Issuu on Google+

You will fill out a form online where you will answer 200 questions as they pertain to the symptoms you have.

SYSTEMS SURVEY FORM

You will then receive a personalized report similar to this I will review each report personally and customize any recommendations report.

Patient Patient, Sample Report

NOTE: 0 Approx Weight PLEASE

Birth Date Pulse: Recumbent Blood pressure: Recumbent

Doctor Ward Hale, AP

/

Standing

Female

No

Be sure to follow these instructions when filling out your survey Awaken after few hours sleep - hard to get back to sleep 3 Crave candy or coffee in afternoons 3 Moods of depression - "blues" or melancholy Abnormal craving for sweets or snacks

52 53 54 55

1 2 3 GROUP 1 - Sympathetic Dominance 1 1 Acid foods upset Pages 1 & 2 are a summary of 2 1 Get chilled often the answers you provided 3 "Lump" in throat 4 1 Dry mouth-eyes-nose This is a generic sample test 5 1 Pulse speeds after meal which I have created. I have 6 Keyed up - fail to calm included several main complaints 7 Cut heals slowly and quite a few functional findings 8 Gag easily 9 2 Unable to relax; startles easily that relate to several different body systems. Not everyone will 10 2 Extremities cold, clammy have so many indications. This 11 1 Strong light irritates report is provided only for 12 Urine amount reduced purposes of illustration. Your 13 1 Heart pounds after retiring report may or may not be so 14 2 "Nervous" stomach involved. I only ask that everyone 15 Appetite reduced answer the questions as honestly 16 Cold sweats often as possibly and follow the 17 Fever easily raised instructions. 18 Neuralgia-like pains 19 3 Staring, blinks little 20 1 Sour stomach often

GROUP 3 - Sugar Handling 42 3 Eat when nervous 43 2 Excessive appetite 44 Hungry between meals 45 3 Irritable before meals 46 3 Get "shaky" if hungry 47 3 Fatigue, eating relieves 48 3 "Lightheaded" if meals delayed 49 1 Heart palpitates if meals missed or delayed 50 3 Afternoon headaches 51 Overeating sweets upsets

Vegetarian:

¨ Yes ¨

Male

1 2 3

MILD symptoms (occurred once or twice last 6 months). MODERATE symptoms (occurred once or twice last month). SEVERE symptoms (chronic, occurred once or twice last week). Leave circles BLANK if they don't apply to you!

GROUP 2 - Parasympathetic Dominance 21 2 Joint stiffness on arising 22 2 Muscle-leg-toe cramps at night 23 2 "Butterfly" stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen, puffy 27 2 Indigestion soon after meals 28 3 Always seems hungry; feels "lightheaded" often 29 Digestion rapid 30 Vomiting frequent 31 3 Hoarseness frequent 32 Breathing irregular 33 2 Pulse slow; feels "irregular" 34 Gagging reflex slow 35 Difficulty swallowing 36 Constipation, diarrhea alternating 37 "Slow starter" 38 1 Get "chilled" infrequently 39 Perspire easily 40 2 Circulation poor, sensitive to cold 41 2 Subject to colds, asthma, bronchitis

þ þ Ragland's Test is Positive ¨

Sex:

THIS SURVEY IS HIPPA COMPLAINT Standing Your medical privacy will / be protected!

INSTRUCTIONS: Fill in only the circles which apply to you.

