Sarah W. Dible Rejuvenance Therapy, LLC NE 20 th Ave, Suite Vancouver WA, phone: Fax:

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Francine Fitzgerald
5 years ago
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1 Client Consent: Sarah W. Dible graduated in 1998 from Andrews University in Berrien Springs MI. She received a Master of Science in Physical Therapy (MSPT). She has been Board Certified since She has practiced in Orthopedics and more recently started practicing Complemetary Energetic Therapies. In 2010, Sarah completed Dr. Ellen Cutlerʼs Basic and Advanced Training and since then completed several advanced training seminars and is a certified practitioner of BioSET in good standing. BioSET (BIO-energetic Sensitivity and Enzyme Therapy) is a complimentary healing arts service. It was developed by Dr. Ellen Cutler D.C. The nature of the BioSET system consists of nutritional, ( enzymatic, homeopathic and dietary) and energetic evaluation and assessment. It is based on the Immunology and Manual therapy philosophy. BioSET is a non-invasive, safe and natural desensitization technique for the often permanent elimination of allergies and sensitivities. The BioSET system, along with dietary, healthy lifestyle modification and exercise, can have beneficial influences in a multitude of health challenges. At no time will your BioSET practitioner recommend that you stop taking your prescription medications without referral to your prescribing physician. Additionally, any supplements you have been recommended to use by another health professional may be continued. Evaluation of the individual biocompatibility and effectiveness of a supplement of medication will be addressed as part of the bio-energetic assessment. However, in many instances, as desensitization to allergic and improper immune responses occur, you may be advised to check with your particular medication. Likewise, supplement use will be evaluated and the need for certain supplements may be altered while undergoing BioSET. The services we provide at Rejuvenance Therapy LLC. are considered "Alternative", and as such are usually only covered by HSA (Health Saving Accounts) or "Flex" spending accounts. These are the only insurance plans we accept. We do NOT accept or file insurance forms for any health insurance plans for BioSET. We do require payment at the time of your appointment; we accept cash, checks, Visa, MC, Fees for BioSET Treatments: Adults and Children BioSET Evaluation (first visit 90 minutes): $160 plus any additional supplements. BioSET Follow-up (45-60 minutes): $80 By signing this form you, the patient, acknowledge the above statements and authorize Sarah W. Dible, MSPT to administer any BioSET treatments and / or diagnostic procedure she deems necessary and advisable for your BioSET sessions; and to release any information pertinent to your case to any health care practitioner involved in this case. Patient Name: Patient Signature : Date: (Or Guardianʼs signature if patient is under 18 years old) 1

2 New Patient Intake Form Name: If a minor, Name of Parents / Guardian: Address: City: State: Zip Code: Home Telephone (with area code): Work Telephone (with area code): Cell Phone (with area code): Date of Birth (month/date/year): Age: Sex: Occupation: Who referred you to Sarah W. Dible? What is the main reason you are seeking care? Surgeries / Major Illnesses: Other Practitioners You See: M.D. Acupuncturist: Chiropractor: Massage Therapist: Naturopath: Medications You Are Currently Taking Name Reason for Taking Frequency of use 2

3 Supplements/ Vitamins / Homeopathics / Herbs You Are Currently Taking Name Reason for taking Frequency of use Health Habits Do you use... How Often? Hours of Sleep Do you feel rested upon waking? Do you exercise? What kind and Frequency? Caffeine: Alcohol: Tobacco: Please indicate the symptoms you are CURRENTLY having or have REGULARLY throughout the year Absent Minded Abdominal Bloating Acne Acid Reflux Addiction to Alcohol Addiction to Drugs Addiction to Tobacco Appetite - Excessive / Low Arthritis Asthma Bad Breath Burping Body Odor Blood Pressure High / Low Breast Pain / Swelling / Lumps Canker Sores / Cold Sores Colds Frequently get Colitis Constipation Cough 3

