JOAN MARGARET, D.C. - Labrys Healthcare Circle

JOAN MARGARET, D.C.
Chiropractor & Applied Kinesiologist
6536 Telegraph Avenue. Suite A102, Oakland, CA 94609
(510) 658-9066 • Fax: (510) 658-9079
Welcome,
You will need to download and print our New Client forms. There are four forms in total. Please
be sure to complete both sides of each form and bring them with you on the day of your visit.
On the day of your appointment please do not wear any scented products or products containing
petrochemicals. Many of Dr. Margaret’s patients are chemically sensitive and are adversely
affected by these products. These chemicals are in laundry detergent, such as Tide, and fabric
softeners, like Downy, or clothes that have been dry-cleaned.
We also request that you do not use your wireless communication devices while in the office
space. Please turn off your cell phones, wireless computers, calendars and/or other wireless
accessories you bring into the office, and refrain from using them at any time in this space.
So, on the day of your visit, please wear clean clothing if possible and come cell phone-free. And
if you think that there are chemicals in the clothes, air them out before using them for Office
Visits. Also shampoos, scented deodorants and antiperspirants may contain harmful chemicals.
Please read your labels and if they have words you find difficult to pronounce, consider them
harmful to both yourself and others in the office.
If you have any questions please call us at the phone number provided above.
We look forward to meeting you,
Joan Margaret and staff
http://www.labryshealthcarecircle.com • info@ labryshealthcarecircle.com
JOAN MARGARET, D.C.
Chiropractor & Applied Kinesiologist
6536 Telegraph Avenue. Suite A102, Oakland, CA 94609
(510) 658-9066 • Fax: (510) 658-9079
LABRYS HEALTHCARE CIRCLE FINANCIAL POLICY
Welcome to Labrys Health Care Circle! According to our policy, fees for all services, including
examinations, treatments, massage, orthopedic supports, nutrition and educational supplies are
payable at the time services are rendered. We accept cash, money orders or checks and Visa and
Master cards.
PLEASE CHECK THE FORM OF PAYMENT THAT APPLIES TO YOU:
 Self-Payment. lf you need a receipt for tax or other purposes, we’ll be glad to give you
one.
 Health Insurance. We currently do not bill individual’s health insurance, but we would
be happy to give you a superbill to send into your insurance company. A superbill will
include your diagnosis, plus dates and charges for your office visits. You are responsible
for knowing such details as number of visits allowed per diagnosis, or per calendar year,
and informing the office of your needs. Tell us if you need your receipt to exclude costs
for food supplements, or other costs.
 Auto Insurance. Most auto insurance policies provide "Med pay" coverage to the
policyholder and to covered dependents for expenses resulting from an accident
regardless of which driver is determined to be at fault. It is your responsibility to contact
the adjuster at your insurance company to determine how much med-pay coverage is on
your policy. Please notify us of this amount and keep track of your total medical
expenses. lf your bill from treatment exceeds the amount your insurance company covers,
you are responsible for paying any remaining balance. If an attorney is handling your
case, please let us know.
After you’ve provided us with your insurance information, we will phone to verify coverage in
your case, please let us know. Ultimately, you are financially responsible for all services
rendered and products received in this office whether or not your legal case is settled to your
satisfaction.
Other: .................................................................................................................................
AGREEMENT TO PAY: I agree to pay for all services rendered and understand that payment
is expected on the day of treatment unless previous financial arrangements have been made.
Signature: ................................................................................................. Date: ............................
http://www.labryshealthcarecircle.com • info@ labryshealthcarecircle.com
JOAN MARGARET, D.C.
Chiropractor & Applied Kinesiologist
6536 Telegraph Avenue. Suite A102, Oakland, CA 94609
(510) 658-9066 • Fax: (510) 658-9079
NAET Treatment Authorization
I ................................................................................. certify that Dr. Joan Margaret does not
claim to cure any illness or disease with Nambudripad’s Allergy Elimination Techniques
(NAET).
I understand that NAET is not a medical diagnostic procedure and therefore does not
diagnose a disease. NTT (Nambudripad’s Testing Techniques), uses various standard medically
proven diagnostic measures and modalities (allopathic, chiropractic, kinesiology and
acupuncture procedures) to diagnose the patient’s condition. NTT gives the practitioner an
indication as to the substances(s) to which the patient may have sensitivity. The premise behind
NAET is to desensitize a patient to a substance(s) using allopathic, chiropractic,
acupuncture/acupressure, nutritional and kinesiological principals so that the patient may not
experience hypersensitive symptoms when they have future contact with the desensitized
allergens.
I understand that I (or my ward) am to continue all medications and other treatment
modalities as they have been prescribed, unless otherwise directed by the doctor who prescribed
them. During the 25 hours after a treatment, if I (or my ward) should get a life-threatening
reaction from the allergen, or from some other sources, I (or my ward) should seek emergency
help immediately. Such help may be from a physician qualified in emergency treatment, or by
calling 911 or by attending an emergency room at the local hospital. If I (or my ward) am
suffering from severe allergic reactions to substances, I agree to consult an appropriate physician
and to take appropriate medication (such as medication to prevent itching, tissue swelling, fever,
cough, pain, infections, mental irritability, violent behaviors, etc.) to keep my (or my ward’s)
symptoms under control while I (or my ward) am in a series of NAET treatments. This way,
essential NAET treatments can be completed without interruption.
I understand that for 25 hours after the treatment I (or my ward) am to avoid eating,
touching, breathing and coming within 5 feet of the substance(s) for which I (or my ward) have
received treatment. If I (or my ward) come in contact with substance(s) for which I (or my ward)
am being treated, I realize that the treatment may not work, and I (or my ward) may have a
sensitivity reaction.
