Dr. Patrick Flynn's Natural Health Care Center

In order for us to help you as quickly and efficiently as possible, please follow all the instructions on this page and do everything as accurately as possible that is contained within this packet.

If you have any questions or concerns, please call us anytime at (920)429-2844.

Please Read
• The Story of Food and Its Relationship to Disease
• The Importance of Nutrition in Health Care

Female History
• If you are a female, please complete Female History.

Medications and Supplements
• List all the medications that you are currently taking as well as how many times and at what times of day that you take them.
• List any and all dietary supplements or herbs that you are currently taking as well as what times of the day you take them.
• Indicate the conditions or reasons why you are taking each of the medications or supplements that you listed.
• You are able to list the above 3 bullets on this Medication and Supplement Sheet.
• If you do not know or remember why you are taking something, please call your prescribing doctor to find out why you are on the certain medication.
• It is extremely important that you do this so we are informed of everything that you are taking (even if it seems harmless or natural)!
• Correct interpretation of your analysis depends on this portion being as complete and accurate as possible.

Daily Record of Food Intake
• List everything that you eat for 7 days on this form.
• Be as honest and accurate as possible. Do not worry if your diet seems less than healthy at this time.
• We are looking thr a representation of how you normally eat.
• Remember we are here to coach and guide you.

Symptom Survey
• Fill out the top portion as completely as possible. Some of the information will be completed later in a brief exam.
• Read through all of the symptoms and mark only the symptoms that apply to you.
• Do not darken in any of the circles for that particular symptom if it does not apply to you.
• Mark 1 if it is a symptom that you have occasionally (a couple of times in a year).
• Mark 2 if it is a symptom that you have frequently (several times in a month).
• Mark 3 if it is a symptom that you have almost constantly (daily/weekly).
• List your 5 main complaints in order of importance at the end of the survey.
Symptom Survey Form

Examination
• When you return your completed materials and results from above, we will schedule a very brief exam and consultation, which will take about one hour to complete.
• We will review your materials and determine if any follow up tests are appropriate.
• The examination will include things such as blood pressure and pulse rate to assess certain physiological responses of the body.
• This will help us evaluate your complaint more completely and efficiently.