Today's Date:   

Name:    Home Phone:   
Gender:       
Cell Phone:    E-mail:   
Fax:       
Address:    City:   
State:    Zip:   
Age:    Birth date:   
Marital Status:    (Spouse's Name):   
Children:    Ages:   
Occupation:    Employer:   
Phone:       
Contact in emergencies:    Phone:   
Relationship:       
What are the reasons you are seeing us today? (Please list in order of importance)
How will you know when you are better?
In the process of getting well, what percentage of the responsibility do you think is your own/doctors?
   Own    Doctor
What are you unwilling to change to get well?
What has prevented you from getting well in the past?
What do you feel is a reasonable time frame in which to reach satisfactory resolution of your primary complaint?
Please list the specific therapies, remedies, and/or treatments that you have tried that:
1. Have helped and continue to help.
2. Have been ineffective.
3. Helped at first but no longer do.
4. Have made you worse.
Name: Address:
Phone: Date of last visit:
Reason for seeing:
Name: Address:
Phone: Date of last visit:
Reason for seeing:
Name: Address:
Phone: Date of last visit:
Reason for seeing:
Name: Address:
Phone: Date of last visit:
Reason for seeing:
List all prescriptions, over-the-counter medications, herbs, vitamins, nutritional supplements, and homeopathic remedies you are currently taking as well as the reason you are taking them:
Please list any additional information that might help Dr. Frank Giantinoto help you:
 

SYMPTOM SURVEY FORM
PATIENT: DOCTOR: DATE:
INSTRUCTIONS: Number the boxes which apply to you with either a 1, 2, or 3.
(1) for MILD symptoms (occur once or twice a year)
(2) for MODERATE symptoms (occur several times a year)
(3) for SEVERE symptoms (you are aware of it almost constantly)
Leave the box BLANK if it does not apply to you.

Group 1
1 Acid foods upset
2 Get chilled often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meals
6 Keyed up - fail to calm
7 Cuts heal slowly
8 Gag easily
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
15 Appetite reduced
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach frequent

Group 2
21 Joint stiffness after arising
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
28 Always seems hungry; feels "lightheaded" often
29 Digestion rapid
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
36 Constipation, diarrhea alternating
37 "Slow starter"
38 Get "chilled" infrequently
39 Circulation poor, sensitive to cold
40 Subject to colds, asthma, bronchitis
41 Joint stiffness after arising

Group 3
42 Muscle-leg-toe cramps at night
43 "Butterfly" stomach, cramps
44 Eyes or nose watery
45 Eyes blink often
46 Eyelids swollen, puffy
47 Indigestion soon after meals
48 Always seems hungry; feels "lightheaded" often
49 Digestion rapid
50 Vomiting frequent
51 Hoarseness frequent
52 Breathing irregular
53 Pulse slow; feels "irregular"
54 Gagging reflex slow
55 Difficulty swallowing

Group 4
56 Constipation, diarrhea alternating
57 "Slow starter"
58 Get "chilled" infrequently
59 Circulation poor, sensitive to cold
60 Subject to colds, asthma, bronchitis

Group 4 (cont.)
61 Joint stiffness after arising
62 Muscle-leg-toe cramps at night
63 "Butterfly" stomach, cramps
64 Eyes or nose watery
65 Eyes blink often
66 Eyelids swollen, puffy
67 Indigestion soon after meals
68 Always seems hungry; feels "lightheaded" often
69 Digestion rapid
70 Vomiting frequent
71 Hoarseness frequent
72 Breathing irregular

Group 5
73 Pulse slow; feels "irregular"
74 Gagging reflex slow
75 Difficulty swallowing
76 Constipation, diarrhea alternating
77 "Slow starter"
78 Get "chilled" infrequently
79 Circulation poor, sensitive to cold
80 Subject to colds, asthma, bronchitis

Group 5 (cont.)
81 Bowel movements painful or difficult
82 Worrier, feels insecure
83 Feeling queasy; headache over eyes
84 Greasy foods upset
85 Stool's light colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks and gallstones
91 Sneezing attacks
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
97 Crave sweets

Group 6
98 Loss of taste for meat
99 Lower bowel gas several hours after eating
100 Burning stomach sensations, eating relieves

Group 6 (cont.)
101 Coated tongue
102 Pass large amounts of foul-smelling gas
103 Indigestion 1/2 to 1 hour after eating; may be up to 3-4 hours
104 Mucus colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating

Group 7

(A)
107 Insomnia
108 Nervousness
109 Can't gain weight
110 Intolerance to heat
111 Highly emotional
112 Flush easily
113 Night sweats
114 Thin, moist skin
115 Inward trembling
116 Heart palpitates
117 Increased appetite without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can't work under pressure

Group 7 (cont.)

(B)
122 Increase in weight
123 Decrease in appetite
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
127 Sensitive to cold
128 Dry or scaly skin
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
132 Headaches upon arising, wear off during day
133 Slow pulse, below 65
134 Frequent urination
135 Impaired hearing
136 Reduced initiative

(C)
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches "splitting or rending" type
141 Decreased sugar tolerance

Group 7 (cont.)

