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Men
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Migraine
Skin Glow
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Exosomes IV
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PK Protocol
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Myer’s Cocktail IV
Vitamin Injections
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Endurance
Lipo B12
Allergies & Gut Health
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Gluten Sensitivity
Seasonal Allergy
Yeast Overgrowth
Food Sensitivities
Gut Testing
Detoxification
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Detox Supplements
Far Infrared Therapy
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IV Nutrient Therapy
B12 Injections
Supplements
Aesthetics Services
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Body Contouring
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EmSculpt NEO
Emtone
VanquishME
CoolSculpting
Body Contouring
Skin Tightening
Facial, Peels & Skin Resurfacing
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Hydrafacial
Dermaplaning
Microdermabrasion
Chemical Peels
Facials & Skin Analysis
EmSculpt NEO
Injectables & Fillers
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PRP Injections
Volume XC Filler
Juvederm Injections
Radiesse Filler
Botox Injections
Xeomin Injections
Belotero Injections
Kybella
Dermal Fillers
Skin Rejuvenation
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IPL Photofacial
Pearl Fractional
Pearl Rejuvenation
Laser Genesis
PRP Microneedling
Fotona Liplase
Skin Tightening
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Fotona 4D Facelift
Ultherapy
TightSculpting
Exilis
Fotona Eyelase
Non-Invasive Facelift
Laser Treatments
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Toenail Fungus Removal
Tattoo Removal
Hair Removal
Spider Vein Removal
Hair Regrowth
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PRP for Hair Restoration
Get Your Hair Back
Acne Treatments
Skin Tag Removal
Cellulite Reduction
Medical Weight Loss
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Semaglutide
CoolSculpting
Emtone Cellulite Treatment
Emsculpt NEO
Fat Reduction
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Fat Reduction
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Vanquish
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Women
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Sexual Enhancement – Women
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Men
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Sexual Enhancement – Men
Erectile Dysfunction
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ALS Information Form
Step
1
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12
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Name
(Required)
First
Last
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(Required)
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(Required)
Street Address
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone Number
(Required)
Cell
Age
D.O.B
(Required)
MM slash DD slash YYYY
Marital Status
Married
Divorced
Living with Partner
Single
Widow
Occupation
In case of emergency contact:
Relationship
Primary Care Physician's Name
EMERGENCY CONTACT
In the event we cannot contact you by the mean’s you’ve provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.
Spouse's Name
First
Last
Spouse's Phone
Caregiver Name
First
Last
Caregiver's Phone
Caregiver's Email
Pharmacy Name
Pharmacy Phone
Pharmacy Fax
Address
Street Address
City
State
ZIP Code
Additional Pharmacy Name
Additional Pharmacy Phone
Additional Pharmacy Fax
Additional Address
Street Address
City
State
ZIP Code
MEDICAL HISTORY
Any known drug allergies
Medications
Nutritional/Vitamin Supplements
Surgeries
Please list down all surgeries you had and when they were done.
Have you served in the Military?
YES
NO
What Branch?
Have you been exposed to:
Lead
Mercury
Cadmium
Copper
Other
Have you had exposure to herbicides or pesticides regularly?
YES
NO
Have you had exposure to diesel fuel or fumes on a regular basis?
YES
NO
Have you had exposure to electrical shock, that is, a shock that caused a burn or caused you to be thrown off your feet?
YES
NO
If “Yes’ was it prior to your ALS diagnosis?
YES
NO
Do you currently have any metallic objects, such as joint replacements?
YES
NO
Have you ever experienced any instances where you hit your head or neck, resulting in one or more of the following symptoms: Being dazed, Confused, Disoriented, “Seeing Stars”.
YES
NO
At the time of incident did you: not remember the incident, experience a headache, dizziness, nausea, irritability, or memory impairments?
YES
NO
Following the incident did you lose consciousness?
YES
NO
If yes, describe incident and date/dates
YES
NO
Have you ever had psychological or psychiatric condition for which you consulted a health professional?
