414 East Dupont Road Fort Wayne, IN 46825 T 260.490.3447 F 260.490.3457 fwcustomrx@gmail.com www.fwcustomrx.

com

Thank you for using our Integrative Nutrition Counseling and Medication Management services. Our goal is to assist you in understanding the nutrients that are important to your health, as well as how to best utilize the medications that were prescribed. Please completely ll out the attached forms in this le before returning them to our pharmacy. Please remember to complete the list of all your medications and over-the-counter products you currently take. We would also like a copy of your most current labs (if you have them) so that we may analyze the information and make recommendations for your nutritional needs. Once you complete this questionnaire, you may submit it however is most convenient to you. You may attach the le to an email, print out the form and fax it, mail the printed form to us, or drop it off at our pharmacy. When the forms are received I will review the information provided and will contact you to schedule an appointment. Please bring all medications and over-the-counter products that you use. Appointment lengths run approximately 1 hour, but may take up to 2 hours if necessary. During the consultation, medications will be reviewed and a nutritional action plan will be set and discussed. After the initial meeting, we will schedule a follow-up to review and monitor the progress of the plan. We will closely monitor and adjust the plan to t your needs. If medical issues occur it may be necessary to contact your physician. All recommendations will be nutritional. Medication adjustments or recommendations will only be made with the permission of your physician. Thank you for choosing Fort Wayne Custom Rx. We look forward to helping you achieve your optimal health! Sincerely,

Gregg Russell, Pharm.D/C.C.N.

Fort Wayne Custom Rx

414 E. Dupont Rd. Fort Wayne, IN. 46825 P. 260-490-3447 fwcustomrx@gmail.com F. 260-490-3457

Medication and Nutritional Evaluation

(All information provided will be kept confidential)

Todays Date: _________________ Name: _______________________________________ Birthdate: _____________ Age: __________ Address: ____________________________________________________________________________ City: ______________________________________________ State: _________ Zip: _____________ Phone: ____________________________ Email: __________________________________________ Gender: Male Female Height ____________ Weight: ____________ Occupation: ________________________________________________________________________________ If YES, how often & how much? Do you use tobacco? Do you use alcohol? Do you use caffeine? Doctors Name:
______________________________________ ______________________________________ ______________________________________

Yes Yes Yes

No ________________________________________________ No ________________________________________________ No ________________________________________________ Address:

__________________________________ __________________________________ __________________________________

Phone:
__________________________ __________________________ __________________________

Primary reason you would like an evaluation: _____________________________________________

_____________________________________________________________________________________________ _____________________________________________________________________________________________

Goals of Therapy: (Improvement or normalization of signs/symptoms/lab tests or reduction or risk) 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ Medication Experience: What is your general attitude towards taking medication? __________________________________________ What concerns/questions do you have with the medications you are taking? __________________________
_____________________________________________________________________________________________ _____________________________________________________________________________________________

How compliant are you with taking your medications?

________________________________________

Other Alerts/Health Aids/Special Needs (sight, hearing, mobility, literacy, disability) _________________
_____________________________________________________________________________________________

Page 1 of 16

Allergies: Medication, Food, and Environmental (Please list below) Type

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Description of reaction
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Family Medical Conditions/Diseases (Please check all that apply to your family) Lung condition (asthma, emphysema, COPD) Arthritis or joint problems Acid Reflux/stomach ulcers Headaches/migraine Eye disease (glaucoma) Heart Disease High blood pressure (Hypertension) High cholesterol or lipids (Hyperlipidemia) Cancer (please specify): Uterine Cancer Ovarian Cancer Fibrocystic breast Breast Cancer Diabetes Thyroid Disease Patient relation _______________________ Patient relation _______________________ Patient relation _______________________ Patient relation _______________________ Patient relation _______________________ Patient relation _______________________ Depression Blood clotting problems Epilepsy Hormonal related issues Osteoporosis Patient relation _______________________ Patient relation _______________________ Patient relation _______________________

Other (please list): __________________________________________________________________ Personal Medical Conditions/Diseases (Please check all that apply to you) Heart disease (Congestive Heart Failure) High cholesterol or lipids (Hyperlipidemia) High blood pressure (Hypertension) Blood clotting problems Acid Reflux/stomach ulcers Thyroid Disease Hormonal related issues Cancer (please specify): __________________ Lung condition (asthma, emphysema, COPD) Diabetes Arthritis or joint problems Depression Epilepsy Headaches/migraines Eye disease (glaucoma) Other (please list): _____________________

