Referred by: C A M OPTIONS, INC. Anthony Speroni, N.D., N.H.D., President, Chief Consultant Primary goal(s): Dr. of Naturopathy ● Dr. of Natural Health ● Board Certified Hypnotherapist ● Complementary and Alternative Medicine (CAM) Specialist
UNITED STATES Electro Interstitial Scan (E.I.S.) System Application 1337 Settlers Loop East Geneva, FL 32732-9332 Today’s Date _ / /______
Voice: 407-349-5100 Basic Contact Data Section Fax: 407-349-0030 Name: Last First Gender (M/F) ___
INTERNATIONAL Date of Birth (mm/dd/yyyy) / / Telephone (______) ______-______
Fax Phones: Marital Status: ______Number of children ______Netherlands (31) Amsterdam, Holland Home Street Address ______020 884 6766 City ______State Zip ______United Kingdom (44) London, England Work Street Address ______0870 063 4778 City ______State Zip ______
Occupation ______Insurance policy number ______INTERNET Websites: E-mail address: ______www.DrSperoni.com www.DrAnthonySperoni.com Basic Identification Data Section
E-mail: Height _____ Weight _____ Blood Pressure Systolic ______Diastolic _____ Pulse _____
[email protected] Race (Circle One) Unknown White (Caucasian) Black African Japanese Chinese Indian Korean South American Other
Blood Type (Circle One) Rhesus factor (Circle One) Not Known, O, A, B, AB Not Known, Rh+, Rh-
Lifestyle (Check One) [__] Sedentary [__] Athletic (3 times/week workouts) Age ____ CONSULTATIONS SERVICES: Acupressure Frequencies Ayurveda E.I.S. Measurement & Calculation Limitation Restrictions (Check all that apply.) Bioenergetics [__] I have an absence of one or more limbs < STOP> Scan can not be conducted Bach Flower Remedies [__] I am unable to be held upright or seated < STOP> Scan can not be conducted Biofeedback [__] I am in my 6th month or later of pregnancy < STOP> Scan can not be conducted Botanicals [__] I have an implanted electronic device (pacemaker) < STOP> Scan can not be done Chelation Chinese & Western Herbs [__] I performed intense physical activity within the last 8 hours Detoxification [__] I have dermatological lesions on my hands, feet, or forehead Electro Interstitial Scans [__] I am experiencing excessive accumulation of body fluid (edema) Gemmotherapy & Oligotherapy [__] I consumed alcohol or stimulants (amphetamines) with the last 12 hours Homeopathy Frequencies [__] I have metal pins or prostheses on the level of the extremities or the joints
(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) [_] Fever (abnormally high body temperature) [_] Phlegmatic (excessive phlegm) [_] Allergy (highly sensitive to a substance) [_] Fistula (abnormal duct inside body) [_] Postoperative and post-traumatic edema [_] Anemia (deficient oxygen-carrying blood) [_] Furunculosis (skin condition of (excessive accumulation of serous fluid in [_] Anguish (physical or mental pain; regret) recurring boils) tissue spaces or a body cavity after trauma) [_] Anorexia (abnormal loss of appetite) [_] Gangrene of the lower limbs (decay of) [_] Pregnancy [_] Asthenia (loss of body strength) [_] Geriatric disorders (aging issues) [_] Premature ageing (getting old too soon) [_] Childhood attention deficit disorder [_] Hyperactivity (unusually highly active) [_] Premature ejaculation (sexual dysfunction) (impulsive & short attention span) [_] Hyperhidrosis (excessive sweat) [_] Quincke's oedema (transient edema) [_] Confusion (impaired mental state) [_] Hyperthermia (high body temperature) [_] Reactive Hypoglycemia (low blood sugar [_] Contusions (bruising) [_] Hypothermia (low body temperature) occurring 1 - 2 hours after eating) [_] Convalescence (recovery from illness) [_] Hypotonia (body tissues or organ sub- [_] Recent emotional shock (substantial [_] Cysts (abnormally filled membranous sac) normal firmness or functional readiness) distress) [_] Depression insomnia (sleep disorder) [_] Infectious disease, virus [_] Senility (mind/body deterioration with age) [_] Difficult child (temper & behavior issues) [_] Injuries [_] Slightest resistance to an infection [_] Discomfort (mental or physical distress) [_] Insomnia (sleep disorder) [_] Smoker (any inhaled tobacco use) [_] Drowsiness (sluggish & sleepy) [_] Local Inflammation (swollen area) [_] Stress (extreme mind or body difficulty) [_] Emotional (abnormally affected by things) [_] Masculine sexual deficiency (impotence) [_] Vagotonia (vagus nerve over-activity [_] Eschars (dry scabs) [_] Nails and hair (weak, brittle, cracking, etc.) or irritability affecting blood vessels, stomach, and muscles) [_] Excessive weight (>20 pounds overweight) [_] Nervosity (excessive nervousness) [_] Vertigo (confused, disoriented mind status) [_] Fasting hypoglycemia (low blood sugar on [_] Obesity (grossly overweight) [_] Weight gain by water retention empty stomach) [_] Pain in a phantom limb (missing limb)
DENTAL DISORDERS [_] Amalgams (mercury/silver dental fillings) [_] Hyposialy (too little saliva) [_] Tongue bright red and smooth [_] Gingival bleeding (gums bleed) [_] Parodontosis (gum disease) [_] Tongue Inflammation (swollen or pained) [_] Halitosis (bad breath) [_] Taste disorders [_] Hypersialy (excess saliva)
