Be Well Associates, Dan O. Harper, M.

D
509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
***PATIENT REGISTRATION ***
Patient Name:
__________________________________________________________________________________________
Last
First
MI
Preferred Name
Male

Female

Married

Single

Child

Birth Date: ______________________

Age: ________

E Mail Address: _________________________________________________Fax:_______________________

Address Street: _____________________________________________________________________________
City: ____________________________ State: _______________________ Zip: _______________________
Phone #s: Home: _____________________________________ Cell: _______________________________
What is the patients religious or spiritual preference? ______________________________________________
Preferred appointment times:

Morning

Afternoon

Evening

Any Time

T W TH Sa

EMPLOYMENT INFORMATION
Student Status / College Attending: ____________________________________________________________
The following is for:

The patient

The person responsible for payment

Employer Name: ________________________________________ Occupation: ________________________

Work: _______________________________ Ext: _______________ Fax: ___________________________
Years Employed: _________________________

APPOINTMENT REMINDER INFORMATION

May we phone you to confirm appointments?

Yes

No

May we leave a message on your answering machine at home or on your cell?

Yes

No

May we leave a message at your place of employment? Yes

No
If YES, please name work contact person and/or work phone and/or work fax
Name: _________________________Work Phone: _________________ ext.:_______ work fax _________________
May we discuss your medical conditions with any member of your household?
If YES, please list names of the household members below.

Yes

No

Names: ______________________________________________________________Phone:_______________________
Relationship to patient_______________________________________________________________________________

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

EMERGENCY CONTACT
__________________________________________________________________________________________
Last
First
MI
Preferred
Gender: M

Relationship To Patient: ___________________________________________

Address Street: ________________________________________________ City: ______________________

State: _____________________ Zip: ____________________
Home Phone: __________________________________ Cell: ______________________________
Work Phone: _____________________________ Ext: ____________

REFERRAL INFORMATION
Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative
Internet
Medical Office Newspaper School Work Other_________________________
Name of person or office referring you to our practice: _____________________________________________

Office Hours: Closed for lunch each day from 12:15 to 1:00.
Monday
9-2
Tuesday
8-5
Wednesday 8-5
Thursday
8-5
Friday
9-2
Saturday
8-5

Please do not email the reception or Dr. Harper under any

circumstances. Please call or fax.
CANCELLATION, RESCHEDULING AND FEE POLICY:

Please arrive at least 10 minutes prior to your scheduled appointment. All patients please note: Since the
doctors appointments run back to back, he cannot carry over into the next patients appointment. Therefore if
you arrive late you will receive the remaining time left in your appointment and you will be charged for the full
fee of your scheduled appointment.
2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

New Patients - All new patient forms must be received at our office prior to scheduling first appointment,
Supplements, BIA analysis or other additional tests are not included in the new patient appointment fees.
Charges for these items must be paid on the day of the new patient appointment. We do not accept checks for
payment of the first visit. We accept cash, Visa, and Mastercard. Fees for young children may be less, as the
first new patient appointment is usually, but not always one hour. Please contact the receptionist at
858.755.1126.

For new patient appointment cancellations we require that the patient or patients guardian call Be Well
Associates at least 48-hours before the scheduled appointment.

For IVs we require that the patient or patients guardian call Be Well Associates at least 48-hours in advance
to cancel or reschedule. Please note: IVs are made of a custom mix of ingredients and cannot be used on any
other patient. They are mixed each morning for the day. Therefore patients will be charged for the full cost
of the IV if we receive the cancellation or reschedule call after the IV is mixed.

For existing patient appointments call at least 24-hours before the appointment time to cancel or reschedule.
If possible, more than 24-hour notice is preferable, so that another patient in need may have your
appointment time.

If we do not receive cancellations or reschedules in the time periods listed above, the patient or patients
guardian will be charged the following:

New Patient Appointments 2 hrs (approx.): $960.00 (If longer than 2 hrs the fee increases.)
Brief Appointment up to 15 min: $120.00
Limited Appointment up to 30 min: $240.00
Intermediate Appointment up to 45 min: $360.00
Extended Appointment up to 1 hr: $480.00
Frequency Specific Microcurrent: $95 - $150
IVs: The cost of your custom mixed IV
House Call: $500 per hour (fee also applies for travel time)

Services & Fees for Medical/Legal Cases:

Please note: For medical/legal cases (which may or may not include disability) a Medical Retainer Services
for Legal Cases agreement must be filled out and signed, before Dr. Harper can start work on the case.
The receptionist can supply this form to you if needed. A $2500 retainer is required to start a medical/legal case
which may be used in various combinations of services below.
o Attorney Preparation & Advisement for Case (Telephone or In-Person)
$635 per hour
o Deposition or Court Testimony (does not include travel expenses)
$635 per hour
o Patient Preparation & Advisement for Case (Telephone or In-Person)
$480 per hour
o Preparation of Medical Information, Legal documents or Special Reports $550 per hour
o Copies of Records
$0.25 per page
o Travel Expenses (Off-Site of Be Well Associates)
As Incurred
o Required Postage, Courier Service and Administrative Fees
As Incurred
2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Payment is due in full at time of service. For each appointment we provide a super bill for submission to
insurance companies. We do not bill insurance directly. Also, we do not accept Medicare. Due to normal
inflation, prices are subject to change without notice. Other prices shall apply for various procedures.
Most times, the day before appointments, our receptionist will give a courtesy reminder call to the phone
number provided to us, but it is important to note that it is the responsibility of the patient or patients guardian
to remember the appointment date and time.
I agree to the above cancellation policy. I also agree to pay Be Well Associates for any missed
appointments, phone consults, house calls, hospital visits and balances due on my account or for services,
products and supplements. If I request products or supplements to be sent to me I agree to pay Be Well
Associates for the items and the shipping/handling charge.

