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EIS Intake Form 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 <STOP> Hypnotherapy [__] I have diarrhea [__] I am taking non-prescription drugs Iridology [__] I am wearing metal objects [__] I have a fever Kinesiology [__] I am wearing an electromagnetic field (EMF) protection disk or device (remove now) L.I.F.E. System Mind-Body Optimization Primary reason(s) for scan (issue, complaint, illness, pain): [__] I am taking medication Natural Health Alternatives Naturopathy 1- 1- Neuro-Linguistic Programming 2- 2- Nutrition Optimization 3- 3- Nutritional Supplements 4- 4- Pain Management [__] more on attached … [__] more on attached … Rife Frequencies Spiritual Direction [__] I have one or more questions written on the reverse side hereof or attached hereto. Visualization [__] I have one or more fears or concerns about the scan, written on a paper attached hereto. Weight Management [__] I am a smoker of tobacco [__] I am suffering from an addiction: _________________ Wellness Optimization (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) C A M OPTIONS, INC. Electro Interstitial Scan (E.I.S.) System Application Page # 3 of 8 pages Clinical Context Section 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)
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