Date 08/23/2011

GROUP 4 - Cardio-Vascular 56 2 Hands and feet go to sleep easily, numbness 57 2 Sigh frequently, "air hunger" 58 2 Aware of "breathing heavily" 59 High altitude discomfort 60 Opens windows in closed rooms 61 2 Susceptible to colds and fevers 62 Afternoon "yawner" 63 3 Get "drowsy" often 64 Swollen ankles, worse at night 65 Muscle cramps, worse during exercise; get "charley horses" 66 Shortness of breath on exertion 67 Dull pain in chest or radiating into left arm, worse on exertion 68 3 Bruise easily, "black and blue" spots 69 Tendency to anemia 70 1 "Nose bleeds" frequent 71 3 Noises in head, or "ringing in ears" 72 2 Tension under the breastbone, or feeling of "tightness", worse on exertion 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97

98 99 100 101 102 103 104 105 106

2 2

2

2

2 2 2

GROUP 5 - Biliary / Liver 3 Dizziness 3 Dry skin Burning feet 3 Blurred vision Itching skin and feet Excessive falling hair Frequent skin rashes Bitter, metallic taste in mouth in mornings Bowel movements painful or difficult 3 Worrier, feels insecure 3 Feeling queasy; headache over eyes Greasy foods upset Stools light colored Skin peels on foot soles 3 Pain between shoulder blades Use laxatives Stools alternate from soft to watery History of gallbladder attacks or gallstones Sneezing attacks 3 Dreaming, nightmare type bad dreams Bad breath (halitosis) Milk products cause distress Sensitive to hot weather Burning or itching anus Crave sweets

2 3 3 3 3 3 3

GROUP 6 - Digestive Loss of taste for meat Lower bowel gas several hours after eating Burning stomach sensations, eating relieves Coated tongue Pass large amounts of foul-smelling gas Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs. Mucous colitis or "irritable bowel" Gas shortly after eating Stomach "bloating" after eating


1 2 3 GROUP 7A - Hyperthyroid 107 Insomnia 108 2 Nervousness 109 Can't gain weight 110 1 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 1 Eyelids and face twitch 120 Irritable and restless 121 1 Can't work under pressure GROUP 7B - Hypothyroid 122 2 Increase in weight 123 Decrease in appetite 124 3 Fatigue easily 125 2 Ringing in ears 126 3 Sleepy during day 127 2 Sensitive to cold 128 Dry or scaly skin 129 Constipation 130 3 Mental sluggishness 131 Hair coarse, falls out 132 Headaches upon arising, wear off during day 133 Slow pulse, below 65 134 2 Frequency of urination 135 Impaired hearing 136 2 Reduced initiative GROUP 7C - Hyperpituitary 137 3 Failing memory 138 3 Low blood pressure 139 Increased sex drive 140 3 Headaches, "splitting or rending" type 141 Decreased sugar tolerance GROUP 7D - Hypopituitary 142 Abnormal thirst 143 2 Bloating of abdomen 144 3 Weight gain around hips or waist 145 3 Sex drive reduced or lacking 146 1 Tendency to ulcers, colitis 147 Increased sugar tolerance 148 Women: menstrual disorders 149 Young girls: lack of menstrual function GROUP 7E - Hyperadrenal 150 3 Dizziness 151 3 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) GROUP 7F - Hypoadrenal 157 3 Weakness, dizziness 158 3 Chronic fatigue 159 3 Low blood pressure 160 3 Nails weak, ridged 161 Tendency to hives 162 Arthritic tendencies 163 Perspiration increase 164 Bowel disorders 165 2 Poor circulation 166 Swollen ankles 167 Crave salt 168 2 Brown spots or bronzing of skin 169 3 Allergies - tendency to asthma

170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224

1 2 3 3 Weakness after colds, influenza 3 Exhaustion - muscular and nervous 3 Respiratory disorders GROUP 8 - Foundational 2 Apprehension 2 Irritability Morbid fears 3 Never seems to get well 3 Forgetfulness Indigestion Poor appetite 2 Craving for sweets Muscular soreness 3 Depression; feelings of dread Noise sensitivity Acoustic hallucinations Tendency to cry without reason Hair is coarse and/or thinning 2 Weakness Fatigue Skin sensitive to touch Tendency toward hives 2 Nervousness 3 Headache Insomnia 2 Anxiety Anorexia 2 Inability to concentrate; confusion 3 Frequent stuffy nose; sinus infections 3 Allergy to some foods Loose joints FEMALE ONLY 3 Very easily fatigued 3 Premenstrual tension Painful menses 3 Depressed feelings before menstruation Menstruation excessive and prolonged 3 Painful breasts Menstruate too frequently 1 Vaginal discharge Hysterectomy / ovaries removed Menopausal hot flashes Menses scanty or missed Acne, worse at menses 3 Depression of long standing MALE ONLY Prostate trouble Urination difficult or dribbling Night urination frequent Depression Pain on inside of legs or heels Feeling of incomplete bowel evacuation Lack of energy Migrating aches and pains Tire too easily Avoids activity Leg nervousness at night Diminished sex drive

