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MELISA Metals Testing
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New IV ordering template-2024
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NEW or CONTINUING or RENEWING
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1.) Prescribed Infusions with Ascorbic Acid
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A. Restoration Protocols
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B. Vitamin C Infusions (Only IV without B-Complex)
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C. Augmented GSH
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D. Cellular Recovery
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Intolerances/Precautions
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2.) CASH ADD-ONS
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A. Glutathione
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B. NAD (ONLY Cellular Recovery or Metabolic Restore)
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C. Vitamin B12
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Intolerances/Precautions
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ANS Diagnosis Codes
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FNE (Physical Exam WIP)
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Observation/Posture Initial
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MCAS Wheal
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Orientation
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Cranial Nerves
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CN-1: Sense of Smell
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CN-2: Pupillary Reflex
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CN-3/4/6
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CN-5: Facial Sensation
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CN-7: Facial Movement
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CN-8: Hearing
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CCN-11: Full symmetrical strength to βil shoulder, neck, SCMs & tr Full symmetrical strength to βil shoulder, neck, SCMs & traps
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Cerebellar/Parietal/Prefrontal Area Function
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Finger-Nose
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Normal Finger-Nose
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Abnormal Finger-Nose
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Abnormal Finger-Nose with ______.
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Finger-1” from Nose
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Normal Finger-1” from Nose
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Abnormal Finger-1” from Nose
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Abnormal Finger-1” from Nose with ______.
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Nose to Finger Tracking
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Normal Nose to Finger Tracking
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Abnormal Nose to Finger Tracking from Nose
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Abnormal Nose to Finger Tracking with ______.
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Pronator Drift
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Rapid Movements
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Single Leg Stance
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Heel-to-Shin
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Normal Heel-to-Shin
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Abnormal Heel-to-Shin
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Abnormal Heel-to-Shin with ______.
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Rebound/Head
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Rebound/Thoracic
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Rebound/Lumbar
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Positive ____ tremor confirmed by laser pointer accuracy.
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Graphesthesia
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Basal Ganglia Function
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Pull Test
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Limb Hypertonia
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Gait
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Gait
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Verbal distraction with Language (L side)
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Verbal distraction with Language (R side)
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Romberg
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Tandem Romberg
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Walking heel/toe with eyes open (3 steps)
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Walking heel/toe with eyes closed (3 steps)
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Right foot in front of the Left
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Left foot in front of the Right
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DTRs
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Bicep
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Tricep
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Brachialis
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Patella
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Achilles
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Motor (need clarification on verbiage)
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Motor
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Pathological Reflexes
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Hoffman's Reflex (Upper Extremity)
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Hypothenar Percussion Test (Upper Extremity)
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Ankle Clonus (Lower Extremity)
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Clonus (Lower Extremity)
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Beighton (EDS scoring positive is 5 or + /9)
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Beighton Score
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Little finger > 90 degrees extension
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Thumb passive apposition to forearm
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Elbows >10 degrees of extension
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Knees >10 degrees of extension
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Fingertips to floor with knees fully extended
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Neurologic Endurance Repeated Testing
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Posture and facial tone ____ throughout the progression of the history and examination.
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Rapid fast finger movements
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FNE (Assessment WIP)
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Assessment
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Symptoms
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Cerebellar dysfunction findings
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Basal Ganglion Dysfunction
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Poor neurologic endurance
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These issues appear to be ____ in nature
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with ______.
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Assessment of therapeutic benefit care:
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Functional Progress Diagnostics Results
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Autonomic Nervous System (ANS)
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Current ANS Testing Date
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ANS Results
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ANS Progress
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RightEye
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Current RightEye Testing Date
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RightEye Test Results
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Brain region dysfunction
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Indicative of:
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RightEye Progress
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BalanceTrack
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Current BalanceTrack Testing Date
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BalanceTrack Score
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BalanceTrack Fall Risk
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Balance Track Progress
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Inbody
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Current Date of InBody Composition
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Skeletal Muscle Mass
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InBody Fat Mass
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Visceral Fat Area
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Visceral Fat Level
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Phase Angle
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Phase Angle
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InBody Progress
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Heavy Metal Toxicity Assessment (WIP)
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Known Heavy Metal Exposure
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Unknown Heavy Metal Exposure
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Brain Localization Questionnaire
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Heavy Metal Questionnaire Symptoms
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Cognitive Impairment
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Right Eye
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ANS Testing
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BalanceTrack
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Positive Exam Findings
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Chelation Therapeutic Benefit Assessment
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Microcurrent (COMPLETE)
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Consent and Procedure
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Location
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Tolerated Procedure
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Patient did not tolerate procedure: (comments)
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Chelation Protocol (COMPLETE)
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Documentation of heavy metal toxicity
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Ordering Chelation Therapeutic Protocol
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Chelation Protocol
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Chelation diagnosis options
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Diagnosis options (PICK AT LEAST 3)
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Order 20 more chelations AFTER protocol completion
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# of IVs a week
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# of weeks
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Concurrent Oral Supplementation
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Diagnostics and FNE (COMPLETE)
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Right Eye, ANS, Balance Track, CBS, InBody
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Individual options
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FNE/Reason for Outcome
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Tracking progress
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Condition
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MSK-DC Referral
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New IV Plan - Sorted by Ingredient (COMPLETE)
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NEW or CONTINUING or RENEWING
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Patient DECLINES IV treatment
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IV Protocols-Customizations need Sean's approval
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1.) Prescribed Infusions with Ascorbic Acid
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A. Restoration Protocols
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A. Restoration Protocols (Additional instructions)
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B. Vitamin C Infusions (Only IV without B-Complex)
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B. Vitamin C Protocols (Additional instructions)
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C. Myer's
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D. Cellular Recovery
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E. Augmented GSH
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F. Anti-Anxiety
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2.) Prescribed Infusions with NAD
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A. Mitochondrial Health (Please order Diagnostics and FNE)
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A. Mito Health Protocols (Additional instructions)
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B. Metabolic Restore
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3.) Chelation Provocation (please choose one time for 12 weeks)
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4.) Miscellaneous Prescribed Infusions
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A. Amino Acids
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B. Brain Boost
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C. MCAS
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D. Tissue and Wound Healing
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E. Hydration
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A. Hydration Protocols (Additional instructions)
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F. Magnesium 3G
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5.) Custom IV's (Please contact Sean for new custom IV's)
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A. Custom Myer's for sensitive patients
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B. Custom Myer's (LAPA000001-specific protocol)
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C. Custom Mito without B-Complex
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D. Custom Brain Boost without Glycine
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E. Custom Anti-Anxiety without B-Complex
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6.) CASH ADD-ONS
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A. Ozonated Saline *CANNOT BE PRESCRIBED BY ITSELF
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B. Exosomes *MUST BE PRESCRIBED WITH RESTO 25
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C. Alpha Lipoic Acid (ALA)
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Frequency, Dx codes, Medical Necessity
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Standing Order
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# of IVs a week
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# of weeks
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Primary diagnosis options (PICK AT LEAST 2)
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Secondary diagnosis options (PICK AT LEAST 2)
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PHQ-9
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Was the PHQ-9 completed before the appointment?
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Therapeutic Infusion Treatment
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*Medications that cause nutrient deficiency
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Antibiotics
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Opioids
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Proton Pump Inhibitors (PPI)
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Psychotropic Medications
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Blood Pressure Medications
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Antifungal Medications
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Diagnostics (Macro)
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New IV Plan - Sorted by Protocol (Rejected)
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Primary diagnosis options (PICK AT LEAST 2)
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Secondary diagnosis options (PICK AT LEAST 2)
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