Electro Interstitial Scan (E.I.S.) System Application

C A M OPTIONS, INC.

Referred by:

Anthony Speroni, N.D., N.H.D., President, Chief Consultant

Primary goal(s):

Dr. of Naturopathy ¡ñ Dr. of Natural Health ¡ñ Board Certified

Hypnotherapist ¡ñ Complementary and Alternative Medicine (CAM) Specialist

UNITED STATES

1337 Settlers Loop East

Geneva, FL 32732-9332

Voice: 407-349-5100

Fax: 407-349-0030

INTERNATIONAL

Fax Phones:

Netherlands (31)

Amsterdam, Holland

020 884 6766

United Kingdom (44)

London, England

0870 063 4778

INTERNET

Websites:





E-mail:

DrAnthony@

Electro Interstitial Scan (E.I.S.) System Application

Today¡¯s Date _

/

/_______

Basic Contact Data Section

Name: Last

First

Date of Birth (mm/dd/yyyy)

/

Gender (M/F) ___

/

Telephone (______) _______-_________

Marital Status: ___________________________

Number of children _______

_________________________

Home Street Address

_______

City

State

_________________________

Work Street Address

_______

City

Occupation

Zip _____________

________

State

Zip _____________

Insurance policy number _________________

E-mail address: _____________________________________

________

___

Basic Identification Data Section

Height _____ Weight _____ Blood Pressure Systolic ______ Diastolic _____ Pulse _____

Race (Circle One)

Unknown White (Caucasian) Black African Japanese Chinese Indian Korean South American Other

CONSULTATIONS SERVICES:

Acupressure Frequencies

Ayurveda

Bioenergetics

Bach Flower Remedies

Biofeedback

Botanicals

Chelation

Chinese & Western Herbs

Detoxification

Electro Interstitial Scans

Gemmotherapy & Oligotherapy

Homeopathy Frequencies

Hypnotherapy

Iridology

Kinesiology

L.I.F.E. System

Mind-Body Optimization

Natural Health Alternatives

Naturopathy

Neuro-Linguistic Programming

Nutrition Optimization

Nutritional Supplements

Pain Management

Rife Frequencies

Spiritual Direction

Visualization

Weight Management

Wellness Optimization

Blood Type (Circle One)

Rhesus factor (Circle One)

Not Known, O, A, B, AB

Not Known, Rh+, RhLifestyle (Check One) [__] Sedentary [__] Athletic (3 times/week workouts)

Age ____

E.I.S. Measurement & Calculation Limitation Restrictions (Check all that apply.)

[__]

[__]

[__]

[__]

[__]

[__]

[__]

[__]

[__]

[__]

[__]

[__]

I have an absence of one or more limbs < STOP> Scan can not be conducted

I am unable to be held upright or seated < STOP> Scan can not be conducted

I am in my 6th month or later of pregnancy < STOP> Scan can not be conducted

I have an implanted electronic device (pacemaker) < STOP> Scan can not be done

I performed intense physical activity within the last 8 hours

I have dermatological lesions on my hands, feet, or forehead

I am experiencing excessive accumulation of body fluid (edema)

I consumed alcohol or stimulants (amphetamines) with the last 12 hours

I have metal pins or prostheses on the level of the extremities or the joints

I have diarrhea

[__] I am taking non-prescription drugs

I am wearing metal objects

[__] I have a fever

I am wearing an electromagnetic field (EMF) protection disk or device (remove now)

Primary reason(s) for scan (issue, complaint, illness, pain):

1234[__] more on attached ¡­

[__] I am taking medication

1234[__] more on attached ¡­

[__] I have one or more questions written on the reverse side hereof or attached hereto.

[__] I have one or more fears or concerns about the scan, written on a paper attached hereto.

[__] I am a smoker of tobacco [__] I am suffering from an addiction: _________________

(Version 20070624)

Page # 1 of 8 pages.

C A M OPTIONS, INC.

Electro Interstitial Scan (E.I.S.) System Application

Page # 2 of 8 pages

Clinical Context Section

Clinical Context Section

Please read thoroughly and check all that apply in all of the following categories.

CHECK-UP

[__] NO SYMPTOM, NO TREATMENT

GENERAL SYMPTOMS

[_] Abscess (inflamed area of pus)

[_] Allergy (highly sensitive to a substance)

[_] Anemia (deficient oxygen-carrying blood)

[_] Anguish (physical or mental pain; regret)

[_] Anorexia (abnormal loss of appetite)

[_] Asthenia (loss of body strength)

[_] Childhood attention deficit disorder

(impulsive & short attention span)

[_] Confusion (impaired mental state)

[_] Contusions (bruising)

[_] Convalescence (recovery from illness)

[_] Cysts (abnormally filled membranous sac)

[_] Depression insomnia (sleep disorder)

[_] Difficult child (temper & behavior issues)

[_] Discomfort (mental or physical distress)

[_] Drowsiness (sluggish & sleepy)