CANCEROUS ATTACKS [_] Acute lymphocytic leukemia of a child [_] Gastric cancer (stomach) [_] Oropharyngeal cancer (part of the pharynx) ([ALL] white blood cells cancer) [_] Left breast cancer [_] Ovarian cancer (female only) [_] Bladder cancer [_] Leukemia (white blood cells cancer) [_] Pancreatic cancer [_] Bony types (bones) [_] Liver cancer [_] Prostate cancer (male only) [_] Cancer of the uterus (female only) [_] Lymphomas (malignant tumors of lymph [_] Pulmonary cancer (lungs) [_] Cerebral cancer nodes or other lymphoid tissue) [_] Right breast cancer [_] Colon cancer [_] Melanomas (malignant tumor in skin) [_] Testicular cancer (testicles – male only) [_] Colorectal cancer (colon & rectum) [_] Oral cancer (mouth)
CARDIVOASCULAR DISORDERS [_] A.A.R. (acute articular rheumatism) [_] Congenital malformation (from birth) [_] Pericardium rustling (fluttering) (inflamed of the muscles, tendons, joints, [_] Coronopathy (coronary diseases) [_] Raynaud's phenomenon (restricted blood bones, or nerves with pain) [_] Disorders of the blood circulation flow to hands) [_] Arrhythmia (irregular heartbeat) [_] Heart murmur (unusual heart sound) [_] Right ventricular hypertrophy (enlarged) [_] Arterial stenosis (artery narrowing) [_] Hypertension (high blood pressure) [_] Stenocardia (coronary arteries obstruction) [_] Arterial Thrombosis (artery clotting) [_] Hypotension (low blood pressure) [_] Stroke (sudden death of some brain cells) [_] Arteriosclerosis (artery thickening) [_] Infarction (heart tissue death due to no O2) [_] Tachycardia (heartbeat >= 100 per minute) [_] Auricular fibrillation (twitching) [_] Ischemic cardiac disease (low blood flow) [_] Thoracic pains (in, near, or of thorax) [_] Bradycardia (slow heart rate <60/minute) [_] Left ventricular hypertrophy (enlargement) [_] Triglycerides (ester [organic compound] of [_] Cardiac insufficiency (Heart failure) [_] Loss of breath three fatty acids and glycerol that is the [_] Cerebral Hemorrhage (ruptured blood chief constituent of fats and oils) vessel in brain) [_] Lower limbs arteritis (inflamed artery) [_] Venous Thrombosis (vein clotting) [_] Cholesterol (imbalance of) [_] Myocarditis (inflamed heart muscle tissue) [_] Coagulation problem (blood clotting)
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DERMATOLOGICAL DISORDERS [_] Acne (eruption of pimples, usually on face) [_] Erythematous Lupus (Lupus erythematous) [_] Petechies ([petechiae] minute red spots) [_] Alopecia (hair loss / baldness) chronic inflammatory autoimmune disease [_] Pruritis (itchy skin) [_] Angiomas (tumors) [_] Exanthema (disease with skin eruption) [_] Psoriasis (reddish skin patches & scales) [_] Cellulite (fatty deposit affecting form) [_] Hematoma (localized swelling of blood) [_] Purpura (small skin hemorrhage) [_] Chilblain (recurrent localized itching, [_] Herpes (blistering viral disease) [_] Pyodermia ([pyoderma] pus infected) swelling of the fingers, toes, or ears) [_] Hyperkeratosis (excessive skin growth) [_] Scars pustule (pus-filled pimple) [_] Cracked skin [_] Icterus (jaundice) skin yellowness [_] Scleroderma (hardening of skin) [_] Cutaneous mycosis (skin fungal infection) [_] Impetigo (bacterial skin infection) [_] Sunburn (inflamed skin from sunlight) [_] Cyanosis (bluish skin from low oxygen) [_] Interdigital mycosis (Athlete's foot - fungi) [_] Ulcerations (skin lesion or infected patch) [_] Dermatitis (skin inflammation) [_] Keloidic scars ([cheloid] raised fibrous) [_] Urticaria (hives) [_] Dry skin [_] Lichen (patchy skin eruptions disease) [_] Vesicles (fluid in a small sac or cyst) [_] Eczema (redness, itching, inflamed skin) [_] Neurodermatitis (inflamed, scaly skin) [_] Zoster (acute viral infection; shingles) [_] Erythematic (skin capillaries congested)
PAIN AFFECTIONS [_] Axillary pain ([axilla] armpit) [_] Headache with digestive problem [_] Right breast pain [_] Cervical pain (neck) [_] Left arm, left wrist or left hand pain [_] Right foot, right knee, or right leg pain [_] Chronic pain (frequent recurrence of pain) [_] Left breast pain [_] Right thumb pain [_] Decompression headache (from diving) [_] Left foot, left knee, or left leg pain [_] Tension headache [_] Digestive pain (breaking down of food) [_] Left thumb pain [_] Thoracic pain (chest pain) [_] Epigastric pain (upper-middle stomach) [_] Liver pain [_] Thoracic vertebras pain (spine/chest pain) [_] Eyes pain [_] Lumbar pain (lower back) [_] Urogenital congestion (urinary & genital) [_] Face pain [_] Right arm, right wrist or right hand pain [_] Urogenital pain (urinary and genital) [_] Headache
