brain bio centre

Brain Bio Centre �: 020 8332 9600

Thank you for contacting the Brain Bio Centre. This is the first clinic of its kind in Britain to offer comprehensive nutritional assessment and treatment for those who wish to improve their mental health. After 20 years of research at the Institute for Optimum Nutrition, working with literally thousands of clients, we feel confident in saying that this approach is highly effective. It should, in our opinion, be the first port of call, not the last, for a wide range of mental health concerns including ADHD, autism, depression, anxiety, bipolar disorder, schizophrenia, learning difficulties, dyslexia, dyspraxia, memory decline, dementia, Alzheimer’s disease and those in recovery from addiction. If you are relatively new to optimum nutrition and its proven benefits for mental health I strongly recommend you read my book, New Optimum Nutrition for the Mind. This book also contains 500 scientific references showing how effective this approach is and is the best background reading for yourself and your doctor, should you want to inform them about this approach. You will also be able to read a small number of the hundreds of success stories from former clients, both children and adults. The book is available in any bookshop or by mail order by calling +44 (0)844 669 6000 or by visiting www.brainbiocentre.com. This book gives you invaluable information to support you through your Brain Bio Centre treatment. If you are in recovery from addictions you will also be interested in my recent book on addiction recovery How to Quit without feeling S**T with David Miller PhD and Dr James Braly (Piatkus). Visit our website www.how2quit.co.uk and contact the Brain Bio Centre to find out more about how we can help after your detox to achieve a successful recovery. If you would like to come and see us, please complete the Patient Information Questionnaire, included in this pack and return it to us with a signed copy of the Terms and Conditions. To secure your appointment, we require a deposit of £50 which will deducted from the cost of your first appointment. Once we receive your Questionnaire, we will contact you to arrange an appointment at our clinic in Richmond, south west London. In the meantime, if you have any questions, once you have read through this information pack, please do not hesitate to call us on +44 (0)20 8332 9600 or email us [email protected]. May I take this opportunity to wish you the very best of health and let you know that my team and I will do our utmost to bring you to the point of optimal health. Yours sincerely

Patrick Holford CEO Food for the Brain Foundation Founder – Institute for Optimum Nutrition


BRAIN BIO CENTRE at the Institute for Optimum Nutrition

The Clinic The Brain Bio Centre is an outpatient clinical treatment centre, specialising in the 'optimum nutrition' approach to mental health problems and nutritional support to those in recovery from addictions. The Brain Bio Centre offers a comprehensive assessment of the biochemical imbalances that can contribute to mental health symptoms and abstinence symptoms as well as detailed advice and guidance on how to correct these imbalances and restore health. The clinic is owned by the Food for the Brain Foundation, a registered educational charity and is located within the Institute for Optimum Nutrition, itself an educational charity.

Conditions That May Be Helped We work with any person who has a mental health concern. A wide variety of mental health problems have been helped through the optimum nutrition approach. These include ADHD, autism, depression, anxiety, bipolar disorder, schizophrenia, learning difficulties, dyslexia, dyspraxia, memory decline, dementia, Alzheimer’s disease and those in recovery from addiction.

The Treatment As a treatment centre of excellence, patients are accepted on the basis of being willing to have a thorough mental health and biochemical assessment and to follow through with nutritional management under medical supervision, over a minimum period of six months.

Consultations The programme starts with a 1 hour appointment with a nutritional therapist. At this first appointment, the nutritional therapist will take a full case history and recommend a number of biochemical tests which can be undertaken at our lab in central London. Your first consultations and a visit to the lab will usually take three to four hours including travel time between clinic and lab.

Please be aware that it may also be necessary for you to see our psychiatrist for a 20 minute brief assessment at the time of your first visit. We will inform you upon receipt of your questionnaire if this is the case.

Your second appointment with the nutritional therapist which is about 4-6 weeks after the first will be scheduled for one hour. It is at this appointment that you will receive the results of the biochemical tests along with specific dietary and nutritional supplement recommendations.

Subsequent appointments with the nutritional therapist are booked as necessary. These may be from 4 weeks to 12 weeks apart and are generally for half an hour, however, you always have the option of booking a longer appointment should you feel you need it.

A full one hour Psychiatric Assessment appointment with the psychiatrist is available to anyone at any time.

In general, most people meet with a nutritional therapist about five times over the course of a year and with the psychiatrist once or twice.

More frequent appointments may be required for children, particularly very young children.

Tests Biochemical screening through blood, urine and hair Biochemical screening through blood, urine and hair Biochemical screening through blood, urine and hair Biochemical screening through blood, urine and hair samples, may include:samples, may include:samples, may include:samples, may include:

Food allergiesFood allergiesFood allergiesFood allergies using quantitative ELISA IgG analysis Mineral imbalancesMineral imbalancesMineral imbalancesMineral imbalances using hair, sweat and blood mineral analysis Pyrroluria (HPPyrroluria (HPPyrroluria (HPPyrroluria (HPL)L)L)L) using urinary reagent analysis NeurotransmitterNeurotransmitterNeurotransmitterNeurotransmitter imbalancesimbalancesimbalancesimbalances using blood platelet determinations of serotonin, noradrenalin, and serum measures of histamine Homocysteine imbalanceHomocysteine imbalanceHomocysteine imbalanceHomocysteine imbalance using blood plasma Essential fatty acidsEssential fatty acidsEssential fatty acidsEssential fatty acids using red blood cells Urinary peptUrinary peptUrinary peptUrinary peptidesidesidesides using urine analysis

Further tests to investigate specific issues may also be Further tests to investigate specific issues may also be Further tests to investigate specific issues may also be Further tests to investigate specific issues may also be recommended where appropriate.recommended where appropriate.recommended where appropriate.recommended where appropriate.

Some patients will be asked to complete a psychometric screening questionnaire prior to the beginning of treatment. These are a useful measure of progress. We are exploring using patient self-reported outcome measures to help you monitor your own progress.

Costs The cost of the programme will vary from patient to patient depending on the tests, consultations and nutritional supplements required. Typically, over a year, most patients spend between £600 to £1,100 on consultations and tests, depending on the number and complexity of tests chosen, plus between £2 and £3 per day for supplements. The supplement programme varies from person to person and is reassessed and adjusted as the patient progresses and we try to work within a patient’s budget.

Some private medical insurance schemes will reimburse the costs of lab tests and consultations.

Appointments Please telephone our helpful clinic staff to discuss your needs in more detail and to make an appointment on

Tel +44 (0) 20 8332 9600 +44 (0) 20 8332 9600 +44 (0) 20 8332 9600 +44 (0) 20 8332 9600 Email [email protected] [email protected] [email protected] [email protected]

We are located at: The Institute for Optimum Nutrition (ION) Avalon House 72 Lower Mortlake Road Richmond Surrey TW9 2JY


People

Patrick Holford BSc, DipION, founded the Brain Bio Centre in 2003 and went on to found the parent charity Food for the Brain in 2005. Patrick trained in psychology in the 1970s and went on to specialise in the nutritional treatment of mental health problems. He became a student of Dr Carl Pfeiffer in Princeton, New Jersey, and Dr

Abram Hoffer, former psychiatric research director in Canada. He is the UK representative of the International Society for Orthomolecular Medicine. Since the 1970s Patrick Holford has successfully treated thousands of patients and carried out original research on schizophrenia and learning difficulties, including ground-breaking research in the mid-80s that showed that vitamin supplements could increase IQ scores in children.

He is author of the book New Optimum Nutrition for the Mind and How to Quit without feeling S**T and is regularly called upon as the nutrition expert for radio and television features. Patrick Holford is CEO of Food for the Brain Foundation and a Fellow of the British Association for Nutritional Therapy (BANT).

Deborah Colson DipION is a

nutritional therapist, trained at the Institute for Optimum Nutrition. She specialises in the nutritional management of mental health

problems and is co-author of Optimum Nutrition for your Child and The Alzheimer’s Prevention Plan. Deborah is

currently a consultant for Food for the Brain, an academic for the Institute for Optimum Nutrition, a nutrition-related MSc postgraduate student and she is a member of BANT and a Nutritional Therapy Council (NTC) Registered Practitioner.

Lorraine Perretta DipION is a

nutritional therapist. She trained at the Institute for Optimum Nutrition. She is author

of the book Brain Food and specialises in the nutritional management of mental health problems. Lorraine is a member of BANT.