Surgical History: (Please list all surgeries) ______________________________________________________

Page 2 of 16

Please list the current prescription medications you are taking. Medication Name Strength Date Started How often per day

Over-the-counter (OTC) medications: Please check all products that you use occasionally or regularly. Check all that apply. Aspirin Acetaminophen (Tylenol) Ibuprofen (Motrin IB) Naproxen (Aleve) Migraine Product Progesterone Cream Antihistamine product (Chlor-Trimeton) Combination product, cough+cold reliever (Triaminic) Sleep aids (Excedrin PM, Unisom, Sominex, Benadryl) Antidiarrheal (Imodium, Pepto Bismol, Kaopectate) Laxatives/stool softeners (Doxidan, Correctol) Diet aids/weight loss products (Dexatrim) Antacids (Maalox, Mylanta, Tums) Decongestant product (Sudafed)

Acid blockers (Tagamet HB, Pepcid AC, Zantac 75, Prilosec) Other ____________________________________________________________________________ Nutritional/Natural Supplements: Supplement Strength Reason for taking

Page 3 of 16

Mens Health (MALES ONLY)

Waist Circumference: ________ Check Yes or No to the following questions. If yes, indicate if symptoms are Mild, Moderate, or Severe. Do you feel more fatigued and/or tired than usual? If yes, check: Mild Moderate Severe Have you noticed a decrease in your muscle mass? If yes, check: Mild Moderate Severe Have you experienced a loss in muscle strength? If yes, check: Mild Moderate Severe Have you experienced an increase in joint and/or muscle pains? If yes, check: Mild Moderate Severe Have you noticed an increase in your waist size? If yes, check: Mild Moderate Severe Do you have trouble losing weight? If yes, check: Mild Moderate Severe Have you experienced a loss in height? If yes, check: Mild Moderate Severe Do you have a decrease in your sex drive? If yes, check: Mild Moderate Severe Experienced difficulty in establishing and maintaining full erections? If yes, check: Mild Moderate Severe Do you have a decrease in spontaneous early morning erections? If yes, check: Mild Moderate Severe Have you experienced changes in your usual sleep pattern? If yes, check: Mild Moderate Severe Do you feel a decrease in your mental sharpness? If yes, check: Mild Moderate Severe Have you had trouble concentrating? If yes, check: Mild Moderate Severe Do you experience less enjoyment in personal interests and hobbies? If yes, check: Mild Moderate Severe I am ______ years old. I feel ______ years old. Yes No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Page 4 of 16

SECTION 1
INSTRUCTIONS: check the number which best describes the intensity of your Symptoms. If you do not know the answer to the question, leave it blank. 0 = Symptom is not present
Section 1A 1. Abnormally rapid or irregular heart beat 2. Nervousness, increased activity, hyperactivity 3. Irritability 4. Insomnia 5. Easily flushed 6. Do your hand shake or tremor 7. Intolerant to high temperatures 8. Strong drive followed by exhaustion 9. Erratic, flighty behavior 10. Fine features, thin skin, thin hair 11. Warm, fine, moist skin 12. Protruding tongue quivers, hands shake or tremor 13. Protruding eyeballs 14. Good appetite but fail to gain weight 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3

1 = Mild

2 = Moderate

3 = Severe

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 5 of 16

Section 1B 1. Trouble waking up in the morning 2. Start slow in morning, gain speed in afternoon 3. Headache on waking which wears off with the day 4. Dizzy or nauseated in morning 5. Dizzy when changing up and down positions 6. Muscles stiff in morning, feel need to limber up 7. Feel creaky after sitting for period of time 8. Heart sometimes seem to miss beats or turn flipflops 9. Dry skin 10. Yellowish tint to skin, particularly on hands or feet 11. Hair scanty, dry, brittle, lusterless 12. Thinning or loss of outside portion of eyebrow 13. Tend to have cold hands or feet 14. Sensitivity to cold, prefer warm to cool climate 15. Difficulty concentrating, easily distracted 16. Failing memory, forgetfulness 17. Slow reflexes 18. Low pulse rate 19. Gain weight easily, fail to lose weight on diets 20. Diminished sex drive 21. Depression or low mood 22. Sleeplessness or restlessness 23. Infertility 24. Ringing in ears 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

25. Headaches

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 6 of 16

26. Basal Temperature Test: Record morning temperature by placing thermometer under armpit for 10 minutes while still in bed. Read and record for 4 days. WOMEN: dont do during ovulation

Day 1: !!! Section 1C

Day 2:

Day 3:

Day 4: !!