List the five main complaints you have in the order of their importance: 1) Severe Headaches / Blurred Vision 2) Depression / Dizziness 3) No Sex Drive 4) Fatigue 5) Poor Long Term Memory Here is the place on the symptom or systems survey where you will list you 5 top concerns, main complaints or wellness goals.


Page 1 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Answer Group:

1

Question

Pages 3 thru 8 are also a summary of your answers But they are grouped according to the system they pertain too

Sympathetic Dominance 3 2 2 2 1 1 1 1 1 1 1

19 9 10 14 1 2 4 5 11 13 20

Staring, blinks little Unable to relax; startles easily Extremities cold, clammy "Nervous" stomach Acid food upset Get chilled often Dry mouth-eyes-nose Pulse speeds after meal Strong light irritates Heart pounds after retiring Sour stomach often

16 Group:

2

Parasympathetic Dominance 3 3 2 2 2 2 2 2 2 1

28 31 21 22 23 27 33 40 41 38

Always seems hungry; feels "lightheaded" often Hoarseness frequent Joint stiffness on arising Muscle-leg-toe cramps at night "Butterfly" stomach, cramps Indigestion soon after meals Pulse slow; feels "irregular" Circulation poor, sensitive to cold Subject to colds, asthma, bronchitis Get "chilled" infrequently

21

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 2 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

3

Next Visit (8 Weeks):

Answer

Question

3 3 3 3 3 3 3 3 2 1

42 45 46 47 48 50 53 54 43 49

Eat when nervous Irritable before meals Get "shaky" if hungry Fatigue, eating relieves "Lightheaded" if meals delayed Afternoon headaches Crave candy or coffee in afternoons Moods of depression - "blues" or melancholy Excessive appetite Heart palpitates if meals missed or delayed

3 3 3 2 2 2 2 2

63 68 71 56 57 58 61 72

1

70

Get "drowsy" often Bruise easily, "black and blue" spots Noises in head, or "ringing in ears" Hands and feet go to sleep easily, numbness Sigh frequently, "air hunger" Aware of "breathing heavily" Susceptible to colds and fevers Tension under the breastbone, or feeling of "tightness", worse on exertion "Nose bleeds" frequent

Sugar Handling

27 Group:

4

Cardiovascular

20

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 3 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Answer Group:

5

Question

Biliary and Liver Dysfunction 3 3 3 3 3 3 3 2 2 2 2 2 2 2

73 74 76 82 83 87 92 75 77 84 91 94 95 97

Dizziness Dry skin Blurred vision Worrier, feels insecure Feeling queasy; headache over eyes Pain between shoulder blades Dreaming, nightmare type bad dreams Burning feet Itching skin and feet Greasy foods upset Sneezing attacks Milk products cause distress Sensitive to hot weather Crave sweets

99 100 102 103 105 106 98

Lower bowel gas several hours after eating Burning stomach sensations, eating relieves Pass large amounts of foul-smelling gas Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs. Gas shortly after eating Stomach "bloating" after eating Loss of taste for meat

108 110 119 121

Nervousness Intolerance to heat Eyelids and face twitch Can't work under pressure

35 Group:

6

Digestive 3 3 3 3 3 3 2 20

Group:

7a Endocrine - Hyperthyroid 2 1 1 1 5

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 4 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Answer Group:

