General Follow-Up Review Form Progress Notes To Be ...



***ERASE THIS TOO COMPREHENSIVE GENERAL FOLLOW-UP FORM ***

Remember to erase everything that is not written in black. Do not leave any colored writing!

At first glance this form may appear "overwhelming". However, when everything is erased that is any color other than black, and once all the extra space is erased that is not needed, you will find that this form will only take up a couple of pages. After it is completed for the first time, it can easily be modified with minimal work for all future follow-ups because most things will remain unchanged, e.g. your child's name, date of birth, what has worked, what has not worked, etc.

NOTE – ALL RED, GREEN, BLUE, AND LAVENDAR IS TO BE ERASED BEFORE SUBMITTING THIS FOLLOW-UP FORM FOR THE UPCOMING CONSULTATION! IN ADDITION, NEVER ERASE THE HEADING OF A SECTION, EVEN IF THE SECTION DOES NOT SEEM TO APPLY TO YOU.

Please complete this form a couple of days ahead of your phone consultation or office visit. ALWAYS TYPE THIS, EVEN IF YOU HAVE TO "HUNT AND PECK" SO THAT YOU WILL HAVE A TEMPLATE FOR ALL OTHER FOLLOW-UP APPOINTMENTS. ONCE DONE THE FIRST TIME, IT WILL ONLY TAKE A FEW MINUTES AT ALL OTHER APPOINTMENTS TO UPDATE IT BUT ONLY IF TYPED!

Be sure to read everything! It has been my experience that this often is overlooked.

As stated above, NEVER ERASE an underlined section heading. Please note that all sections are important to have an answer or a "does not apply". Please do not be too quick to put "does not apply" until you have thoughtfully considered each answer.

PLEASE REMEMBER, THE FIRST THING TO ERASE IS THIS LINE AND THE ABOVE PARAGRAPHS INCLUDING THE WORDS "COMPREHENSIVE GENERAL FOLLOW-UP FORM

Parent: With rare exceptions, these answers will not be known until after the first follow-up office visit.

MTHFR results were: _________ Indicate this when known; otherwise say unknown

Homocysteine results were: _____ Indicate this when known; otherwise say unknown

Vitamin D results were: ________ Indicate this when known; otherwise say unknown

Ferritin results were: _________ Indicate this when known; otherwise say unknown Carnitine results were: _________ Indicate this when known; otherwise say unknown

COMPREHENSIVE VERSION OF THE GENERAL FOLLOW-UP FORM

Consider this as your opportunity to enter as much data as possible into the doctor's computer (brain) so he can turn around, hit a button, and the computer generates a detailed printout of all the possibilities by pulling out of its various databases. THE MORE COMPLETELY AND THOUGHTFULLY YOU DO THIS, THE MORE INFORMATION THE DOCTOR WILL BE ABLE TO GIVE YOU IN ORDER TO HELP YOUR CHILD GET FURTHER MORE QUICKLY AND LESS EXPENSIVELY. REMEMBER TO ERASE ALL THE RED LETTERS IN THIS BOX

PARENTS: DO NOT ERASE ANY OF THE "UNDERLINED MAIN SECTIONS" SHOWN BELOW. HOWEVER, DO ERASE THESE WORDS IN RED AND THE “WHITE SPACE' LEFT BEHIND IN ORDER TO CLEAN UP THE DOCUMENT)

NAME:

DATE: Always be sure to update this (a common mistake if for it not to be changed)

YOUR DIAGNOSIS(ES):

DOB:

AGE IN YEARS AND MONTHS:

WEIGHT: Always be sure to update this (a common mistake if for it not to be changed)

WILL SWALLOW PILLS? (Not just the contents of):

WHAT DIET(S) ARE YOU CURRENTLY USING?: CFGF, CF only, GF only, SCD, LOD, phenol-free, salicylate-free, Feingold, allergy avoidance, other (IF NONE, WRITE NONE. REMEMBER TO ERASE ALL THE DIETS THAT DO NOT APPLY AND ANY EXTRA “WHITE SPACE” to clean up the document)

|PARENTS: THIS IS WHAT YOU DID FOR SECTION 'A-2' ON THE ASD QUESTIONNAIRE YOU PROVIDED AT THE INITIAL OFFICE VISIT. YOU CAN ADD |

