CASE HISTORY FORMAT
© June 2016, L.D. Wilson
Consultants, Inc.
This is a simple format or template for writing up
your clients’ case histories, which is so important for teaching and spreading
nutritional balancing science.
Here is what to include:
1.
Identity of the client: Name (initials only for privacy),
gender, age, and possibly location if it is important for the case.
2. Initial set of symptoms. Explain
these briefly, but in detail as best one can. This can include (and better if it does) a) medical
diagnoses, b) medical test reports such as blood pressure, blood abnormalities,
other tests like MRIs and others, c) initial medications or supplement use, d)
narrative, if helpful. This means informal language to explain symptoms.
At
times, it is also very helpful to include how long each symptom had been
present, and how intense symptoms are.
Other medical history may be needed, at times, such as that everyone in
the family has the same problem, or the person grew up near a toxic waste facility
or drinking alcohol, etc.
3. Initial hair mineral analysis
readings/chart. If possible, include the chart itself,
as this is easiest to read. If not
available, then list the main numbers.
4. Main initial hair analysis patterns,
such as:
1. Oxidation rate
2. Na/K
ratio
3.
Ca/Mg ratio (and other dietary and lifestyle indicators, if applicable)
4. Four
lows/four highs
5.
Calcium shell
6.
Burnout Patterns
7.
Sympathetic dominance patterns
8. Poor
eliminator patterns
9.
Trauma
10.
Others
5. Time (months) until retest.
6. Changes in symptoms. Be as
specific as possible.
7. Retest hair readings. If
possible, include the retest chart itself.
8. Changes in patterns: which remain the same, which are gone, which are
improved, and which are worse, and new patterns on second test.
9. Repeat steps 5, 6, 7 and 8 if there
is more than one retest to consider.
10. Discussion and conclusions. This can
be brief, especially if it was covered in earlier parts of the write-up. In some cases, it may be more extensive
if it is a very interesting case.
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