YES
NO
Please describe
Do you have Allergies? Have they been diagnosed by a physician only?
What is your blood type?
FAMILY HISTORY
1.
List name and age when diagnosed.
3.
List name and age when diagnosed.
2.
List name and age when diagnosed.
ALS/MND CLINICAL INFORMATION
In which month and what year did you get your first symptoms of ASL/MND?
Right upper limb muscle weakness
Left upper limb muscle weakness
Right lower limb muscle weakness
Left lower limb muscle weakness
Muscle twitches (fasciculations)
Slurred speech
Difficulty swallowing
Shortness of breath
Spasticity (increased muscle tone)
Other (please specify)
What type of ALS/MND have you been diagnosed as having?
Amyotrophic lateral sclerosis (“classic” ASL)
Pattern; Mixed upper and lower motor neuron signs in limbs and bulbar region
Progressive muscular atrophy
Pattern; Pure lower motor neuron syndrome
Primary lateral sclerosis
Pattern: Pure upper motor neuron syndrome
Progressive bulbar palsy
Pattern; Isolated upper or lower motor neuron signs, or both, only in bulbar muscles (which are involved, for example, in speech and swallowing)
ALS/MND and frontotemporal dementia
Pattern: A combination of any type of ALS/MND and frontotemporal dementia
I do not know what type of ALS/MND I have been diagnosed with.
Other
Have you had a positive genetic test for a known ALS/MND gene?
YES
NO
I do not know
Has your personality changed since you were diagnosed with ALS?
YES
NO
I do not know
If so, in what way?
Please compare your memory now, to what it was before you got your first symptom of ALS/MND. We understand this might be difficult, but we are interested in your opinion.
Better
Much Better
About the same
Worse
Much Worse
I am unable to make a comparison
FUNCTIONAL STATUS
Item 1: SPEECH
4 • Normal speech process
3 • Detectable speech disturbance
2 • Intelligible with repeating
1 • Speech combined with non-vocal communication
0 • Loss of useful speech
Item 2: SALIVATION
4 • Normal
3 • Slight but definite excess of saliva in mouth; may have nighttime drooling
2 • Moderately excessive saliva; may have minimal drooling (during the day)
1 • Marked excess of saliva with some drooling
0 • Marked drooling; requires constant tissue or handkerchief
Item 3: SWALLOWING
4 • Normal eating habits
3 • Early eating problems – occasional choking
2 • Dietary consistency changes
1 • Needs supplement tube feeding
0 • NPO (exclusively parenteral or enteral feeding)
Item 4: HANDWRITING
4 • Normal
3 • Slow or sloppy: all words are legible
2 • Not all words are legible
1 • Able to grip pen, but unable to write
0 • Unable to grip pen
Item 5a: CUTTING FOOD AND HANDLING UTENSILS - Patients without gastrostomy Use 5b if >50% is through g-tube
4 • Normal
3 • Somewhat slow and clumsy, but no help needed
2 • Can cut most foods (>50%), although slow and clumsy; some help needed
1 • Food must be cut by someone, but can still feed slowly
0 • Needs to be fed
Item 5b: CUTTING FOOD AND HANDLING UTENSILS - Patients with gastrostomy 5b option is used if the patient has a gastrostomy and only if it is the primary method (more than 50%) of eating
4 • Normal
3 • Clumsy, but able to perform all manipulations independently
2 • Some help needed with closures and fasteners
1 • Provides minimal assistance to caregiver
0 • Unable to perform any aspect of task
Item 6: DRESSING AND HYGIENE
4 • Normal function
3 • Independent and complete self-care with effort or decreased efficiency
2 • Intermittent assistance or substitute methods
1 • Needs attendant for self-care
0 • Total dependence
Item 7: TURNING IN BED AND ADJUSTING BED CLOTHES
4 • Normal function
3 • Somewhat slow and clumsy, but no help needed
2 • Can turn alone, or adjust sheets, but with great difficulty
1 • Can initiate, but not turn or adjust sheets alone
0 • Helpless
Item 8: WALKING
4 • Normal
3 • Early ambulation difficulties
2 • Walks with assistance
1 • Non-ambulatory functional movement
0 • No purposeful leg movement
Item 9: CLIMBING STAIRS
4 • Normal
3 • Slow
2 • Mild unsteadiness or fatigue
1 • Needs assistance
0 • Cannot do
Item 10: DYSPNEA
4 • None
3 • Occurs when walking
2 • Occurs with one or more of the following: eating, bathing, dressing (ADL)
1 • Occurs at rest: difficulty breathing when either sitting or lying
0 • Significant difficulty: considering using mechanical respiratory support
