Kalpana D.Patel, M.D. Cheektowaga, NY 14225 Date ... · Kalpana D.Patel, M.D. 65 Wehrle Drive...

Kalpana D Patel MD65 Wehrle DriveCheektowaga NY 14225

PATIENT INFORMATION SHEET (pLEASE PRINT) Date__------------

Patients Name_- SocialSecurity _

Date of Birth Age Sex ----

Person Responsible for the Bill _

Street Address City _

State Zip Code Phone _

Marital Status of Parents Married __ Divorced__ Separated __ Other _

Fathers Name Social Security _

Name amp Address of Employer _

________________________ Phone __

Mothers Name Social Security _

Name amp Address of Employer _

_________________________________ Phone ~ __

Name amp Address of Friend orRelative Not living with YOUL _

__________ Relationship to you -__ Phone _

Insurance Information

Nameof~ured ---------------------

Nameof~uranceCompany __PolicyorCon~ct ~

PLEASE READ All professional services are charged to the patient Payment is required in full at thetime of each visit You are responsible for all fees regardless of your insurance coverage We willsupply you with all the information necessary for you to file your insurance for reimbursement All of theoffice financial policies have been explained to me and I understand that all office visits are to be paid infull at the time of service

PERSON RESPONSIBLE FOR THE BILL ---- ---(Signature Here for above statement) ([)

Kalpana D Patel MD65 Wehrle DriveCbeektowaga NY 14225

-

___

DOB _ PATIENT HISTORY FORM

NAME DATE __CHIEF COMFLAINTS

1 OMamp~ __---------------2 Omci ~

3 O~cl ___

4 _ -- ~cl~-----------------5 Onset _

6 ___O~ _

7 Onscl __

PAST HISTORYList any previous surgery the doctor and the year --- __

List serious injuries or broken hones---- _

List serious illnesses ----------------------------------List-any foods or medications to which you are allergicFGo~ ___Medi-caiions ---------------------------------------middotJG you have hayfever any chronic lung disorders (Astbmt or Bronchitis)

List alimedications you are on now _

FMIDrVIDSroRY

FaftterMotherBrolherSisterSonsDang1lters

Present age State of Health Age at Death Canse of death

Does anyone inyour family have Tubercalosis Diabetes Heart Disease Cancer Kidney Diseaseor Vascular Disease Ifso who1

AllergyEnvironmental Care Center

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NAME---------------------- PATIENT HISTORY DATE _

Please rate and complete the following It is very important to know all about your problems in treatment planning Numberthe items that apply to you with either a (1) for MILD (2) for MODERATE and (3) for SEVERE problems Leave BLANK ifit does not apply to you

SKIN

EYES

CIRCULATORY___ Awareness of pulsations in the abdomen__ -Any Abnormal examination I test___ Chest paintightness or pressure___ Cord hands I feet___ Cofor changes in toes or feet___ Difficulty walking one or two blocks___ Discoloration I Ulcers I Sores of leg or feet___ Heart murmur or Mitral Valve Prolapse___ Heart attack or any heart disease___ High Cholesterol or Triglycerides___ High or Low blood pressure___ Leg cramps at rest or night___ Palpitations___ Rapid heartbeats___ Irregular or Skipped heartbeats___ Rheumatic fever____ Stroke___ Swelling of hands feet or ankles___ Vericose Veins I Phlebitis

__ --Abnormal pigmentation or Brown spots__ -Acne___ Change in Mole___ Dry I scaly skin___ Easy Bruising or Frequent itching___ Excessive Sweating___ Flushing or hot flashes___ Frequent infectionsBoil___ Hair loss___ Hives Rash Eczema___ Oily Skin___ Skin CancerSkin Diseases

___ Bags or Dark circles under eyes___ Blurred vision or other vision disturbances___ Cataract or Glaucoma___ Swollen reddened or sticky eyelids___ Watery itchy eyes___ Other Eye diseases or injury

NOSE

RESPIRATORY__ Asthma I Chronic Bronchitis I Emphysema___ Chest congestions I frequent cough___ Coughing up Blood___ Frequent exposure to dust chemicals fumes___ Pleurisy I Pneumonia I Tuberculosis___ Shortness of breath or Difficulty breathing___ Smoking___ Sputum___ Wheezing___ Any other trouble with lung

