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1 Multiple Sclerosis Study Questionnaire Case History Date Name Birthdate Last First Middle Address Street City State/Prov Zip/Post Telephone: Home Work With Area Code Occupation Referred by Emergency Contact Name Telephone Address Please Answer the following questions to the best of your ability. Where were you born? Where did you spend your teen years? When were you diagnosed with Multiple Sclerosis? What type do you have? Who made the diagnosis, and how was the diagnosis arrived at? What tests have been done? When and where were they done?
2 MS is a disease of cycles. Please indicate the duration of your cycles (lengths in days of months)of worsening symptoms (exacerbations) and reduction of symptoms (remissions). How has your disease progressed over time? When was your worst symptom experience? When was your best experience since your diagnosis? On a scale of 1 to 10 of overall severity or impact on your life (1= No impact, 10= The worst your could imagine) Please rate the following: Symptom Please circle one Global impact of MS on your life Gait disturbance (Problems with walking) Problems with balance Walk with assistance? (Cane, Walker) Use a wheelchair? (How much time?) Sensitivity to heat Fatigue/ Energy level? Cognitive performance? (Memory, Concentration) Mood Swings (Irritability, Elation, depression) Urinary Incontinence Constipation Difficulty in swallowing Decreased sexual desire/ response Muscle spasms/ Stiffness/ Spasticity
3 Double Vision Nystagmus (Rapid Eye Movement) Vertigo Muscle Jerking/ Overactive Reflexes Right Arm Weakness Left Arm Weakness Right Arm Numbness Left Arm Numbness Right Arm Tingling Left Arm Tingling Right Leg Weakness Left Leg Weakness Right Leg Numbness Left Leg Numbness Right Leg Tingling Left Leg Tingling Facial Numbness (Which Side?) Both? Facial Pain (Tic Doloureux) Other Pain (Feet/ Hands/ Arms/Legs/Back? Past Medical History Major Illness:
4 Hospitalizations/Surgeries- Please Give Month/Year if Possible: Past Prescriptions and treatments for your Multiple Sclerosis- names and doses (any reactions?) Allergies and Sensitivities-Foods, Environmental, etc.-ever tested? Copies of reports? Occupational Exposures Vaccinations [ ] DPT (Diphtheria, Pertussis, Tetnus) Year(s) [ ] Booster (usually DT) Year(s) [ ] Polio injection [ ]Polio oral Year(s) [ ] MMR(Measles, Mumps, Rubella) Year(s) [ ] HBV (Hepatitis B Vaccine) Year(s) [ ] Other Did you have any illness, fever or other side effects after the vaccinations? If you did have any reaction, do you know the batch and lot number of the vaccine used (old shot records)
![Occupational Exposures Vaccinations [ ] DPT (Diphtheria, Pertussis, Tetnus) Year(s) [ ] Booster (usually DT) Year(s) [ ] Polio injection [ ]Polio oral Year(s) [ ]](/docs-images/54/10344897/images/page_4.jpg "MMR(Measles, Mumps, Rubella) Year(s) [ ] HBV (Hepatitis B Vaccine) Year(s) [ ] Other Did you have any illness, fever or other side effects after the vaccinations?")
5 Women Only: Last Pap First day of Last Menstrual Period Marital History: Years Married # of Children Ages No. of Pregnancies Deliveries Complications Use of Contraceptive? What Type? Lifestyle Factors- Please fill in the appropriate amounts: Never Occasionally Weekly Daily Coffee Tobacco Alcohol Exercise Activities Never Minutes Hours Daily Weekly Swim Run Walk Dance Bike Garden Weights Golf Other Family History- Please see attached page Dietary History- Please see attached page
6 Diet Log Please write down what you eat and drink for a week! This includes juice, coffee, alcohol. If you re attempting to follow any particular diet, please indicate that in the space below the table, IE Swank diet, Atkins. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Breakfast Snack Lunch Snack Dinner Snack
7 Family Medical History Please give age, lists of any illness, or if deceased. If deceased, list cause of death and age of death. Mother: Possibilities Allergies Alcoholism Asthma Bleeding Tendency Father: Cancer-Type Chron s Disease Diabetes-Age at Onset Drug Abuse Epilepsy Brothers and Sisters: Mother s Parents: Father s Parents: Gall Bladder Glaucoma Heart Disease-Type High Blood Pressure Hearing Loss Hypoglycemia Kidney Disease Liver Disease-Type Lupus Mental Illness- Type Multiple Sclerosis Rheumatoid Arthritis Thyroid Disease Tuberculosis Skin Disease-Type Other Conditions
8 Consent for Procarin Therapy for Multiple Sclerosis Nature of Treatment I understand that I am requesting to purchase for self use only, the Procarin therapy under the direction and care of my primary physician, with whom I have consulted regarding my use of Procarin therapy as a possible treatment of my disease, multiple sclerosis. I understand that I am purchasing this treatment under the direction of my primary physician who has written an off label prescription for my use of the compounded medications contained in the Procarin therapy for the treatment of multiple sclerosis. I understand that the administration of the compounded medications contained in the Procarin therapy via a transdermal patch, subcutaneous injection, oral, or intravenous is not approved by the FDA as a treatment