|MORE THINGS IF YOU LIKE SO WE CAN TRACK THEM OVER TIME. |

|SYMPTOM SUMMARY RESPONSE TO TREATMENT |

|List the Major Symptoms your child had at your Initial Office Visit so that we will be able to follow your child’s response over |

|the duration of treatment; when applicable, add any new ones that appear over time. (Please note that this is a new section. For |

|our Established Patients – please complete using your child’s current status). |

| |

|Use a scale from 0 to 10 with 0 representing absent and 10 being the most severe. |

|NOTE THAT NO LANGUAGE IS AS BAD AS IT CAN GET SO IS GIVEN THE NUMBER “10”, NOT A “0” (ZERO)! |

|For each follow-up consultation enter the date in the column and grade the symptom. |

Symptom to be followed |Date 1 |Date 2 |Date 3 |Date 4 |Date 5 |Date 6 |Date 7 |Date 8 |Date 9 | | |IOV date

|1st F/U date

| | | | | | | | |1. | | | | | | | | | | |2. | | | | | | | | | | |3. | | | | | | | | | | |4. | | | | | | | | | | |5. | | | | | | | | | | |6. | | | | | | | | | | |7. | | | | | | | | | | |8. | | | | | | | | | | |9. | | | | | | | | | | |10. | | | | | | | | | | |11. | | | | | | | | | | |12. | | | | | | | | | | |

PRESCRIPTION MEDICATIONS: WHEN FINISHED ANSWERING, ERASE ALL RED, GREEN, AND BLUE. What medications are currently being taken, including methyl-B12 (name, dose, volume, if a liquid, the mg’s or mcg’s per unit volume, e.g. per cc = ml, per tsp; frequency, prescribing doctor, reason for taking) [Note that 5 mL = 1 tsp] ( read and follow all requirements. REMEMBER THAT EACH PART IS REQUIRED FOR A LIQUID~!

DID YOU MAKE SURE TO INDICATE THE NUMBER OF MILLIGRAMS TAKEN "PER DOSE" OF YOUR MEDICATION WHEN YOUR MEDICATION IS A LIQUID? IF NOT, PLEASE CORRECT THIS OVERSIGHT. REMEMBER THE VOLUME OF SOMETHING TELLS ME NOTHING ABOUT HOW STRONG THE MEDICINE IS YOU ARE TAKING, ONLY THE "SIZE" BEING TAKEN. FOR EXAMPLE, A SMALL CUP OF EXPRESSO COFFEE HAS MUCH MORE CAFFEINE (THE MEDICATION'S NAME) IN IT AND IS MUCH MORE POWERFUL THAN AN EIGHT OUNCE CUP OF DUNKIN'DONUTS COFFEE.

PUT SEVERAL STARS IN FRONT OF EACH PRESCRIPTION THAT NEEDS TO BE REFILLED FOR THE “NEXT ROUND = THE NEXT SIX WEEKS OR THREE MONTHS, ETC.” PLEASE PAY ATTENTION TO THIS REQUEST. THANK YOU.

REMEMBER TO MAKE BIG ******* STARS OR MANY *********** STARS IN FRONT OF EACH MEDICATIONS YOU NEED US TO REFILL. THIS DOES NOT MEAN FOR YOU TO STAR THE MEDICATIONS THAT WE HAVE PREVIOUSLY ORDERED REFILLS FOR YOU THAT THE PHARMACY HAS ON FILE. PLEASE CHECK YOUR PAST SIGNOUTS AND LOOK TO SEE THE DATE OF THE LAST PRESCRIPTION YOU ARE NEEDING TO BE REFILLED AND THEN SEE IF YOU REALLY NEED ANY UNTIL WE HAVE OUR NEXT APPOINTMENT AFTER THIS ONE.

REMEMBER TO ERASE ALL THE RED, GREEN, AND BLUE, AND LAVENDAR LETTERING HERE AND ABOVE.

1. MB12 concentration is xxxx mg/mL; the shot volume is 0.xxxx cc per shot; the frequency of the injections if for one shot to be given every xxxx day(s). ERASE IF MB12 IS NOT BEING GIVEN.

2. If the medication is a liquid follow this format and erase everything else that dose not apply: Name of medication; the concentration of the medication is xxxxx mg per (mL, teaspoon, etc); the volume of the medication is xxxxx (mL, teaspoons, etc); the frequency of the medication is one dose every xxxxx (hours, day, etc). ERASE IF THIS DOES NOT APPLY.