ENDOCRINE DISORDERS [_] Amenorrhea (absence of menstruation) [_] Growth disorders [_] Menopause (aged female hormone decline) [_] Andropause (aged male hormone decline) [_] Hypermenorrhea (heavy menstruation) [_] Menopause disorders [_] Belated puberty (delayed onset of puberty) [_] Hyperthyreosis (disturbance in thyroid) [_] Nausea and vomiting of pregnancy [_] Breast fissures (cracklike sore or ulcer) [_] Hypomenorrhoea (light menstrual periods) [_] Painful menstruation [_] Collapsus ([Collapse] deflation) [_] Hypophyseal dysfunction (pituitary gland) [_] Spontaneous abortion [_] Colpitis (inflamed vagina; vaginitis) [_] Hypothyreosis ([hypothyroidism] insuffic- [_] Sterility (incapable of reproduction) [_] Cushing's Syndrome (complex hormonal ient production of thyroid hormones) [_] Thyroid nodules (small tissue mass) condition) [_] Insulin-resistant diabetes [_] Thyroidal dysfunction [_] Dysmenorrhea (painful menstruation) [_] Late menstruation [_] Type I insulin-dependent diabetes [_] Endometriosis (endometrial cells grow [_] Mastitis (inflamed breast) outside the uterus) [_] Type II non insulin-dependent diabetes [_] Mastodynia (breast pain; also mammalgia) [_] Goiter (enlarged thyroid gland)
GASTROINTESTINAL DISORDERS [_] Alimentary hepatitis (digestive inflamed [_] Digestive inflammation (swelling or pain) [_] Intestinal spasms in children liver) [_] Digestive intolerance (sensitivity / allergy) [_] Intestinal stasis (ileus {obstruction}) or [_] Anal fissure (cracklike sore or ulcer) [_] Drug-related hepatitis (inflamed liver) occlusion {closure of passageway}) [_] Appendicitis (inflamed appendix) [_] Duodenal ulcer (duodenum lesion) [_] Megacolon (abnormal colon enlargement) [_] Bacterial flora disorders (microorganisms) [_] Duodenitis (inflamed duodenum) [_] Nausea (sick stomach with urge to vomit) [_] Burns [_] Dysentery (inflamed lower intestinal tract) [_] Obstructive hepatitis (blocked up liver) [_] Chronic hepatitis (liver inflammation) [_] Dyspepsia (indigestion) [_] Polyps (protruding growths) [_] Chronic pancreatitis (inflamed pancreas) [_] Enterocolitis (inflammation of both the [_] Pyrosis (heartburn) [_] Cirrhosis of the liver (hardening) small intestine and the colon) [_] Rectal Prolapsus (slipped out of place) [_] Colitis (inflamed colon; colonitis) [_] Epigastric Syndrome (upper middle) [_] Spasmodic colitis (spasmodic colonitis) [_] Constipation (hardened feces in bowels) [_] Gastric acidosis (abnormal acidity) [_] Stomach ulcer (stomach lesions) [_] Constipation (more than 5 years) [_] Gastritis (stomach inflammation) [_] Ulcer (lesion) [_] Diarrhoea ([diarrhea] watery feces) [_] Gastro-enteritis (inflamed mucous [_] Vesicular lithiase (Pathological formation [_] Digestion disorders membrane of stomach and intestines) of mineral concretions in body) [_] Digestive allergies or alimentary [_] Gastro-esophageal reflux (Hiatus hernia) [_] Viral hepatitis (inflamed liver with virus) intolerances (extreme sensitivity) [_] Hemorrhoids (swollen dilated veins) [_] Vomiting (throwing up food) [_] Digestive hemorrhage (profuse bleeding) [_] Hiatal hernias (part of stomach protrusion through diaphragm)
IMMUNE DISORDERS [_] AIDS [_] Autoimmune disease (body turns against [_] Immune depression (weakened immunity) (acquired immune deficiency syndrome) its own cells)
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NEUROLOGICAL DISORDERS [_] Acroparesthesia (abnormal sensations in [_] Depression (extended debilitating sadness) [_] Neurasthenia (nervous system exhaustion) extremities) [_] Encephalitis (brain inflammation) [_] Paralyses (impaired movement) [_] Alzheimer disease (cognitive ability losses) [_] Facial paralysis (impaired movement) [_] Paraplegia (full lower-body paralysis) [_] Attention-Deficit/Hyperactivity Disorder [_] Gilles de Latourette ([Tourette's syndrome] [_] Paresthesy (feelings in peripheral nerves) (ADHD) children body tics & obscenities) [_] Parkinson Disease (disease of nerves) [_] Behavioral disorders (misbehaving) [_] Memory disorders (recall issues) [_] Polyneuritis (many inflamed nerves) [_] Cerebral circulation disorders (brain) [_] Motor excitation (very stimulated activity) [_] Schizophrenia (psychotic disorder) [_] Climatic neurosis (climate disorder) [_] Multiple sclerosis (central nervous system [_] Slow intellectual activity (smartness) [_] Concussion (violent injury to head/brain) disease) [_] Trigeminal neuralgia (facial nerve pain) [_] Convulsions (intense muscular contraction) [_] Neuralgia (sudden onset of nerve pain)
NEUROMUSCULAR DISORDERS [_] Leg cramps (sudden, involuntary, [_] Myasthenia (muscular weakness or fatigue) [_] Spasmophilia (chronic muscle twitching) spasmodic muscular contraction causing [_] Myogelosis (abnormal muscle hardening) [_] Tenosite and tenosynovitis (inflamed severe pain) [_] Myotonia (decreased muscle tone) tendon and tendon sheath) [_] Lumbago (painful state in lower back) [_] Myxoedema (swollen lips & nose / thyroid) [_] Tetany (constant spasm - immobility) [_] Lumbago and sciatic nerve (low back/hip) [_] Sciatic left (related to hipbone region) [_] Torticolis (severe neck spasm) [_] Muscular ache (dull, steady pain in muscle) [_] Sciatic right (related to hipbone region) [_] Muscular weaknesses (little strength)
OCULAR DISORDERS [_] Nocturnal blindness (night) [_] Troubles of the retina (light-sensitive [_] Troubles of the vision (problems with [_] Ocular dryness (dry eyes) membrane lining the inner eyeball) eyesight)