The individual seeking treatment or consultation is not considered a patient until Dr. Harper has
completed the new patient appointment. If Be Well Associates staff or Dr. Harper receives new patient
forms, lab tests, or medical records this does not constitute a doctor /patient relationship until the new
patient appointment is completed.

I am fully aware that I must pay in full after the first and every appointment.
Note, new patient appointments may range from $960 (if only 2 hours) or
more, not including supplements, tests, BIA, IVs or medications.

Please sign below to acknowledge your agreement:

Patient Name (print): ____________________________________________________
Patient Signature: _______________________________________________________
Date: ____________________________
If applicable:

Patients Legal Representative (Print): __________________________________________

Patients Legal Representative Signature: ________________________________________
Patients Legal Representative Phone:
Home____________________ Work____________________ Cell___________________
Relationship to Patient: _____________________________________________________

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

Patients Request for Non-Medicare Services

Section 4507 of the 1997 Balanced Budget Act allows a physician or practitioner to enter a private contract with a
Medicare beneficiary. Signatures from the provider, a witness and the patient/beneficiary or their legal
representative are required below. The supplier must submit an affidavit to Medicare expressing his/her decision
to opt-out. This agreement is between Dan O. Harper, MD (NPI-1811085244)
and (Patient) ___________________________________________________________

I, Dan O. Harper, M.D., have not been excluded from Medicare under sections 1128, 1156, or 1892 of the Social
Security Act.
I (the Medicare beneficiary) or my legal representative accept full responsibility for payment of charges for all services
furnished by Dan O. Harper, M.D.
I (the Medicare beneficiary) or my legal representative understand that Medicare limits do not apply to what Dan O.
Harper, M.D. may charge for items or services furnished.
I (the Medicare beneficiary) or my legal representative agree not to submit a claim to Medicare or to ask Dan O. Harper,
M.D. to submit a claim to Medicare.
I (the Medicare beneficiary) or my legal representative understand that Medicare payment will not be made for any items
or services furnished by Dan O. Harper, M.D. that would have otherwise been covered by Medicare if there were no
private contract and a proper Medicare claim were submitted.
I (the Medicare beneficiary) or my legal representative enter into this contract with the knowledge that I have the right to
obtain Medicare-covered items and services from a physician and/or practitioner who has not opted out of Medicare, and
I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other
physicians or practitioners who have not opted out. The expected or known effective date and expected or known
expiration date of the opt-out period is July 1, 2014 and June 30, 2016.
I (the Medicare beneficiary) or my legal representative understand that Medigap plans do not, and that other
supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
I (the Medicare beneficiary) or my legal representative will receive or have received a copy (a photocopy is permissible)
of this contract, before items or services are furnished to me under the terms of this contract.
This contract cannot be entered into by me, (the Medicare beneficiary), or my legal representative during a time when I,
(the Medicare beneficiary), require emergency care services or urgent care services. (However, a
physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with
3044.28 of the Medicare Carriers Manual).
I, Dan O. Harper, M.D., understand that the current private contract remains in effect for two years. If I again opt-out of
Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the
appropriate affidavit(s) to all local Medicare carriers.

Please sign below to acknowledge your agreement:

Patient Name (print): ____________________________________________________
Patient Signature: ___________________________________________ Date: ___________________________
Physician Signature: _________________________________________ Date: ___________________________
If applicable:

Patients Legal Representative (please print): _____________________________________

Patients Legal Representative Signature: ________________________________________
Patients Legal Representative Phone: ______________________________
Relationship to Patient: _____________________________________________________
Medical Office Signature:
Witness Signature: ____________________________________Date:__________________________
https://med.noridianmedicare.com/web/jeb/enrollment/opt-out