EARS___ Drainage from ear___ Earaches ear infection___ Hearing Loss___ Itchy Ears___ Ringing in Ears

___ Frequent stuffy or runny nose___ Frequent colds___ Hay fever___ Nose Bleeds___ Sneezing Attacks___ Sinus problems

DIGESTIVE__ Appetite(good poor medium)___ Belching pass gas___ Bleeding I black stools___ Bloated feeling___ Colitis Diverticulitis or Polyps___ Constipation I painful bowl movements___ Diarrhea___ Gall bladder disease___ Heartbum I Indigestion___ Hemorroids___ Hepatitis or other liver trouble___ Jaundice

Mucous in stool---___ Nausea or vomiting___ Peptic Ulcer (stomach or duodenal)

MOUTHrrHROAT___ Bleeding gums___ Canker Sores___ Chronic coughing___ Dry Mouth___ Gagging frequent need to clear throat___ Lump in throat___ Sore throat 1hoarseness 1 loss of voice___ Sore tongue___ Swollen or discolored tongue gum lips

AllergyEnvironmental care Center

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Page 2 of 3

DOB

PATIENT HISTORY DATE _


KIDNEY8LADDER___ Blood I sugar I pus in urine____ Burning or painful urination___ Frequent urinating I Night time urination___ Gravell stone in urine___ Kidney I bladder infections or disease___ Water retention___ Weak Bladder

JOINTSMUSCLES___ Swelling Pains or aches in jotnts___ Arthritis___ Back or Neck Pains___ Bursitis___ Difficulty in walking___ Disc Problem Slipped disc___ Feeling of Weakness or tiredness___ Gout___ Pain aches cramps or spasm in muscles____ Sciatica___ Stiffness or limitation of movement___ Tremors of hands I feet

NEUROLOGICAL___ Back pains___ Convulsions or tremors___ Epilepsy___ Fainting spell___ Frequent headaches I Migraines___ Head injury I Concussion___ Loss of coordination___ Memory problems___ Mental Disorder___ Multiple Sclerosis___ Muscle twitchings___ Nervous Disease___ Neuritis___ Paralysis___ Radiating pain down the legs___ Tingling I Numbness of the arms legs or face___ Weakness of arms legs or facial muscles

ENDOCRINE___ Change in tolerance to heat or cold___ Diabetes___ Ever taken any steroid for any reason___ Excessive thirst___ Frequent urination___ Thyroid disease or medications

(Hypo or Hyperthyroidism)

HEMATOLOGICAL___ Abnormal bleeding or any kind___ Anemia (Past or Present)____ Any other blood disease___ Cuts or bruises slow to heal___ Phlebitis or thrombosis

GENERAL___ Excessive fatigue___ Frequent Anger Irritability Frustration___ Frequent bad dreams___ Frequent crying spells___ Frequent depressed spells___ Frequent illness___ Frequent loneliness___ Frequent thoughts of suicide___ General weakness tire easily___ Insomnia or sleep related problems___ Loss of ambition___ Mood Swings___ Nervous breakdown___ Poor general health____ Stressful job I Life___ Unusual fears___ Unusual Stress I Anxiety I Nervousness____ Sex drive reduced or lacking___ Other sexual problems

MIND___ Confusion___ Difficulty making decisions__ Irritability___ Learning disabilities slow leamer___ Poor concentration Easily distracted___ Poor memory___ Slurred speech___ Stutteringstammering

WEIGHT___ Binge eating I drinking___ Compulsive eating___ Craving certain foods___ Over weight I Underweight____ Water retention

ENERGYACTIVITY__ Apathy Lethargy___ Fatigue Sluggishness___ Hyperactivity___ Restlessness


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NAME------------------------ PATIENT HISTORY DATE ------------------Please rate and complete the following It is very important to know all scout your problems in treatment pfanning Numberthe items that apply to you with either a (1) for MILD (2) for MODERATE and (3) for SEVERE problems Leave BLANK ifit does not apply to you

MALES FEMALES

___ Discharge from penis___ Painful or swollen testicles___ Prostate trouble___ Sex drive reduced or lacking___ Trouble with ejaculation___ Trouble with erection___ Venereal disease

