Wellness Questionnaire

IAL IDENT F N O C Page 1 of 1

Survey Comparison Report SAMPLE REPORT

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: Codio, Mirlene .

Doctor: Ward Hale, AP

Survey 02/03/2012

Group Description

Survey

Survey Survey Score (0 to 1000) Score 0

(Higher is better)

500

1000

678 Group Score

1

Sympathetic Dominance

02/03/2012

21

2

Parasympathetic Dominance

02/03/2012

13

3

Sugar Handling

02/03/2012

34

4

Cardiovascular

02/03/2012

1

5

Biliary and Liver Dysfunction

02/03/2012

63

6

Digestive

02/03/2012

96

7

Endocrine

02/03/2012

0

7a

Endocrine - Hyperthyroid

02/03/2012

1

7b

Endocrine - Hypothyroid

02/03/2012

42

7c

Endocrine - Hyperpituitary

02/03/2012

1

7d

Endocrine - Hypopituitary

02/03/2012

10

7e

Endocrine - Hyperadrenal

02/03/2012

1

7f

Endocrine - Hypoadrenal

02/03/2012

14

8

Foundational Issues

02/03/2012

29

F

Female

02/03/2012

31

Percent of Highest Score 0%

(Lower is better)

50%

Report created by Systems Survey Maestro v6.51 - Copyright (c) 2002-2011 Greene Software. All rights reserved.

Licensed to: E. Ward Hale

100%

These are your functional stress findings based on this survey

Printed on:

2/20/2012

In your Systems Review each system exhibiting functional stress will be explained in this fashion . Page 1 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: Codio, Mirlene

Survey Date: 2/3/2012

Doctor: Ward Hale, AP

Group:

6

Next Visit (4 Weeks):

Digestive

Primary indicators of Digestive symptoms from your Systems Survey form are: (99) Lower bowel gas several hours after eating

(102) Pass large amounts of foul-smelling gas

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

(104) Mucous colitis or "irritable bowel"

(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

(20) Sour stomach often

(27) Indigestion soon after meals

(93) Bad breath (halitosis)

(143) Bloating of abdomen

(164) Bowel disorders

Report created by Systems Survey Maestro v6.51 - Copyright (c) 2002-2011 Greene Software. All rights reserved.

Licensed to: E. Ward Hale

Printed on:

2/20/2012

Page 1 of 1

Patient Supplement Schedule Please Post This On Your Refrigerator For Patient: .Codio, Mirlene

Survey Date: 2/3/2012

Doctor: Ward Hale, AP

Next Visit (4 Weeks): Upon Arising

Supplement

Breakfast

10 am

Lunch

3 pm

Dinner

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

2

2

2

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

2

2

2

Symplex® F .............................

1

1

1

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.

Symplex® F Combination of Thyroid, Adrenal, Pituitary, and Ovary support factors for general female glandular support.

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.

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

APPROVED

By Ward at 7:18 am, 2/21/12

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

Report created by Systems Survey Maestro v6.51 - Copyright (c) 2002-2011 Greene Software. All rights reserved.

Licensed to: E. Ward Hale

Date

Printed on:

2/20/2012

Note: This protocol is being provided for educational purposes.

A final protocol will be decided upon based on other findings and further consultation.

. Page 1 of 1

Patient Score Sheet 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: .Codio, Mirlene Doctor: Ward Hale, AP

Your Survey Score: 678 (0-1000, where 1000 is a perfect score)

Survey Date: 2/3/2012 Next Visit (4 Weeks):

Group Totals Group Percent of Score Group Score

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

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

96 63 42 34 31 29 21 14 13 10 1 1 1 1

27% 18% 12% 10% 9% 8% 6% 4% 4% 3%

Adjusted Ranking

0%

50%

100%

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

357

A cost breakdown is provided for your convenience

Supplements - Costs and Quantities (for a 1 day supply)

Supplement A-F Betafood速 Catalyn速 Symplex速 F Zypan速

Product Code 0775 2140 7780 8475

Daily ---------------Costs Per-------------# of Dosage Day Week Month Bottles 6 6 3 6

$0.83 $0.70 $0.57 $0.83

$5.83 $4.90 $3.97 $5.83

$25.00 $21.00 $17.00 $25.00

1 1 1 1

21

$2.93

$20.53

$88.00

4

Bottle Size 90 90 90 90

Unit Price

Total Price

$12.50 $10.50 $17.00 $12.50

$12.50 $10.50 $17.00 $12.50 $52.50

This is a whole food based suggested protocol using whole food concentrate products that have been used in clinical nutrition practices for decades. These products have a long track record of use.

These are foundational products for supporting function and repleting deficiency in the body. However, this is but one Report created by Systems Survey Maestro v6.51 - Copyright (c) 2002-2011 Greene Software. All rights reserved.

Printed on: 2/20/2012 approach.

Licensed to: E. Ward Hale WE offer other approaches as well based on European remedies and much more.

We can further personalize a great wellness protocol designed to suit your personal tastes!

Please contact us for more information and further consultation.

Findings on your survey that should be brought to the attention of your family doctor Page 1 of 1 .

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

1st priority

For Patient: .Codio, Mirlene

Survey Date: 2/3/2012

Doctor: Ward Hale, AP

Next Visit (4 Weeks):

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

Question

Answer

54

3

Question Text

physician

Please consult with your family doctor about this finding.

Moods of depression - "blues" or melancholy

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

Zypan速

Special Information: Chewing this product is not recommended.

Report created by Systems Survey Maestro v6.51 - Copyright (c) 2002-2011 Greene Software. All rights reserved.

Licensed to: E. Ward Hale

Printed on:

2/20/2012