Dr Siobhain Quinn MBChB

MRCPsych DipCBT, Consultant Psychiatrist. Siobhain is a consultant psychiatrist who trained in London and also works in the NHS. She is a specialist in liaison psychiatry i.e. the interface between psychological and physical disorder and older peoples’ mental health. She takes a holistic approach to

health and disease using a variety of therapies including psychological, pharmacological and mind-body.

Dr Shauki Mahomed LRCPandS(I), DPM, MRCPsych Consultant Psychiatrist. He qualified at the Royal College of Surgeons in Dublin and also works in the NHS. He is a specialist in Psychological Medicine and has vast experience in many aspects, both dynamic and organic. He is a firm believer in the importance of nutrition, firstly, as a key

part of any health programme and, secondly, to maximise the treatment in the event of illness.

Bronia Nowak BA is the Clinic Manager. She manages appointments and handles all client queries, arranges biochemical tests, liaises with laboratories and handles all administrative matters. Bronia is usually your first point of contact with the clinic on

020 8332 9600 or [email protected].


SCIENTIFIC ADVISORY BOARD

Our Experts We work together as a team to ensure you receive the best possible care and attention.

The Brain Bio Centre’s treatment protocols are informed by scientific evidence and guided by the expertise of Food for the Brain’s Scientific Advisory Board:

Professor David Smith Faculty of Medical Science Deputy Head, Division of Medical Sciences. Professorial Fellow, Lady Margaret Hall. Professor Smith has spent his entire academic career at the University of Oxford and has held the Chair of Pharmacology since 1984. In 1985 the Medical Research Council appointed him Honorary Director of the newly established Anatomical Neuropharmacology Unit in Oxford, which has pioneered ways of studying neural networks in the brain. In 1988 he established the Oxford Project to Investigate Memory and Ageing (OPTIMA) – a clinicopathological longitudinal study. Alzheimer’s disease remains his main research interest today and he was the first Chairman of the Scientific Advisory Board of the Alzheimer’s Research Trust, UK.

Dr James Braly MD has specialised in alternative and nutritional treatments for numerous chronic conditions, including addiction, for 30 years and is currently researching nutritional approaches for addiction. Dr Braly has authored many books including Dr Braly’s Food Allergy and Nutrition Revolution, Dangerous Grains, The H Factor and Hidden Food Allergies. He has helped establish nutritional treatments in many medical clinics and treatment centres in the US. Working with David and Merlene Miller, James Braly has pioneered and developed highly effective nutritional therapy for addiction. He conducted the first semi-quantitative study of efficacy and safety of intravenous and oral nutritional therapy for recovering alcoholics. He introduced and popularised testing for and treating hidden (IgG) food allergies, the concept of leaky gut syndrome and the importance of lowering homocysteine – factors that affect many people recovering from serious addictions. For several years he has focused exclusively on helping those with some of the worst addictions, who have struggled to become and stay drug-free or sober.

Dr David Miller PhD has worked in the addiction field for 30 years. He was associate professor of addiction studies at Graceland University in Missouri, where he was on the faculty for eight years. Before that he taught addiction studies at Park University in Missouri for 11 years. Over the last 30 years David has practiced addiction counselling in private practice, in an intensive outpatient treatment programme, in a detoxification programme, in a family intervention practice and in a food addiction programme. He has also acted as consultant to numerous treatment centres. The focus of his work and research has been on finding effective treatment methods to aid those for whom traditional treatment has not worked. Several years ago David met Dr James Braly, who has improved and refined nutritional therapy. Dr Braly, David and his wife Merlene have worked as a team committed to furthering this work. Merlene, an expert in addiction and a skilled writer and communicator, also contributed greatly to the writing of this book.

Assoc. Professor Martha Morris (ScD) is an Associate Professor at the Rush Institute for Healthy Aging and the Department of Internal Medicine at Rush University Medical Center. She is the organizing chairperson of the International Academy of Nutrition and Aging 2006 Symposium on Nutrition and Alzheimer's Disease/ Cognitive Decline, Chicago, USA. Dr. Morris is one of the pioneers in research on dietary risk factors for Alzheimer's disease (AD) and cognitive change with aging. She has published findings on the relation of antioxidant nutrients, dietary fats, and the B-vitamins to these conditions.

Dr Abram Hoffer MD, PhD, former psychiatric research director for Saskatchewan Canada, and president of the Canadian Schizophrenia Foundation, has fifty years experience treating over 4,000 people diagnosed with schizophrenia. Since 1955 he has published 19 books and 600 papers in medical journals.

Professor Helfa Refsum, MD PhD is Professor of Nutrition

University of Oslo and visiting Professor of Human Nutrition, University of Oxford. She has pioneered research into homocysteine and related B vitamins for the past 20 years. She is a member of the Norwegian Academy of Science and Letters. Refsum’s focus of research today is the relation of B vitamins with aging. Her work is supported by the Alzheimer’s Research Trust UK.

Professor Philip Cowen, Psychopharmocology Research Unit, Warneford Hospital. Philip Cowen is Professor of Psychopharmacology and MRC Clinical Scientist at the University of Oxford. His research and clinical interests are in the biochemistry and treatment of mood disorders, and particularly the pharmacological management of resistant depression. He also has an interest in the use nutritional interventions such as folic acid to prevent mood disorders in those at increased risk.

Professor Peter Ryan, Professor at the Department of Mental Health and Social Work at Middlesex University.

For more detailed information on the Brain Bio Centre and the ‘optimum nutrition’ approach to mental health and abstinence support:

• Visit www.brainbiocentre.com

Further reading:

• How to Quit without feeling S**T (2008) Patrick Holford with David Miller PhD and Dr James Braly (Piatkus) and visit the website www.how2quit.co.uk

• New Optimum Nutrition for the Mind (2007) Patrick Holford (Piatkus)

• Optimum Nutrition for your Child (2008) Patrick Holford & Deborah Colson (Piatkus)

• The Alzheimer’s Prevention Plan Patrick Holford & Deborah Colson (Piatkus)

• To order books call +44 (0)844 669 6000, visit www.patrickholford.com or any good bookstore


DESCRIPTION OF CONSULTATIONS AND TESTS

ConsultationsAt your first appointment, your nutritional therapist will make recommendations to undertake appropriate tests.

The initial appointment with your nutritional therapist (and the brief Psychiatric Assessment with our psychiatrist if necessary) involves a review of your health history.

An initial analysis is made and recommendations for biochemical tests are given. Once test results are available, a 1 hour follow-up appointment with the nutritional therapist will be arranged to explain the test results and to provide dietary and supplement recommendations. Further follow-up appointments with

the nutritional therapist are generally for half an hour, unless you feel you may need longer to discuss your progress.

A 20 minute Brief Psychiatric Assessment appointment with our psychiatrist may be required prior to the initial appointment with the nutritional therapist. We will advise you about this when booking your appointment. A more extensive Full Psychiatric Assessment appointment (1 hour) with the psychiatrist is also available to anyone at any time. In general, most people meet with a nutritional therapist three to four times over the course of about six to nine months. They may also meet with the psychiatrist once or twice.

Tests Biochemical tests to help assess your nutritional statusBiochemical tests to help assess your nutritional statusBiochemical tests to help assess your nutritional statusBiochemical tests to help assess your nutritional status

Food Allergies can contribute to a variety of symptoms and disorders including depression, fatigue, ‘brain fog’, anxiety, psychosis, ADHD and autism. We use the Quantitative ELISA IgG analysis. The FoodScan 113 Test assesses IgG antibody response to 113 commonly eaten foods including grains, dairy products, meats, fish, nuts, vegetables, fruits, herbs and spices.

Neurotransmitter Imbalances are assessed from blood platelet levels of neurotransmitters. This test requires venous blood (i.e. drawn from a vein). Blood will need to be drawn at a private practice in central London. Levels of platelet determinations of serotonin and noradrenalin (norepinephrine) are measured. An imbalance in these neurotransmitter levels is principally associated with symptoms of depression and lack of drive.

Histamine Imbalance is assessed from blood plasma. This test requires venous blood (i.e. drawn from a vein). Blood can be drawn at a private practice in central London. An imbalance in histamine is associated with symptoms of schizophrenia and depression.

Homocysteine levels are assessed from blood plasma. This test requires a sample of blood. Homocysteine is a potentially harmful sulphur bearing amino acid produced in the body. Elevated levels of homocysteine in the blood may be related to Alzheimer’s, depression, schizophrenia and autism.