Question

7b Endocrine - Hypothyroid 3 3 3 2 2 2 2 2

124 126 130 122 125 127 134 136

Fatigue easily Sleepy during day Mental sluggishness Increase in weight Ringing in ears Sensitive to cold Frequency of urination Reduced initiative

137 138 140

Failing memory Low blood pressure Headaches, "splitting or rending" type

144 145 143 146

Weight gain around hips or waist Sex drive reduced or lacking Bloating of abdomen Tendency to ulcers, colitis

150 151

Dizziness Headaches

19 Group:

7c Endocrine - Hyperpituitary 3 3 3 9

Group:

7d Endocrine - Hypopituitary 3 3 2 1 9

Group:

7e Endocrine - Hyperadrenal 3 3 6

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 5 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Answer Group:

Question

7f Endocrine - Hypoadrenal 3 3 3 3 3 3 3 3 2 2

157 158 159 160 169 170 171 172 165 168

Weakness, dizziness Chronic fatigue Low blood pressure Nails weak, ridged Allergies - tendency to asthma Weakness after colds, influenza Exhaustion - muscular and nervous Respiratory disorders Poor circulation Brown spots or bronzing of skin

176 177 182 192 197 198 173 174 180 187 191 194 196

Never seems to get well Forgetfulness Depression; feelings of dread Headache Frequent stuffy nose; sinus infections Allergy to some foods Apprehension Irritability Craving for sweets Weakness Nervousness Anxiety Inability to concentrate; confusion

200 201 203 205 212 207

Very easily fatigued Premenstrual tension Depressed feelings before menstruation Painful breasts Depression of long standing Vaginal discharge

28 Group:

8

Foundational Issues 3 3 3 3 3 3 2 2 2 2 2 2 2 32

Group:

F

Female 3 3 3 3 3 1 16

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 6 of 6

Patient Survey Form - Summary iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report Doctor: Ward Hale, AP

Five Main Complaints

Survey Date: 8/23/2011 Next Visit (8 Weeks):

Matching complaints for specific symptom(s)

1) Severe Headaches / Blurred Vision 2) Depression / Dizziness 3) No Sex Drive 4) Fatigue 5) Poor Long Term Memory Barnes Thyroid Test Date

Temperature

For people who suspect they might be hypothyroid, there is an old-fashioned screening test you can do which is called the Barnes Thyroid Test. It involves using a thermometer under your arm before you get out of bed in the morning and recording your body temperature for 5 to 7 days. I can supply you with an instruction sheet upon request. If your body temperature is found to be below normal, this is one possible reason and would warrant further testing. Disclaimer: This test is not diagnostic for hypothyroid. It is merely a functional test that is not diagnostic in nature. There can be many reasons for low body temperature in the mornings. Please see your physician if you suspect you have a thyroid condition.

Other Tests These findings are part of an in-house functional physical exam

Blood Pressure Reading Unknown Blood Pressure: Recumbent / Standing / Pulse: Recumbent Standing Hema-Combistix Urine Readings: pH Albumin % Glucose % pH of Saliva pH of Stool Specimen Blood Clotting Time Hemoglobin Blood Type Weight 0 Ragland's Test is Positive (drop in excess of 9mm) No

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Occult Blood

Printed on:

08/23/2011


Page 1 of 1

Survey Comparison Report Pg 9 is a Ranking in a Graphical Form of symptoms according to Systems

iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Doctor: Ward Hale, AP

Survey 08/23/2011

Group Description

Survey

Survey Survey Score (0 to 1000) Score 0

(Higher is better)