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

MEDICAL DISCLAIMER
Be Well Associates, Dan O. Harper, M.D.
I,

__________________________________, have read and agree to the following statements:

There are no warranties, assurances, or guarantees of successful treatment.
There are no claims of healing or cures made, only efforts to return the body to its original state of health to resume
healing itself the way it was designed to.
Some of the treatments given at the clinic may not be FDA approved, but that careful investigation has been done to
find therapies to return my body to its original state of health, and that I may choose to use these after having the
opportunity to have my questions answered by Dr. Harper and his staff.
I will take full responsibility for my health by following the suggestions given to me by Dr. Dan and doing the
treatments recommended. I am free to stop these at any time without reprisal or condemnation from the clinic staff, or
resume them if I so choose. Such decisions are mine to execute.
My possessions that I bring to the clinic during evaluation and treatments are my responsibility to care for, and the
clinic will not be responsible for any lost or damaged items.
I will provide supervision for any young children that may accompany me to the clinic and that I will be responsible
for any items damaged.
I will carefully follow the instructions given to me concerning any equipment used in my treatments, and that any
injuries resulting from not following those instructions will be my responsibility and I will not hold the clinic liable in
any form.
I understand that many of the clinics staff and clients, including are chemically sensitive. I will refrain from
wearing colognes, perfumes or fragrances that might endanger their health. If I unknowing forget or violate this, I
will have to be rescheduled for another day and full charge for that scheduled visit may be assessed.
I have also been informed or am now told that the World Health Organization has declared Cell Phone use to be a
Class 2B carcinogen, and that the harmful microwave frequencies generated by my cell phone, even if on vibration
or flight mode, may be harmful to others in the clinic, and may interfere with therapies given in the Be Well
Associates office and therapy room. I will therefore turn off my cell phone before entering the clinic building. If
emergency contact is needed for me, I will give them the clinic number, 858-755-1126 to reach me.

Please sign below to acknowledge your agreement:

Patient Name (print): ____________________________________________________
Patient Signature: _______________________________________________________
Date: ____________________________
If applicable:

Patients Legal Representative (Print): __________________________________________

Patients Legal Representative Signature: _______________________________________
Patients Legal Representative Phone:
Home___________________ Work____________________ Cell___________________
Relationship to Patient: _____________________________________________________

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

Consent for Treatment by Dan O. Harper, M.D.

I have sought medical care from Dan O. Harper, MD. I have chosen to do this of my own free will. I am aware that Dr.
Harper is board certified as both an allopathic family practice physician and as a holistic physician. He also is also
licensed as a homeopathic physician. Allopathic medicine refers to medicine as it is commonly practiced in the United
States, a system that uses pharmaceuticals and surgery as the primary modes of therapy. Holistic medicine refers to a
system which uses naturally derived substances such as homeopathic remedies, herbs, vitamins, enzymes, etc. to promote
and restore a healthy balance to the body. Since Dr. Harper is dually trained and board certified in both systems, he is
fully qualified to determine whether the use of homeopathic treatments, allopathic treatments, or a combination thereof
would be in my best interest. Dr. Harper emphasizes the importance of nutrition, exercise, attitude, and non-toxic
remedies as the therapeutic mainstays for restoring a patient to his or her optimal state of health.
I realize that Dr. Harpers integrated approach to medical therapy may not be as rapid as pharmaceutical or surgical
therapy, that it may require more effort from me than the simple administration of a symptomatic medication for each
complaint. Some medical authorities consider such treatment to be unproven, ineffective. I also understand that every
patient is unique so that Dr. Harper cannot warrant or guarantee that his treatment programs will always result in an
improvement of the condition being treated.
I also understand that many insurance plans have clauses which limit coverage to usual and customary fees for
reasonable and necessary services. I realize that some of the holistic medical services provided by Dr. Harper will not fall
under this description, and I do not hold him responsible for the possible decision by an insurance company that services
provided to me are not covered under a specific insurance contract. Please note, we do not bill insurance companies. We
will provide the patient with a super bill and it is the patients responsibility to obtain reimbursement from any insurances.
I am consulting with Dr. Harper solely for the reasons concerning my own health. I am not consulting Dr. Harper in order
to provide any information to any enforcement, regulatory, or investigative agency of any kind.
I release and forever discharge Dr. Dan Harper and his heirs, successors, and administrators from any and all claims, loss,
damages, and injuries, present and future, in any manner arising out of my consultations with him. This release covers all
damages, whether or not contemplated at the present time and includes situations undeveloped and unknown at the present
time, as well as those now known.
If I choose not to have any holistic medical treatments or any type of medical treatment, I will notify Dr. Harper
immediately. If explanations for any treatments are not fully understood by the patient I will also tell Dr. Harper.
By my signature below I state that I have had adequate time to read and understand the above information.

Please sign below to acknowledge your agreement:

Patient Name (print): ____________________________________________________
Patient Signature: _______________________________________________________
Date: ____________________________
If applicable:

Patients Legal Representative (Print): __________________________________________

Patients Legal Representative Signature: ________________________________________
Patients Legal Representative Phone:
Home___________________ Work____________________ Cell___________________
Relationship to Patient: _____________________________________________________
2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

Acknowledgment of Receipt of HIPAA Privacy Practices

We at Be Well Associates Inc., APC are required by law to maintain the privacy of
individuals and provide individuals with our Notice of our legal duties and privacy
practices with respect to protected health information. If you have any objections to
the Notice, please ask to speak with our Office Manager in person or by phone at our
number above. If you would like a copy of our entire HIPAA Privacy Practices,
please ask.

Patient Name (Print): ___________________________________________________

Patient (Sign): __________________________________________________________
Patient Date of Birth: ___________________________
Todays Date: ___________________

If applicable:
Patients Legal Representative (Print): _____________________________________
Patients Legal Representative (Sign):______________________________________
Relationship to Patient: __________________________________________________
Todays Date: ___________________

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

NOTICE TO CONSUMERS
Medical doctor, Dan O. Harper, M.D. of Be Well Associates, is licensed and regulated by the
Medical Board of California. (800) 633-2322 www.mbc.ca.gov

By signing this document, I hereby acknowledge that I have read and understand the
above-referenced notice.

