• FMP Other Assessments

    Patient Health Information
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  • Horowitz/MSIDS 38 Point Symptom Checklist

    Patient Health Information

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • Copyright ©Dr. Richard Horowitz, published in “How Can I Get Better: An Action Plan for Treating Resistant Lyme and Chronic Disease.” St. Martin’s Press, 2017. Empirical Validation of the Horowitz Multiple Systemic Infectious Disease Syndrome  Questionnaire for Suspected Lyme Disease. Maryalice Citera*, Ph.D., Phyllis R. Freeman2, Ph.D., Richard I. Horowitz2, M.D., International Journal of General
    Medicine 2017:10 249–273. http://www.ncbi.nlm.nih.gov/pubmed/28919803

  • This is a questionnaire to determine the probability of your having Lyme disease and other tick borne disorders.

  •  
  • {section1}

    Section 1 Score

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • {section2209}

    Section 2 Score

  • {section3215}

    Section 3 Score

  • {finalScore}

    Final Score

  • Please take your final score and compare it to the scale used by Dr. Horowitz:

    0--20 points Tick Borne Illness not likely
    21--45 points Tick Borne Illness possible
    46 points or more Tick Borne Illness highly likely

  • Brain Health and Nutrition Assessment Form (BHNAF)

    SFM New Patient Health Information

  • (c)2013 Datis Kharrazian

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • Brain Region Localization Form

    SFM New Patient Health Information

  • (c)2019 Datis Kharrazian and the Kharrazian Institute

  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed

  • The purpose of this questionnairer is to identify difficulties that you may be experiencing. Please answer every question, do not skip any questions. Follow the 0 to

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  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • {patientName} 

    		  

    {patientDate180}

    		  

    {date57}
    Patient Name    Patient Date of Birth    Date Completed
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  • Congratulations! You have now reached the end of SFM's Functional Medicine Program New Patient Application. You can review the information saved on the forms by using the "Back" buttom.

    When you are finished with these forms, please select the "Submit" buttom. A copy of the forms will be sent to the provided email. A staff member from Sparks Family Medicine will be in touch. Thank you! 

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