500

1000

200 Group Score

1

Sympathetic Dominance

08/23/2011

31

2

Parasympathetic Dominance

08/23/2011

51

3

Sugar Handling

08/23/2011

175

4

Cardiovascular

08/23/2011

51

5

Biliary and Liver Dysfunction

08/23/2011

282

6

Digestive

08/23/2011

317

7

Endocrine

08/23/2011

0

7a

Endocrine - Hyperthyroid

08/23/2011

12

7b

Endocrine - Hypothyroid

08/23/2011

75

7c

Endocrine - Hyperpituitary

08/23/2011

21

7d

Endocrine - Hypopituitary

08/23/2011

18

7e

Endocrine - Hyperadrenal

08/23/2011

17

7f

Endocrine - Hypoadrenal

08/23/2011

103

8

Foundational Issues

08/23/2011

73

F

Female

08/23/2011

50

Percent of Highest Score 0%

(Lower is better)

50%

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

100%

Printed on:

08/23/2011


Page 1 of 2

Question Based Support - Analysis iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Group Totals Each question on the Systems Survey form is associated with one or more primary groups and zero, one or more secondary groups. This is a summary of the score for each group from all questions that were answered with either 1, 2 or Calculation Method: Specific Question-Based Support - Standard Process Ordered by: Total Score This is a summary based on the degree of severity of symptoms listed, and whether they are Primary weighted in a Primary or Secondary fashion Group Description Score 6 5 3 7f 7b 8 4 2 F 1 7c 7d 7e 7a

Digestive Biliary and Liver Dysfunction Sugar Handling Endocrine - Hypoadrenal Endocrine - Hypothyroid Foundational Issues Cardiovascular Parasympathetic Dominance Female Sympathetic Dominance Endocrine - Hyperpituitary Endocrine - Hypopituitary Endocrine - Hyperadrenal Endocrine - Hyperthyroid

Secondary Score

Total Score

292 99 116 62 36 73 37 36 36 23 21 18 14 6

25 183 59 41 39

3 6

317 282 175 103 75 73 51 51 50 31 21 18 17 12

869

407

1,276

14 15 14 8

0%

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

50%

Printed on:

100%

08/23/2011


Page 2 of 2

Question Based Support - Analysis iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Supplements Summary Each question on the Systems Survey form is associated with one or more primary supplements and zero, one or more secondary supplements. This is a summary of the score for each supplement from all questions that were answered with either 1, 2 or 3. Calculation Method: Specific Question-Based Support - Standard Process Ordered by: Total Score

Supplement Cataplex® B Zypan® A-F Betafood® Diaplex® Paraplex® Symplex® F Lact-Enz® Livaplex®

Primary Score

Secondary Score

Total Score

214 215 95 144 144 104 133 94

34 17 108 45 29 48 12 28

248 232 203 189 173 152 145 122

This list of potentially beneficial supplements are suggested based on the computer program's built-in algorithms. The supplement companies that Maestro uses for suggested protocols include Standard Process (Whole Food Supplements) and Mediherb (High Quality Herbal Products) from Australia. Standard Process has been in business since 1929 and their products have a proven track record of benefit in the field of clinical nutrition and functional endocrinology. Mediherb is one of highest quality herbal companies in the world and offer pristinely pure formulas. Standard Process requires that before any of their products are dispensed that a proper consultation relationship is established. This questionnaire is an excellent way to 'open' a proper wellness conversation about your health and wellness goals. I should mention however, that in my practice I deal with many professional quality companies from around the world and my suggestions are based on my clinical experience. My recommendations are based on a personal assessment of your needs and is not entirely based on these computerized suggestions or confined to these 2 mentioned companies.

