FUNCTIONAL MEDICINE MATRIX MODEL TM

1. Mitochondrial Energy _________________ _________________ _________________ _________________ _________________ Methylation/ Liver Detoxification _________________ _________________ _________________ _________________ Hormones / Adrenals _________________ _________________ _________________ _________________ _________________ Infections, Immune System, Inflammation _________________ _________________ _________________ ____________ Neurotransmitters _________________ _________________ _________________ Food & Gut Function __________ ___________ __________ ___________ __________ ___________ __________ ___________ __________ ___________ FUNCTIONAL MEDICINE MATRIX MODELTM The Patient’s Story Retold Antecedents (Predisposing) ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ Triggering Events (Activation) ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ Mediations ___ ___________________________ _______________________________ _______________________________ ____________________ QEEG / Brain waves _________________ _________________ _________________ _________________ Nutrient Deficiencies _________________ _________________ _________________ _________________ _________________ _________________ Early Developmental Trauma _________________ _________________ _________________ Ego Strength/ Values _________________ _________________ _________________ Diet _________________ _________________ _________________ Date:________Name:________________________________Age____Sex____Chief Complaints:______________________________ Toxins / Heavy Metals _________________ _________________ _________________ Unconscious _________________ _________________ _________________ Ayurvedic Dosha _________________ _________________ _________________ Relationships _________________ _________________ _________________ Genetic Profile _________________ _________________ Spiritual Practice _________________ _________________ _________________ Healthy Home vs. “Toxic” Home ___________________________ ___________________________ ___________________________ Structural / Biomechanical Head Injury ___________________________ ___________________________ ___________________________ Exercise _________________ _____________________ _____________________ _____________________ Sleep __________________ __________________ __________________ __________________ Stress Management ______________ _________________ _________________ _________________ Brain Optimization __________________ __________________ ___________________