Mineral Imbalances are assessed by hair

mineral analysis. This test requires a small sample of hair (about 2 teaspoons) taken from the back of the head. The hair sample must be untreated (i.e. not dyed or permed) and cut close to the scalp. If scalp hair is not available, then sweat may be used. Deficiencies, excesses or imbalances of minerals including toxic metals may contribute to a variety of symptoms including paranoia, anxiety, aggression, depression, poor memory and concentration.

Urinary Peptides An early morning urine sample is collected, frozen and returned to the laboratory. The sample is then tested for chains of amino acids (peptides). Elevated levels of these peptides result from partially undigested milk or gluten foods being absorbed into the blood stream. Most of the peptides are flushed out of the body in the urine but a small proportion will cross into the brain and interfere with function. This often results in the symptoms such as autistic spectrum disorders and learning and behavioural problems.

Comprehensive Stool Analysis is done from stool samples. The test kit contains full instructions and all equipment required to perform this test at home, plus self-addressed packaging to return the sample to the laboratory. Two samples must be provided on consecutive days. The Comprehensive Stool Analysis offers a comprehensive view of the health of the gastrointestinal tract, with information about digestion, absorption, bacterial balance, yeast overgrowth,


inflammation, metabolic activity, and immune function. Imbalances in any of these areas can produce a variety of symptoms, as gut health may directly or indirectly affect mental health.

HPL (hydroxyhemopyrrolin-2-one) is

assessed by urinary reagent analysis. This test requires 2 urine samples. Pyrroluria, which is an elevated level of HPL in urine, may be a factor in depression, psychosis, anxiety and autism.

Adrenal Stress Index assessed from saliva samples. Four saliva samples are collected at home over a 24 hour period. The test assesses the body’s freecirculating, biologically active hormones of cortisol and DHEA (dehydroepiandrosterone). This shows how well the body is coping with emotional, physical and chemical stresses. Symptoms of anxiety, stress, depression, fears, fatigue, ‘brain fog’, lack of drive, are associated with imbalances in cortisol and DHEA.

Female Hormone Panel from saliva samples. This test analyses eleven saliva samples over a 28- day period for the levels of ß-estradiol, progesterone, and testosterone. This test may be useful if mental health symptoms are related to hormonal cycle.

Detoxification Capacity Profile is assessed from urine and saliva samples. Saliva samples are collected following the ingestion of a premeasured amount of caffeine, while urine is collected following the ingestion of aspirin and acetaminophen (Paracetamol). The test assesses the body’s capacity to detoxify environmental and gut-derived toxins and the body’s own hormones and other compounds. This test is useful if it is suspected that the mental health symptoms are related to toxic exposure, hormonal imbalances, gut dysbiosis or a history of drug or alcohol abuse. Associated symptoms may include eczema, joint aches, and mental health symptoms that are worse after eating.

Parasitology is assessed from stool samples. The test kit contains full instructions and all equipment required to perform this test, plus self-addressed packaging to return the sample to the laboratory. Two samples must be provided on consecutive days. Parasitology detects the presence of intestinal parasites including amoebae, flagellates, ciliates, coccidian and microsporidia.

Gut Permeability is assessed from urine

samples. This test involves collecting samples before and after consuming a premeasured challenge drink containing lactulose and mannitol. The kit includes full instructions plus challenge drink and collection containers. This test assesses intestinal permeability and absorption levels. Intestinal permeability may lead to an increased burden on detoxification systems, the

development of food allergies and autoimmune conditions. It has been associated with autism, schizophrenia and psychosis.

Secretory IgA (SigA) is assessed from saliva samples. Measuring levels of SigA can provide the link between gut disorders and systemic illness. SigA production is greatly influenced by aging, antibiotics, intestinal infection, chronic alcohol intake, maldigestion, malabsorption, NSAIDs and chronic stress levels.

Vitamin D is assessed from blood samples. Vitamin D has a hormone like effect. There is growing evidence for the contribution of low circulating 25-hydroxyvitamin D derivative levels to the development of a wide range of bone, autoimmune, and nervous system diseases as well as obesity, diabetes and cardiovascular diseases. The biologically active vitamin (1-alpha, 25-dihydroxyvitamin D3) is produced locally in various tissues where it modulates calcium and inflammatory responses. Most Vitamin D is stored in body tissue as 25(OH). Total body vitamin D nutritional status is indicated by serum 25(OH) D measurement.

Metabolic Analysis Profile is measured from 2 x 5ml first morning urine samples. This profile provides a unique way of assessing various cellular processes and the efficiency of metabolic function by measuring intermediates that are excreted in the urine.

Candida Antibody Profile is measured from 1 x 10ml ETDA sample or 1 x plain saliva sample. Candida Albicans is a naturally occurring yeast species that is found in the large intestine, genital tract, mouth and throat. Under normal conditions it is compatible with good health and usually kept under control by beneficial bacterial flora, the immune system and proper intestinal PH. However, under certain circumstances, Candida can become pathogenic and may overgrow leading to a pronounced immunological reaction.

Gluten Sensitivity Profile is assessed by 1 x 10ml EDTA sample. Intolerance to the gluten component of wheat, rye, oats and barley causes gluten sensitive enteropathy (GSE), which is characterised by chronic inflammation of the intestinal mucosa and flattening of the epithelium. Gluten intolerance can cause both acute and chronic symptoms, including anaemia, unexplained weight loss, diarrhoea, bloating, wind, low energy, general malaise, dermatitis herpetiformis, psychiatric problems, aching joints and muscles.

Total Thyroid Screen is assessed from 1 x 10ml serum sample. It assesses thyroid gland function.


FEE SCHEDULE Many of our clients opt to have screening tests which can provide further insight into nutritional status and/or biochemical imbalances. The nutritional therapist will be able to give guidance on which tests may be most appropriate for you.

Consultations

Nutritional Therapist consultation (1 hr) £145

Nutritional Therapist consultation (30 mins) face to face or by phone £75

Brief Psychiatric assessment (20mins) £70

Full Psychiatric assessment (1 hour plus report) £190

Tests

FoodScan IgG 113 £250

Food Intolerance IgE £120

Hair Mineral Analysis £55

HPL £35

Serotonin and Noradrenalin (Norepinephrine) £170

Histamine £55

Homocysteine £75

Comprehensive Stool Analysis and Parasitology £240

Intestinal and gut permeability £125

Detoxification Capacity Profile £160

Adrenal Stress Index £110

Female Hormone Panel £155

Urinary Peptides £60

Essential Fatty Acids £80

RBC Magnesium £25

Vitamin Profile £120

Sweat mineral analysis £60

Vitamin D3 £60

Secretory IgA £60

Metabolic Analysis Profile £240

Payments A deposit of £50 must be included with each completed Patient Information Questionnaire.

Cancellation fee (if less than 2 working days notice given) is the full consultation fee.

Test fees are payable on ordering. Consultation fees are payable at the time of the consultation.

You have the right to opt out of any tests that you have ordered within 14 days provided that you give written notice and return any home test kits unused. You will receive a full refund less 15% administration charge.

We accept cash, cheques, postal orders and all major credit and debit cards.

Cheques and postal orders should be made payable to the Brain Bio Centre.

Prices are subject to change without notice.


FREQUENTLY ASKED QUESTIONS

I have an appointment for my Autistic/ADHD child. Shall I bring him/her with me to the clinic? While it may be helpful for the nutritional therapist to see the child in person, sometimes the stress of the visit to the clinic may be counterproductive. If this is the case, then the nutritional therapist can get all the information about the child from you the parent or guardian.

Which conditions can you help with? The Brain Bio Centre is experienced in working with any person who has a mental health concern. It may include depression/anxiety, phobias, psychoses, bipolar disorder, developmental/ behavioural disorders, degenerative disorders (Parkinson’s, Huntington’s, Alzheimer’s, dementia) and those in recovery from addictions. Since our approach is to assess and address underlying biochemistry, other disorders not listed here but that relate to brain function may be helped.

Does the person with the health concern need to attend the clinic in person? Your first consultation will be face to face, however under some circumstances the nutritional therapist will agree to consultations undertaken by a parent / guardian / carer or by telephone.

If I am on medication, will this affect the programme? You should be sure to provide accurate details of your medication so that your nutritional therapist will be able to factor this in when interpreting test results and making nutritional supplement recommendations. You should not adjust or discontinue medication without the full consent of your prescribing doctor.