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 1 of 9

Patient Group Descriptions Pages 12-21 provide you with some basic health information concerning the systems exhibiting the most functional stress based on Maestro's findings. Each group is listed in order of importance.

iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

6

Next Visit (8 Weeks):

Digestive

Primary indicators of Digestive symptoms from your Systems Survey form are: (98) Loss of taste for meat

(99) Lower bowel gas several hours after eating

(100) Burning stomach sensations, eating relieves

(102) Pass large amounts of foul-smelling gas

(103) Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs

(105) Gas shortly after eating

(106) Stomach "bloating" after eating Secondary (underlying) indicators of Digestive symptoms from your Systems Survey form are: (1) Acid food upset

(14) "Nervous" stomach

(20) Sour stomach often

(23) "Butterfly" stomach, cramps

(27) Indigestion soon after meals

(94) Milk products cause distress

(143) Bloating of abdomen

(146) Tendency to ulcers, colitis

(170) Weakness after colds, influenza

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 2 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

5

Next Visit (8 Weeks):

Biliary and Liver Dysfunction

Primary indicators of Biliary and Liver Dysfunction symptoms from your Systems Survey form are: (73) Dizziness

(74) Dry skin

(75) Burning feet

(76) Blurred vision

(77) Itching skin and feet

(82) Worrier, feels insecure

(83) Feeling queasy; headache over eyes

(84) Greasy foods upset

(87) Pain between shoulder blades

(91) Sneezing attacks

(92) Dreaming, nightmare type bad dreams

(94) Milk products cause distress

(95) Sensitive to hot weather

(97) Crave sweets

Secondary (underlying) indicators of Biliary and Liver Dysfunction symptoms from your Systems Survey form are: (4) Dry mouth-eyes-nose

(5) Pulse speeds after meal

(13) Heart pounds after retiring

(41) Subject to colds, asthma, bronchitis

(53) Crave candy or coffee in afternoons

(72) Tension under the breastbone, or feeling of "tightness", w

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 3 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

5

Next Visit (8 Weeks):

Biliary and Liver Dysfunction

(75) Burning feet

(77) Itching skin and feet

(91) Sneezing attacks

(92) Dreaming, nightmare type bad dreams

(99) Lower bowel gas several hours after eating

(100) Burning stomach sensations, eating relieves

(102) Pass large amounts of foul-smelling gas

(105) Gas shortly after eating

(106) Stomach "bloating" after eating

(140) Headaches, "splitting or rending" type

(150) Dizziness

(151) Headaches

(157) Weakness, dizziness

(159) Low blood pressure

(168) Brown spots or bronzing of skin

(169) Allergies - tendency to asthma

(172) Respiratory disorders

(173) Apprehension

(174) Irritability

(176) Never seems to get well

(177) Forgetfulness

(180) Craving for sweets

(182) Depression; feelings of dread

(187) Weakness

(192) Headache

(196) Inability to concentrate; confusion

(197) Frequent stuffy nose; sinus infections

(198) Allergy to some foods

(205) Painful breasts

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 4 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

3

Next Visit (8 Weeks):

Sugar Handling

Primary indicators of Sugar Handling symptoms from your Systems Survey form are: (42) Eat when nervous

(43) Excessive appetite

(45) Irritable before meals

(46) Get "shaky" if hungry

(47) Fatigue, eating relieves

(48) "Lightheaded" if meals delayed

(49) Heart palpitates if meals missed or delayed

(50) Afternoon headaches

(53) Crave candy or coffee in afternoons

(54) Moods of depression - "blues" or melancholy

Secondary (underlying) indicators of Sugar Handling symptoms from your Systems Survey form are: (28) Always seems hungry; feels "lightheaded" often

(82) Worrier, feels insecure

(97) Crave sweets

(103) Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs

(151) Headaches

(191) Nervousness

(192) Headache

(196) Inability to concentrate; confusion

(201) Premenstrual tension

(203) Depressed feelings before menstruation

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 5 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report Doctor: Ward Hale, AP

Group:

3

Survey Date: 8/23/2011 Next Visit (8 Weeks):

Sugar Handling

(207) Vaginal discharge

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 6 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Group: 7f Endocrine - Hypoadrenal

Primary indicators of Endocrine - Hypoadrenal symptoms from your Systems Survey form are: (157) Weakness, dizziness

(158) Chronic fatigue

(159) Low blood pressure

(160) Nails weak, ridged

(165) Poor circulation

(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

Secondary (underlying) indicators of Endocrine - Hypoadrenal symptoms from your Systems Survey form are: (58) Aware of "breathing heavily"