ENT DISORDERS [_] Acouphenes (constant internal noise heard) [_] Epistaxis (nosebleed) [_] Middle ear otitis (inflammation) [_] Allergic rhinitis (inflamed nasal mucous [_] External otitis (inflammation of the ear) [_] Pharyngitis (inflamed throat / pharynx) membranes) [_] Frontal sinusitis (inflammation of sinuses) [_] Tonsillitis, flu (inflamed tonsils / flu) [_] Balance disorder (trouble standing) [_] Infectious parotiditis (mumps) [_] Vasomotor rhinitis (inflamed blood [_] Diminution of the hearing capability [_] Laryngitis (Inflammation of the larynx) vessels) [_] ENT Allergies (Ear, Nose, & Throat) [_] Maxillary sinusitis (jaw area inflammation)
BONE DISEASES [_] Arthritis (inflammation of a joint) [_] Lesion on intervertebral disks (infected or [_] Rheumatoid spondylitis ([ankylosing [_] Arthrosis (degenerative disease of a joint) diseased patch on spinal column vertebrae) spondylitis] inflamed spine/other joints) [_] Bony pains (pains in the bones) [_] Osteochondrosis (bone growth disease) [_] Sacroiliac imbalance (sacrum and ilium) [_] Cervical arthrosis (neck degeneration) [_] Osteomalacia (bone softening) [_] Scapulohumeral Periarthritis (a shoulder [_] Chronic rheumatoid polyarthritis (inflam- [_] Osteomyelitis (bone infection) joint inflammation) mation of many joints) [_] Osteopathy (musculoskeletal system) [_] Scintillating scotoma (diminished vision [_] Condyloma (a wartlike growth) edged by shimmering colored lights) [_] Osteopenia (decreased bone mass) [_] Deformation of the vertebrae (back) [_] Secondary sclerosis, amyotrophia [_] Osteoporosis (porous bone disease) [_] Discal lesions (injured vertebral disc) (wasting of muscle tissues) [_] Paget's disease (enlarged & weak bones) [_] Dupuytren's contraction (scarred and [_] Shoulder-hand syndrome (shoulder pain [_] Pain on mobilization (movement) curved 4th finger) with hand pain, swelling, & stiffness) [_] Periarthritis (inflammation around a joint) [_] Intercostal neuralgia (pain between ribs) [_] Spontaneous fractures (bone break) [_] Periostitis (bone surface inflammation) [_] Intermittent Claudication (leg muscles [_] Sprains or dislocations [_] Polyarthritis (many joints inflamed) lameness & pain due to poor blood supply) [_] Twisted ankle
[_] Joint disorders (like knees, elbows, etc.)
PULMONARY DISORDERS [_] Asthma (chronic respiratory disease) [_] Oedema or pulmonary embolism (swollen) [_] Respiratory insufficiency (lung failure) [_] Bradypnea (abnormal slow breathing) [_] Pleural rustling (fluid-filled cavity) [_] Strong cough (noisy expulsion of air from [_] Bronchectasia (dilation of bronchia) [_] Pleurisy (inflamed pleura [serous {body the lungs) [_] Chronic bronchitis (inflamed mucous fluid, usually watery} membrane]) [_] Tachypnea (abnormal rapid breathing) membrane in bronchial tubes) [_] Pneumonia (inflamed lungs) [_] Tuberculosis (infectious disease from [_] Chronic recurrent cough [_] Pneumothorax (air or gas in chest cavity) bacteria that effects lungs & any organ) [_] Dry cough, then secreting mucus [_] Pulmonary abscess (pus on lungs) [_] Whistling dyspnea (labored breathing) [_] Loss of breath when in an effort [_] Pulmonary inflammation (swollen lungs)
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RENAL AND UROGENITAL DISORDERS [_] Albuminury ([albuminuria] blood protein [_] Glomerulonephritis (inflamed kidney cells) [_] Pyelocystitis (inflamed renal pelvis & in urine) [_] Gynecological disorders (female organs) bladder) [_] Benign hypertrophy of the prostate [_] Hydronephrosis (excess urine in kidney) [_] Pyelonephritis (inflamed kidney & pelvis) (enlargement of prostate without cancer) [_] Intense thirst with abounding urines [_] Renal disorders (kidney problems) [_] Bladder stone [_] Leucorrhoea (whitish vaginal discharge) [_] Renal insufficiency (kidney failure) [_] Bursitis (inflamed shoulder, elbow, other) [_] Nephretic colic ([nephritic] kidney pain) [_] Renal Lithiasis (kidney stones {calculi}) [_] Cholangeitis, cholecystitis, cholelithiasis [_] Salpingitis (inflamed fallopian tube) (inflammation, bile duct/gallbladder stones) [_] Nephritis (chronic kidney inflammation) [_] Nephropathia (kidney abnormality/disease) [_] Tendo vaginitis ([tenovaginitis] inflamed [_] Cystalgia (bladder pain) tendon sheath) [_] Cystitis (bladder inflammation) [_] Nephrosclerosis (nephro-angiosclerosis) (diseased hardening of the kidney) [_] Urea (urine organic chemical compound) [_] Dacryocystitis (Inflamed tear glands) [_] Nephrosis (degenerative kidney lesions) [_] Urinary infections [_] Effort urinary incontinence (uncontrolled) [_] Parametritis (inflamed uterine connective [_] Uterine atonia (decreased uterine tone) [_] Endometritis (inflamed lining of uterus) tissue) [_] Uterine Prolapsus (slipped out of place) [_] Enuresia ([enuresis] involuntary urination) [_] Prostatitis (Inflamed prostate gland) [_] Vaginitis (inflammation of the vagina) [_] Fibroblastic induration of penis (hardening)
VENOUS AND LYMPHATIC DISORDERS [_] Congestion of the portal vein [_] Progressive lymphadenopathy [_] Varix (enlarged vein; artery; lymph vessel) [_] Oedema ([edema] swelling, inflammation) (disease of the lymph nodes) [_] Venous-lymphatic insufficiency (failure) [_] Painful lymphatic ganglions (nerves) [_] Sanguineous disorders of the circulation [_] Venous stasis (stopped flow in vein) [_] Painless lymphadenopathy (disease of the [_] Thrombophlebitis (inflamed vein due to lymph nodes) blood clot)