What are your success rates? We have hundreds of satisfied clients, however the degree of improvement varies widely from client to client and is affected by many factors including level of compliance, length of illness and other medical complications, so it is not possible to state a ‘success rate’.

Do I need to bring urine/hair/blood samples with me to my appointment? The Brain Bio Centre does not have a laboratory on the premises. We work with a lab in central London who processes all samples for us. However, we may send you urine collection pots with instructions for the collection of urine samples. You will be able to take this to the lab when you visit there for tests. In rare circumstances, you may not be visiting the lab on the same day as your first appointment, in which case we will post your sample on to the lab.

What is the orthomolecular approach? Orthomolecular psychiatry (first described by Dr Linus Pauling in 1967) is a form of complementary medicine that aims to treat disease by restoring the optimum environment of the body by correcting the metabolic imbalances or deficiencies causing disease. Treatments are based on patients’ personal biochemistries and employ naturally occurring or bioequivalent (bio) molecules, such as vitamins, dietary minerals, proteins, antioxidants, amino acids, lipotropes, prohormones, dietary fibre, fatty acids and other similar substances. Proponents hold that biochemical imbalances and/or nutritional deficiencies can be prevented and treated by achieving optimum bodily levels of these substances.

The doctor has told me that nothing can be done to help my illness except to take the medication, is this true? Your doctor may not be aware of the orthomolecular approach to mental illness as it is not taught in medical school.

Is there anything I can do to improve my outcome? The most important factor in the success of any individual case is the degree of compliance to the programme. On the whole, the more closely you follow the advice given, the more likely you are to experience the maximum improvement possible.

I have been addicted to drugs / other substances, can optimum nutrition help me quit? Many people have tried to give up their addictions only to be defeated by cravings, exhaustion, anxiety, mood swings, sleep problems, depression, shakiness or fatigue. These withdrawal or “abstinence” symptoms can prevent you from even attempting to quit. A fundamental imbalance in the brain’s chemistry underlies all chemical addictions, from caffeine to cocaine. However the right combination of nutrients can restore this balance and help reverse and even prevent withdrawal symptoms, thus significantly improving the chances of quitting for good. If you want to learn more about this approach read How to Quit without feeling S**T and visit www.how2quit.co.uk

How much will it cost? The cost of the programme will vary from client to client, depending on the tests, consultations and nutritional supplements required. Read the Fees Schedule to get an idea of the fees involved. Most clients spend between £500 to £1100 over a period of about a year on consultations and tests plus up to £2 to £3 per day for supplements over this time.


FREQUENTLY ASKED QUESTIONS

Can you guarantee a cure for my condition? We cannot guarantee a cure for any condition. We can provide nutritional support to address nutritional deficiencies and biochemical imbalances that may be major factors in your illnesses thereby enabling the brain and body to achieve balance.

Can recreational drugs (eg cannabis, cocaine)cause a mental illness/mental health symptoms? In our experience recreational drugs do not ‘cause’ a mental illness. We generally find that those who experience a ‘drug-induced’ illness have one or more biochemical imbalances that would predispose anyone towards mental illness and that drug use may be the ‘last straw on the camel’s back’. Clearly, continued drug use would be unwise for that individual.

Does Patrick Holford see clients? No. Patrick Holford is founder and director of the clinic and as such oversees the clinic and presides over regular practitioner forum meetings where individual cases may be discussed. All clients can be assured of benefiting from his experience and expertise.

When will I start to feel better? How long does the ‘getting better’ process take? This varies widely from client to client and is affected by many factors including level of compliance, length of illness and other medical complications. As a guideline, most clients begin to feel better within a few weeks.

Should I stop my medication? Do not adjust or discontinue any medication without the full consent of your prescribing doctor.

What can I do if I have no money? You should begin by reading Patrick Holford’s book How to Quit without feeling S**T and you can also visit the website www.how2quit.co.uk. This book contains a great deal of practical advice and information from which you can begin to help yourself. If you also have other mental health concerns, you may also be interested in reading New Optimum Nutrition for the Mind, also by Patrick Holford.

Adult Questionnaire 10

PRIVATE AND CONFIDENTIAL

Patient Information How did you hear about the Brain Bio Centre? _________________________________________________________________

Today’s Date ____________________________

Title __________ First Name _______________________________ Last Name ________________________________________

Address ________________________________________________________________________ Post Code ________________

Telephone: home ___________________________________ mobile/work ____________________________________________ Can we leave messages on voicemail linked to this number? Y N Can we leave messages on voicemail linked to this number? Y N

E-mail ______________________________________________ Occupation ____________________________________________

Date of Birth _______________________________________ Ethnic Origin _____________________________________________

Weight __________ Height____________ Resting Pulse __________ Blood Pressure __________ Blood Type _____________

We require details of your GP to book an appointment for you. Name ________________________________________ Role ______________________ Telephone Number _________________

Address ________________________________________________________________________ Post Code _________________

Sometimes it is necessary for the Brain Bio Centre to contact your doctor to share information. If we do need to obtain information from your doctor about you, we will ask you for your consent first.

Have you been assessed or been to see your doctor or other medical professional for : a mental health concern? addiction rehabilitation or related issues?

Please give contact details of any other healthcare professionals or addiction recovery group who are involved with your care e.g. psychiatrist, community mental health team worker, AA / NA / CA sponsor, CITA, etc.

Name ________________________________________ Role ______________________ Telephone Number _________________

Address __________________________________________________________________________Post Code _________________

Name ________________________________________ Role _______________________ Telephone Number _________________

Address __________________________________________________________________________Post Code _________________

Name any other sources of support that you have. e.g. spouse, family, friend _____________________________________________

PATIENTS UNDER 18 YEARS OF AGE: Please provide parent/carer details

Title ___________ First Name _____________________________ Last Name ________________________________________

Relationship to Patient __________________ Telephone: home ___________________ mobile/work ______________________

Address ____________________________________________________________________ Post Code ______________________


Relationship to Patient __________________ Telephone: home ___________________ mobile/work_______________________

Address ____________________________________________________________________ Post Code ______________________

PATIENTS AGED 18 YEARS AND OVER

Do you have a spouse, partner, relative, friend, carer or advocate who you would like to represent you, be present or involved in your consultations and care? If yes, please give details:


Relationship to Patient __________________ Telephone: home ___________________ mobile/work ______________________

Address ________________________________________________________________________ Post Code _________________

Patient’s Signature________________________________________________________________ Date ______________________


Your health: What are your primary mental health problems? (continue on a separate sheet if necessary)

Mental Health problems Duration Factors that make it better or worse

What other general health issues do you have, if any?

General Health problems Duration Factors that make it better or worse

Please list any previous major illnesses ___________________________________________________________________________

Please list any operations you have had___________________________________________________________________________

Medication

Please list all medication you are currently taking - prescribed (include dose) or over the counter. ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Please state whether you are experiencing side-effects from any of your current medication and if so, what these adverse effects are and whether you attribute them to a particular medication. ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Have you experienced benefits from any of your medications? Yes / No

If yes, please describe these: __________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Have you ever taken any psychiatric medications that you have not already listed e.g. antipsychotics, antidepressants, tranquillisers, sedatives, mood stabilisers? Please state the names and when you were taking them: _____________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Please list any herbs or supplements that you are currently taking. ___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Have you taken ‘broad spectrum’ antibiotics or tetracycline antibiotics? Yes / No


Mental Health

Are you experiencing any of the following? If so please tick and give a score of severity, where 0 is no problem at all and 5 is the worst ever:

Yes Score (e.g. 3)

Irritability _____

Anger _____

Excess energy _____

Agitation or excitability _____

Restlessness _____

Thoughts of harming yourself _____

Suicidal thoughts _____

Thoughts of harming others _____

Lack of energy _____

Nausea _____

Difficulties with sex _____

Have you had a diagnosis of mental illness? Yes / No

If yes, what was the diagnosis? _________________________________________________________________________________ Have you ever been treated as an inpatient at a psychiatric hospital? Yes / No

If yes, please give details? _____________________________________________________________________________________ Have you ever been diagnosed with any of the following? Please tick.

schizophrenia psychotic disorder or psychosis delusional disorders

schizotypal disorder personality disorder drug induced psychosis

schizoaffective disorders severe depression or psychotic depression

manic depression, mania or bipolar affective disorder

Have you ever attempted suicide? Yes / No If yes, please provide date of most recent occurrence ___________________

Have you ever self-harmed? Yes / No If yes, please provide date of most recent occurrence ___________________ Has your mental health problem ever resulted in you becoming aggressive or violent to others? Yes / No ______________________

___________________________________________________________________________________________________________

Is there a family history of mental health or addiction problems? Yes / No ________________________________________________

___________________________________________________________________________________________________________

Do you have concerns about your ability to carry out a nutritional treatment programme at present (e.g. due to problems with memory, motivation, living circumstances)? Yes/ No. If so please state what these are: ___________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Are you consulting any complementary/alternative therapists? Please name therapy and length of time you have been using it.