____ Irregular or painful menses___ Bleeding between periods___ Cysts I tumor of Ovary or Uterus___ Sex drive reduced or lacking___ Pain during intercourse___ Vaginal dryness___ Vaginal infections itching or discharge___ Hair growth on face or body___ Hot flashes I mood swings I depression_____ Date of last prostate exam

____ Date of last PSA test

Result____ Date of last menstrual period____ Date of last mammogram____ Date of last pap smear

Result of previous pap (NormalAbnormal)

PAST MEDICAL HISTORY(Please give year If you remember)

SURGERIES (What kind where and when)

1 _ 1 _2 __ 2 _

3~~~~=_--~~--~~~----~~--~-ALLERGIES to Drugs Foods etc (Very important please list all)

3 _

HABITS FAMILY HISTORY (Mention in whom)

High BP __Heart Disease _StrokeDiabete-s----------------------Cancer ~_-- _Other Important Information

Coffee (ReglDecaf) Tea (cups a day) _

Alcohol (kind) Am0unt_freq uency _

Exercise (Frequency) kind_-- __ Time _

Smoking (Amount amp No ofyears) _

Daily Diet Healthy or Good I Average I Poor

LIST OF DRUGS being taken (Use back page if necessary)(Name How often Dose What is ft for For how long)

LIST OF VITAMINS amp SUPPLEMENTS(Currently being taken)

o


DOB ~ __

NAME DATE------------------------------------ --------------Please circle one

Do yon smoke YES NO

Have you ever smoked YES NOIfyes How many per day For how many years ----

Did you ever have a sexually transmitted diseaseIFyes WHEN WlIAT --------

YES NO

Have yon ever done renovation to your house YES NOIFy~~N __

Were yon occupying your house while itwas being done YES NO

Wkst renovations were done to your house ------

Do you have any hobbies YES NOlFy~~T _

J)() y~ll work ~ Il~~t strlppers glnes etpound YES NO

Doyou liav~pr~~t~ withinseCt~ YES NO

()~Ari~~~~~ ~~~~~4sect~~f~~~~middot~f~y ~~~ ~y~uhaveworked wiamp_-----

~_ ~~- - A~~ ~ ~~ ~~ ~ - ~

JOBS THAT yenOUIlAVE ~LD (First Jobto Last job) FROM TO

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DOB _

NAME DATE _

CANDIDA

ARE YOUR HEALTH PROBLEMS YEASTCONNECTED

1 Have you taken prolonged courses of antibacterial drugs _

2 Doyouhave recurrent vaginal prostatic or urinary infections _

3 Doyoufeelsickall overwithoutfinding the cause_-----

4 Are yon bothered by hormone distarbanees including PMS menstrualirreguIarities sexual dysfunction sugar craving low body temperatures orfat4oue _

5 Are you unusually sensitive to tobaeco smoke perfumes colognes and otherchemicals------

6 Are you bothered by memory or eonceatration problems _

7 Have you tak-enprolong~middot~nrses fprednisone or steroids or oralcontrace_pfivesior more than 3y-ears _

8 Do some foods ~ with y~u _

9 Do _yousUffer with -constipation diarrhea bloating or abdominal pain 1__

10Doesyour MIl itch tingle -orburn isit dry are you bothered by rashes_

WOMEN Scoring 9 or more is probably yeast related 10 is quitelikely

MEN Scoring 7 or more -probably yeast related lOis quite likely

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Food Allergy - Nntriti~nal Qnestionnaire DOB ------NAME __DATE--------

PLEASE READ EACH QUESTION CAREFULLY Then circle YES or NO to indicate your answer Ifyes please explain

YES NO I Are there any foods or beverages that yon a) crave or b) eat frequentlyList a) b) ----

YES NO 2 Are there any foods or beverages that you dislike UST _

YES NO 3 Are you awakened between the hours of 100 am and 500 am with thefollowing symptoms headache dizziness stomach cramps bloating ordry cough (Circle which)

4 Do you or anymember of your family have hayfever asthma hives chronicskin conditions migraine headaches or colitis (Circle which)

