 Indigestion 1/2 - 1 hour after
eating; may be up to 3-4 hrs.
105 Gas shortly after eating
106 Stomach "bloating" after
eating
GROUP SEVEN
Insomnia
137 Failing memory
150 Dizziness
Nervousness
Can't gain weight
Intolerance to heat
Highly emotional
Flush easily
Night sweats
139 Increased sex drive
140 Headaches, "splitting or
rending" type
141 Decreased sugar tolerance
152 Hot flashes
154 Hair growth on face or body
(female)
107
108
109
110
111
112
113
90 History of gallbladder attacks or
gallstones
97 Crave sweets
138 Low blood pressure
151 Headaches
153 Increased blood pressure
157 Weakness, dizziness
159 Low blood pressure
160 Nails weak, ridged
161 Tendency to hives
158 Chronic fatigue
Thin, moist skin
Inward trembling
Heart palpitates
Increased appetite without
weight gain
Pulse fast at rest
Eyelids and face twitch
Irritable and restless
114
115
116
117
118
119
120
Can't work under pressure 121
122 Increase in weight
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
123 Decrease in appetite
127 Sensitive to cold
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
128 Dry or scaly skin
142 Abnormal thirst
144 Weight gain around hips or
waist
145 Sex drive reduced or lacking
146 Tendency to ulcers, colitis
143 Bloating of abdomen
147 Increased sugar tolerance
148 Women: menstrual disorders
149 Young girls: lack of menstrual
function
156 Masculine tendencies
(female)
155 Sugar in urine
(not diabetes)
162 Arthritic tendencies
164 Bowel disorders
165 Poor circulation
166 Swollen ankles
163 Perspiration increase
167 Crave salt
168 Brown spots or bronzing of
skin
170 Weakness after colds,
influenza
171 Exhaustion - muscular and
nervous
172 Respiratory disorders
169 Allergies - tendency to
asthma
77 Itching skin and feet
78 Excessive falling hair
79 Frequent skin rashes
80 Bitter, metallic taste in mouth
in mornings
81 Bowel movements painful or
difficult
82 Worrier, feels insecure
132 Headaches upon arising, wear
off during day
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative
133 Slow pulse, below 65
(A)
(B)
(C)
(D)
(E)
(F)
1 2 3 1 2 3 1 2 3
1 2 3 1 2 3 1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
SYMPTOM SURVEY FORM - PAGE 3
FEMALE ONLY
200 Very easily fatigued
208 Hysterectomy/ovaries
removed
201 Premenstrual tension
202 Painful menses
203 Depressed feelings before
menstruation 209 Menopausal hot flashes
210 Menses scanty or missed
211 Acne, worse at menses
212 Depression of long standing
MALE ONLY
213 Prostate trouble
214 Urination difficult or dribbling
215 Night urination frequent
204 Menstruation excessive and
prolonged
205 Painful breasts
206 Menstruate too frequently
207 Vaginal discharge
216 Depression
217 Pain on inside of legs or
heels
218 Feeling of incomplete bowel
evacuation
219 Lack of energy
220 Migrating aches and pains
221 Tire too easily
222 Avoids activity
223 Leg nervousness at night
224 Diminished sex drive
IMPORTANT
Please list the five main complaints you have in the order of their importance:
1.
2.
3.
4.
5.
1 2 3 1 2 3 1 2 3
GROUP EIGHT
173 Apprehension 183 Noise sensitivity
191 Nervousness
174 Irritability
175 Morbid fears
176 Never seems to get well
184 Acoustic hallucinations
185 Tendency to cry without reason
186 Hair is coarse and/or thinning
187 Weakness
188 Fatigue
189 Skin sensitive to touch
192 Headache
193 Insomnia
194 Anxiety
195 Anorexia
196 Inability to concentrate;
confusion
190 Tendency toward hives
197 Frequent stuffy nose; sinus
infections
177 Forgetfulness
178 Indigestion
179 Poor appetite
180 Craving for sweets
181 Muscular soreness
182 Depression; feelings of dread
198 Allergy to some foods
199 Loose joints
BARNES THYROID TEST
Date
Date
Date
Date
Date
Date
Date
Temperature
This test was developed by Dr. Broda Barnes, M.D. and is a measurement of
the underarm temperature to determine hypo and hyperthyroid states. The test
is conducted by the patient in the a.m. before leaving bed - with the
temperature being taken for 10 minutes. The test is invalidated if the patient
expends any energy prior to taking the test - getting up for any reason, shaking
down the thermometer, etc. It is important that the test be conducted for
exactly 10 minutes, making the prior positioning of both the thermometer and a
clock important.