URINE ANALYSIS [_] Bilirubin (bile pigment found in blood) [_] Increase of the 17-cetosteroi [_] Presence of vanillylmandelic acid [_] Calcium (found in urine) [_] Increase of the urinary estrogens [_] Proteinury (excessive protein in urine) [_] Diminution of the 17-cetosteroi [_] Microscopic or macroscopic hematury [_] Pyury (pus in urine) [_] Germs in urine (excessive blood in the urine) [_] Uric acid (excessive amount in urine) [_] Glycosury (excessive glucose in the urine) [_] Plaquettes (excess fatty materials in urine)
BLOOD ANALYSIS [_] ASLO (antistreptolysine O of [_] Increase of phosphorus (element) [_] Presence of hemoglobin S the rheumatism) [antistreptolysin O] [_] Increase of reticulocytes (red blood cells) [_] Presence of macrocytary erythrocytes [_] Blood germs [_] Increase of sodium (metallic element) (abnormally large red blood cells) [_] BUN (sanguineous ureic nitrogen) [_] Increase of the cholesterol level [_] Presence of plasmodies (amoeboid cells) [_] Diminution of hematite (low iron mineral) [_] Increase of the hematite (red mineral) [_] Presence of spherocytes (sphere-shaped) [_] Diminution of tumoral markers (tumor) [_] Increase of the leucocytes (white cells) [_] Reduction of sodium [_] Eosinophily (type of white blood cell) [_] Increase of the lymphocytes (lymph cells) [_] Reduction of albumins [_] Hyperchromy (unusual intense color) [_] Increase of the monocytes (white cells) [_] Reduction of bicarbonates [_] Hypochromy (unusual dull color) [_] Increase of the serum's pH [_] Reduction of calcium [_] Increase glycaemia on an empty stomach ([glycemia] glucose in blood) [_] Increase of the SS (sedimentation speed) [_] Reduction of erythrocytes [_] Increase of potassium (in blood) [_] Increase of the thrombocytes (platelets) [_] Reduction of hemoglobin [_] Increase of alkaline phosphates (in blood) [_] Increase of the total albumin (proteins) [_] Reduction of iron [_] Increase of amylases (enzyme in blood) [_] Increase of triglycerides (fatty acids +) [_] Reduction of phosphorus [_] Increase of ASAT (aspartate-amino- [_] Increase of tumoral markers (tumor) [_] Reduction of potassium transferase - enzyme of amino group) [_] Increase of uric acid [_] Reduction of reticulocytes [_] Increase of bicarbonates (compound) [_] Increase T3 (Triiodothyronine hormone) [_] Reduction of serum's pH [_] Increase of calcium (metal element) [_] Increase T4 (Thyroxine thyroid-produced) [_] Reduction of the cholesterol level [_] Increase of hemoglobin (red blood cells) [_] Increase TSH (Thyroid stimulating horm.) [_] Reduction of the leucocytes [_] Increase of iron (metal element) [_] Presence of falciform hematite (sickle- shaped red-color blood cells)
PERSONAL HISTORY [_] Allergic (having allergies) [_] Digestive surgery [_] Pulmonary edema (swelling of lungs) [_] Bone surgery [_] Hip prosthesis (artificial device / body part) [_] Radiotherapy [_] Cancer surgery [_] Myocardial infarction (heart attack) [_] Thyroid surgery (ablation) [amputation] [_] Cardiac surgery (triple [or other] bypass) [_] Organ transplant (______) [_] Traumatic shock (accidents, violence ...) [_] Chemotherapy (cancer killing chemicals) [_] Pacemaker [_] Urogenital surgery (urinary system) [_] Coronary stents (supporting tubes / heart) [_] Plastic surgery [_] Weigh—loss diet [_] Depression (longtime sadness)
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RECORDS [_] Alzheimer in the family [_] Diabetes in the family [_] Myocardial infarction in the family [_] Asthma in the family [_] Endometriosis in the family [_] Obesity in the family [_] Atherosclerosis in the family [_] Hemorrhagic troubles in the family [_] Osteoporosis in the family [_] Cancer in the family [_] Hypertriglyceridemia in the family [_] Parkinson in the family [_] Cholesterol in the family [_] Hyperlipemia in the family (excess lipids) [_] Pulmonary pathology in the family [_] Cirrhosis in the family [_] Hypertension in the family [_] Surgical personnel (self and/or in family) [_] Coronaropathy in the family (heart failure) [_] Medical personnel (self and/or in family) [_] Thrombosis in the family (fibrous clot) [_] Crohn's disease in the family
CURRENT TREATMENT - Allergology [_] Antihistamines anticholinergics (drugs) [_] Homeopathy [_] Somatic acupuncture [_] Auricular acupuncture (ear) [_] Micronutrition (supplement trace elements) [_] Trace elements (minerals) [_] Bioresonance (Bioenergetic therapy) [_] Non-anticholinergic antihistamines (drugs)
CURRENT TREATMENT - Analgesics-Antipyretics-Antiinflammatories [_] Anticholinergic antispasmodic [_] Micronutrition (supplement trace elements) [_] Osteopathy [_] Anticholinergic antispasmodic [_] Morphinic analgesics (morphine drugs) [_] SAI: Corticoids [_] Auricular acupuncture [_] NSAI and derivaties (paracetamol, [_] Somatic acupuncture [_] Codeine in association salicylates ...) {drugs} [_] Trace elements (nutritional supplements) [_] Homeopathy