Patient name (Print): ______________________________________________________

Patient Signature: _________________________________________________________
Date: __________________________

If applicable:
Patients Legal Representative (Print): ________________________________________
Patients Legal Representative (Sign): _________________________________________
Relationship to Patient: ____________________________________________________
Date: ___________________________

2016

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530

Health Appraisal Questionnaire

Name:
Date of Birth:
Medication allergies:

Reason for this health consultation:

1. Please check () all of the conditions which you now have or have been treated for in the past:

Diabetes mellitus
Hypo/ hyperglycemia
Elevated cholesterol
Elevated triglycerides
Emphysema/ COPD
Asthma/ Reactive Airway Disease
Anginachest pains
Cardiac arrhythmias- A.fib/ PVCs
Heart Attack/ coronary artery dis.
Heart Valve aortic/
mitral/tricuspid
High blood pressure
Stroke/ TIA (mini-stroke)
Varicose Veins
Anemiatype:________________
Chronic Fatigue Syndrome
Fibromyalgia
Multiple Chemical Sensitivities
Mold Sensitivity/ Infection
Electromagnetic Field Sensitivity
Obesity
Epilepsy/ Seizures

Pneumonia
Glaucoma
Macular Degeneration- wet/ dry
Food intolerances/ allergies
Hayfever/ airborne allergies
Headaches- tension/ migraine
Sleep Apnea
Insomnia/ sleep disorders
Depression
Anxiety

Parkinsons Disease
Diverticulitis/ diverticulosis
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Ulcerative Colitis
Crohns Disease
Lupus
Rheumatoid Arthritis
Osteoarthritis
Other Autoimmune Disorders

Bipolar
Obsessive compulsive disorder
Alzheimers / dementia
Osteoporosis / osteopenia
Pagets Disease
Thyroid diseasehyper/ hypo-Gallbladder disease/ gallstones
Liver Disease
Kidney failure
Kidney stones
Multiple sclerosis

Meningitis/ Encephalitis

ALS

Cancer:_______________________
HIV/ AIDS
Lyme Disease
Recurrent Infection:____________
Females: Endometriosis
Post-partum blues
Fibroids
Polycystic Ovary Disease
Hormonal Imbalance
Males: Erectile Dysfunction
Benign Prostatic
Hypertrophy
Other:________________________
2016

10

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
2. Do you have any close relatives with any of the following health conditions? Please check () if yes.

Asthma/ severe hay fever

Drug/ Alcohol Addiction

Diabetes: __childhood /__ adult

onset
Eczema/ psoriasis
Emphysema/ COPD
Multiple Sclerosis/ Parkinsons
Arthritis/ Rheumatism
Cystic Fibrosis
Autism
Thyroid disease
Heart Disease
Autoimmune diseases
Depression/ mental disorder
Stroke/ TIAs
Cancer: type____________________
Alzheimers dementia
Thrombophlebitis /blood clots
Other:__________________________
Did any of these relatives have a heart attack (myocardial infarction) or stroke before age 65? ( ) yes / Before age
55? ( ) yes
3. Have you been hospitalized in the last five years?

For Infections? TypeFor injuries? Type-

For surgery? TypeFor illness? TypeFor mental health?

4. Pregnancy / Delivery: (Females

Complications of pregnancy or delivery (please

list)___________________________
Number of pregnancies :___ / How many: term births___, premature births___, still-born___ miscarriages___,
surgical abortions___
Number of living children:_________
Number of children still at home:__________
only)

5. Types of known infections from pastcheck () those that you know you have had or been treated for--

Mono/ EBV
Herpes simplex
Her. zoster
/shingles
CMV

Hepatitis A
Hepatitis B
Hepatitis C

Mycoplasma
Chlamydia
Gonorrhea

HIV

Lyme: Borrelia

Coxsackie virus
West Nile Virus

Polio
Strep throat

Lyme: Babesia
Lyme: Ehrlicia

Lyme: Bartonella
H. pylori
Giardiasis or
Ameba
Rocky Mt. Spot
Fever
Q Fever
Brucellosis

Anthrax
Mumps
Malaria
Candida (yeast)
Tuberculosis
Other:

6. Types of surgeries you have ever had performed: (check () all that apply). Also indicate year of surgery if known.

Tonsillectomy

Appendectomy
Gallbladder
CABG (heart)
Heart stent
CataractR / L

Bilateral Tubal
Ligation
Vasectomy

Knee
Replacement
Hip Replacement
Laser Eye
Surgery
Lasix Eye
Correct

Fibroid removal

Stomach Banding

Hysterectomy?ovary
Hemorrhoidectomy

Stomach Stapling

Bone Plate or
ORIF
Neck Surgery

Thyroid Nodule

Lumbar surgery

Vein Stripping
Stomach Ulcer
Surgery
Whipple Procedure

Thyroidectomy
Vessel Bypass or
Stent in artery not

Harrington Rod

Breast Augmentation

Other:

7. Significant Traumas: (check () all that apply). Also indicate year of trauma if knownsuch as 04

Motor Vehicle Accident

Head injuries

Gunshot Wound

2016

11

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Motorcycle Accident
Significant fall
Second or third degree burns

Bicycle Accident
Sports Injury
Physical Assault / Abuse

Stabbing
Molestation/ Rape
Other:

8. Stress Questions: In the last year, have you had any of the following? (check () all that apply).

Death of a spouse
Divorce
Marital Separation
Legal Troubles
Molestation/ Rape
Death of a Family Member
Loss of Self-Confidence
Personal Injury or Illness
Marriage

Change in Level of Faith

Loss of Job
Retirement
Illness of a Family Member
Pregnancy
Sexual Difficulties
Addition of a new family member
Loss of a close friend
Changed Line of Work

Troubles with spouse

Foreclosure of a loan
Change in job description
Child leaving home
Trouble with in-laws
Teenager problems
Change in sleep habits
Change in residence
Tension at workplace

9. Stress Reduction: What do you do to reduce the above stress? (check () all that apply).

Exercise
Biofeedback
Crying
Dancing
Talking to friend or fellow
employee
Eating healthy

Comfort foods/ binge eating

Gardening
Hiking
Rest/ get lots of sleep
Hobby:

Laughter/ joking around

Massage
Musiclistening or playing
Reading
Prayer

Hot tub or hot shower

Other:

10. Immunizations: check () all that you have been vaccinated for and list approximate date:

MMR-measles/mumps/rubella

Hepatitis A

Pneumococcal Date

Polio

Hepatitis B

Influenza

Smallpox

Yellow Fever

Tetanus

Chickenpox/ shingles

Dengue Fever

Cholera

Meningococcal

Typhoid

Other:

11. Examinations: (please write in the year of last exam in the blank---i.e. 1997)

____Complete Physical Examination

____EKG
____Lab panel
____Chest X-ray
____Colonoscopy
____Cardiac Stress Test

____Ultrasound
____C.T. Scan
____MRI or PET scan
If female: ____PAP
____Mammogram
____Thermography of Breasts

12. Environment Influences: (check () all that apply). Circle all that are problematic.

Mold/ black
fungus
Loud noises
Pesticides

Dental Implants
Chlorine
Fluoride

Printing press
fumes
HVAC ducts-old
Solvents

____Dental Exam
____Eye Exam
____ Other:
If male: ____PSA blood test
____Prostate Exam

Near high power lines

Remodeling home

Near cell phone tower

Remodeling work
Pets indoor home

Near drilling well

2016

12

Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Radiation from
X-ray
EMFs/ wi-fi--

microwave

Dust
Car Exhaust

Paint / varnish
fumes
Asbestos

New carpets

Cigarette smoke

Cleaning
solutions
Concussion

Air /car fresheners

Mercury
Diesel Exhaust
Mining operations
Amalgams
Post-Traumatic Stress
Root Canals
Gasoline fumes
Lead pipes/ paints
List any specific chemicals at work or home that you know are causing reactions:
14. Residence: (check () all that apply).

Others:

Live in single family

home
Live in mobile home

Dwelling in suburban
area
Dwelling in rural area

Dwelling is over 25 years old

House has central air

Use humidifier in home

Live in condo
Live in rental apartment

Dwelling newly built

Use air conditioner in home

House has central

vacuum
Heating system is oil
Heating system is coal

Live in car or tent

Dwelling 3-10 years old

Use air conditioner in bedroom

Dwelling in city

Dwelling is 11-25 years

old

Dwelling is newly remodeled

Use air conditioner

work

Use air conditioner in

car

Heating system is
electric
Heating is wood
burning

15. Bedroom Environment: (check () all that apply).

Mattress is:
Feather
Memory foam
Horse hair

Pillow is:
Flooring:
Items near head at night while sleeping:
Feather
Hardwood
Cell phone
Dacron
Carpet
Plugged in alarm clock/ lamp near bed
Memory
Stone or tile
Computer or wi-fi equipment
Foam
Organic cotton/wool
Foam rubber
Linoleum
TV or stereo speakers- ---corded or remote
Do you have allergy control products on the pillows, mattress and box springs? ( ) yes / ( ) no
16. Tobacco Exposure: (check () all that apply).
a. Have you been exposed to tobacco smoke? ( ) at home, ( ) at work, ( ) in stores, ( ) while in car, ( ) place of worship
b. Did you experience second hand cigarette or cigar smoke while growing up? ( )yes, number of years_____; ( )no
c. Do you personally smoke cigarettes now? ( ) yes, number of packs per day___/ number of years_____; ( ) no
d. Do you personally smoke cigars? ( ) yes, __ years ( ) no; smoke pipe? ( ) yes, ___# times/day, ___years, ( ) no
e. Do you currently use or have you used chewing tobacco? ( ) yes, ___cans per week, ___#years; ( ) no, never have
With smoke fumes you experience: (check

Fast Heart Beat

() all that apply).