PRE-MENSES FEMALES AND MENOPAUSAL FEMALES
Any two days during the month
FEMALES HAVING MENSTRAUL CYCLES
The 2nd and 3rd day of flow OR any 5 days in a row
MALES
Any 2 days during the month
You can do the following test at home to see if you may have a functional
low thyroid. Use an oral thermometer or a digital one. When you use a
digital one, place the probe under your arm for 5 minutes then turn your
machine on; continue on for an additional 5 minutes. When using a regular
one, shake down the night before.
Temperature
Temperature
Temperature
Temperature
Temperature
Temperature
1 2 3 1 2 3 1 2 3
1. DIGESTIVE
a. Nausea and/or vomiting 0 1 2 3 4
b. Diarrhea 0 1 2 3 4
c. Constipation 0 1 2 3 4
d. Bloated feeling 0 1 2 3 4
e. Belching and/or passing gas 0 1 2 3 4
f. Heartburn 0 1 2 3 4
Total:
2. EARS
a. Itchy ears 0 1 2 3 4
b. Earaches or ear infections 0 1 2 3 4
c. Drainage from ear 0 1 2 3 4
d. Ringing in ears or hearing loss
0 1 2 3 4
Total:
3. EMOTIONS
a. Mood swings 0 1 2 3 4
b. Anxiety, fear, or nervousness 0 1 2 3 4
c. Anger, irritability 0 1 2 3 4
d. Depression 0 1 2 3 4
e. Sense of despair 0 1 2 3 4
f. Uncaring or disinterested 0 1 2 3 4
Total:
4. ENERGY / ACTIVITY
a. Fatigue or sluggishness 0 1 2 3 4
b. Hyperactivity 0 1 2 3 4
c. Restlessness 0 1 2 3 4
d. Insomnia 0 1 2 3 4
e. Startled awake at night 0 1 2 3 4
Total:
5. EYES
a. Watery or itchy eyes 0 1 2 3 4
b. Swollen, reddened, or sticky eyelids
0 1 2 3 4
c. Dark circles under eyes 0 1 2 3 4
d. Blurred or tunnel vision 0 1 2 3 4
Total:
6. HEAD
a. Headaches 0 1 2 3 4
b. Faintness 0 1 2 3 4
c. Dizziness 0 1 2 3 4
d. Pressure 0 1 2 3 4
Total:
7. LUNGS
a. Chest congestion 0 1 2 3 4
b. Asthma or bronchitis 0 1 2 3 4
c. Shortness of breath 0 1 2 3 4
d. Difficulty breathing 0 1 2 3 4
Total:
8. MIND
a. Poor memory 0 1 2 3 4
b. Confusion 0 1 2 3 4
c. Poor concentration 0 1 2 3 4
d. Poor coordination 0 1 2 3 4
e. Difficulty making decisions 0 1 2 3 4
f. Stuttering, stammering 0 1 2 3 4
g. Slurred speech 0 1 2 3 4
h. Learning disabilities 0 1 2 3 4
Total:
9. MOUTH/THROAT
a. Chronic coughing 0 1 2 3 4
b. Gagging or frequent need to clear throat
0 1 2 3 4
c. Swollen or discolored tongue, gums, lips
0 1 2 3 4
d. Canker sores 0 1 2 3 4
Total:
10. NOSE
a. Stuffy nose 0 1 2 3 4
b. Sinus problems 0 1 2 3 4
c. Hay fever 0 1 2 3 4
d. Sneezing attacks 0 1 2 3 4
e. Excessive mucous 0 1 2 3 4
Total:
11. SKIN
a. Acne 0 1 2 3 4
b. Hives, rashes, or dry skin 0 1 2 3 4
c. Hair loss 0 1 2 3 4
d. Flushing 0 1 2 3 4
e. Excessive sweating 0 1 2 3 4
Total:
12. HEART
a. Skipped heartbeats 0 1 2 3 4
b. Rapid heartbeats 0 1 2 3 4
c. Chest pain 0 1 2 3 4
Total:
13. JOINTS / MUSCLES
a. Pain or aches in joints 0 1 2 3 4
b. Rheumatoid arthritis 0 1 2 3 4
c. Osteoarthritis 0 1 2 3 4
d. Stiffness or limited movement
0 1 2 3 4
e. Pain or aches in muscles 0 1 2 3 4