Item 11: ORTHOPNEA
4 • None
3 • Some difficulty sleeping at night due to shortness of breath, does not routinely use more than two pillows
2 • Needs extra pillows in order to sleep (more than two)
1 • Can only sleep sitting up
0 • Unable to sleep without mechanical assistance
Item 12: RESPIRATORY INSUFFICIENCY
4 • None
3 • Intermittent use of BiPAP
2 • Continuous use of BiPAP during the night
1 • Continuous use of BiPAP during day & night
0 • Invasive mechanical ventilation by intubation or tracheostomy
DENTAL HISTORY
Have you ever had an amalgam restoration? (silver filling)
YES
NO
How many?
Hoe many currently?
LIFESTYLE
Habits/Hobbies
How often are you engaged in these daily activities?
How often were you engaged in these activities prior to ALS diagnosis?
If yes, how often?
Do you meditate?
How many hours of sleep do you get often?
PERSONALITY
Below is a collection of phrases that can describe some aspects of a person’s personality. For each item, selectbthe option that best indicates how much you agree with the statements as they apply to you. Please select the option that would have applied to you BEFORE your ALS/MND diagnosis. Rate on a scale of 1-10.
I am able to adapt when changes occur
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I have at least one close and secure relationship that helps me when I am stressed
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
When there are no clear solutions to my problems, sometimes fate or GOD can help
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I can deal with whatever comes my way
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
Past successes give me confidence in dealing with new challenges and difficulties
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I try to see the humorous side of things when I am, faced with problems
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I tend to ounce back after an illness, injury or other hardships
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
Good or bad, I believe that most things happen for a reason
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I give my best effort no matter what the outcome may be
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I believe I can achieve my goals, even if there are obstacles
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
Even when things look hopeless, I don’t give up
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
During times of stress/crisis. I know where to turn for help
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
Under pressure, I stay focused and think clearly
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I prefer to take the lead in solving problems rather than letting others make all the decisions
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I am not easily discouraged by failure
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I think of myself as a strong person when dealing with life’s challenges and difficulties
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
I can make unpopular or difficult decisions that effect other people, if it is necessary
Please enter a number from
1
to
10
.
Please enter a number from 1 to 10.
EXERCISE
What is your current exercise regimen?
How often do you exercise
What did a normal day look like prior to being diagnosed with ALS?
What type of exercise activity did you perform and how often?
EATING HABITS
What is your current dietary practice?
Organic
Vegetarian
Vegan
Lactose Intolerance
Gluten Free
Select All
What type of water do you drink?
Tap/Municipal
Well Water
Rainwater
Flat Bottle Water
Sparkling Bottled Water
Select All
How often do you drink a beverage containing caffeine?
How many drinks do you have per day?
How often do you drink alcoholic beverages?
How often do you drink five or more alcoholic beverages on one occasion?
Select all that apply
Cigarette
E-Cigarette
Cigar
None
7 Day Journal
Please describe your daily diet intake.
Monday Breakfast
Monday Lunch
Monday Dinner
Tuesday Breakfast
Tuesday Lunch
Tuesday Dinner
Wednesday Breakfast
Wednesday Lunch
Wednesday Dinner
Thursday Breakfast
Thursday Lunch
Thursday Dinner
Friday Breakfast
Friday Lunch
Friday Dinner
Saturday Breakfast
Saturday Lunch
Saturday Dinner
Sunday Breakfast
Sunday Lunch
Sunday Dinner
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