CURRENT TREATMENT - Cancerology - Hematology [_] Anti-emetic [_] Haematopoiesis stimulant [_] Monoclonal antibodies [_] Auricular acupuncture (ear) ([Hematopoiesis] blood stem cells) [_] Osteopathy [_] Biphosphanates (type of drugs) [_] Homeopathy [_] Radiotherapy [_] Chemo-protectors [_] Hormone therapy [_] Somatic acupuncture [_] Cytotoxic chemotherapy (toxic to cells) [_] Immune response modifier [_] Surgery [_] Electromagnetic frequencies [_] Local antimitotics (prevents cell division) [_] Trace elements [_] Folinates (anti-cancer drugs) [_] Micronutrition (supplement trace elements)
CURRENT TREATMENT - Dermatology [_] Anti-acneic (anti-acne) [_] Dermocorticoids (steroid hormones) [_] Phytotherapy (plant cell therapy) [_] Auricular acupuncture [_] Homeopathy [_] Somatic acupuncture [_] Botulin toxin (neurotoxin) [_] Micronutrition (supplement trace elements) [_] Trace elements
CURRENT TREATMENT - Endocrinology [_] Androgens (masculine steroid hormone) [_] Gonatrophics (pituitary gland hormone) [_] Phytotherapy (plant cell therapy) [_] Anti-androgens: cyproterone (synthetic [_] Growth hormone antagonist: pegvisomant [_] Prolactin inhibitor steroid) [masculine steroid hormone] [_] Homeopathy [_] Somatic acupuncture (physical body) [_] Anticortisolic hormones (steroid hormone) [_] Micronutrition (supplement trace elements) [_] Somatostatin analogue [_] Antidiuretic hormones (prevents diuresis) [_] Mineralocorticoid hormones [_] Thyroid hormones [_] Anti-thyroids [_] Osteopathy [_] Trace elements (called oligotherapy) [_] Auricular acupuncture (ear) [_] Parathormone inhibitor cinacalcet
CURRENT TREATMENT - Gastroenterohepathology [_] Antacid and gastrointestinal dressings [_] Interferon [_] Probiotics (good friendly bacteria) [_] Antidiarrhetics (anti-diarrhea drugs) [_] Lactitol (laxative used to treat constipation) [_] Prostaglandins (potent hormonelike [_] Anti-intestinal bacterials [_] Laxatives (treats constipation) substances used for regulation in body) [_] Auricular acupuncture (ear) [_] Micronutrition (supplement trace elements) [_] Proton pump inhibitors [_] Diet monitoring [_] Osteopathy [_] Somatic acupuncture (physical body) [_] Gastric antisecretories (ulcers) [_] Peristaltogens [_] Trace elements (oligotherapy) [_] H2 Anti-histamines [_] Phytotherapy ( plant cell therapy [_] Treatment of biliary lithiasis (pathological gemmotherapy) [_] Homeopathy masses of mineral in bile or gallbladder)
CURRENT TREATMENT - Gynaecology - Obstetrics [_] Auricular acupuncture (ear) [_] Micronutrition (supplement trace elements) [_] Phytotherapy (plant cell therapy) [_] Homeopathy [_] Non-contraceptive oestroprogestatives [_] Somatic acupuncture (physical body) [_] Hormonal contraceptives (sterility or dymenorrhea) [_] Trace elements (trace minerals) [_] Menopausal replacement treatment [_] Oestrogens [estrogen] (dysmenorrhea) (Oestrogens / Oestroprogestatives)
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CURRENT TREATMENT - Immunology [_] Immunosuppressor [_] Phytotherapy (plant cell therapy)
CURRENT TREATMENT - Infectiology - Parasitology [_] Antibiotics (anti-microorganisms) [_] Homeopathy [_] Trace elements (oligotherapy) [_] Antivirals (anti-virus) [_] Systemic antiparasitics (anti-parasite) [_] Vaccines-immunotherapy
CURRENT TREATMENT - Metabolism Diabetes Nutrition [_] Antiasthenics [_] Metformin [_] Phytotherapy (plant cell therapy) (Vitamins, trace elements, amino acids...) [_] Auricular acupuncture (ear) [_] Metformin-glibenclamide [_] Somatic acupuncture (ear) [_] Homeopathy [_] Metformin-rosiglitazone [_] Sulfamides [_] Hypolipemiants (fibrates, statins) [_] Micronutrition (supplement trace elements) [_] Trace elements (minerals / oligotherapy) [_] Insulin and analogues [_] Obesity drugs
CURRENT TREATMENT - Neurology [_] Antiepileptics (anti-epilepsy) [_] Micronutrition (supplement trace elements) [_] Treatment of amyotrophic lateral sclerosis [_] Anti-Parkinson's disease drugs [_] Phytotherapy (plant cell therapy) (degeneration of the nerve cells in the [_] Antivertiginous drugs (anti- vertigo; dizzy) [_] Rye ergot derivatives (anti-migraine drugs) central nervous system with thickening or [_] Auricular acupuncture (ear) [_] Somatic acupuncture (physical body) hardening - Lou Gehrig's disease) [_] CVA treatment (Cerebrovascular Accident) [_] Trace elements (trace minerals) [_] Treatment of multiple sclerosis (Interferon) [_] Homeopathy
CURRENT TREATMENT - Pneumology [_] Antibiotics (anti-microorganisms) [_] Corticoids (adrenal steroid hormones) [_] Pulmonary surfactants (lung-coating fluids) [_] Antihistamines (chemical stimulants) [_] Homeopathy [_] Respiratory analeptics (stimulating drugs) [_] Antitussives (anti-coughing) [_] Micronutrition (supplement trace elements) [_] Somatic acupuncture (physical body) [_] Auricular acupuncture (ear) [_] Osteopathy [_] Trace elements (oligotherapy) [_] Bronchial fluidifiers [_] Phytotherapy (plant cell therapy)