f. Recurrent back aches 0 1 2 3 4
g. Feeling of weakness or tiredness
0 1 2 3 4
Total:
14. WEIGHT
a. Binge eating or drinking 0 1 2 3 4
b. Craving certain foods 0 1 2 3 4
c. Excessive weight 0 1 2 3 4
d. Compulsive eating 0 1 2 3 4
e. Water retention 0 1 2 3 4
f. Underweight 0 1 2 3 4
Total:
15. OTHER:
a. Frequent illness 0 1 2 3 4
b. Frequent or urgent urination 0 1 2 3 4
c. Leaky bladder 0 1 2 3 4
d. Genital itch, discharge 0 1 2 3 4
Total:
Section I: Symptoms Rate each of the following based upon your health profile for the past 90 days.
Toxicity Questionnaire | The Toxicity Questionnaire is designed to aid the practitioner in assessing a patient’s or client’s potential need for a purification program.
Circle the corresponding number.
0 Rarely or Never Experience the Symptom
1 Occasionally Experience the Symptom, Effect is Not Severe
2 Occasionally Experience the Symptom, Effect is Severe
3 Frequently Experience the Symptom, Effect is Not Severe
4 Frequently Experience the Symptom, Effect is Severe
Section I Total:
Name: Date:
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Section II: Risk of ExposureRate each of the following situations based upon your environmental profile for the past 120 days.
a. How often are strong chemicals used in your home?
(disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.) 0 1 2 3 4
b. How often are pesticides used in your home? 0 1 2 3 4
c. How often do you have your home treated for insects? 0 1 2 3 4
d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?
0 1 2 3 4
e. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics? 0 1 2 3 4
f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes? 0 1 2 3 4
Total:
a. Have you noticed any negative change in your health since you moved into your home or apartment? 0 1 2 3
b. Have you noticed any change in your health since you started your new job? 0 1 2 3
Total:
No Yes
a. Do you have a water purification system in your home? 2 0
b. Do you have any indoor pets? 0 2
c. Do you have an air purification system in your home? 2 0
d. Are you a dentist, painter, farm worker, or construction worker? 0 2
Total:
Section II Total:
Grand Total (Section I & Section II)
0 Never 1 Rarely 2 Monthly 3 Weekly 4 Daily
16. Circle the corresponding number for questions 16a-16f below.
0 No 1 Mild Change 2 Moderate Change 3 Drastic Change
17. Circle the corresponding number for questions 17a-17b below.
18. Answer yes or no and circle the corresponding number for questions 18a-18d below.
Add up the numbers to arrive at a total for each section, and then add the totals for each section to arrive at the grand total.
If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a purification program.
Adapted with permission from the author of Clinical Purification™: A Complete Treatment and Reference Manual, Dr. Gina L. Nick.
