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P.O. Box 532-Yermo Ca-92398
760-254-3273
Danny L. Abaldo .!.
!erbal "n#a$e
#r%#&andmer'ym(n()#r(e)*l(+e.'om
Cl(en#) ,ame
Addre))
P&one
ma(l
Da#e o/ B(r#&
oday1) Da#e
"n)#r%'#(on) /or yo%r (r)# !erbal Con)%l#a#(on&an$ yo% /or (+(n #&o%&#/%l 'on)(dera#(on a) yo% 'omle#e #&e en'lo)ed ,e Cl(en#
%e)#(onna(re. Yo% (ll &a+e amle oor#%n(#y #o addre)) any 'on'ern) #&a# re%(re more de#a(
d%r(n yo%r ao(n#men# (#& Danny
e%(red /or yo%r /(r)# +()(#
Comle#ed ,e Cl(en# %e)#(onna(re : Paeror$
lea)e al)o br(n #&e /ollo(n
Any lab); blood #e)#) or o#&er er#(nen# med('al (n/orma#(on yo% #&(n$ may be &el/%l.
"/ yo% are #a$(n any &arma'e%#('al); o+er-#&e-'o%n#er dr%); &erb); and<or )%lemen#); lea
br(n #&em (n #&e(r or((nal 'on#a(ner) )o yo%r ra'#(#(oner 'an be )%re #o )ee &a# (nred(en#) an
amo%n#) are (n #&e rod%'#).
l(en# 'on/(den#(al(#y (ll be ob)er+ed %nder all '(r'%m)#an'e).
,e Cl(en# %e)#(onna(re
l(en# 'on/(den#(al(#y (ll be ma(n#a(ned a# all #(me). &e (n/orma#(on ro+(ded on #&()
%e)#(onna(re may only be d()'lo)ed
(#& #&e exre)) r(##en 'on)en# o/ #&e (nd(+(d%al named &ere(n or; (/ %nder #&e ae o/ =8; &() or &er l
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%ard(an.
lea)e allo 30-45 m(n%#e) #o 'omle#e #&() %e)#(onna(re. Plea)e an)er #&e %e)#(on) belo a)
&oro%&ly a) o))(ble )o #&a# " may ma$e #&e be)# o))(ble 'l(n('al a))e))men# and de+elo a
eal()#(' and or$able lan /or )%or#(n yo% (n rea'&(n yo%r &eal#& oal). Yo%r an)er) #o
er)onal %e)#(on) )%'& a) rela#(on)&( )#a#%); rel((on; e#'; are (mor#an# a) #&ey ro+(de
el/%l 'on#ex# /or e)#abl()&(n a rod%'#(+e ar#ner)&( (#& yo%. &a# )a(d; lea)e an)er only
&e %e)#(on) yo% are 'om/or#able an)er(n.
L()# any and all Per)e'%#(on Dr%) yo% are '%rren#ly #a$(n
L()# any OC1) yo% are '%rren#ly #a$(n
L()# any !erb) and >%lemen#) yo% are on
ed('al "n/orma#(on
Are yo% %nder a med('al do'#or?) 'are /or yo%r 'ond(#(on@ "/ )o; &a# are yo% be(n #rea#ed /or@
. Are yo% '%rren#ly #a$(n any re)'r(#(on or o+er-#&e-'o%n#er
dr%)@ "/ )o; lea)e l()# ea'& dr% and &a# (# () /or.
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!a+e yo% been d(ano)ed by a l('en)ed &y)('(an (#& any o/ #&e /ollo(n@ C&e'$ all #&a# aly.
A"D>
An(na
Ar#&r(#() &e%ma#o(d
Ar#&r(#() O)#eo
Arr&y#&m(a (rre%lar &ear# bea#
A)#&maA##en#(on De/('(en# D()order
ADD<AD!D
A%#o(mm%ne D()order); >e'(/y
e'(/(' >ym#om)
C&e'$ any o/ #&e /ollo(n emo#(on) yo% /(nd (# d(//('%l# #o deal (#&; e(#&er (n yo%r)el/ or o#&er).
mo#(onAner
"rr(#ab(l(#y
r%)#ra#(on
Anx(e#y
ear
>adne))
Dere))(on
x'(#emen#
La%&#er
La'$ o/ en#&%)(a)mLa'$ o/ oy
Eorry
D(e)#(+e; L(+er and "n#e)#(nal >ym#om). C&e'$ all #&a# aly.
Abdom(nal a(n or d()'om/or#
A'(d (nd(e)#(on; &ear#b%rn or a'(d re/l%x
Bad brea#&
Bloa#(n; bel'&(n or (n#e)#(nal a)
Con)#(a#(on boel mo+emen#) le)) #&an on'e er
dayCra+(n) /or )%ary /ood)
D(arr&ea or loo)e )#ool)
ood aller(e); )e'(/y /ood) #&a# (+e yo% roblem)
e)(ra#ory >y)#em >ym#om). C&e'$ all #&a# aly.
C&ron(' or /re%en# 'o%&
Cold )ore)
x'e)) m%'%) rod%'#(on
re%en# (n/e'#(on)
!ay-/e+er and re)(ra#ory aller(e)
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C(r'%la#ory >y)#em >ym#om). C&e'$ all #&a# aly.