I understand that I (or my ward) must return after the 25 hours avoidance period,
preferably within 7 days, to see if I (or my ward) have cleared for the substance(s). I fully
understand that I (or my ward) may still experience a reaction to the substance(s) of unknown
severity if I (or my ward) come in contact with them and I (or my ward) did not clear them
completely. If I (or my ward) did not clear them completely, I (or my ward) may be required to
repeat the procedure (more office visits at my cost) until I (or my ward) clear them satisfactorily.
I have read or have had read to me the above statements and have had the opportunity to
ask questions about its contents and by signing below I agree to the terms and procedures.
Patient’s Signature ............................................................................... Date ...................................................
Name of Minor..................................................................................... Relationship to Ward.........................
Signature of Witness ............................................................................ Date ...................................................
http://www.labryshealthcarecircle.com • info@ labryshealthcarecircle.com
Labrys Healthcare Circle
6536 Telegraph Avenue, Suite A102, Oakland, CA 94609 • (510) 658-9066
Confidential Health History Form
Name ................................................................................. Date....................................................................
Street Address ................................................................... City, State, Zip....................................................
Phone........................................ Other phone .................... Referred by ........................................................
Date of Birth ...................................... Occupation ..............................(PDLO...........................
Height.........................Weight ............. Body frame (S,M,L)............Number of children ................................
Ancestry (List all) ...........................................................................................................................................
Exercise, recreation .......................................................................................................................................
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Relaxation/stress reduction............................................................................................................................
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Rate energy level (1=low, 10=high) .............. Endurance ...................... Mental Clarity.................................
Memory ..........................................................................................................................................................
Health concerns, short term...........................................................................................................................
Health concerns, long term ............................................................................................................................
Dental history .................................................................................................................................................
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Family Health History.....................................................................................................................................
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Health History ................................................................................................................................................
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Other health practitioners currently seeing: (Please include professional designation and phone number)
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http://www.labryshealthcarecircle.com • info@labryshealthcarecircle.com
Labrys Healthcare Circle
6536 Telegraph Avenue, Suite A102, Oakland, CA 94609 • (510) 658-9066
Confidential Health History Form
Current prescription medications ...................................................................................................................
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Current food supplements..............................................................................................................................
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Stressors........................................................................................................................................................
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Trauma/Accidents ..........................................................................................................................................
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Abnormal lab tests in the last 2 years ............................................................................................................
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Allergies to foods, airbornes, contactants ......................................................................................................
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Toxins encountered at work or home.............................................................................................................
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Addictions/Cravings .......................................................................................................................................
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Periods of Malnutrition/dieting........................................................................................................................
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Smoker now? How long? .........................................If in past, for how long? ................................................
Average amount of sleep per night ................................................................................................................
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Amount of water consumed per day ..............................................................................................................
Other comments ............................................................................................................................................
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Signature.....................................................................................................Date
http://www.labryshealthcarecircle.com • info@labryshealthcarecircle.com
Metabolic Assessment Formtm
Name: ___________________________________________ Age: ______ Sex: _____
Date: ______________
PART I
Please list your 5 major health concerns in order of importance:
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
PART II
Please circle the appropriate number on all questions below.
0 as the least/never to 3 as the most/always.
Category I Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
Category II
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Abdominal intolerance to sugars and starches
Category III Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc
Multiple smell and chemical sensitivities
Constant skin outbreaks
Category IV
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Category V
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or
carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus,
peppers, alcohol, and caffeine
Category VI
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
© 2013 Datis Kharrazian. All Rights Reserved.
SMGEMAF04(061313)
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0
1
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0
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1
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3
3
Category VI (Cont.)
Nausea and/or vomiting
Stool undigested, foul smelling, mucous like,
greasy, or poorly formed
Frequent urination
Increased thirst and appetite
0
1
2
3
0
0
0
1
1
1
2
2
2
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1
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0
0
0
1
1
1
1
Yes
Category VIII
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat
0
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1
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Category IX Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision
0
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3
Category X
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
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1
1
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2
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2
3
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3
Category VII
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours
after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to
normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.
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No
Category XI
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
Category XII
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little
or no activity
Category XIII
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing
Category XIV
Tired/sluggish
Feel cold―hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive
hair loss
Dryness of skin and/or scalp
Mental sluggishness
Category XV
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
0
0
0
0
0
0
0
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1
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3
3
Category XV (Cont.)
Night sweats
Difficulty gaining weight
0
0
1
1
2
2
3
3
Category XVI (Males Only)
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category XVII (Males Only)
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
0
0
0
0
0
0
0
0
0
0
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1
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3
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3
3
3
3
3
3
3
Category XVIII (Menstruating Females Only)
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning
0
0
0
0
0
0
0
0
0
Yes
Yes
Yes
Yes
1
1
1
1
1
1
1
1
1
Category XIX (Menopausal Females Only)
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching
_______ years
Yes No
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
PART III
How many alcoholic beverages do you consume per week? Rate your stress level on a scale of 1-10 during the average week:
How many caffeinated beverages do you consume per day? How many times do you eat fish per week?
How many times do you eat out per week?
How many times do you work out per week?
How many times do you eat raw nuts or seeds per week?
List the three worst foods you eat during the average week:
List the three healthiest foods you eat during the average week:
PART IV
Please list any medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
© 2013 Datis Kharrazian. All Rights Reserved.
SMGEMAF04(061313)
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