02/08 L7125
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Five Brain Systems checklist
Please read this list of behaviors and rate yourself (or the person you are evaluating) on each behavior listed. Use the following scale and place the appropriate number next to the item. Five or more symptoms marked 3 or 4 or a total of 20 or higher indicate a high likelihood of weakness with that brain system. A total between 10 and 20 indicates a possibility of an imbalance. Deep Limbic
1. Feelings of sadness/crying 2. Moodiness/negativity 3. Low energy 4. Irritability 5. Decreased interest in others 6. Feelings of hopelessness about the future 7. Feelings of helplessness or powerlessness 8. Feeling dissatisfied or bored 9. Excessive guilt/low self esteem 10. Suicidal feelings 11. Lowered interest in things usually considered fun 12. Sleep changes (too much or too little) 13. Appetite changes (too much or too little) 14. Decreased interest in sex 15. Negative sensitivity to smells/odors 16. Poor concentration/forgetfulness
Total_____
Basal Ganglia
1. Feelings of nervousness or anxiety 2. Panic attacks or tics/ Avoidance of public places for fear of having an anxiety attack 3. Symptoms of heightened muscle tension (headaches, sore muscles, hand tremor) 4. Periods of heart pounding, rapid heart rate, or chest pain 5. Periods of trouble breathing or feeling smothered 6. Periods of feeling dizzy, faint, or unsteady on your feet 7. Periods of nausea or abdominal upset 8. Periods of sweating, hot or cold flashes, cold hands 9. Tendency to predict the worst/ Conflict avoidance 10. Fear of dying or doing something crazy 11.Excessive fear of being judged or scrutinized by others, worry about what others think 12. Persistent phobias/ Shyness or timidity 13. Low motivation/ Excessive motivation 14. Poor handwriting 15. Quick startle reaction/ Low threshold of embarrassment 16. Tendency to freeze in anxiety-provoking situations
Total_____
Prefrontal Cortex
1. Inability to give close attention to details or avoid careless mistakes 2. Trouble sustaining attention in routine situations (home work, chores, paperwork, etc.) 3. Trouble listening/ Distractibility 4. Poor organization of time or space/ Inability to finish things, poor follow-through 5. Lack of clear goals or forward thinking 6. Difficulty expressing feelings or empathy 7. Excessive daydreaming or talking too little 8. Apathy or lack of motivation, boredom 9. A feeling of spaciness or being “in a fog” 10. Restlessness or trouble sitting still, talking too much 11. Difficulty remaining seated in situations where remaining seated is expected 12. Conflict seeking 13. Blurting out of answers before questions have been completed, difficulty awaiting turn 14. Interruption of or intrusion on others (e.g., butting into conversations or games) 15. Impulsivity (saying or doing things without thinking first) 16. Trouble learning from experience; tendency to make repetitive mistakes
Total_____
0= never 1= rarely 2= occasionally 3= frequently 4= very frequently
Cingulate System
1. Excessive or senseless worrying 2. Being upset when things do not go your way 3. Being upset when things are out of place 4. Tendency to be oppositional or argumentative 5. Tendency to have repetitive negative thoughts 6. Tendency toward compulsive behaviors 7. Intense dislike of change 8. Tendency to hold grudges 9. Trouble shifting attention from subject to subject 10. Difficulties seeing options in situations 11. Tendency to hold on to own opinion and not listen to others 12. Tendency to get locked into a course of action, whether or not it is good 13. Being very upset unless things are done in a certain way 14. Perception by others that you worry too much 15. Tendency to say no without first thinking about questions 16. Tendency to predict negative outcomes
Total_____
Temporal Lobe
1. Short fuse or periods of extreme irritability 2. Periods of rage with little provocation 3. Frequent misinterpretation of comments as negative when they are not 4. Irritability that tends to build, then explodes, then recedes; person often feels tired after a rage 5. Periods of spaciness or confusion 6. Periods of panic and/or fear for no specific reason 7. Visual or auditory changes, such as seeing shadows or hearing muffled sounds 8. Frequent periods of deja vu (feelings of being somewhere you have never been) or jamais vu (not recalling a
familiar place or person) 9. Sensitivity or mild paranoia 10. Headaches or abdominal pain of uncertain origin 11. History of a head injury or family history of violence or explosiveness 12. Dark thoughts, such as suicidal or homicidal thoughts 13. Periods of forgetfulness 14. Memory problems 15. Reading comprehension problems 16. Preoccupation with moral or religious ideas
Total_____
Comprehensive Total:_________
*Based on and interpreted from the work of Dr. Daniel Amen and his book Change Your Brain, Change Your Life.