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________


3 Day Food Diary

Please write down all the foods and drinks consumed over the next 2 days, starting today. Give as much detail as possible including time of consumption, description of the foods, drinks, quantities eaten and brand names.

Use a separate sheet if you like.

Weekday 1 Weekday 2 Weekend / day off

Breakfast

Time:

Time:

Time:

Lunch

Time:

Time:

Time:

Evening

Meal

Time:

Time:

Time:

Snacks

Time:

Time:

Time:

Drinks

Please list the types of drinks and how many. Eg 3x water, 2x red wine, 1x juice


Questionnaire

Please tick any the conditions / symptoms which apply to you:

Brain, Emotion & Mood Habits & Behaviour Physical Attributes Sleep and Energy

□ forgetful □ eat sweet foods □ crowded front teeth □ light sleeper

□ confused □ add sugar to hot drinks □ large ears □ difficulty falling asleep

□ difficulty concentrating □ crave sugar □ long fingers/toes □ wake up during the night

□ lack of mental clarity □ drink alcohol alone □ insomnia

□ dyslexia □ smoke cannabis joints daily Weight □ dream infrequently

□ memory decline □ need alcohol to relax □ unstable weight □ poor dream recall

□ short attention span □ drink alcohol most days □ difficulty losing weight □ night sweats

□ not thinking straight □ regular recreational drug use (eg. twice a month or more)

□ difficulty gaining weight □ feel drained

□ suspicious of people □ 5 or more cigarettes a day □ physical fatigue

□ difficulty learning new things

□ take recreational drugs alone

Immune System □ mental fatigue

□ difficulty visualising things □ obsessive or compulsive tendencies

□ sore throat □ lethargy

□ inner tension □ rituals □ nasal congestion □ grind teeth in sleep

□ ‘driven’ feeling □ restless □ frequent colds □ frequently tired

□ phobias □ rarely initiate tasks □ infections □ reduced stamina

□ nervousness □ socially withdrawn □ sneeze in sunlight □ feel weak

□ cry easily □ rarely complete tasks □ seasonal allergy(hay fever)

□ shy □ lack of drive / motivation □ colic Symptoms

□ depressed for no reason □ asthma □ worse in damp weather

□ emotional instability Circulation □ ear infections □ worse in muggy weather

□ hyperactive □ intolerant to the cold □ blocked nose □ worse around mould

□ suicidal thoughts □ colds hands/feet □ worse after food

□ schizophrenia □ ‘warm-blooded’ Senses □ worse in winter

□ impulsive □ raised blood pressure □ eyesight deteriorating

□ delusions □ rapid heartbeat □ eyes burn Digestion

□ illusions □ irregular heartbeat □ eyes itch □ dry mouth

□ paranoia □ heart palpitations □ eyes tear easily □ salivate

□ violent behaviour □ low blood pressure □ sensitive to pain (low pain threshold) □ feel nauseous easily

□ see/hear things abnormally □ trembling □ tolerate pain (high pain threshold) □ crowded front teeth

□ hear’ your own thoughts □ dizziness upon standing □ difficult orgasms with sex □ grind teeth

□ feel ‘unreal’ □ fainting □ easy orgasm with sex □ loose bowel at onset of mental health issue

□ anger

For Women For Men

□ PMS □ symptoms related to menstrual cycle

□ genito-urinary conditions □ slow metabolism

□ painful periods □ irregular menstruation □ wake at night to urinate □ difficult to stop or start urine stream

□ breast pain □ peri- or post-menopause □ fertility problems □ pain or burning when urinating

□ contraceptive pill □ miscarriages □ problems achieving /maintaining erection

□ hormonal migraine □ hormone replacement therapy

□ frequent or difficult urination

□ fertility issues □ hot flushes □ prostate problems


Work your way through the following list of symptoms and tick where appropriate. Some questions may sound similar to those you have already answered but please still give a response to all questions.

Your digestion:

Yes No Indicate if you often experience any of the following:

poor appetite

bad breath

a burning sensation in your stomach

regularly use indigestion tablets

diarrhoea

constipation

bloated stomach

nauseous

belching or wind

stomach pains

sleepy, after meals

How many bowel movements do you have per week?

Methylation indicators

Yes No Indicate your response to the following questions:

Are you tired a lot of the time?

Is your stamina, or ability to keep going, noticeably decreasing?

Are you having a hard time keeping your weight stable?

Do you often experience physical pain, be it arthritis, muscle aches or migraines?

Do you get frequent colds?

Is your eyesight deteriorating?

Is your mental clarity or concentration decreasing?

Are you experiencing more sleeping problems?

Is your memory on the decline?

Are you often depressed?

Do you average two or more alcoholic beverages daily?

Do you drink more than three cups of coffee daily?

Do you smoke cigarettes?

Are you a strict vegetarian?

Do you eat red meat at least once a day?

Energy levels:

Yes No Do you:

have trouble getting up in the morning?

rely on a cup of coffee to get you going in the morning?

feel tired all the time or frequently feel weak?

often feel foggy, fuzzy or dull?

have trouble concentrating?

use sugar, caffeine (tea, coffee, caffeinated drinks) or a cigarette as a pick-me-up throughout the day?

often feel irritable or angry, for no apparent reason?

experience moods which go up and down for no apparent reason?

experience mood swings which are relieved by food, especially sweets?

have trouble falling asleep at night?

have headaches or shaky feelings that are relieved by sugar, caffeine or cigarettes?

suspect you’re addicted to coffee, caffeinated cola, or cigarettes?

find yourself operating from crisis to crisis?

find yourself drawn to thrills, danger and drama in your life?


Excessive daytime sleepiness:

(Measured using the Epworth Sleepiness Scale)

Think of the situations listed below and rate how likely you would be to fall asleep: 0 - you would never doze 1 - a slight chance 2 - a moderate chance 3 - a high chance

0 - 3

Sitting and reading

Sitting inactive in a public place (such as a theatre, lecture, or meeting)

Watching TV

As a passenger in a car for an hour or longer without a break

Lying down to rest in the afternoon

Sitting and talking to someone

In a car, while stopped in traffic

Your liver-detox potential:

Please tick to indicate which apply to you::

headaches or migraine bloating

watery or itchy eyes strong reaction to caffeine

dark circles under eyes A strong reaction to alcohol

a bitter taste in your mouth or a furry tongue sweat a lot and have a strong body odour

you are underweight and find it hard to gain weight excessive mucous, a stuffy nose or sinus problems

acne, skin rashes or hives nausea or vomiting

joint pains or muscle aches frequent or urgent urination

itchy ears, earache, ear infections, drainage from the ears or ringing in the ears

sluggish metabolism and find it hard to lose weight


TERMS AND CONDITIONS 1. Payment 1.1 A deposit of £50 is required to make an appointment. This deposit is deductible from the consultation fee for the first appointment.

1.2 Balance of payment for consultations will be payable no later than the day of appointment.

1.3 Payment for tests must be made at the time of purchasing/ordering the test.

1.4 A current schedule of all fees can be found in ‘Fee Schedule’.

2. Cancellations and Refunds 2.1. Cancellations of all booked appointments must be made no later than 48hrs i.e. 2 working days before the appointment.

2.2 Cancellations made within 48hrs i.e. 2 working days of a scheduled appointment or no shows will be subject to a cancellation charge of the full consultation fee.

2.3 Tests that have been arranged, paid for and not taken, may be cancelled within 14 days. To cancel, give written notice and where applicable, return the test kits unopened. Money will be refunded in full, less 15% administration charge. We reserve the right to change our fees.

Your Right to Cancel Pursuant to the Consumer Protection (Distance Selling) Regulations 2000. This notice fulfils the requirement set out in Regulation 7:

(1) The supplier of the services is Brain Bio Centre, Avalon House, 72 Lower Mortlake Road, Richmond, TW9 2JY, Tel: 020 8332 9600. email [email protected]

2) This is a contract for the booking, administration and provision of assessment and remediation services for mental health conditions.