[_] Emotional (abnormally affected by things)

[_] Eschars (dry scabs)

[_] Excessive weight (>20 pounds overweight)

[_] Fasting hypoglycemia (low blood sugar on

empty stomach)

[_] Fever (abnormally high body temperature)

[_] Fistula (abnormal duct inside body)

[_] Furunculosis (skin condition of

recurring boils)

[_] Gangrene of the lower limbs (decay of)

[_] Geriatric disorders (aging issues)

[_] Hyperactivity (unusually highly active)

[_] Hyperhidrosis (excessive sweat)

[_] Hyperthermia (high body temperature)

[_] Hypothermia (low body temperature)

[_] Hypotonia (body tissues or organ subnormal firmness or functional readiness)

[_] Infectious disease, virus

[_] Injuries

[_] Insomnia (sleep disorder)

[_] Local Inflammation (swollen area)

[_] Masculine sexual deficiency (impotence)

[_] Nails and hair (weak, brittle, cracking, etc.)

[_] Nervosity (excessive nervousness)

[_] Obesity (grossly overweight)

[_] Pain in a phantom limb (missing limb)

[_] Phlegmatic (excessive phlegm)

[_] Postoperative and post-traumatic edema

(excessive accumulation of serous fluid in

tissue spaces or a body cavity after trauma)

[_] Pregnancy

[_] Premature ageing (getting old too soon)

[_] Premature ejaculation (sexual dysfunction)

[_] Quincke's oedema (transient edema)

[_] Reactive Hypoglycemia (low blood sugar

occurring 1 - 2 hours after eating)

[_] Recent emotional shock (substantial

distress)

[_] Senility (mind/body deterioration with age)

[_] Slightest resistance to an infection

[_] Smoker (any inhaled tobacco use)

[_] Stress (extreme mind or body difficulty)

[_] Vagotonia (vagus nerve over-activity

or irritability affecting blood vessels,

stomach, and muscles)

[_] Vertigo (confused, disoriented mind status)

[_] Weight gain by water retention

[_] Hyposialy (too little saliva)

[_] Parodontosis (gum disease)

[_] Taste disorders

[_] Tongue bright red and smooth

[_] Tongue Inflammation (swollen or pained)

[_] Gastric cancer (stomach)

[_] Left breast cancer

[_] Leukemia (white blood cells cancer)

[_] Liver cancer

[_] Lymphomas (malignant tumors of lymph

nodes or other lymphoid tissue)

[_] Melanomas (malignant tumor in skin)

[_] Oral cancer (mouth)

[_] Oropharyngeal cancer (part of the pharynx)

[_] Ovarian cancer (female only)

[_] Pancreatic cancer

[_] Prostate cancer (male only)

[_] Pulmonary cancer (lungs)

[_] Right breast cancer

[_] Testicular cancer (testicles ¨C male only)

[_] Congenital malformation (from birth)

[_] Coronopathy (coronary diseases)

[_] Disorders of the blood circulation

[_] Heart murmur (unusual heart sound)

[_] Hypertension (high blood pressure)

[_] Hypotension (low blood pressure)

[_] Infarction (heart tissue death due to no O2)

[_] Ischemic cardiac disease (low blood flow)

[_] Left ventricular hypertrophy (enlargement)

[_] Loss of breath

[_] Lower limbs arteritis (inflamed artery)

[_] Myocarditis (inflamed heart muscle tissue)

[_] Pericardium rustling (fluttering)

[_] Raynaud's phenomenon (restricted blood

flow to hands)

[_] Right ventricular hypertrophy (enlarged)

[_] Stenocardia (coronary arteries obstruction)

[_] Stroke (sudden death of some brain cells)

[_] Tachycardia (heartbeat >= 100 per minute)

[_] Thoracic pains (in, near, or of thorax)

[_] Triglycerides (ester [organic compound] of

three fatty acids and glycerol that is the

chief constituent of fats and oils)

[_] Venous Thrombosis (vein clotting)

DENTAL DISORDERS

[_] Amalgams (mercury/silver dental fillings)

[_] Gingival bleeding (gums bleed)

[_] Halitosis (bad breath)

[_] Hypersialy (excess saliva)

CANCEROUS ATTACKS

[_] Acute lymphocytic leukemia of a child

([ALL] white blood cells cancer)

[_] Bladder cancer

[_] Bony types (bones)

[_] Cancer of the uterus (female only)

[_] Cerebral cancer

[_] Colon cancer

[_] Colorectal cancer (colon & rectum)

CARDIVOASCULAR DISORDERS

[_] A.A.R. (acute articular rheumatism)

(inflamed of the muscles, tendons, joints,

bones, or nerves with pain)

[_] Arrhythmia (irregular heartbeat)

[_] Arterial stenosis (artery narrowing)

[_] Arterial Thrombosis (artery clotting)

[_] Arteriosclerosis (artery thickening)

[_] Auricular fibrillation (twitching)

[_] Bradycardia (slow heart rate ................
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