CLIENT INFORMATION. Last Name: First Name: Address: City, Zip: Date of Birth: / / Primary Number: Home: Cell/Alternate: Work:
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1 CLIENT INFORMATION Today s Date: / / Last Name: First Name: Parent Guardian of Client? Name and Relationship to Client: Address: City, Zip: Date of Birth: / / Primary Number: Home: Cell/Alternate: Work: REFERRED BY (specify) Name: What health conditions are you currently being treated for and by whom? Have you ever had colonics? If so, how many? When?
2 A Contraindication is any indication or symptom that makes it inadvisable to use a particular therapy. The following are contraindications for colon hydrotherapy. If any of these apply to you we are not able to provide you with colon hydrotherapy at this present time. If you have any of these contraindications you may still be eligible to receive colon hydrotherapy once they have subsided or been eliminated or if you are under the order, guidance and supervision of a qualified physician working with us. Please put an X in the appropriate box. If you have a prescription from a doctor showing supervision over services provided by us, please check the box to the right of that condition. Yes No Condition Prescription Colon Cancer or GI tract Acute Abdominal Pain History of rectal bleeding Congestive Heart Failure Uncontrolled Hypertension History of Seizures Carcinoma of the rectum Abdominal surgery Intestinal perforation Abdominal hernia Colon or rectal surgery Diverticulitis Recent heart attack General dibilitation Vascular aneurism Renal insufficiency Epilepsy or psychoses Severe hemorrhoids Cirrhosis Fissures or fistula Pregnancy Ulcerative colitis Acute Crohn s disease Rectal or abdominal tumors
3 please circle all that apply GENERAL MUSCLE & JOINT GASTRO INTERNAL CARDIOVASCULAR Anxiety Arthritis Constipation High Blood Pressure Agorophobia Bursitis Diarrhea Hardening of the Arteries Back Pain Low Back Pain Spastic colon Angina (Chest pain) Brain Fog Neck Pain Gas, bloating Poor Circulation Chemical Sensitivity Other Joints Candida Rapid heart beat Depression Depersonalization (Feeling numb) Parasites GENITO-URINARY Excessive belching WOMEN Derealization (Fish Bowl) Kidney infection or stones Heart Burn Painful menstruation Dizziness Fatigue Brain Zaps Double Vision Fanting Spells Fatigue/Exhaustion Voice Echo Detached feeling Fibromyalgia Panic Attacks how many when Painful urination RESPIRATORY I.B.S Irritable Bowel Syndrome Date of last menstral cycle / / Is it heavy? Vaginal Discharge Breast Pain Are you pregnant? SKIN Headaches Shortness of Breath Bruise easily Insomnia Chronic Cough Dryness Metal Toxicity Heavy mucus production Itching Night Sweats Emphysema Rash Feelings of Vertigo Bronchitis Acne Weight issues Asthma Psoriasis Social Phobia Other Phobias Bowel Related Information How many bowel movements a day or a week (on average) do you have? Are you now, or any possibility of being pregnant? YES NO Are you breastfeeding? YES NO Do you have pain in areas of your abdomien or bowel? YES NO Any abdominal surgeries or pregnancies? YES NO What type How many When
4 Antibiotics Please describe your historical use of the following Birth Control Chemical Laxatives Tobacco Coffee Pharmaceutical aid/or recreational drugs NUTRITION & LIFESTYLE Do you buy organically grown fruits and vegetables? Dairy and Meat Do you follow a special diet? If yes, how would you describe the diet? (ie. Raw food, Vegan, Vegetarian, Low Carb, Gluten Free, Paleo Diet etc) What do you eat on a typical day? Breakfast Lunch Dinner Snacks: Foods you tend to crave: Foods you dislike: Describe your daily liquid intake in ounces Water (filtered?) Soda Herbal Tea Alcohol Juice Coffee Black Tea Other ALLERGIES (to medications, chemicals or foods):
5 Do you have any known nutritionial deficiencies:? Describe your exercise habits: Other types of body work you receive: Rate on a scale of 1-10 the stress in your life: Are you currently taking any supplements? (Vitamins, minerals, fiber, friendly bacteria, digestive support or other? GOALS: What would you most like to achieve through your work? MAJOR SYMPTOMS: Please list in order of importance what symptoms are of concern to you. (most concerning to least, along with the duration of the symptom) SURGICAL HISTORY (Please list any surgical procedure and dates) SOCIAL HISTORY Do you have a known history of any exposure to toxic substances? If so, please list which and when you first noticed symptoms? In the past year, how many days have been significantly affected by your health? How many days/years did you generally feel poor? How many times were you in the hospital? How many hours of sleep do you usually get per night during the week? Do you awake feeling rested? Do you feel you sleep well at night?
6 AMENDMENT IX, U.S. CONSITUTION The enumeration in the Consitution, of certain rights, shall be construed to deny or disparage others retained by the People. Protected against governmental infringement through the Ninth Amendment to the Consitution of the United States of America, I retain the right to receive education and information of any nature related to this transmittal and to act upon the information in any way I see fit. In its acceptance, as is my right and duty, I assume full responsibility for its application if acted upon. CONSTRUCTIVE NOTICE Notice is hereby given to any person who receives a copy of this transmittal and who, acting under the color of law intentionally interferes with the free exercse of the rights retained by me as enumerated herein, that he may be in violation of my civil and consitutionally protected rights, Title 42, U.S.C seq. and Title 18, Section 241. I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder and does not prescribe medical treatment or pharmaceuticals. It has been made clear to me that colon hydrotherapy is not a cure, substitute for medical examination or diagnoses and it is recommended that I see a physician for any ailments I might have. I agree that the therapist is helping me with natural hygiene at my request, and is not diagnosing, nor treating disease, nor practicing any form of medicine. Natural Pure Living is a private wellness club, of which I agree to membership by-laws, which include the bove amendment and constructive notice. For a copy of all membership considerations as well as a primer in your consitutional rights, please ask for a full packet. Signed: Dated:
COLON HYDROTHERAPY CONSENT FORM
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PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership
Health History Questionnaire Name Date Age Date of Birth Gender Married Single Separated Divorced Widowed Partnership Live with: Spouse Partner Parents Children Friends Alone Please complete these next
NEW PATIENT QUESTIONNAIRE
Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
HOW DID YOU HEAR ABOUT US?
427 Bloomfield Ave. Ste. 306 Montclair, NJ 07042 Phone: 973-746- 2848 Fax: 973-746- 2088 HOW DID YOU HEAR ABOUT US? Eastern School of Acupuncture and Traditional Medicine Student Clinic Intake Form Intake
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS
Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR 97838 Phone:541-371-3700 Fax:541-515-7022 PERSONAL INFORMATION: First Name: Last Name: Middle Initial: Email for doctor communications:
Candida Questionnaire: Are your health problems yeast connected?
Candida Questionnaire: Are your health problems yeast connected? The following questionnaire can be given to your clients if you suspect candida is a problem. YES NO Have you taken repeated courses of