3) Delivery or postage may be charged.

4) Payment arrangements are set out in the ‘Fee Schedule’. You may pay by cheque, cash, or major credit card. We do not accept American Express.

5) You have the right to cancel this agreement within 7 working days after the day on which you receive the information. To cancel, you must contact us in writing at our address as set out in (1).

6) If you have any complaints please contact us, in writing, at our address as set out in (1).

7) In addition to your statutory right to cancel as set out above, you have the contractual right to terminate the contract at any time.

But you will remain liable to pay any outstanding fees (including fees for sessions booked but not attended unless they were cancelled giving the notice required as outlined in our terms and conditions and returning any unused tests kits).

Data Protection Information about the patient will be stored by the Brain Bio Centre for the purposes of monitoring the progress of his/her programme. Such information includes personal data relating to the patient’s health record and brief details of their family unit. Brain Bio Centre has taken measures to keep such information secure and our policy is not to disclose it to a third party other than those professionals directly involved in the programme.

We use other (non-medical) personal information provided by patients and their parents or guardians for the purposes of administration, including collection of money due to us, for which purpose the information may be disclosed to debt collection and tracing agencies. Returning the Patient Information form signed by the patient, or by a parent or guardian if the patient is under 18 years old, constitutes the patient’s express written consent to the processing of such data. Any queries regarding the processing of personal data may be directed to the Brain Bio Centre Clinic Manager at the Brain Bio Centre who is responsible for data protection matters.

Evaluation and Research Anonymised patient information and test results may be used in the evaluation of Brain Bio Centre treatment protocols to expand knowledge and understanding of the interplay between nutrition and mental health and contribute to the continual improvement of the effectiveness of our treatment programmes.

PATIENT TO SIGN HERE I have read and agree to the terms and conditions outlined above. Name ............................................................................ Signed ........................................................................... Date ............................................................................ If patient is under 18 years of age, this form must be signed by the legal guardian.


Deposit Form

Patient’s Full Name _______________________________ Date of Birth ______________

Please indicate your payment method below and supply credit/debit card details if paying by this method. Do not send cash through the post. Note: cash is an acceptable form of payment when attending the clinic in person. � Payment by Cheque Please enclose a cheque for £50 made payable to the Brain Bio Centre and enclose with your completed forms � Payment by Credit/Debit Card Please complete the details below. The Brain Bio Centre will process a payment of £50 against this card.

Type of card: MasterCard / Visa / Switch (please circle one)

Card number _______________________________________

Start date ________ Expiry date _______ Issue number (if applicable) _____

Name on Card ____________________________________________________

Signature ________________________________


TERMS OF ENGAGEMENT

as specified by the British Association for Applied Nutrition and Nutritional Therapy

Introduction Good nutrition helps build the body’s natural strength and resistance, however, no claim is made as to the efficacy of any nutritional protocols. The degree of benefit obtainable from Nutritional Therapy may vary between clients with similar health problems and following a similar Nutritional Therapy programme.

The nutritional therapist

• Nutritional advice will be tailored to support diagnosed conditions and/or health concerns identified and agreed between both parties.

• Nutritional therapists are not permitted to diagnose, or claim to treat, medical conditions.

• Nutritional advice is not a substitute for professional medical advice and/or treatment.

• Standards of professional practice in Nutritional Therapy are governed by the BANT Code of Ethics and Practice.

The client • You are responsible for contacting your GP about

any health concerns.

• If you are not being treated by your GP, you should still let them know that you are receiving nutritional therapy.

• If you are receiving treatment from your GP, or any other medical provider, you should tell them about any nutritional strategy provided by a nutritional therapist. This is necessary because of any possible reaction between medication and the nutritional programme.

• It is important that you tell your nutritional therapist about any medical diagnosis, medication, herbal medicine, or food supplements, you are taking as this may affect the nutritional programme.

• If you are unclear about the agreed nutritional therapy programme/food supplement doses/time period, you should contact your nutritional therapist promptly for clarification.

• You must contact your nutritional therapist should you wish to continue any specified supplement programme for longer than the original agreed period, to avoid any potential adverse reactions.

• You are advised to report any concerns about Nutritional Therapy promptly to your nutritional therapist for discussion and action.

We understand the above and agree that our professional relationship will be based on the content of this document.

Signed by client:........................................................................... Date........................................................... Signed by nutritional therapist:.................................................. Date...........................................................

(a signed copy of this document to be retained by both the client and the nutritional therapist)

Children’s Questionnaire 20

PRIVATE AND CONFIDENTIAL

Patient Information for babies and children aged 0-10 years

How did you hear about the Brain Bio Centre? ____________________________ Today’s Date _____________________

Child’s First Name ________________________ Last Name ___________________________ Date of Birth ______________

Address _______________________________________________________________________________________________

_____________________________________________________________________________ Post Code ________________

Home Tel No ___________________________ Parent Tel No _____________________________

Mobile _________________________________ Contact Email of Parent _________________________________________

Gender (M/F) __________________ Child’s / Baby’s Age ___________ years ___________ months

Resting Pulse ________________ Blood Pressure _______________ Blood Type _________________________

Main reason for visit: ________________________________________________________________________________

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________

GP Details GP Name: __________________________________________________________________________________________ Address: ___________________________________________________________________________________________ ________________________________________________________ Telephone No: _____________________________ Is your GP aware that you are consulting a nutritional consultant? Yes/No Are you happy for your GP to be kept informed on the progress of your child? Yes/No Any other health professionals involved in your childs care: ____________________________________________________ Address: _________________________________________________ Telephone No: ______________________________

Family Details

Mother Name: ___________________________________________________ Age: _______________________ Health problems: __________________________________________________ Are you the birth mother? Yes/No Father Name: ___________________________________________________ Age: _______________________

Health problems: __________________________________________________ Are you the genetic father? Yes/No

Brothers/sisters:

Male/Female Age: Health problems: _________________________________________________________ Male/Female Age: Health problems: _________________________________________________________ Male/Female Age: Health problems: _________________________________________________________ Male/Female Age: Health problems: _________________________________________________________


Family History Please read through the following list of medical conditions and tick the appropriate box corresponding to whether family members have a history of suffering from the listed medical conditions.

Medical History Father Mother Sibling(s) Maternal Grand mother

Maternal Grand father

Paternal Grand mother

Paternal Grand father

Other

Allergy to milk

Allergy to wheat

Other allergy

Arthritis

Asthma

Crohn’s disease

Coeliac disease

Diabetes

Ear infections recurrent

Eczema

Other skin complaint

Fungal infection

Heart disease

High blood pressure

Hives

Irritable bowel syndrome

Migraines

Malabsorption

Phenylketonuria

Stroke

Anorexia Autism

Asperger’s syndrome

Bulimia

Depression

Downs syndrome Dyslexia

Hyperactivity Learning difficulties

Schizophrenia

Speech delay

Tendency to be a loner

Night blindness

Home Life: Who lives at home with your child? ________________________________________________________________________ Does your child attend? (Please tick) � Day Nursery � Child minder � Playgroup � School/Special School Occupation of Mother _____________________________ Occupation of Father ________________________________ Do you have any pets at home? Yes/No If yes, please list: __________________________________________

Pollution Profile Does your child live in a city or by a busy road? Yes/No Does your child live in a smoky atmosphere? Yes/No Does your child usually drink filtered or bottled water? Yes/No Does your child eat non-organic food? Yes/No Does your child have a computer or TV in their bedroom? Yes/No Does your child have a mobile phone, which is used regularly? Yes/No Is the main house near to: pylons, mobile phone mast, factory, petrol station, agricultural land, flight path (please underline)


Pregnancy Details Were there any particular difficulties during the pregnancy? Yes/No If yes, please list _____________________________________________________________________________________

Birth Details: Was this your first labour? Yes/No Duration of pregnancy (normal gestation is 40 weeks) _______________________________________________________ Were there any particular difficulties relating to the birth? Yes/No If yes, please list _____________________________________________________________________________________ APGAR score _______________________________________________________________________________________ Did the baby suffer (please tick) � jaundice � oxygen deficit � any other problems __________________ Did the baby require special care? Yes/No Why/duration ____________________________________________ Additional information about labour/birth: __________________________________________________________________

Child’s Health Profile Please circle all that apply now, and underline all that previously applied Miscellaneous symptoms