5 During childhood did you have any of the following Eczema hayfeverasthma food feeding problems (Circle Which)

6 Do y-QU ever have itching of the skin palate or roof of your mouth or skinrash (Cir-clewhich)

7 Do you frequently notice swelling of YOn ankles feet hands or face(Circle which)

8 Do you have marked fatigue two to three hours after meals9 Do yon eat snacks frequently between meals List examples

YES NOYES NOYES NOYES NO

YES NOYES NO

YES NO 10 Poy~~~r~ ex~~ ~~IDg~ aSBdden-cliange intemperature occursYEs NO 11 ~omiddotyGtfi3v~-ft~~t~besor ~eRs NO 12 ~(fyenO~ ~err~ecentbcentl~ abdomiDitmstentio~ bloating or cramps

fii~o~1 YES ~o 13 ~~~jGngtn~~~ numbness Qflhe face arms or legs at periodic intervals for no

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YES NO 14 Doye~mve(]r)wsinessheadache or bloating following the ingestion of a ~~~fyen ~~~~~~~ofwine (Circle which)YES NO 15 ~a yOnhavealtemafingconstiPafiariai1d~eaYES NO 16 Do y()lihave jtimt or muscle pain or stiffuessYES NO 17 Do you have fiuctnafing visionYES NO 18 Do you have recurring fungal infections (vaginitis afuletes foot jock itch

or ring worm) YES NO 19 Do you have fluctuating ringing in1heears or dizziness


CHEMICAL ALLERGY QUESTIONNAIRENAME DATE DOB--------------------------------~YES NO 1 Do you dislike the taste of tap water ordo you feel that it causes symptoms

YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17

Do you react to wood burning stoves fireplaces or kerosene space heaters

Do you react when entering fabric shops carpet stores grocery stores ordepartment stores

Do you react or dislike the odor of perfume soap detergents colognesor other solvents such as fingernail polish remover paint removermodel airplane glue etc

Do you dislike or react to disinfectants insecticides sprays ammonia ormoth balls

Do you react or dislike the odor of Christmas trees or other indoor evergreendecorations odor from sanding or woodworking odor of a cedar closet orpine-scented household deodorants shampoos or turpentine based paints

Do you react to or dislike the odor of exhaust fumes jet airplane exhaustsoil or gas fumes) or diesel fumes from trucks and buses

Do you feel that you react to your working environment either continuouslyor depending upon the area of the workplace that you are in

Do you have hobbies that involve exposure to smells odors chemicalspaints ceramics or dusty moldy chemically contaminated areas

Do you have a tendency to have unpleasant feelings or reactions to allmedicines taken by mouth regardless of-what condition they are given for

Do you take large amounts of over-the-counter medications such asvitamins headache pills sinus pills etc

Do you react to other peoples use of tobacco (cigarettes pipes cigars)

Do you react to all types of fresh fruit and vegetables and improve if thesubstances are cooked and peeled

Do you react to foods that are commercially prepared while not reactingto the same foods that are eaten fresh or prepared at home

Do you have difficulty eating in restaurants but are able to eat the sameFoods when prepared at homeDo you feel thai you perform or feel better in natural lighting compared toFluorescent lighting

Do you react to newsprint or other printed material

-4-PATIENT HISTORY SHEET

DOB _Name _SOCIAL HISTORY Smoker---

ENVIRONMENTAL HISTORY_____yo houseapt appl iance s---

heat--- ___ carpets

EM~OYHENT HISTORY

ENVIRONMENTAL EXPOSURESSENSITIVITIES NOTED

Da t~ ofOns~t Chemicals

Date ofOnse t Inhalan ts

natural gas

fr e s h ne spape rs

car exhaust

perfumespesticides

cooking odors

plastic

gasoline

carpets-newoldfabric stores

chlorinepaintsaerosols

disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I

Patient History SheetDOB _

HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS

SENSITIVITY TO MEDlCENES

FAMITYHISTORY

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--_sore throats (recurring)

__ Swollen glands especially neck and under arms

__ Anxiety and vvorry attacks others perceive as very anxious

7 of 14

Babeslosis

J As withother co-infections there is a lot of overlap of symptoms between Lymedisease-and Babesiosis An accumulation of the following signs and symptomsprobab1(warranttesting andor treatment of Babesiosis

