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Home
Neurology
Main Sections
Neurology Main Page
Neurology Patient Portal
Conditions & Procedures
How We Can Help
Peripheral Neuropathy
Electromyography | EMG
Become A Patient
Neurology Self Referrals
Clinical Trials
Functional Medicine
Main Pages
Sharlin Functional Medicine
Sharlin Functional Medicine Protocol
Free Consultation
Toolbox
Healthy Brain Toolbox Book
Free E-Book – “Master Chronic Pain”
ProLon Fasting Mimicking Diet
Brain Tune Up! Genomics Powered by IntellxxDNA
Laboratories
Memory Loss and Alzheimer’s Disease Risk Evaluation
Late Onset Alzheimers Disease FAQ
Links From Healthy Brain Toolbox Book
Dr. Terry Wahls Video Blog Series
Articles
Treatments
The Wahls Protocol
Bredesen Protocol
Memory Loss Treatment
Alzheimer’s Disease Treatment
Multiple Sclerosis Advanced Treatment
Amyotrophic Lateral Sclerosis (ALS)
Parkinson’s Disease
Fibromyalgia
Chronic Migraine
About
Meet Dr. Ken Sharlin
Our Team
Speaking Engagements
Press Room
Payment Information
Blog
Results
Patient Results
Testimonials
Reversal of Cognitive Decline: 100 Patients
Memory Loss Patient Testimonial: Do You Know Mike?
Breakthrough Alzheimer’s Disease Treatments
Contact
Brain Tune Up! Protocol
Schedule
Functional Medicine Initial Consult
Schedule
Traditional Neurology
Schedule
Services
Health Coaching
Brain Tune-Up! University
EvexiPEL – Hormone Pellet Therapy
Neurofitness
Joint Pain Treatment
Sleep Impairment Treatment
Muscle Ache Treatment
Memory Impairment Treatment
Brain Fog Treatment
Chronic Fatigue Treatment
Chronic Dizziness Treatment
Chronic Numbness & Tingling Treatment
Dr. Sharlin’s Supplements
Patient Portal
Medical Fitness Assessment
Name
First
Last
Email
Phone
DOB:
How, specifically, would you like your habits, your health, your eating and/or your body to be different?
Out of all of the changes you’d like to make, which ones feel most important/urgent?
Have you tried anything in the past (or recently) to change your habits, your health, your eating, and/or your body? If so, what?
Which of these things worked well and why?
Which of these things didn’t work well and why?
Have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?
When were you diagnosed, or when did the injury occur?
What have you tried (medication and lifestyle) to improve your health and well-being?
Do you currently take any medications or supplements? Please list:
Are there any helpers, healer, or therapies with which you are currently involved?
Are you regularly active in sports and /or exercise? If so, approximately how many hours per week?
What types of sports and/or exercise do you typically do?
Approximately how many hours a week do you do other types of physical activity? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening)
What other types of movement and/or activities do you do?
If we were having this conversation one year from today, what would have had to happen in that time for you to be successful in our program? What would your goals be for doing our program?
What do you think would prevent you from achieving those goals?
What or who is your support system?
In a given week how many times do you eat out?
In a given week how many times do you drink caffeine?
In a given week how many times do you drink alcohol?
In a given week how many times do you smoke?
In a given week how many times do you crave sugar?
In a given week how many times do you ever feel fatigued?
Do you have any allergies or sensitivities?
On average, how many hours per night do you sleep?
On a scale of 1-10, how ready are you to change your behaviors and habits?
On a scale of 1-10, how willing are you to change your behaviors and habits?
On a scale of 1-10, how able are you to change your behaviors and habits?
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes
No
Do you know of any other reason why you should not do physical activity?
Yes
No
Is there anything additional you would like to share?
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