Earache Poor Co-ordination Obsessive Behaviour Catarrh Head banging/Rocking Mood Swings Colic Sensitivity to Noise Thrush Excessive crying Phobias Night Terrors Aggression Shows no Fear Disturbed Sleep Constant Runny Nose Recurrent chest infections Snoring Threadworms Specific Disorders

Asthma ADD/ADHD Down’s Syndrome Eczema/Dermatitis Autism/Autism Spectrum Disorder Cleft Palate Hayfever Aspergers Syndrome Heart Disease Food Allergies Epilepsy Sickle Cell Anaemia Dyslexia Crohn’s Disease Diabetes Dyspraxia Phenylketonuria Haemophilia Cerebral palsy AIDS Cancer Child’s Personality/Behaviour

Nervous Irritable Contented Popular Plays well with others Unhappy A ‘Holy Terror’ Very ‘Good’ Easily Distracted Sociable Temper Tantrums Restless Wide-Awake Learning Difficulties Tip Toes Impulsive Tough Tidy ‘Gifted’ Child Affectionate Excitable Emotional Messy Lazy/Lethargic Rejects Affection Nail Biter ‘All Over the Place’ Clumsy Sleepy Agile

Medical History How many courses of antibiotics has the child taken over the past 3 years? (Please tick)

� none � 1-3 courses � 4-9 courses � more than 10 courses Does/has your take/taken any other prescribed medications? Yes/No If yes, please give age, illness and treatment _______________________________________________________________ Does your child take over the counter medications? Yes/No


If yes, which and what for? _____________________________________________________________________________ Has your child ever been referred to a specialist? Yes/No If yes, please give age, reason and type of specialist: ___________________________________________________________ What tests has your child had done by GP, specialist, other? _____________________________________________________ Has your child received medical diagnosis of any condition? Yes/No If yes, please expand (e.g. Asthma, Coeliac Disease, Anaemia) ___________________________________________________ Have you sought ‘alternative health care advice for your child e.g. Homeopath, Cranial Osteopath Yes/No If yes, please state which: _________________________________________________________________________________ Does your child have a history of contracting any viral infections? Tick all that apply

� none � encephalitis � meningitis � chicken pox � measles

� mumps � rubella � unknown viral infection

� other, please specify __________________________________________________________________________________ Does your child have a history of epilepsy or seizures? Yes / No If yes, please specify type of epilepsy, date of diagnosis and date of last episode: _____________________________________

______________________________________________________________________________________________________ Does your child have a history of bacterial or fungal infections? Tick all that apply. � none � oral thrush � genital thrush � athletes foot � impetigo

� other, please specify _____________________________________________________________________________________ Does your child have any history of the following problems with their ears? Tick all that apply.

� none � hearing loss � persistent ear infection � redness of ears � use of grommets/tubes

� other, please specify _____________________________________________________________________________________ Does your child have any history of the following problems with their eyes? Tick all that apply.

� none � loss of sight � dark rings around the eyes � squint

� other, please specify _____________________________________________________________________________________ Additional medical information? _________________________________________________________________________ List any previous major illnesses _____________________________________________________________________________

________________________________________________________________________________________________________

List any operations that the child has had _______________________________________________________________________

________________________________________________________________________________________________________

Immunisation Programme

Has your child received the recommended standard immunisations? Yes/No If no, please detail those given and those excluded and why: __________________________________________________ __________________________________________________________________________________________________ Has your child ever had an adverse reaction to any vaccine? Yes/No If yes, please specify _________________________________________________________________________________ Does your child suffer from frequent colds, coughs infections? Yes/No Does your child have eczema, asthma, hayfever, arthritis? Please underline which Does your child suffer from food sensitivity? Yes/No Have you noticed any adverse reactions in your child after eating certain foods? Yes/No


If yes, state which foods and what reactions _______________________________________________________________

Development History Has your GP or any other medical practitioner ever expressed concern regarding your child’s development? Yes/No If yes, please expand e.g. speech, learning, walking etc ______________________________________________________ Have there been any hearing problems? Yes/No Has your child’s growth been ‘normal’ e.g. Height, Weight, Growth Centile Yes/No If no, please detail ___________________________________________________________________________________ __________________________________________________________________________________________________

Digestive Profile – please circle as appropriate Does your child chew food well? Yes/No Does your child suffer from bad breath? Yes/No Does your child suffer tummy upsets? Yes/No Does your child suffer with an itchy bottom? Yes/No Does your child have a daily bowel movement? Yes/No Does your child suffer from diarrhoea? Yes/No Does your child suffer from constipation? Yes/No Does your child suffer from bloating/excessive wind Yes/No Are the stools normal, pale, offensive, floating (please underline which) Does your child have a history of bowel problems?

� no � yes � don’t know Is your child fully bowel continent (i.e. not using a nappy at all during the day or night)?

� no � yes � don’t know Type of bowel problem. Tick all that apply

� diarrhoea � constipation � alternating diarrhoea/constipation � undigested food in stools

� blood in stools � mucus in stools � loose stools

� other, please specify _____________________________________________________________________________________ How long have the bowel symptoms been present? Tick one box only.

� 0-3 months � 4-6 months � 7-12 months � more than a year How many bowel movements does your child have in the average week (over the past 3 months)? Tick one box only.

� none � 1 bowel movement per week � 2 bowel movements per week � 3 bowel movements per week

� 4 bowel movements per week � 5-15 bowel movements per week � more than 1 per week Please describe the normal consistency / type of stool your child produces from the items shown below. Tick all that apply.

� separate hard lumps (nut-like) � sausage shaped and lumpy

� sausage shaped with cracked surface � sausage shaped or snake-like smooth and soft

� fluffy pieces with ragged edges and mushy � soft blobs but with clear-cut edges

� watery with no solids � frothy stools

� large bulky stools

� other, please specify _____________________________________________________________________________________ Does your child ever require any manual manoeuvres to help with defecation? Tick all that apply.

� none � digital evacuation (use of hands) � support of the pelvic floor

� other, please specify _____________________________________________________________________________________ Please describe the general colour of the stools produced. Tick all that apply.

� light brown � dark brown � black � yellow, sand coloured � green

� other colour, please specify________________________________________________________________________________


Does your child ever present with any of the following problems? Tick all that apply.

� bloating � distension (pot belly) � indications of pain on passing stools � indications of abdominal pain

� flatulence (frequent passing of wind) � none Diagnosed bowel complaints/infections. Tick all that apply.

� Coeliac disease � Crohn’s disease � ulcerative colitis

� lymphoid-nodular hyperplasia

� other, please specify _____________________________________________________________________________________

Urination Is your child fully bladder continent (i.e. not using a nappy at all during day or night)?

� no � yes � don’t know How many times does your child go to the toilet for a wee? Tick one box only.

� none � 1-4 times per day (24 hours) � 5-8 times per day (24 hours) � 9-12 times per day (24 hours)

� more than 12 times per day (24 hours) � unknown

Skin Does your child have a history of skin complaints?

� none � yes � don’t’ know Type of skin complaint. Tick all that apply.

� eczema / contact dermatitis � acne � bumpy skin � dryness � urticaria / hives


Respiratory Does your child have any history of respiratory complaints?

� none � yes � don’t know Type of respiratory complaint. Tick all that apply.

� asthma � wheeze � persistent congestion � runny nose


Sleep Does your child have any current problems with sleeping?

� none � yes � don’t know Type of sleeping problem. Tick all that apply.

� insomnia � night waking � excessive sweating � frequent indications of nightmares

Eating Was your child breast-fed as an infant? (for more than 4 weeks)

� no � yes Did your child experience any problems after feeding as a young baby? (e.g. vomiting, projectile vomiting, colic, failure to feed)

� none

� yes, please specify ______________________________________________________________________________________ Are there any current or previous problems with food allergy / intolerance?

� none � don’t know

� yes, please specify and provide details of testing used for diagnosis _______________________________________________

________________________________________________________________________________________________________


Does your child show any of the following problems with feeding. Tick all that apply.

� none � over-eating � diagnosed anorexia � diagnosed bulimia

� regurgitation of food / drink � pica (eating of non-edible objects such as earth or sand) Does your child have any problems with restricted eating habits based on either taste or texture?

� no � yes � don’t know If yes, which types of food / drink?

� milk � other dairy products (yoghurts, cheese) � bread

� pasta � cereals (eg Weetabix)


________________________________________________________________________________________________________ Are there any foods that your child is not permitted to have in their diet?