modality for Multiple Sclerosis. I understand that the safety, effectiveness, and tolerability if the Procarin therapy has not been yet determined. Nevertheless, I have freely chosen to purchase and /or use the Procarin therapy. I understand I bear all risks associated with the use of this product. Costs I understand that I am responsible for the cost of the Procarin therapy. I understand that I am responsible for any costs incurred for any medical attention or treatment required as a result of my use of the Procarin therapy. I understand that the cost of this treatment may not be covered by my medical insurance nor may the cost of medical attention and treatment I may require in the event of an adverse reaction or side effect to the Procarin Therapy. Risk of Treatment 1. Pain, tenderness, bruising, swelling, inflammation, or rash at the patch or injection sites. 2. Flushing, dizziness, headache, fainting, cyanosis (bluish coloring) of the face. 3. Hypo tension, hypertension pulse irregularities, rapid pulse, chest pains. 4. Dyspnea (difficult in breathing.) 5. Abdominal discomfort, nausea, vomiting, and diarrhea. 6. Increased urination. 7. Increase in symptoms of bursitis and tendonitis. 8. Burning or itching skin 9. Nervousness 10. Metallic taste 11. Blurred vision 12. Blood clots in arms or legs. 13. Severe allergic reaction that could result in shock, convulsions, and death. I have chosen to purchase and /or use the Procarin therapy of my own free will, and I understand that I bear all risk associated with the use of this product. I agree to hold harmless EDMS, LLC, and any and all of its associates, and Key Pharmacy and any and all of its associates for any and all injury and incurred costs of such injury as a result of my use of the Procarin therapy. I authorize the release of medical information to EDMS consisting of my name, address, phone number, and prescriber for the medical purpose of studying the effects of Procarin therapy. Date Witness Patient Physician
9 *Very Important Information ** Please Read Carefully, Initial and Sign After Reading We at the Tahoma Clinic are here to help you take care of your health in the best way that we know how. We realize you came in about health and not finances. The following is to assist you in understanding the Tahoma Clinic financial policies. Payment Requirements: Appointments must be paid for at time of service. We accept Visa, MasterCard, Discover, American Express, check, cash, or Traveler s check. Please contact bookkeeping for more details. You will be charged a $25 fee for returned checks. Any services rendered at the Tahoma Clinic Dispensary and Meridian Valley Lab must be paid directly to them. Appointments: We require 48 hours notice if you need to change or cancel your appointment. You will be charged a fee of 50% of the total cost of any missed appointment, or if the 48 hour cancellation policy was not met. Records: We keep a record of your health care. Tahoma Clinic patients are given their patient records upon completion of their doctor visit. If for some reason your records become unavailable to you, we will furnish you with a copy of your medical records upon your signing an authorization form and returning it to our records department. Please allow up to 10 working days for us to process the request. A small fee will be charged for this service. We will not disclose your record to others unless you direct us to do so or unless the law authorizes us to. Insurance and Medicare: Tahoma Clinic does not bill insurance companies. Our doctors are not preferred providers for any insurance company. You may submit your paid invoice to your insurance for reimbursement. We are not a Medicare provider. Medicare will not reimburse you for services rendered at the Tahoma Clinic and you should not seek reimbursement from Medicare. We do have staff available to answer any of your insurance questions. INITIAL INITIAL INITIAL INITIAL INITIAL I understand that I will have asked a practitioner of the Tahoma Clinic for help and that he/she will help to the best of his/her ability. I have read and understand the above statements. Print Name Signature (signed by guardian if under-age) Date OFFICE USE ONLY BELOW THIS LINE Treating Physician or Practioner Print Name Signature of doctor Date
10 Tacoma Clinic Nutrition Center and Dispensary 801 Sw 16 th Suite 121 Renton WA Jonathan V. Wright, MD Medical Director Multiple Sclerosis Study Participation Using Procarin It has always been the policy of the Tahoma Clinic to schedule a full hour appointment for each new patient attending our clinic. We believe that spending this time with you at the beginning of the treatment promotes the concepts of holistic medicine by establishing a meaningful patient to doctor relationship. This will allow you and your doctor adequate time to get to know each other, to ask important questions and consider the many options available for comprehensive medical treatment. For us, it is considered the standard of good medical practice. To your health and wellness, Jonathan V. Wright, MD
Patient Name: Date: This is to confirm my appointment on: at: Physician:
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