3.

4.

5.

6.

(ERASE ANY EXTRA NUMBERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

YOUR INSTRUCTIONS TO US AS WE CONSIDER HOW TO HANDLE YOUR CASE:

1. How limited am I in regards to your finances as to what treatments or tests I order? (Please note that this section is to let me know what you can really do, not what you would like to do. That way I can govern myself as to how I pace things, especially when a treatment may help a small percentage of children but be very expensive. You do not need to say that "we'll find the money somehow". This does not tell me how We will always talk about tests and their costs ahead of time so you do not need to write that "it depends upon what you want to do".)

2. How limited am I in ordering lab tests from financial reasons or just not wanting to let your child undergo blood tests, etc.?

3. Will you use prescription as well as non-prescription medications?

LABORATORY TESTS PENDING, DELAYED, OR NOT YET BACK FOR US TO REVIEW TODAY: a) that you completed and submitted but are still pending follow-up with the doctor; b) tests that have not been collected or submitted yet; c) tests that you have decided to delay; tests you have decided to not do at all. (Indicate for each test: i) when it was ordered; ii) if pending interpretation, the date scheduled/to be scheduled for the doctor to review; iii) if delayed, how long you anticipate the delay will be and the reason why; iv) if you have decided not to do the test, indicate the reason why in the section that will follow below.

[REMEMBER TO ERASE ALL THESE WORDS AND ANY EXTRA “WHITE SPACE” TO CLEAN THIS DOCUMENT]

1.

2.

3.

4.

5.

6.

(ERASE ANY EXTRA NUMBERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

TREATMENTS OR TESTS RECOMMENDED BUT THAT WE DECIDED NOT TO DO: (Indicate when the treatment or test was recommended, and if not by doctor Neubrander, then by whom, and why you decided not to do it) [WHEN DONE READING THIS SECTION, ERASE THE ENTIRE SET OF WORDS AND ANY “WHITE SPACE” TO CLEAN UP THE DOCUMENT]

1.

2.

3.

4.

(ERASE ANY EXTRA NUMBERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

METHYL-B12: (ERASE ALL WORDS AND ANSWERS THAT DO NOT APPLY AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT)

1. Is your child a METHYL-B12 RESPONDER? Yes. No

2. If yes, indicate if your overall response is a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

3. If yes, when did you start?

4. If yes, does you child do better on daily, every other day, or every three day shots?

5. “We are on our xxxx cycle of MB12” and have been receiving MB12 for xxxx months.

A cycle is not the number of shots but the number of times between follow-up consultations to review the results. [When finished reading this definition, erase it entirely to “clean up the document”]

6. Use the space below to describe anything you would like us to know about your child’s response to methyl-B12 in general. If you have nothing to say, write the words "not applicable" or the abbreviation "NA". Then erase the red lettering and any extra “white space” to clean up the document.

(ERASE ALL WORDS AND ANSWERS ABOVE THAT DO NOT APPLY. REMOVE ALL WORDS IN RED OR BLUE. REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT)

HYPERBARIC OXYGEN: [IF HYPERBARIC TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

1. Is your child an HBOT RESPONDER? Yes. No.

2. If yes, indicate if your overall response is a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

3. If yes, did he or she respond to a hard chamber, soft chamber, or both?

4. If to both, to which one better, hard or soft?

5. “We have completed xxxx total hours of soft chamber HBOT sessions”:

6. If you have done soft chamber sessions, indicate if your child’s overall response as a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

7. “We have completed xxxx total hours of hard chamber HBOT sessions”:

8. If yes, indicate if your child’s overall response as a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant ([Choose only one answer and erase all the rest that do not apply and erase these words in red]

9. Use the space below to describe anything you would like us to know about your child’s response to hyperbaric oxygen treatment in general. If you have nothing to say, write the words "not applicable" or the abbreviation "NA". Then erase the red lettering and any extra “white space” to clean up the document.

[IF HYPERBARIC TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

NEUROFEEDBACK: [IF NEUROFEEDBACK TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

1. Is your child a NEUROFEEDBACK RESPONDER? Yes. No

2. If yes, indicate if your overall response is a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

3. If yes or no, when did you start?

4. If yes or no, approximately how many sessions have you done to date with a technician?

4. If yes or no, how many sessions do you average a week completed with a technician?

5. If yes or no, how many sessions a week do you do alone as "practice sessions"?

6. Use the space below to describe anything you would like us to know about your child’s response to neurofeedback treatments in general. If you have nothing to say, write the words "not applicable" or the abbreviation "NA". Then erase the red lettering and any extra “white space” to clean up the document.