Shortness of breath

Headache
Wheezing

Nausea
Other:__________________

17. Mold Exposure: If you have any symptoms in the presence of mold, please indicate below: (check () all that apply).

Muscle Aches
Joint Pains
Fatigue/ Weakness
Memory Issues
Cognitive Dysfunction
Sinusitis

Headache
Bloating/ gas

Heartburn/Indigestion

Shortness of Breath
Anxiety
Depression

Irritability
Visual Changes
Chest tightness
Insomnia
Dizziness
Numbness/tingling

Laryngitis
Nausea
Skin Rashes
Tremors
Heart Palpitations
Onset of Fibromyalgia
2016
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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
18. Electro-Magnetic Field Exposure: If you have symptoms in the presence of EMFs: (check () all that apply).
Swollen mucous membranes
Sensitivity to light/ glare
Localized tingling
Tachycardia

Localized heat
Headache
Brain fog
Nausea

Dry eyes
Muscle Aches
Joint Aches
Heart Palpitations

Dizziness on rising
Ringing in the ears
Insomnia
Sensitivity to Noise

Burning Skin
Tremors
Blushing/ red face
Other:

19. Chemically Sensitive: please indicate which of the following are true today in your present condition: (check
apply).

() all that

a. Symptoms are reproducible with repeated (chemical) exposures.

b. The condition has persisted for a significant period of time.
c. Low levels of exposure (lower than previously or commonly tolerated) result in manifestations of the
syndrome (i.e. increased sensitivity).
d. The symptoms improve or resolve completely when the triggering chemicals are removed.
e. Responses often occur to multiple chemically unrelated substances.
f. Symptoms involve multiple-organ symptoms (runny nose, itchy eyes, headache, scratchy throat, ear ache,
scalp pain, mental confusion or sleepiness, palpitations of the heart, upset stomach, nausea and/or diarrhea,
abdominal cramping, aching joints).

20. If the issues are predominately related to the skin, please answer the following: (check () all that apply).
Skin itchesworse ( )night, ( ) heat,
( ) under stress, ( ) in EMFs,( )
other____
Feel things crawling under skin or
organs
Have tracks or streaks under or on skin
Have seen organisms under or on skin
Skin burns or stings or has numbness
Skin forms red blisters or hemangiomas

Things are pushed out through skin

( ) fibers, ( ) crystals, ( ) critters,
( ) plastic threads, ( ) black beads,
( ) pus-like material, ( )
other_________

Others in room begin to itch, sneeze, or get rash

Lint floats off skincolor--___________

Skin ulcerations

Skin sloughing or peeling

Skin cracking and bleeding
Brain fog with itching or worse rash
Insomnia from itch or skin pain
Co-infections: ( ) yeast, ( ) skin fungus,
( ) intestinal parasites, ( ) insect bites,
( ) recent travel illnesses, ( )other-_____

Give brief description of when and how problems in #17, #18, #19 or #20 occurred and how they have progressed
to this pointmay finish writing on back, if necessary:

21. If your problems are mostly allergic in nature, please indicate which conditions make them worse: (check () all that apply).

Indoors
Outdoors
At Home
At Work
In car
Morning
Afternoon
At Night
Weather changes

Windy Day
Hot day
Cold Day
Air Conditioning
In Barns
Damp Areas
Hay, mown grass
Dusty areas
High Air Pollution

Smoke from wood

Cigarette smoke
Soap powder
Insecticides
Paint fumes
Perfumes
Cosmetics
Wave sets
Newspapers/print

Milk products
Eggs
Soy products
Wheat/gluten
Nuts
Beans or seeds
Chocolate
Fish
Shellfish

Vegetables
Wine
Beer
Hard liquor
Cheese
Mushrooms
Other food:
Aspirin
NSAIDS
2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Wet Weather
Animals
Wool
Meats
Drug:
Dry Weather
Cooking Odors
Road Dust
Fruit
Other:
Is there a specific month or months it is worse?
( ) Jan; ( ) Feb; ( ) Mar; ( )Apr; ( ) May; ( )Jun; ( )Jul; ( )Aug; ( )Sep; ( )Oct; ( )Nov; ( )Dec; ( )Year round
22. If symptoms are related to the mouth and throat, please indicate which you are experiencing: (check () all that apply).

Mouth pain or burning

Denture/ plate problem

Mouth sores/
ulcerations
Sore tongue
Geographic/white tongue

Pus on/ or swollen

tonsils
Dry mouth
Toothaches

Bleeding / swollen
gums
Gum abscess/infection

Hoarseness of voice

Loss of taste
Metallic taste

Trouble swallowing
Other:_________________

Belchy taste in mouth

23. If symptoms are related to the nose or nasal passages, please indicate which you are experiencing: (check () all that
apply).

Nasal discharge
Sinus pain

Nasal congestion

Nasal dryness
Nasal ulcerations or
sores
Nosebleeds

Nasal polyps
Septal deviation

Change in sense of smell

Snoring at night

Septal perforation

Other:_________________

24. If symptoms are related to the ears or hearing, please indicate which you are experiencing: (check () all that apply).

Earaches

External ear discharge:

Tinnitus/ ear ringing

-Blood from ear

Decrease in hearing

-Pus from ear

Vertigo (room
spinning)
Mold growing in ear
canal
Popping in ears

Pressure at elevations
Pulsation in ears

Other:__________________

25. If symptoms are related to the eyes / vision, please indicate which you are experiencing: (check () all that apply).

Blurred vision
Double vision
Floaters in visual fields
Blind spots in visual
fields

Glaucoma
Cataracts
Lazy eye
Crossed eyes

Eye redness
Eye irritation
Eye discharge
Blindness: ( )R/ ( ) L
eye

Recent change in vision

Trouble seeing to read
Wear glasses/ contacts
Other:_________________

26. If symptoms are related to the brain /nervous system, please indicate which you are experiencing: (check () all that apply).

