PLEASE READ THIS SECTION FIRST BEFORE PROCEEDING:

PLEASE REMEMBER TO COMPLETE BOTH STEPS ONE AND TWO ON THIS WEBSITE 72 HOURS BEFORE YOUR SCHEDULED APPOINTMENT:

PLEASE - NO PERFUMES OR COLOGNES!!!

You MUST complete the Intake Forms and return them to us (either electronically, via fax, or by dropping them off to our office) by TWO DAYS BEFORE your scheduled appointment. All those who get these forms to us later than 3PM 2 DAYS PRIOR to your appointment will have their appointment rescheduled. Also included is an explanation of the Quantum Biofeedback machine that Dr. Amadi uses.

Please note that our new patient appointment fee is $380.00 with a $80.00 deposit at the time of making the appointment.

Please note that we require a 48-hour notice of cancellation for a new patient appointment in order for us to refund the deposit. You may also leave a voice mail of this 48-hour cancellation, however this notice must during operating office hours.

General new patient appointment $380.00 – 90 minutes

IMPORTANT NOTE FOR GENERAL NEW PATIENTS ONLY:

Please remember NOT to take any hormones (including thyroid hormones like Synthroid, Armour thyroid or Cytomel), or supplements on the day of your appointment. Please bring the medicines and supplements in their bottles with you so that Dr. Amadi can test them on the Quantum Biofeedback machine.

Every new patient should EAT and DRINK As USUAL on the day of their appointment. Please do NOT fast. IF YOU HAVE ANY QUESTIONS ABOUT WHETHER YOU SHOULD TAKE MEDICATIONS ON THE DAY OF YOUR APPOINTMENT PLEASE CALL THE OFFICE BY 3 PM OF THE DAY PRIOR TO YOUR APPOINTMENT.

Our address is 10189 W. Sample Rd., Coral Springs, FL 33065. We are two lights west of University. If traveling west on Sample Rd., we will be on the north side of Sample Rd., right next door to the Pearl Building at 10191 W. Sample Rd., just west of and in the same plaza as, the Tavolino della Notte restaurant. All patients who arrive 30 minutes or more late will be re-scheduled.

Management,

Office Manager/Assistant

CHECK THE ACKNOWLEDGEMENT BUTTON BELOW TO PROCEED:

I ACKNOWLEDGE THAT I HAVE READ THE ABOVE LETTER IN ITS ENTIRETY AND UNDERSTAND IT.

01. 1 OF 3 ANSWER KEY TO SOC FORM

02. 2 OF 3 ANSWER KEY TO SOC FORM

03. 3 OF 3 ANSWER KEY TO SOC FORM

HEPSHARAT AMADI, M.D. L.Ac.

10189 W. SAMPLE RD.

CORAL SPRINGS, FL 33065

PH: 954-757-0064

Fax 954-757-2612

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DR. AMADI - ANSWER KEY TO SOC FORM

Name

Phone

1. Number of organs removed - include tonsils, adenoids, appendix, gallbladder, uterus, ovaries, fallopian tubes, thyroid. All teeth removed count as 1 organ.

2. Number of synthetic (Prescription and non-prescription drugs currently (within past month. “Synthetic” drugs means both prescription medications and over-the-counter medications. It does NOT include supplements, herbs or homeopathic remedies.

3. Amount of times you smoke. (This does NOT include marijuana).

4. Number of steroid type drugs used in the last year (includes asthma inhalers, shots in joints and pills that are prescribed in very low numbers at a time i.e: 2 or 3 pills in prescription.) Examples of steroids include cortisone, prednisone, prednisolone, Medrol dose packs. This category does NOT include bio-identical hormones.

5. Number of metal (amalgam) fillings current or “Present during the last year”. These are the ones that appear silver.

6. Number of street drugs used in the past month. By “street drugs”, I mean illicit drugs, for example, cocaine, heroin, methamphetamines, etc. I do NOT mean marijuana or “over-the-counter” medicines such as cold preparations or antihistamines.

7. Number of known allergies. This is referring to major groups like dairy, wheat and major items like prescriptions, penicillin, sulfur and bee stings, etc. (Do NOT list independent allergies or you may have hundreds, and it will make a difference in the SOC score.

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8. Number of unresolved mental factors (include major items that will not go away if you went on vacation; financial, job stress, parents, children, economy, also items like depression, paranoia, fear, etc.)

9. Responsibility for my body = how willing are you, on a scale of 1-10 to take care of your body by following the right lifestyle habits, once you learn what these are? 10 = completely willing. 1 = not very willing at all.

10. Amount of fat in diet as a percent: #’s 1-9, not 10-90 (includes processed foods). Remember that national average in the USA is 40% and those who eat very health conscious, eat approximately 20%. For example, “4” would be if you think your fat/processed food intake is about the average American’s. “3” or even “2” if it is less than that. “5” or above if it is more.

01. 1 OF 3 ANSWER KEY TO SOC FORM

02. 2 OF 3 ANSWER KEY TO SOC FORM

03. 3 OF 3 ANSWER KEY TO SOC FORM

HEPSHARAT AMADI, M.D. L.Ac.

10189 W. SAMPLE RD.

CORAL SPRINGS, FL 33065

PH: 954-757-0064

Fax 954-757-2612

_______________________________________________________________

11. Personal stress 0 to 10 max. (If you were a barometer and 10 were your breaking point, where would you fall on an AVERAGE day.

12. Number of sugar type products per day (include sugar in coffee, tea, on cereal, soft drinks, candy, cookies, etc.). Do not include natural fruit or fruit juice.

13. Number of exercise sessions per week for 20 minutes or more per day (work does not count - because you are unable to use this to de-stress.)

14. Number of alcoholic drinks per day on average (as with everything else, you may have to take the total per week and divide by 7 to get your daily average. If it is below 1, for the week, put in zero.)

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15. Number of cups of coffee, tea, caffeinated soda, chocolate per day, any product with caffeine.

16. Number of extreme toxic exposures per year (radiation, insecticides, chemicals, etc.) Do you work in a paint shop, dry cleaning store, beauty or nail salon, use insecticides in your work or cleaning products that contain Chlorox, live near a toxic waste dump, land fill, or close to power lines, work for a hospital or have taken X-rays (e.g., dental)/CT Scan/MRI recently?

17. Number of major injuries (anything that would have put you into bed for 3-5 days. Include any surgeries unless they are minor, for example, like skin cancer biopsies which do not require general anesthesia. Major emotional traumas are also included, like a death you have not been able to deal with, or a divorce.

18. Number of MAJOR infections past and present. Mono, hepatitis, spinal meningitis, pneumonia, chronic bronchitis, chronic sinusitis, chronic infections, AIDS, etc.

19. Number of 8 ounce glasses of water per day – (not tea, coffee, etc.), or “natural” fruit juice per day. Natural fruit juice is either fresh squeezed or store bought, that is ORGANIC with no added sugar, corn syrup, or other chemicals added.

20. How many kilos overweight (as seen by you, the client) 2.215 lbs = 1 kilo. Take how many (if any) pounds that you consider yourself to be overweight (If you do at all; this is a subjective assessment), and divide it by 2 to get the approximate number of kg. for example, 10 pounds overweight divided by 2 = 5 kg, so enter in ‘5’.

COMPLETE BOTH STEPS ONE AND TWO ON THIS WEBSITE 72 HOURS BEFORE YOUR APPOINTMENT: (After submitting this STEP ONE FORM please return to REQUIRED FORMS on the website to complete STEP TWO FORM)