[IF NEUROFEEDBACK TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

CHELATION: [IF CHELATION TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

1. Is your child a CHELATION RESPONDER? Yes. No.

2. If yes, indicate if your overall response is a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

3. What agent or agents worked best: EDTA, DMPS, DMSA, natural agent(s), etc?

4. What route of administration worked best, e.g. oral, suppository, IV, transdermal?

5. How many total months have you chelated to date (with or without a break)?

6. Use the space below to describe anything you would like us to know about your child’s response to major chelation in general or to any specific types of “chelating agents” or chelation protocols. If you have nothing to say, write the words "not applicable" or the abbreviation "NA". Then erase the red lettering and any extra “white space” to clean up the document.

[IF CHELATION TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

INTRAVENOUS TREATMENTS: [IF INTRAVENOUS TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

1. Have you ever used IV treatments? Yes. No.

2. If yes, indicate if your overall response is a) mild; b) mild-to-moderate; c) moderate; d) moderate-to-significant; e) significant [Choose only one answer and erase all the rest that do not apply and erase these words in red]

3. If yes, what type of IV treatments have you ever used, e.g. glutathione, vitamin C, phosphatidylcholine, secretin, vitamins and minerals, etc?

4. For each type of IV used, indicate your child's responsiveness or apparent lack thereof.

5. Use the space below to describe anything you would like us to know about your child’s response to intravenous treatment in general that is not indicated above. If you have nothing to say, write the words "not applicable" or the abbreviation "NA". Then erase the red lettering and any extra “white space” to clean up the document.

[IF INTRAVENOUS TREATMENT HAS NOT BEEN DONE, DO NOT ERASE THE UNDERLINED HEADING. WRITE THE WORDS "NOT DONE". THEN ERASE THE REST OF THIS ENTIRE SECTION AND REMOVE ANY EXTRA “WHITE SPACE” TO CLEAN UP THE DOCUMENT.]

1. What treatments are you currently doing? (Remember to list MB12 if it is one of the treatments. If giving supplements, just write the word supplements. Do not list each one separately. Remember to erase these words in red)

a)

b)

c)

d)

e)

(ERASE ANY EXTRA LETTERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

2. What treatments have you tried that have not worked?

a)

b)

c)

d)

e)

(ERASE ANY EXTRA LETTERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

3. What treatments do you want to try now or in the future?

a)

b)

c)

d)

e)

(ERASE ANY EXTRA LETTERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

4. What are you afraid to try?

a)

b)

c)

d)

e)

(ERASE ANY EXTRA LETTERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

5. What do you need to have better explained to you?

a)

b)

c)

d)

e)

(ERASE ANY EXTRA LETTERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

6. How are you feeling about all phases of life right now, e.g. overwhelmed, hopeful, discouraged, encouraged, situations at home, school, etc?

HOW HAS YOUR CHILD BEEN DOING SINCE THE BEGINNING OF TREATMENT AND FROM THE LAST CONSULTATION (Be specific; give as many examples as possible. Remember that how things were before and how they are now with an intensity grading when appropriate helps document changes and progress best) [WHEN FINISHED READING THIS DEFINITION, ERASE IT TO “CLEAN UP THE DOCUMENT”]

YOUR QUESTIONS FOR THE DOCTOR TODAY (Be specific. Ask your questions in detail with complete sentences. Do not just use a few words that mean something to you but do not mean anything specific to us. WHEN FINISHED READING THIS DEFINITION, ERASE IT TO CLEAN UP THE DOCUMENT):

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

(ERASE ANY EXTRA NUMBERS AND “WHITE SPACE” NOT NEEDED TO CLEAN UP THE DOCUMENT)

REVIEW YOUR ANSWERS. ERASE ALL RED, GREEN, LAVENDAR, AND BLUE WRITING. ERASE ANY EXTRA SPACE, LETTERS, OR NUMBERS NOT NEEDED IN ORDER TO "CLEAN UP THE DOCUMENT" SO THAT IT IS EASY TO READ AND SO THAT IT DOES NOT WASTE PAPER. REMEMBER TO ERASE THIS PARAGRAPH ALSO. THANK YOU.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download