Seizures/ epilepsy

Nervous/ anxious

Syncope/ blackouts
Tremors
Twitching/ tics

Emotional outbursts
Panic attacks

Memory loss- short

term
Memory loss- long
Cognitive issues

Focus issues/ ADD / ADHD

Inappropriate
fears/phobia
Disorientation
Rapid mood swings
Seeing things

Burning/ pain in nerves

Depression/ blues

Hallucinations

Paralysis

Seasonal Affective Disorder

Numbness/ tingling
Migraines
Headaches

Spinal/ nerve damage

Restless leg syndrome
Other:__________________

Compulsive thoughts or
acts

Brain fog
Insomnia/ sleep issues

Mini-strokes (TIAs)
Stroke (CVA)
Weakness of extremity

2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
27. If symptoms are related to the blood or hematological system: (check () all that apply) and ________type

Bleeding tendency
Leukemia __________
Easy bruising

Anemia________________
Required transfusion
Reynauds phenomena

Hemangiomas
Heavy menses
Low white count

Platelet disorders
Bone marrow problems
Other:_________________

28. If symptoms are related to the endocrine system, please indicate which you are experiencing: (check () all that
apply).

Heat intolerance
Cold intolerance

Hair loss for no reason

Abnormal hair
distribution
Undesired weight gain

Fatigue
Excessive thirst/
urination
Loss of outer eye
brows
Lack of endurance

Abnormal thyroid tests

Goiter/ thyroid nodules

Bone density loss

Mano/Menopause

Abnormal adrenal
studies
Loss of libido

Excessive/ unusual sweating

Undesired weight loss

Inches not desired

Other:_________________

Insatiable appetite

29. If your symptoms are related to the musculoskeletal system, please indicate which you are experiencing: (check

Sore joints
Swollen joints
Deformed joints

Stiff joints/limited motion

Muscle
spasms/cramps

Gouty attacks
Muscle weakness
Painful muscles/fascia
Loss of coordination
Herniated discs

Sciatica /pain into legs

Scoliosis/ spinal curve
Frozen shoulder
Rotator cuff tear
Grinding/clicking joints

Stiff neck

Headache coming from neck

Trigger finger
Bursal swelling on elbow
Other:_________________

30. If your symptoms are related to the kidneys or bladder, please indicate which you are experiencing: (check

Burning on urination
Frequent urination
Trouble starting
urination
Urinary incontinence

() all that apply).

Urinary urgency
Interstitial cystitis
Voiding at night

Too little urine

Dark or colored urine
Flank or mid back pain

Kidney stones
Dribbling urine
Foul smelling urine

Too much urine

Blood in urine

Other:_________________

31. If your symptoms are related to the stomach or intestines, please indicate which you are experiencing: (check

Change in appetite

Food not digesting

Heartburn

Mal-absorption

Belchy taste in mouth in

a.m.

Abdominal
distention/bloating
Black, tarry stools

Vomiting blood
Flatus/ extra gas
Constipation
Diarrhea
Change in bowel
habits

() all that apply).

Food intolerances
Pain after eating
Nausea
Stomach ulcers

() all that apply).

Jaundice or yellow
eyes
Blood seen in / on
stools
Rectal bleeding

Vomiting

Food sticking in
esophagus

Worms in stool

Trouble swallowing
Abdominal pain
Gallbladder problems
Abdominal cramping

Nervous stomach
Frequent bowel movements

Hemorrhoids
Rectal pain after BM
Rectal itching
Other:_________________

2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
32. If you have symptoms of the heart or blood vessels, please indicate which you are experiencing: (check

() all that apply).

Chest pain at rest

Chest pain with
exertion
Shortness of breath
laying
Leg swelling/ edema

Low blood pressure

High blood pressure

Heart murmur
Heart valve problem

Arm or leg numbness

Thrombophlebitis /clots

Dizziness on standing

Exertional shortness of breath

Reynauds phenomena

Palpitations

Leg sores / ulcers

Rapid heart beats

Hardened arteries in
heart

Coldness of feet or
hands
Discolored feet or
hands

Other:_________________

33. If you have any symptoms of sleep disturbances, please indicate which you are experiencing: (check () all that apply)*

Snore loudly
Feel tired

Someone observed you stop

breathing during sleep
High blood pressure

Overweight

Over 50 years old

Neck circumference 15 3/4

(40cm) or larger
Male

*If more than three are checked, a sleep apnea monitor test should be arranged.

34. If you have symptoms related to the lungs or your breathing, please indicate which ones you are experiencing: (check
apply).

Wheezing

Cough

Rattle in chest

Chest pain with deep breath

Change in
sputum

Coughing up blood

Cant take a
deep breath

Exposure to
tuberculosis
Coughing up
mucous

Shortness of breath
Periods of apnea

Other:_________________

35. For females only: please indicate which of the symptoms you might be experiencing: (check

Painful periods

Mood changes near

period
Painful intercourse

Dry vaginal area

Headaches around
Bloating at time of
period
period
Vaginal discharge
Abnormal PAP in past
Vaginal itching
Pain on ovulation
Endometriosis
Hot flashes
Breakthrough bleeding
Loss of libido
Ovarian cysts
Use this area to further explain any of the symptoms in numbers #24 to #34:

36. Exercise: Do you exercise at least 4 days a week?( )-no ( )-yes

Walking ___________miles
Swimming/ Surfing
Jogging ___________miles
Free weights
Hiking ____________miles
Treadmill
Biking ____________miles
Golf

() all that

() all that apply).