(61) Susceptible to colds and fevers

(63) Get "drowsy" often

(73) Dizziness

(138) Low blood pressure

(197) Frequent stuffy nose; sinus infections

(198) Allergy to some foods

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 7 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

Group: 7b Endocrine - Hypothyroid

Primary indicators of Endocrine - Hypothyroid symptoms from your Systems Survey form are: (122) Increase in weight

(124) Fatigue easily

(125) Ringing in ears

(126) Sleepy during day

(127) Sensitive to cold

(130) Mental sluggishness

(134) Frequency of urination

(136) Reduced initiative

Secondary (underlying) indicators of Endocrine - Hypothyroid symptoms from your Systems Survey form are: (2) Get chilled often

(31) Hoarseness frequent

(38) Get "chilled" infrequently

(40) Circulation poor, sensitive to cold

(42) Eat when nervous

(43) Excessive appetite

(74) Dry skin

(125) Ringing in ears

(212) Depression of long standing

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 8 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Group:

8

Next Visit (8 Weeks):

Foundational Issues

Primary indicators of Foundational Issues symptoms from your Systems Survey form are: (173) Apprehension

(174) Irritability

(176) Never seems to get well

(177) Forgetfulness

(180) Craving for sweets

(182) Depression; feelings of dread

(187) Weakness

(191) Nervousness

(192) Headache

(194) Anxiety

(196) Inability to concentrate; confusion

(197) Frequent stuffy nose; sinus infections

(198) Allergy to some foods

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 9 of 9

Patient Group Descriptions iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report Doctor: Ward Hale, AP

Group:

8

Survey Date: 8/23/2011 Next Visit (8 Weeks):

Foundational Issues

Secondary (underlying) indicators of Foundational Issues symptoms from your Systems Survey form are: No secondary questions answered for this group.

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 1 of 1

Clinician Warnings Some symptoms that you might indicate, may have stronger clinical indications. These symptoms needed to be discussed in a responsible fashion with your primary care provider - MD.

iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Next Visit (8 Weeks):

The following questions, answered by the patient, need to be reviewed by the Clinician for possible medical conditions: Question

Answer

54 72 100 138 140 150 157 159 182 212

3 2 3 3 3 3 3 3 3 3

Question Text Moods of depression - "blues" or melancholy Tension under the breastbone, or feeling of "tightness", worse on exertion Burning stomach sensations, eating relieves Low blood pressure Headaches, "splitting or rending" type Dizziness Weakness, dizziness Low blood pressure Depression; feelings of dread Depression of long standing

The following recommended supplements have cautions and/or contraindications: Note: This is not necessarily a complete and exhaustive report of all potential cautions and contraindications. Please use all reference materials available for the products being recommended regarding cautions, potential adverse reactions and interactions with drugs. Supplement

Cautions and Contraindications

Cataplex速 B

Contraindicated in patients with high blood pressure. Warning: This product may Increase Blood Pressure.

Zypan速

Special Information: Chewing this product is not recommended.

For products that have known contraindications, if any of these products occur in your suggested protocol, the contraindication will be mentioned here

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on:

08/23/2011


Page 1 of 1

Patient Score Sheet

iPlanet Health 11701 Lake Victoria Gardens Ave This page is a recap. Also the protocol of products Suite that7108 I am suggesting are included here along with a pricing Palm you Beachto Gardens, breakdown. This will allow make FL an33410 informed financial decision. (561)337-9435 You will also receive in addition to this summaryiplanethealth@gmail.com sheet....detailed product information PDF's attached to the Report www.iplanethealthoffice.com email. This is a courtesy on our part that will help you to make better wellness decisions.