CURRENT TREATMENT - Psychiatry [_] Anxiolytics (antianxiety drugs) monoaminooxidasa inhibitor) [_] Phytotherapy (St John's Wort) - gemmo [_] Auricular acupuncture (ear) [_] IRS (Fluvoxamine) [_] Psycho stimulants [_] Caffeine (prescribed mild stimulant) [_] IRSN (Antidepressant) [_] Somatic acupuncture (physical body) [_] Homeopathy [_] Micronutrition (supplement trace elements) [_] Tianeptine (Stablon) - serotonin enhancer [_] Hypnotics (sedatives) [_] Neuroleptics (antipsychotic medications) [_] Trace elements (also called oligotherapy) [_] IMAO (Antidepressant – [_] Non-IMAO imipraminic antidepressants
CURRENT TREATMENT - Rheumatology [_] Auricular acupuncture (ear) [_] Homeopathy [_] Phytotherapy (plant cell therapy) [_] Biphosphanates (potent inhibitors of bone [_] Infiltrations [_] Raloxifen reabsorption) [_] Interleukin-1 inhibitors [_] Somatic acupuncture (physical body) [_] Calcitonin (thyroid-made peptide hormone) [_] Micronutrition (supplement trace elements) [_] Teriparatide (bone strength drug) [_] Colchicin (poisonous alkaloid to treat gout) [_] Myorelaxants (muscle relaxants) [_] Trace elements (oligotherapy) [_] Corticoids (adrenal-made steroid hormone) [_] Osteopathy [_] Gold salts
CURRENT TREATMENT - Toxicology [_] Atropin [_] Dimercaprol [_] Nalorphine (narcotic antagonist drug) [_] Deferiprone [_] EDTA [_] Succimer (lead chelating [binding] agent) [_] Deferoxamine [_] N- acetylcysteine
CURRENT TREATMENT - Urology Nephrology [_] 5-Alpha-reductase inhibitor [_] Osteopathy [_] Treatment of retrograde ejaculation [_] Alpha-blockers [_] Phytotherapy (plant cell therapy) (semen travels backward into the bladder) [_] Auricular acupuncture (ear) [_] Somatic acupuncture (physical body) [_] Treatment of urinary infections [_] Enuresis drugs (involuntary urination) [_] Trace elements (oligotherapy) [_] Urinary lithiasis drugs (mineral concen- [_] Homeopathy [_] Treatment of erectile dysfunction trations in urinary tract) [_] Micronutrition (supplement trace elements) [_] Treatment of renal insufficiency
C A M OPTIONS, INC. Electro Interstitial Scan (E.I.S.) System Application Page # 8 of 8 pages Clinical Context Section and Agreement
CURRENT TREATMENT - Cardiology - Angeiology [_] Acetysalicylic acid [_] Calcium inhibitors [_] Micronutrition (supplement trace elements) [_] Angiotensin conversion enzyme inhibitors [_] Digitalins (heart disease drugs) [_] Nitrated derivatives (CEI) [_] Diuretics (increase the discharge of urine) [_] Osteopathy [_] Angiotensin II antagonist [_] Fibrates (lower blood triglyceride levels) [_] Phytotherapy (plant cell therapy) [_] Anticoagulant (not transformed to solid) [_] HMG Co-A reductase inhibitors (statins) [_] Platelet anti-aggregants [_] Antihypotensor (lowers blood pressure) [_] Homeopathy [_] Somatic acupuncture (physical body) [_] Auricular acupuncture (ear) [_] Inhibitors of intestinal absorption [_] Trace elements (oligotherapy) [_] Beta-blocker of cholesterol [_] Vasodilators (expands blood vessels)
LIFESTYLE AND NUTRITIONAL HABITS [_] Beer less than 2 glasses per day [_] High consumption of salt [_] Red meat smoked more than 2 times p/wk [_] Beer more than 2 glasses per day [_] High level athletes (professionals) [_] Red meat smoked occasionally [_] Broccoli less than 2 times per week [_] Ketchup every day [_] Sauce tomato every day [_] Broccoli more than 2 times per week [_] Ketchup less than 2 times per week [_] Sauce tomato less than 2 times per week [_] Butter every day [_] Ketchup more than 2 times per week [_] Sauce tomato more than 2 times per week [_] Butter less than 2 times per week [_] Low consumption of bread [_] Smoking less than 20 cigarettes per day [_] Butter more than 2 times per week [_] Low consumption of salt [_] Smoking more than 20 cigarettes per day [_] Carrots every day [_] Medium consumption of bread [_] Sports activity: 2 times per week [_] Carrots less than 2 times per week [_] Medium consumption of salt [_] Sports activity: every day [_] Carrots more than 2 times per week [_] Oil : Arachide [_] Sports activity: less than 2 times per week [_] Coffee every day [_] Oil : Colza [_] Strict vegetarian [_] Coffee less than 2 times per week [_] Oil : Nut [_] Strong Alcohol less than 2 glasses p/d [_] Coffee more than 2 times per week [_] Oil : Olive [_] Strong Alcohol more than 2 glasses p/d [_] Dairy products : less than 2 times per week [_] Oil : Sunflower [_] Tomato every day [_] Dairy products every day [_] Ovo-vegetarian [_] Tomato less than 2 times per week [_] Dairy products more than 2 times per week [_] Passive smoking (environment) [_] Tomato more than 2 times per week [_] Diet after medical consultation [_] Personal diet [_] Vegetables / fruits less than 6 times per/day [_] Exposure to neurotoxins or pesticides [_] Pork grilled every day [_] Vegetables / fruits more than 6 times p/day [_] Fish grilled more than 2 times per week [_] Pork grilled more than 2 times per week [_] Vegetarian eating eggs and fish [_] Fish grilled occasionally [_] Pork grilled occasionally [_] Vegetarian eating fish but not eggs [_] Fish grilled every day [_] Pork raw [_] Vie citadine [_] Fish raw every day [_] Pork raw every day [_] Vie rurale [_] Fish raw more than 2 times per week [_] Pork raw more than 2 times per week [_] White meat grilled every day [_] Fish raw occasionally [_] Pork smoked every day [_] White meat grilled more than 2 times /wk [_] Fish smoked every day [_] Pork smoked more than 2 times per week [_] White meat grilled occasionally [_] Fish smoked more than 2 times per week [_] Pork smoked occasionally [_] White meat raw every day [_] Fish smoked occasionally [_] Red meat grilled every day [_] White meat raw more than 2 times /wk [_] Grapefruit and juice every day [_] Red meat grilled more than 2 times p/wk [_] White meat raw occasionally [_] Grapefruit and juice [_] Red meat grilled occasionally [_] White meat smoked every day less than 2 times per week [_] Red meat raw every day [_] White meat smoked more than 2 times/wk [_] Grapefruit and juice [_] Red meat raw more than 2 times per week [_] White meat smoked occasionally more than 2 times per week [_] Red meat raw occasionally [_] Wine less than 2 glasses per day [_] High consumption of bread [_] Red meat smoked every day [_] Wine more than 2 glasses per day
Contract for Services, Declaration, and Authorization (Please carefully read this entire document before signing.) I, the undersigned, hereby authorize CAM Options, Inc., Dr. Anthony Speroni, President, and their representatives (hereinafter collectively the “practice”) to assess my health concerns and perform an ElectroScanGram (ESG) study. I warrant that all information submitted to the practice, hereinabove, is correct and true to the best of my knowledge. Further, I hereby give the practice my permission to release my medical records and information pertaining to my conventional medical and complementary and alternative therapies, to a specific person(s), only upon the practice receiving authorization from me in writing and dated with a specified name (or names). Furthermore, I and any of my family members, heirs, or any other parties, hereby hold the practice et al harmless in any and all ways for all causes. I understand the EIS is a programmable electro medical system (PEMS) that generates an ESG used to: study body composition; compute various physiologic parameters in certain organs; explore probabilities of the functional risks of the various body systems; scrutinize effectiveness of treatments used to cure or attenuate an organic dysfunction or a disease. The ESG creates a 3-D model representing organs, organ function, and the interstitial fluid; providing a noninvasive and fast study, quantitated within the clinical context provided above; making it possible for medical practitioners to have a functional appraisal of my organs and organ systems, using visualized therapeutic control and various physiologic parameters. Hence, the regulation of any medicament treatment cannot be set up by the ESG. The ESG results obtained are not used imperatively to confirm the diagnosis of structure (imagery) or blood (laboratory tests) established by other examinations. Instead, they bring functional and complementary new elements from the interstitial level. Each medical examination has its specificities; the EIS as a whole investigates the function of select organs via the interstitial fluid with its specificities and data, which can be extracted from the EIS study. Just like laboratory tests, the interpretation of the ESG thus requires that one has knowledge of adequate references, the clinical context (above), and a list of variables which can modify the results. I understand only licensed medical doctors diagnose or treat a patient, using medical devices designed specifically for diagnosis and/or with pharmaceutical products approved by the U. S. Food and Drug Administration (FDA); and the practice is not a medical doctor or allopathic practitioner; and the ESG is not a diagnosis. This practice and the PEMS are not designed to and do not diagnose, prevent, treat, cure, mitigate, or prevent anything (including, but not limited to, diseases, ailments, disorders, and medical conditions). It also does not replace a medical examination but is, rather, considered a complementary tool for an exam. Furthermore, I understand a result of the EIS showing no abnormal values does not mean that I am healthy; it only indicates that there are no physiological tissue parameter or interstitial biochemical value disorders. I hereby attest and affirm that I am now and at all future times meeting with the practice solely as a client, on my first and all, if any, subsequent visits (in person, through e-mail communications, or by telephone consultation), and solely on my own behalf; and not as an agent of any agency, people, or other parties. I also attest that any person or persons present with me at any time while meeting with the practice, either in person, through e-mail communications, or via telephone consultation, are strictly present at my request to accompany me and not as an agent of any agency, people, or other parties. Finally, I understand the practice will not advise me regarding the use of any pharmaceutical agents as relates directly to me.
(Printed Name)______(Signature)______
(Parent/Guardian Printed Name)______(Signature)______