Fibroids

Breast lumps
Fibrocystic Breasts
Hx of rape or molestation
Other:_________________

Type of exercises:
Tennis
Pilates
Aerobics
other:_________________
2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Do you exercise to:
Lose weight
Reduce stress
Increase motivation/ feel good
Gain weight
Increase strength
Increase flexibility
Cardiovascular conditioning
Maintain health
Condition for sports
What limits your physical activity? ( ) injuries listed below, ( ) lack of time, ( ) fatigue, ( ) just not my thing
Arm / elbow injury
Nerve damage
Groin injury
Shoulder injury
Wrist / hand injury
Hamstring pull
Ankle / foot injury
Hip / pelvis injury
Bone spurs
Recent fracture/ stress fracture
Tennis elbow
Joint disease
Low back pain
Neck injury
Abdominal pain
Arthritis
Upper back injury
Dizziness
Bursitis /calcium deposit
Knee / thigh injury
Chest pain
37. Foods and Beverages: Think of the meals and snacks that you have had in the last weekindicate in the box how
many portions of each you had in that week. Example: for five helpings of brown rice last week--brown rice

Potatobaked, mashed
Ice cream
Beef
Dry cereals
Butter
Pork
Brown rice
Milk
Chicken/ turkey
White rice
Margarine / Veg. Oil
Candy bars/choc.
Rolls / biscuits
Eggs
Chips
White bread
Nuts / nut butter
Sweet snacks
Whole wheat bread
Oatmeal
Soda pop / lemonade
Pasta
Fresh vegetables
Fruit juice
Cakes / pies / pastries
Fresh fruits
Beer
Cottage cheese
Fresh salads
Liquor
Yogurt
Shellfish
Wine
Cheese
Fish
other:___________
Food preparation: total % needs to add to 100% -Frozen foods-___% +Canned foods-___% +Fresh foods-____% +Dehydrated foods-___%
= to 100% of foods
Most meals are: ( ) at home; ( ) on the road; ( ) fast foods- eat out; ( ) fast foods- take home/delivered; ( ) mooch off family/ friends
38. Life Style Choices: (check () all that apply).

Drink the fluoridated tap water

Drink Reverse Osmosis Water-trace minerals

added

Drink Bottled or Delivered Water

Drink Filtered Water
Drink at least 6 glasses of plain
water

Use a microwave to heat food or water

Use a cell phone or cordless

phone
Use a router/ wi-fi on home
computer

Live within mile of high power

lines
Live with a mile of cell phone
tower
Cell phone receivers on work
place
Cell phone receivers
church/mosque
Use artificial air fresheners at
home
Use artificial car air fresheners

For Women:
Acrylic nails- non-toxic
Use wireless bras
Skin lotions/ natural --nonparaben
Use bio-identical hormone

Use scented detergents/fabric softener

Use hair dyes that are natural

Use all natural make up

Use artificial cologne or perfume

Use natural hair spray/ mousse

2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Sleep with computer router still
on

Use antiperspirant:
type___________
Use seat belts in car

Sleep with cell phone on

Have SDGE Smart Meter on
home
Get eight hours or more of
sleep/night

Have a central vacuum in home

Have an air filtration unit in
home
Spray pesticides in or near home
Meditate or relax daily

Recycle when possible

Focus on positive things

Have 1-2 daily bowel
movements

Choose to eat healthy

Choose to shop for natural
foods

Have a loving pet/ mate/ friend

Enjoy the sunshine often

Have plugged in alarm clock near head

Get 30+minutes of exercise 45days/week

Avoid talking on cell /texting in

car
Use non-synthetic
vitamins/minerals
Use non-PABA sunscreen
Use non-sugar/non-fluoridated tooth
paste

Choose non-toxic products

What have you done in the last few years to try to improve your health (e.g. other doctors, treatments, massages,
acupuncture, craniosacral therapy, chiropractors, etc.)?

What areas of your lifestyle are likely involved with your condition and you would like to have improved: (please
prioritize #1, 2, 3, etc.)
___my level of anxiety
___not enough time spent in nature
___my pace of living
___my creative expression
___not enough peace and quiet
___my feelings about my career
___my diet and nutrition program
___my social and family life
___my exercise program
___my communications skills
What obstacles could prevent you from changing those things in your lifestyle that are undermining your health?

2016

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Be Well Associates, Dan O. Harper, M.D

509 South Cedros Ave., Suite B, Solana Beach, CA 92075, 858-755-1126, Fax 858-755-3530
Other issues or concerns you want addressed:

List your special interests and passions in life:

I understand that there are no guarantees in the field of health. I realize that if I am not willing to work towards my
health or the health of my loved ones seeking consultation with Dr. Harper, that none of the suggestions made will
correct improper diet, unhealthy lifestyle, or years of bad habits.
The work is up to me, with Dr. Harper as a consultant and educator.
Print______________________________________________Signed:_________________________________________
Date: ______________________

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