Name * First Name Last Name Email * Phone (###) ### #### DOB * MM DD YYYY Condition/Diagnosis * Please explain your condition. What is your current treatment plan? * Are you on medication? List your meds. * Neurobehavioral * Short attention span Impulsitivity Procrastination Not organized Poor judgments Lack of empathy Lack of insight in daily activities None Frontal Cortex * Problems urinating more or less frequently Noticed an change in ability to concentrate or personality Experienced blurred or double vision when reading or with eye movements Problems with hand dexterity, writing, and holding on to objects, etc. Neither Anterior Cingulate * Get stuck on thoughts on a regular basis Patient worries excessively about minor issues Patient holds grudges Patient obsesses about things Patient is becoming very compulsive in actions Patient has an addiction personality Argumentative or oppositional in nature, malcontent Makes multiple errors in daily living decisions. Patient cannot stop saying “NO “to everything Neither continued * Patient demonstrated anxiety type personality or disorders Post traumatic syndrome disorder (PTSD) history OCD ( obsessive-compulsive disorder ) spectrum history Patient presents with abnormal eating habits or eating disorder Neither Basal Ganglia (high) * Increase in anxiety or panic in the patient Patient avoids conflict in life excessively Patient is pessimistic and always predicts worse scenarios in life Patient presents with excessive motivation personality Neither Basal Ganglia (low) * ADHD (attention deficit-hyperactivity disorder ) type syndromes Decreased motivation personality Movement disorders such as Parkinsonism Neither Parietal Cortex * sensory perception problems Experiencing numbness in the upper or lower extremities Notice chronic area(s) of pain in body not leaving, fibromyalgia syndromes Neurobehavioral: poor sense of direction. Eyes do not track objects (double vision) Neither Temporal Cortex * loss of smell or taste on one or both sides Patient noticed a ringing or hum in the ear(s) or decreased hearing Patient noticed a decrease in short or long term memory function Any changes in speech such as slowness, “tongue tied”, slurred speech Neither high * Prone to seizures Mysticism type behavior or experiences Perverted religious or sexual experiences or behavior Hallucinations or illusions Neither low * Difficulty learning or retaining information Various dementias noticed Epilepsy type seizures of any magnitude Aggressive behavior actions on the rise Suicidal thoughts or behavioral tendencies Neither Deep Limbic System * high Frequently or always in a sad mood or experiencing negative thoughts You have little or no motivation in life Person is “a loner”. They isolate themselves from family, no friends. Loss of libido or sexual arousal Multiple areas of pain in body such as seen in fibromyalgia. Neither Deep Limbic System * low Presents with decrease in reaction times Continually depressed Demonstrates cyclic mood swings such as seen in PMS ADD (attention deficit disorder) or ADHD (attention deficit-hyperactivity) Neither Occipital Cortex * any changes in vision, ability to see, spots or sparklers in eyes (note if white or colored sparklers) Normal Cerebellum * Patient having postural compromise, slumped over, unable to rise from chair with ease, difficulty going up and down stairs. Chronic pain in the neck, mid or lower back regions, may be accompanied by antalgic lean. Tremors in hands or feet, or numbness in hands, feet or both Cold hands or feet those are constant or worsen at a certain time of day. Decrease in coordination, stumps toe, bumps into walls going down hall Dizziness, intermittent or constant loss of balance that will not subside for prolonged periods of time. Neither b * Impulse control problems Organizational skills are decreased Speed of thought is compromised, learning, memory, etc Very refined peripheral movements are compromised, especially in hands and feet Neither Brainstem * (highway between brain, cerebellum and body) Blurred vision Loss of smell or taste Changes in hearing , ringing or hum sound in ears Chronic high or low blood pressure Chronic respiratory issues Chronic digestive issues, constipation, diarrhea , bloating, flatuance, etc Increased or decreased heart rate Difficulty swallowing with or without eating and drinking Skin slow to heal or constant cold hands and feet Numbness of hands and feet constantly, loss of balance, dizziness Neither Next Steps * What are you looking to gain? Info & Tips Treatment Recommendations See the Herbalist Start a Standard Wellness Plan Customize a Wellness Plan Alternative to Insurance We don't accept insurance but have options so that you could get the plan you need. FSA HSA Thank you! We are right there with you. Our founders are hard at work, exploring holistic ways to bring you back into good health and good spirits.