Anem(a
C&e)# a(n
Cold &and) and /ee#
am(ly &()#ory o/ &ear# d()ea)e
F(n(+(#() or %m d()ea)e
!ear# al(#a#(on)
!(3& blood 4re))%re; )4e'(/y blood 4re))%re n%mber)-
r(nary and l%(d >y)#em >ym#om). C&e'$ all #&a# aly.
Bladder (n/e'#(on)
Blood (n #&e %r(ne
B%rn(n or a(n/%l %r(na#(on
D(//('%l#y )#ar#(n %r(na#(on
x'e))(+e er)(ra#(on
re%en# ale %r(ne
re%en# %r(na#(on
!()#ory o/ $(dney )#one)
❑ ,(&# )ea#)
❑ Pa(n (n #&e m(d #o lo ba'$
❑ P%//(ne)) %nder eye)
❑ >'an#; dar$ %r(ne
❑ Gr(nary (n'on#(nen'e dr(bbl(n
❑ Gr(nary #ra'# (n/e'#(on) G")
❑ Ea#er re#en#(on or edema
❑ >ollen lym& node)
Fland%lar >y)#em >ym#om). C&e'$ all #&a# aly.
B%rn(n )en)a#(on) (n &and) and /ee#
Cold &and) and /ee#
Dar$ '(r'le) %nder eye)
Dry )$(n
x'e)) e(&#
x'e)) e(&# aro%nd #&e abdomen
a#(%e (n #&e a/#ernoon)a#(%e; '&ron(' or ex'e))(+e
eel(n '&ron('ally )#re))ed
eel(n ex&a%)#ed; Hb%rned-o%#I
re%en# #&(r)#
ale) Only
D(//('%l#y %r(na#(on
re'#(le dy)/%n'#(on
"n/er#(l(#y
La'$ o/ )ex dr(+e
emale) Only
Cra+(n) /or '&o'ola#e (#& er(od)
Dere))(on (#& er(od)dema or bloa#(n a))o'(a#ed (#& er(od)
!ea+y men)#r%al bleed(n
!o# /la)&e) and<or n(&# )ea#)
"n/er#(l(#y
"rr(#ab(l(#y (#& er(od)
❑ La'$ o/ )ex%al de)(re
❑ !a(r lo)) or #&(nn(n
❑ La'$ o/ )#am(na
❑ Lo)) o/ )&or#-#erm memory
❑ Lo body #emera#%re; ea)(ly '&(lled
❑ en#al )l%()&ne)); Hbra(n /oI
❑ood )(n)
❑ %ddled #&(n$(n; 'on/%)(on
❑ e)#le)) d()#%rbed )lee
❑ e)#le)) dream) or n(&#mare)
❑ Ea$(n % a# n(&# %nable #o o ba'$ #o )lee
❑ Ea$(n % /re%en#ly a# n(&#
❑ Lo)) o/ )el/-'on/(den'e and dr(+e
❑ ,(&##(me %r(na#(on
❑ Pro)#a#e roblem)❑ Gr(na#(n a# n(&#
❑ en)#r%al 'ram)
❑ ,%r)(n '%rren#ly
❑ Pa(n/%l men)#r%a#(on
❑ P>
❑ Po)#-menoa%)al
❑ Prenan# '%rren#ly
❑ Ja(nal d()'&are
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Ja(nal dryne))
,er+o%) >y)#em >ym#om). C&e'$ all #&a# aly.
Ab)en#-m(ndedne))
Al'o&ol()m
Anx(e#y; ner+o%)ne))
C&ron(' m%)'le #en)(on
D(//('%l#y e##(n #o )lee
D(KK(ne)) or l(&# &eadedne)).
x'(#ab(l(#y; d(//('%l#y relax(n
eel(n dere))ed or d()'o%raed
!eada'&e)
❑ en)(on &eada'&e) (#& #(&#; 'on)#r('#ed /eel(n
>#r%'#%ral >y)#em >ym#om). C&e'$ all #&a# aly.
A'ne
Ar#&r(#()
Ba'$ a(n
Br(##le /(nerna(l)'Kema
Fo%#
"#'&(n; )$(n
o(n# a(n
Le 'ram) or a(n)
%l#(le roo# 'anal)
❑ Po%nd(n &eada'&e) l($e &ead () exlod(n
❑ !eada'&e) aro%nd eye) or /ore&ead
❑ (ra(ne)
Lo)) o/ memory
Pan(' a##a'$)
Per(&eral ne%roa#&y
Poor 'on'en#ra#(on
>&a$y &and)
%)'le 'ram)
,e'$ a(n
O)#eoro)()a)&e)
o)a'ea
>#(//; a'&(n or a(n/%l m%)'le)
ee#& r(nd(n
en)e m%)'le)
Eea$ le); $nee) or an$le)
()# an# o#&er (llne))e) anyone (n yo%r /am(ly &a) &ad.
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xamle; yo%r Dad &ad Can'er.
Add any add(#(onal (n/orma#(on yo% /eel may be &el/%l (n e+al%a#(n yo%r )(#%a#(on.
"n#a$e !erbal()# ,o#e)- Plea)e do no# r(#e (n #&() area.
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