Your Survey Score: 200

For Patient: Patient, Sample Report Doctor: Ward Hale, AP

(0-1000, where 1000 is a perfect score)

Survey Date: 8/23/2011 Next Visit (8 Weeks):

Group Totals Group Percent of Score Group Score

Group Description 6 5 3 7f 7b 8 4 2 F 1 7c 7d 7e 7a

Digestive Biliary and Liver Dysfunction Sugar Handling Endocrine - Hypoadrenal Endocrine - Hypothyroid Foundational Issues Cardiovascular Parasympathetic Dominance Female Sympathetic Dominance Endocrine - Hyperpituitary Endocrine - Hypopituitary Endocrine - Hyperadrenal Endocrine - Hyperthyroid

317 282 175 103 75 73 51 51 50 31 21 18 17 12

25% 22% 14% 8% 6% 6% 4% 4% 4% 2% 2% 1% 1% 1%

Adjusted Ranking

0%

50%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1276

Supplements - Costs and Quantities (for a 30 day supply)

Supplement A-F Betafood速 Catalyn速 Cataplex速 B Zypan速

Product Code 0775 2140 1200 8475

Daily ---------------Costs Per-------------# of Dosage Day Week Month Bottles 6 6 6 6

$0.83 $0.70 $0.63 $0.83

$5.83 $4.90 $4.43 $5.83

$25.00 $21.00 $19.00 $25.00

2 2 2 2

24

$3.00

$21.00

$90.00

8

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Bottle Size 90 90 90 90

Unit Price

Total Price

$12.50 $10.50 $9.50 $12.50

$25.00 $21.00 $19.00 $25.00 $90.00

Printed on:

08/23/2011


Page 1 of 1

Patient Supplement Schedule Please Post This On Your Refrigerator For Patient: Patient, Sample Report

Survey Date: 8/23/2011

Doctor: Ward Hale, AP

Supplement

Next Visit (8 Weeks): Upon Arising

Breakfast

10 am

Lunch

3 pm

Dinner

A-F Betafood® ..........................

2

2

2

Catalyn® ................................

2

2

2

Cataplex® B .............................

2

2

2

Zypan® ...................................

2

2

2

Before Sleep

7 pm

Supplement Descriptions: A-F Betafood® Supports Gall Bladder and Liver function and supports Thyroid function. Relieves fat digestion problems and helps fight sweet cravings. Should be used with caution when gall stones are present or suspect. Catalyn® High concentration of multiple vitamin factors used to support repair and healing for long-term conditions. Used for supplementing highly refined diets, lowered resistance, and to speed action of other nutritional supplements. Cataplex® B Source of Vitamin B complex factors. Supports Heart function, muscle tone, Nervous system function. Assists with low energy, and emotional stability. Zypan® Supports Digestive and Pancreas function. Assists with digestion and absorption of nutrients and minerals found in diet, and can assist to relieve digestive discomfort due to dietary imbalance. I will not sign this authorization unless I feel a proper consultation has been achieved. Clinician Notes:

iPlanet Health 11701 Lake Victoria Gardens Ave Suite 7108 Palm Beach Gardens, FL 33410 (561)337-9435 iplanethealth@gmail.com www.iplanethealthoffice.com

Please Note the Disclaimer

There are many sites on the internet and stores to choose from when making supplement selections. My goal is to help you to make better supplement selections in a more 'targeted' fashion that address your wellness needs. However, it is not the intention of this consultation service to replace in any way responsible medical care.

Please note

Authorizing Signature E. Ward Hale Not Valid Unless Signed By a Qualified Doctor

Date

My hope is to provide you with valuable wellness information. Information that you can use and benefit from. I very often say that health and wellness is a conversation and that through proper rapport and consultation you will hopefully receive the greatest benefit and value for your wellness dollar. I will do my best to help you achieve your wellness goals!

Report created by Systems Survey Maestro v6.10 - Copyright (c) 2002-2010 Greene Software. All rights reserved. Licensed to: E. Ward Hale

Printed on: 08/23/2011


Naturopathic Health Questionnaire