(F) cont.
142 Abnormal thirst
143 Bloating of abdomen
144 Weight gain around hips or waist
145 Sex drive reduced or lacking
146 Tendency to ulcers, colitis
147 Increased sugar tolerance
148 Women: menstrual disorders
149 Young girls: lack of menstrual function

(E)
150 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 Hair growth on face or body (female)
155 Sugar in urine (not diabetes)
156 Masculine tendencies (female)

(F)
157 Weakness, dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails weak, ridged
161 Tendency to hives
162 Arthritic tendencies

Group 7 (cont.)

(F) cont.
163 Perspiration increase
164 Bowel disorders
165 Poor circulation
166 Swollen ankles
167 Crave salt
168 Brown spots or bronzing of skin
169 Allergies - tendency to asthma
170 Weakness after colds, influenza
171 Exhaustion - Muscular and nervous
172 Respiratory disorders

Female Only
173 Very easily fatigued
174 Premenstrual tension
175 Painful menses
176 Depressed feelings before menstruation
177 Menstruation excessive and prolonged
178 Painful breasts
179 Menstruate too frequently
180 Vaginal discharge
181 Hysterectomy/ovaries removed
182 Menopausal hot flashes
183 Menses scanty or missed

Female Only (cont.)
184 Acne, worse at menses
185 Depression of long standing

Male Only
186 Prostate trouble
187 Urination difficult or dribbling
188 Night urination frequent
189 Depression
190 Pain on inside of legs or heels
191 Feeling of incomplete bowel evacuation
192 Lack of energy
193 Migrating aches and pains
194 Tire too easily
195 Avoids activity
196 Leg nervousness at night
197 Diminished sex drive
     
     
     
     
     
     

IMPORTANT
TO THE PATIENT: Please list below the five main health complaints you have in order of their importance:
1.
2.
3.
4.
5.
 


Thyroid Function

There are more than 70 signs of Thyroid imbalances which may impair your health. As the normal Thyroid regulates metabolism, imbalances in the Thyroid may first come to your attention as decreasing levels of energy, tiredness, lethargy, muscle aches and the like. With just a few drops of  Iosol (water-soluble non toxic ammonium iodide), metabolism can be dramatically changed to improve these energy level and relieve symptoms.

The most common complaints, after low energy levels are:       

  • Cold Hands and Feet
  • Inability to gain or Lose weight
  • Loss of Hair
  • Brittle or irregular nails
  • Redness and chaffing behind the heels
  • Depression

An UNDER-FUNCTIONING Thyroid is often UNDETECTED on a blood panel.

    According to Broda Barnes, M.D. the blood test criterion for Thyroid disease should never “be all or end-all” in the diagnosis.
This is often just one parameter, and often an inadequate one.
Note: The BEST test for hypothyroidism is the basal metabolic rate: (BMR)
1.Place a thermometer by your bed. Shake it down below 96
2.Immediately upon waking place the thermometer under your armpit and leave it there for 10 minutes before getting up.

There are certain other blood test criteria to corroborate the hypothyroid diagnosis with the Barnes Basal Metabolic Rate.
1.Cholesterol in excess of 252
2.Triglyceride level greater than 150
3.Total CPK level above 30
4.Bunt to creatinine ratio less than 12
5.LDH level greater than 40
6.Cholesterol to HDL level greater than 5
7.Increased B-2 fraction in lipoprotein electrophoresis.

 

Signs of Possible Iodine Deficiency

Please check anything related to you.
Radiation exposure causes thyroid gland symptoms
Ringing in the ears is associated with decreased blood pressure and a slow pulse rate.


IOSOL - Ammonium iodide and iodine. The reason to use this iodine and the possible diagnostic side effects (+)
Elevates thyroid metabolism
Increases energy
Restores the electrical balance
Reduces mucous
Thins the blood and makes the system work faster


Possible Iosol side effects:
Headaches indicate other deficiencies
Metallic taste = iodine deficiency
Nose becomes "runny" = sufficient Iosol


Potassium/Sodium Iodine and Iodide may cause the following toxic effects: (-)
Abdominal pain
Black, tarry stools
Diarrhea
Confusion, disorientation
False elevation in thyroid function
Fever
Heart palpitations
Irregular heartbeat
Interferes with electrical balance
Interferes with naturally occurring steroids
Irreversible or chronic hyperthyroid gland
Skin rash
Sore teeth or gums
Stomach disturbance, nausea
Swollen neck or throat
Tiredness or weakness
 
Nervousness
 
Daily Record of Food Intake
Each day, record all the foods you eat and drink. Be sure to include the approximate amount of each food. Patient:
Your diet may be the key to better health. Address:

 Health Care Professional:

   Dr. Frank Giantinoto D.C.

Pro-Health4Ever.com
Kinesiology Center
  631-834-6828
 
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