__Fatigue and often excessive sleepiness

__ Highfever at onset of illness

__ NightsWeats that are often drenching and profuse

__Setere muscle pains especially the large muscles of the legs (quads buttocksetc)

__ Neuroloqical symptoms often described as dizzy tipsy and spaciness similar-toa seqaticin offloating or walking off the topof a mountain onto a cloud

~Epis()desbfbreathlessness air hunger andor cough

_- Sp1eenarlddr Hveretilarqement

At)i6rm~naBs16wvJhitEfblo6dc6unt low platelet counts mild elevation of~ivef~~yili~~afitLel~vat~d sed rate)

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__ anxietypanic (more common with Bartonella)

__ Lymph gland swelling (more common with Bartonella and Lyme)

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TruthAboutLymeDiseasecom View topic ~Cr nfection symptoms amp bttpllwwwtruthabr lymediseasecomlphpBB3viewtopicphpf-=lO

-_ __ -Eplsodes of confusion and dlsorlentatton that are usually transient (and veryscary) often can be seizure-like in nature

__Poorsleep (especially difficulty failing asleep) poor sleep quality

__Jointpain and stiffness (often both Left and Right sides as opposed to Lymewhich is often on one side only with pain and stiffness that changes locations)

__ Muscle pains especially the calves may be twitching and cramping also

_Foot pain more in the morning lnvolvinq the heels or soles of the feetsometimes misdiagnosed as plantar fasciitis)

__ Nervelrrttatlon symptoms which can be described as burning vibrating numbshooting etc

__ Tremors andor musde twitching

_ Heaft palpitations and strange chest pains

__ Episodes of-breathlessness

__ Strangerashes recurring on the body often red stretch marks and peculiartenderlumps and nodules along the sides of the legs or arms spider veins

__ Gastroiiitesti nalsyrnptoms abdominal pain and acid reflux

~Shinboampepain andtenderness

Ba~t6tl~fikjsa baoterlurnthat causes illness the most commonly known of which isa di~easectet~11edCatScratch Fever~Thousands of known casesof Bartonella occurillfhf1J]~~~chY~armiddotwiththevastmiddotrrajority of known casesdue tobites from fleasth~drif~~fcats ()f lnfecteddoqs (may also occur directlyfrorn bites and scratchesfrbiTi infected dogs or cats) Bartonella can also be transmitted by ticks thattr2insmitLYmeDisease In fact in a study published recently deer ticks from NewJersey had a higher prevalence of Bartonella organisms than of Lyme organisms

It is unclear whether the organism that we see transmitted along with Lyme diseaseis actually a Bartonella species (such as B henselae or B quintana) or isBartonella-Like Organism (BLO) that is yet to be fully identified While BLOhasfeatures similar to organisms in the Bartonella family it also has features slimiar tothe Mycoplasma and the Francisella (causes tularemia) families

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OOB Date __ ~ __

DiseasePlease date the top oftlY ~ and tkten using 1-1-0in terms of severity 10 being the

most severe ~lace the num1er after all that applies to you

Fatigue

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Low Grade FeverHot FlashesChillsNight Sweats

Swollen GlandsStiff NeckMisratinz Arthralzias

Siiffn~smiddotMvalziacheki yenalolPalpatationsAbdoavrnal Pain Naase

Poor Concentration MemorvLoss

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T~~tt~ldarlPervicPainTerliQ-o

Headache]gt~hfH~adedness Dizziness Ne~-veDisturbanceFacial P~inINumbness

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Kalpana D Patel MD65 Wehrle DriveCbeektowaga NY 14225

-

___

DOB _ PATIENT HISTORY FORM

NAME DATE __CHIEF COMFLAINTS

1 OMamp~ __---------------2 Omci ~

3 O~cl ___

4 _ -- ~cl~-----------------5 Onset _

6 ___O~ _

7 Onscl __

PAST HISTORYList any previous surgery the doctor and the year --- __

List serious injuries or broken hones---- _

List serious illnesses ----------------------------------List-any foods or medications to which you are allergicFGo~ ___Medi-caiions ---------------------------------------middotJG you have hayfever any chronic lung disorders (Astbmt or Bronchitis)