1. Poor memory or mental focus 2. Inability to make clear decisions 3. Weight gain around waistline 4. Poor recovery from injury or illness 5. Decreased stamina or exercise tolerance 6. Insomnia 7. Feelings of apathy or depression 8. Feeling anxious 9. Increased irritability 10. Loss of sexual enjoyment 11. Low sex drive, lack of interest 12. Difficulty attaining and/or maintaining an erection 13. Sensitive to exhaust fumes, smoke, smog, petrochemicals 14. Easily shaken or startled, heart pounds from unexpected noise 15. Emotional upsets cause complete exhaustion 16. Feel weak and shaky 17. Depression or rapid mood swings 18. Dizziness upon standing 19. Lack of mental alertness 20. Perfectionist who sets high standards 21. Cannot tolerate much exercise 22. Catch colds easily when weather changes 23. Headaches

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 7 of 16

24. Difficulty breathing 25. Water retention 26. Periodic constipation 27. Dark circles under the eyes
Section 1D 1. Dizziness when standing suddenly 2. Loss of vision when standing suddenly 3. Feel shaky or jittery 4. Irritable if a meal is missed 5. Feel tired or weak if a meal is missed 6. Impatient, moody, nervous 7. Feel tired 1 to 3 hours after eating 8. Calmer after eating 9. Crave sweets or carbohydrates (bread) excessively 10. Headaches relieved by eating sweets or drinking alcohol 11. Heart palpitations after eating sweets 12. Need to drink coffee to get started 13. Wake up in middle of night craving sweets 14. Feel faint 15. Family history of diabetes 16. Poor memory 17. Poor concentration

0 0 0 0

1 1 1 1

2 2 2 2

3 3 3 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 8 of 16

Section 1E 1. Night sweats 2. Increased thirst 3. Lowered resistance to infection 4. Fatigue 5. Boils and/or leg sores 6. Wounds or cuts take a long time to heal 7. Poor circulation 8. Failing eyesight 9. Chronic yeast infections or toenail fungus 10. Feel pick up from exercise 11. Overweight 12. Do you crave sweets 13. Sugar in urine 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 9 of 16

SECTION 2
INSTRUCTIONS: Circle the number which best describes the intensity of your symptoms. If you do not
know the answer to the question, leave it blank. 0 = Symptom is not present Section 2A 1. Burping constant need to burp 2. Bloating or fullness for extended time after meals 3. Stomach upsets easily, indigestion 4. Poor appetite 5. Constipation Section 2B 1. Abdominal cramps 2. Fatigue after eating 3. Roughage and fiber causes indigestion 4. Excessive lower bowel gas 5. Alternating constipation and diarrhea 6. Diarrhea 7. Mucous in stools 8. Undigested food in stool 9. Dry, flaky skin and/or dry brittle hair 10. Acne 11. Difficulty gaining weight 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 1 = Mild 2 = Moderate 3 = Severe

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 10 of 16

Section 2 C 1. Chronic stomach pains 2. Stomach pains just before and/or after meals 3. Stomach pain when emotionally upset 4. Sudden or acute indigestion 5. Butterfly sensations in stomach 6. Relief of stomach pain by drinking carbonated beverages 7. Relief of stomach pain by drinking cream or milk 8. Relief of stomach pain temporarily by eating 9. Black stool when not taking iron supplements 10. History or current symptoms of ulcer or gastritis 11. Dependency on antacids 12. History of chronic aspirin or NSAIDs use (ibuprofen, Aleve) Section 2D 1. Vaginal yeast infections 2. Toenail or fingernail fungus / athletes foot / recurrent sinus infections. 3. Abdominal cramps 4. Hard or difficult bowel movements 5. Fullness in the lower abdomen Section 2E 1. Nose runs or drips 2. Nose bleeds 3. Loss of smell 4. Throat infections or chronic sore throat 5. Loss of taste 6. Cold sores or fever blisters 7. Chronic/swollen lymph glands 0 0 0 0 0 0 0 1 1 1 1 1 1 1 2 2 2 2 2 2 2 3 3 3 3 3 3 3 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 NO NO 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 YES YES