4 Carve Salt / Sour / Sweet Diarrhea Digestive Troubles Dreams Disturbing Dry Eyes Dry Skin Ears Ache / Infection / Congested Ear Ringing Eating Disorder Edema (swelling) Excessive Thirst Eyes Watery Eyes Red / Puffy / Itchy Eye Vision Problems Fatigue Fungus Gas Gums Swollen / Red Hay Fever Headaches High Alt. Problems Hot Flashes Hoarseness Humidity Discomfort Hyperactivity Indigestion Insomnia Irritable Bowel Joint Pain / Swelling Infections Loss of Taste/ Smell Lump in Throat Menses - Difficulty Mental Confusion Metallic Taste Moody Motion Sickness Muscle Cramps Muscle Spasms Nasal Polyps Nasal Congestion Nasal Drip Nausea 4

5 Nervous Stomach Night Sweats Numbness Psoriasis Restless Leg Seizures Shortness of Breath Sinusitis Skin Rash Skin Itch Skin Burning Sleeping Problems Sneezing Sore Throat Stomach Discomfort Swollen Glands Teeth Pain Tongue Swelling Throat Constriction Tightness in Chest Tires Easily Urinary Tract Disorders Urination Painful / Burning Vomiting Weight Loss / Gain Yeast Infections Any other symptoms: Is there anything else you would like Sarah to know about your health? What are your personal goals for BioSET:

6 Please mark all the foods you consume. Circle any that you know bother you. NUTS Almond Brazil Cashew Coconut Hazelnut Macadamia Peanut Pecan Pinenut Pistachio Sesame Seed Sunflower Seed Walnut, Black Walnut, English OIL Oil, Almond Black Currant Seed Oil, Canola Oil, Corn Crisco Evening Primrose Fish Oil Flaxseed Oil Olive Oil Coconut Oil Oil, Peanut Oil, Sesame Superheated Vegetable oil SPICES Allspice Anise Seed Basil Bay Leaf Bay Berry Caraway Seed Celery Seed Chili Powder Cilantro Cinnamon Clove Coriander Cumin Curry Dill Fennel Seed Ginger Lemon Grass Marjoram Mustard Seed Nutmeg Oregano Paprika Pepper, Black Poppyseed Quince Seed Red Pepper Rosemary Saffron Sage Savory Sesame Seed Spearmint Tarragon Thyme Turmeric Valerian Vanilla VEGETABLES Alfalfa Sprouts Arrowroot Artichoke Asparagus Bamboo Shoots Bean, Black Bean, Garbanzo Bean, Kidney Bean, Lima Bean, Navy Bean, Pinto Bean, Red Kidney Bean, Soy Bean Sprouts Bean, String (Green) Beet, Garden Red Blackeye Peas Broccoli Brussel Sprouts Cabbage Carob Carrot Cauliflower Celery Chives Collard Greens Corn Cucumber Dandelion Eggplant Endive Fennel Garlic Garbonzo Beans Heart of Palm Horseradish Jicama Kale Kelp Leek Lentils Lettuce Mushrooms Mustard Greens Okra 6

7 Vegetables continued Olive, Green Onion Parsley Parsnip Pea, Green Pepper, Green/Red Pickles, Dill Pickles, Sweet Pimento Potato, Sweet Potato, White Potato, Red Pumpkin Radish Rhubarb Sea Weed Spinach Squash, Winter Squash, Yellow Swiss Chard Tofu Tomato Turnip Water Chestnut Watercress Yam Zucchini CONDIMENTS Ketchup Mayonnaise Miracle Whip Mustard, Dijon Mustard, Yellow Teriyaki Sauce PLEASE keep a food diary 3-5 days prior to your Appointment Arrive for your appointment fasting for 6-8 hrs for adults and 3-4 hours for children. Food Diary Day 1 7

8 Food Diary Day 2 Food Diary Day 3 8

9 Food Diary Day 4 Food Diary Day 5 9

Sarah W. Dible, MSPT Rejuvenance Therapy, LLC

Sarah W. Dible, MSPT Rejuvenance Therapy, LLC Client Consent: Sarah W. Dible graduated in 1998 from Andrews University in Berrien Springs MI. She received a Master of Science in Physical Therapy (MSPT). She has been Board Certified since 1998. She