12/11/2022 at 02:55, SO, Female – heard about us: Recommendation
[Patient First Name] is a [Patient Age] year old [Patient Gender] today who came to me for symptoms of Autoimmunity (thyroid , skin, atopy/allergy)fertility. Their current diagnoses include Hypothyroidism (Hashimoto’s) Eczema Alopecia areata Uterine fibroid (2017) ,, PTSD ,.
Medications and Past Medical History
Their current medications are: Levothyroxine 175mcg Fexondenadine 2-3x recommended dose Ceterizine hydrochloride Upto 40mg/day Current supplements include Circum Evail (Turmeric), Invivo BioMe Femme probiotic mix, Invivo probiotic mix for gut health, CoQ10,Omega3+6, Viridian Fertility for Women, They have previously tried the following treatments: Steroid creams 12/11/1993 15/08/2020 Tacrolimus 16/03/2018 15/08/2020 Equine therapy. Their past medical/surgical history is significant for: Myomectomy 07/07/2019 ACL repair 01/05/2005 Concussions19/04/2019. Health problems in the family include Late Father -rheumatoid, coeliac, , allergy.
PHQ9: 8 – Mild
GAD: 2 – Low
Fatigue Symptom Severity Score (FFS): 36 – Significant
OPIOID RISK: 4 – Moderate
R Score: 47.5 – Mood: 6, Energy: 4, Mental Clarity: 4, Calm: 5
Mental Health Risk Assessment
They have previously been diagnosed with the following: Depression . No current or recent thoughts about self harm. There is history of past self harm or suicide attempts. No history of alcohol abuse, no history of illegal drug use, no history of prescription medication abuse.
Medical Cannabis Assessment
The patient has been informed about the status of medical cannabis as an unlicensed medication in the UK and Yes to treatment. Yes have tried at least 2 treatments to solve their symptoms before trying medical cannabis including Pain killers, Anti depressants, Anti inflammatories, Other psychotherapy, Physiotherapy Acupuncture.. . No history of cardiac problems, No active liver disease, No history of anaphylaxis to cannabis.
Habits/Lifestyle, Stress and Nutrition
The sea, nature, my donkeys, feeling well, tiny humans, food, creating, dancing brings them joy, main sources of stress are My health (skin especially), finances, fertility, relationship, cope with stress with/by Journaling, painting, exercise, Friend,s, my donkeys, nature, therapy, meditation, writing, Sensate. They rate their sense of purpose and meaning in life as 5/5. They use They currently are active in the following activities Walking, Running / cardio exercises, Yoga, Pilates, Strength exercises, Gardening  for Less than 1 hour, Less than 1 hour, Less than 1 hour, Less than 1 hour, Less than 1 hour hours per week. They spend 8-10 hours/night in bed and rate their sleep quality as Perfect, Perfect, Perfect, Perfect. Issues they experience are Falling asleep, Staying asleep, Restless / disrupted sleeping, Waking feeling unrested, Nightmares . They consume 0 caffeinated drinks and 0 sweetened drinks per day. Currently smoking: No . Alcohol: 0. Occasionally I might have one drink, rarely units per week. Other current substance use: No. Previous substance use: No
Current cannabis use
Current cannabis use Never Tried some CBD cream on my skin -it irritated it
This [Patient Age] year old [Patient Gender] patient suffering from difficult to treat . All treatment options and benefits/risks were discussed.