NO YES NO YES

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 11 of 16

8. Inflamed or bleeding gums 9. Ear infections 10. Hair falls out 11. Hair grows slowly 12. Slow to recover from cold or flu 13. Catch colds or flu easily 14. Poor wound healing 15. Get boils or styes 16. Bumpy skin on back of arms
Section 2F 1. Itching of nose or eyes 2. Discharge from eyes 3. Watery eyes 4. Puffiness or dark circles under eyes 5. Itching of roof of mouth or throat 6. Mucous in throat 7. Postnasal drip 8. Nasal congestion 9. Sneezing 10. Breathe through mouth 11. Swollen tongue 12. Difficulty swallowing 13. Ear discharge or ears stuffed up 14. Migraine headaches 15. Chronic lung congestion 16. Wheezing 17. Food Sensitivity or Allergy

0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 12 of 16

18. Painful stomach and/or intestine 19. Alternating constipation and diarrhea 20. Certain foods make you sick, depressed, jittery 21. Entire body aches, painful to touch 22. Swollen joints 23. Skin rashes 24. Chronic pain 25. Hyperactivity 26. Bedwetting 27. Use aspirin or Tylenol regularly
Section 2G 1. Very susceptible to infections 2. Flu-like symptoms often occur 3. Swollen glands in armpit, groin, tonsils 4. Feeling of puffiness in throat 5. Soreness on both sides of neck at shoulder level 6. Irregular heartbeat 7. More than usual number of cavities 8. Look older than chronological age 9. Have you had your spleen removed? Section 2H 1. Head feels heavy 2. Light headedness or fainting 3. Dizziness 4. Ringing or buzzing in ears 5. Tingling pain sensation 6. Loss of feeling in hands and/or feet (toes)

0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3

0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 NO

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 YES

0 0 0 0 0 0

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 13 of 16

7. Trembling hands 8. Limbs feel too heavy to hold up 9. Loss of grip strength 10. Burning sensation in limbs 11. Restless legs or arms at night 12. Loss of balance 13. Poor coordination 14. Accident prone 15. Exhaustion on slightest effort 16. Nervousness
17. Loss of muscle tone 18. Need 10 to 12 hours of sleep 19. Have had shingles 20. Convulsions Section 2I 1. Cant fall asleep 2. Replay events from day over and over in mind preventing Sleep 3. Intense dreams 4. Nightmares 5. Awake frequently throughout night 6. Wake up in the middle of night, cant fall back to sleep 7. Restless, uneasy sleeper 8. Leg cramps or restless leg at night 9. Sleepwalk

0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 NO NO NO

2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 YES YES YES

0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 NO

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 YES

Copyright 2008 James B. LaValle, Integrative Health Resources, LLC All rights reserved.

Page 14 of 16

SECTION 3
INSTRUCTIONS: Circle the number which best describes the intensity of your symptoms. If you do not know the answer to the question, leave it blank. 0 = Symptom is not present 1 = Mild 2 = Moderate 3 = Severe

MALES ONLY
Section 3A 1. A feeling of bladder fullness 2. Difficulty urinating 3. Increased straining with smaller and smaller amount of urine 4. Pain or burning while urinating 5. Wake up at night to urinate 6. Dripping after urination 7. Rose colored (bloody) urine 8. Pain or fatigue in the legs or back 9. Past or present rash on penis 10. Cloudy urine 11. Strong smelling urine 12. Back pain in the kidney area 13. History of kidney or bladder infections? 14. Have used antibiotics to control urinary tract infections? Dates last used: !!!!! Treatment duration: !!!!! 15. Have venereal disease (gonorrhea, syphilis, herpes or other) now? 16. Have had venereal disease (gonorrhea, syphilis, herpes or other) in past? NO YES NO YES 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 NO NO 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 YES YES

Page 15 of 16

Section 3B

1. Premature ejaculation 2. Pain or coldness in genital area 3. Cant hold urine 4. Varicose veins on scrotum 5. Low sperm count 6. Infertile
Section 3C 1. Discharge from penis 2. Swollen genitals 3. Swelling in groin 4. Frequent urination 5. Rarely need to urinate Section 3D 1. Apathy or depression 2. Loss of sexual enjoyment 3. Feelings of anxiety 4. Irritable or angry 5. Inability to make clear decisions 6. Poor memory, concentration 7. Weight gain, waistline 8. Insomnia 9. Poor recovery from injury or illness 10. Decreased stamina, endurance, or strength 11. Erectile dysfunction 12. Loss of sex drive

0 0 0

1 1 1 NO

2 2 2

3 3 3 YES

NO YES NO YES

0 0 0 0 0

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

0 0 0 0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3

Page 16 of 16