List alimedications you are on now _

FMIDrVIDSroRY

FaftterMotherBrolherSisterSonsDang1lters

Present age State of Health Age at Death Canse of death

Does anyone inyour family have Tubercalosis Diabetes Heart Disease Cancer Kidney Diseaseor Vascular Disease Ifso who1



~ NIt14225(716) 833-2213 Fax(716) 833-2244 DOB



SKIN

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MALES FEMALES








1 _ 1 _2 __ 2 _


3 _










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Do yon smoke YES NO



YES NO








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YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


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MALES FEMALES








1 _ 1 _2 __ 2 _


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YES NO








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YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


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MALES FEMALES








1 _ 1 _2 __ 2 _


3 _










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Do yon smoke YES NO



YES NO








~_ ~~- - A~~ ~ ~~ ~~ ~ - ~


ltraquo


DOB _

NAME DATE _

CANDIDA














-(_


I

-J












YES NOYES NO



~~ -3ppaF bull





YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





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f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[



~J NlJ14225(716) 833-2213 Fax (716) 833-2244

DOB


MALES FEMALES








1 _ 1 _2 __ 2 _


3 _










o


DOB ~ __


Do yon smoke YES NO



YES NO








~_ ~~- - A~~ ~ ~~ ~~ ~ - ~


ltraquo


DOB _

NAME DATE _

CANDIDA














-(_


I

-J












YES NOYES NO



~~ -3ppaF bull





YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





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f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[


DOB ~ __


Do yon smoke YES NO



YES NO








~_ ~~- - A~~ ~ ~~ ~~ ~ - ~


ltraquo


DOB _

NAME DATE _

CANDIDA














-(_


I

-J












YES NOYES NO



~~ -3ppaF bull





YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



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_

~

bull

~-






7 of 14

Babeslosis










-

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f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[

ltraquo


DOB _

NAME DATE _

CANDIDA














-(_


I

-J












YES NOYES NO



~~ -3ppaF bull





YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



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_

~

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7 of 14

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httpwwwphpbbcom

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f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[

-(_


I

-J












YES NOYES NO



~~ -3ppaF bull





YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

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httpwwwphpbbcom

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f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[



YES NO 2

YES NO 3

YES NO 4

YES NO 5

YES NO 6

YES NO 7

YES NO 8

YES NO 9

YES NO 10

YES NO 11

YES NO 12

YES NO 13

YES NO 14

YES NO 15

YES NO 16

YES NO 17



















heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





httpwwwphpbbcom

of14 121122011 943 A
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[




heat--- ___ carpets

EM~OYHENT HISTORY




natural gas


car exhaust

perfumespesticides

cooking odors

plastic

gasoline



disinfectants

cigarette smoke

pollens

dust

moldsdog dander

ca t dander

Drinker

Date __ __-____

pets----

___ plants

Dat~ ofOnset Foods

citru~

onionss uo a r

chocolate

pork

poultry

nutsfishbeans

corn

wheat

yeast

milk product

eggs

soy

alcohol

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





httpwwwphpbbcom

of14 121122011 943 A
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[

middot

Name__ ---------------Date I


HOSPITALIZATIONS

CHRONIC ILLNESSES

SURGERIES

l1EDICATIONS


FAMITYHISTORY


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





httpwwwphpbbcom

of14 121122011 943 A
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[


~ 1 _

r





~ bull



i








_

~

bull

~-






7 of 14

Babeslosis










-

bull bull





httpwwwphpbbcom

of14 121122011 943 A
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[

Babeslosis










-

bull bull





httpwwwphpbbcom

of14 121122011 943 A
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[
















f-_



sNllille ~----~ ~~~~~

OOB Date __ ~ __



Fatigue

i





- _ ~ rmiddot J ~ ~__ ~ -




[

Kalpana D.Patel, M.D. Cheektowaga, NY 14225 Date ... · Kalpana D.Patel, M.D. 65 Wehrle Drive...

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Transcript of Kalpana D.Patel, M.D. Cheektowaga, NY 14225 Date ... · Kalpana D.Patel, M.D. 65 Wehrle Drive...