� none � yes (specify from options below)

� casein-free diet � gluten-free diet � vegetarian

� other, please specify _____________________________________________________________________________________ Does your child show any signs of having an excessive thirst?

� no

� yes, (specify types of drink and average amount per day) _______________________________________________________

Additional Information Is there any other information relevant to the child’s medical history that you feel is of relevance? e.g. contact with hazardous substances. Other events related to symptom onset.

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

Nutritional Information – Child’s Feeding History Did you bottle feed at all? Yes/No From what age? ________________ Which formula? ___________________ Which, if any, special formula were required e.g. soya, casein free? ____________________________________________ How old was your baby when your started weaning onto solids? _______________________________________________ Which foods were introduced and in what order? 1.__________________________________ Any Reactions ________________________________ Age _____________ 2. _________________________________ Any Reactions _________________________________ Age ______________ 3. _________________________________ Any Reactions _________________________________ Age ______________

Current Eating Habits Would you describe our child’s appetite as: (please tick) � good � medium � poor Is your child a fussy eater? Yes/No Is your child currently following a specific dietary regime e.g. gluten free? Please describe ____________________


__________________________________________________________________________________________________ Are there any foods that your child craves? Please describe __________________________________________ __________________________________________________________________________________________________ Are there any foods that your child dislikes intensely? Please describe ___________________________________ __________________________________________________________________________________________________ Do you go out of your way to avoid giving foods containing preservatives and additives? Yes/No Do you avoid giving foods that contain sugar? Yes/No How many cans of fizzy drinks does your child drink in a week? _________________________________________________ How many times a week does your child have meals containing fried or fast foods (e.g. fish fingers, McDonalds) ___________ ____________________________________________________________________________________________________ How many portions daily of fruit and vegetables does your child have? ___________________________________________ How many slices of bread or rolls does your child eat in a week? ________________________________________________ Do you normally eat white or wholemeal rice, pasta and flour? __________________________________________________ Does your child eat at nursery or at school? Yes/No If yes, please describe this food/drink ______________________________________________________________________ ____________________________________________________________________________________________________ Does your child take a ‘lunch box’ to school Yes/No What nutritional supplements does your child take on a daily basis? ______________________________________________

Food Diary

Write down the daily food and drink consumption of the child for 2 representative days. Give as much detail as possible including description of the foods, drinks, quantities eaten and brand names.

Day 1 Day 2

Breakfast

Breakfast

Lunch

Lunch

Evening Meal

Evening Meal

Snacks and Drinks Snacks and Drinks

Activity Profile: How much time per day does your child watch TV? ___________________________________________________________ How much time per day does your child use a computer (including school and home)? _______________________________


How much exercise does your child have in a week? _________________________________________________________ What sport does your child play? _________________________________________________________________________ Any activities, hobbies or clubs (e.g. dancing) _______________________________________________________________

TERMS AND CONDITIONS

1. Payment 1.1 A deposit of £50 is required to make an

appointment. This deposit is deductible from the consultation fee for the first appointment.

1.2 Balance of payment for consultations will be payable no later than the day of appointment. 1.3 Payment for tests must be made at the time of purchasing/ordering the test kits. 1.4 A current schedule of all fees can be found in ‘Fee Schedule’. 2. Cancellations and Refunds 2.1 Cancellations of all booked appointments must

be made no later than 2 working days before the appointment.

2.2 Cancellations made within 2 working days of scheduled appointment or no shows will be subject to a cancellation charge of the full consultation fee.

2.3 Tests that have been arranged and paid for may be cancelled within 14 days. To cancel, give written notice and return the test kits which must be unopened. Money will be refunded in full, less 15% administration charge. We reserve the right to change our fees.

Your Right to Cancel Pursuant to the Consumer Protection (Distance Selling) Regulations 2000. This notice fulfils the requirement set out in Regulation 7:

1) The supplier of the services is Brain Bio Centre, Avalon House, 72 Lower Mortlake Road, Richmond, TW9 2JY, Tel: 020 8332 9600. email: [email protected]

2) This is a contract for the booking, administration and provision of assessment and remediation services for mental health conditions.

3) Delivery or postage may be charged. 4) Payment arrangements are set out in the

‘Fee Schedule’. You may pay by cheque, cash, or major credit card. We do not accept American Express.

5) You have the right to cancel this agreement within 7 working days after the day on which you receive the information. To cancel, you must contact us in writing at our address as set out in (1).

6) If you have any complaints please contact us in writing, at our address as set out in 1).

7) In addition to your statutory right to cancel as set out above, you have the contractual right to terminate the contract at any time. But you will remain liable to pay any outstanding fees (including fees for sessions booked but not attended unless they were cancelled giving the notice required as outlined in our terms and conditions and returning any unused tests kits).

Data Protection Information about the patient will be stored by the Brain Bio Centre for the purposes of monitoring the progress of his/her programme. Such information includes personal data relating to the patient’s health record and brief details of their family unit. Brain Bio Centre has taken measures to keep such information secure and our policy is not to disclose it to a third party other than those professionals directly involved in the programme. We use other (non-medical) personal information provided by patients and their parents or guardians for the purposes of administration, including collection of money due, for which purpose the information may be disclosed to debt collection and tracing agencies. Returning the Patient Information form signed by the patient, or by a parent or guardian if the patient is under 18 years old, constitutes the patient’s express written consent to the processing of such data. Any queries regarding the processing of personal data may be directed to the Brain Bio Centre Clinic Manager at the Brain Bio Centre who is responsible for data protection matters. Evaluation and research Anonymised patient information and test results may be used in the evaluation of Brain Bio Centre treatment protocols to contribute to the continual improvement of the effectiveness of our treatment programmes. PATIENT TO SIGN HERE I have read and agree to the terms and conditions outlined above. Signed..................................................................

Date.....................................................................

If patient is under 18 years of age, this form must be signed by the legal guardian.


Deposit Form

Patient’s Full Name ______________________________ Date of Birth _______________

Please indicate your payment method below and supply credit/debit card details if paying by this method. Do not send cash through the post. Note: cash is an acceptable form of payment when attending the clinic in person. � Payment by Cheque Please enclose a cheque for £50 made payable to the Brain Bio Centre and enclose with your completed forms � Payment by Credit/Debit Card Please complete the details below. The Brain Bio Centre will process a payment of £50 against this card.

Type of card: MasterCard / Visa / Switch / (please circle one)

Card number _______________________________________

Start date _______ Expiry date ________ Issue number (if applicable) _____

Name on Card ____________________________________________________

Signature ________________________________


TERMS OF ENGAGEMENT

as specified by the British Association for Applied Nutrition and Nutritional Therapy

Introduction Good nutrition helps build the body’s natural strength and resistance, however, no claim is made as to the efficacy of any nutritional protocols. The degree of benefit obtainable from Nutritional Therapy may vary between clients with similar health problems and following a similar Nutritional Therapy programme.

The nutritional therapist

• Nutritional advice will be tailored to support diagnosed conditions and/or health concerns identified and agreed between both parties.

• Nutritional therapists are not permitted to diagnose, or claim to treat, medical conditions.

• Nutritional advice is not a substitute for professional medical advice and/or treatment.

• Standards of professional practice in Nutritional Therapy are governed by the BANT Code of Ethics and Practice.

The client • You are responsible for contacting your GP

about any health concerns.

• If you are not being treated by your GP, you should still let them know that you are receiving nutritional therapy.

• If you are receiving treatment from your GP, or any other medical provider, you should tell them about any nutritional strategy provided by a nutritional therapist. This is necessary because of any possible reaction between medication and the nutritional programme.

• It is important that you tell your nutritional therapist about any medical diagnosis, medication, herbal medicine, or food supplements, you are taking as this may affect the nutritional programme.

• If you are unclear about the agreed nutritional therapy programme/food supplement doses/time period, you should contact your nutritional therapist promptly for clarification.

• You must contact your nutritional therapist should you wish to continue any specified supplement programme for longer than the original agreed period, to avoid any potential adverse reactions.

• You are advised to report any concerns about Nutritional Therapy promptly to your nutritional therapist for discussion and action.

We understand the above and agree that our professional relationship will be based on the content of this document. Signed by client:........................................................................... Date...........................................................

Signed by nutritional therapist:.................................................. Date........................................................... (a signed copy of this document to be retained by

both the client and the nutritional therapist)

brain bio centre

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