Nancey C. Savinelli, PhDc, Naturopath, CNC, LMT, MA Crown Valley, #35D, Laguna Niguel, CA /
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- Daniella Rose Bridges
- 5 years ago
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1 Nancey C. Savinelli, PhDc, Naturopath, CNC, LMT, MA Crown Valley, #35D, Laguna Niguel, CA / / nancey@naturalhealthctr.net CLIENT INFORMATION Name:Date: Address:City:,CA zip: Home Phone: Sex: M, F Birthdate: Age: Occupation:Employer: Address:City: CA, Zip: Business Phone: Educational level:degree: Name of physician:phone: In Case of emergency call:phone: Spouse/significant other:phone: His/her birthdate:age: PERSONAL & FAMILY ISSUES: Current marital status: Married, years. Divorced, years. In a relationship, years. Single, years. Do you have children? yes, no. If so, how many?:. Where were you born?: City: State: Country: Where did you grow up?: CURRENT CONDITIONS: What is your blood type?:o, A, B, AB Height: Weight: Do you feel you are overweight: Y, N Undeweight: Y, N
2 Do you have any current conditions? Appetite problems Sleep,too much, too little Heart palpitations Stomach problems Nightmares Panic Attacks Headaches Dizziness Phobias Digestive problems Depressed Panic / Fear Angry Anxious Fatigue Fainting spells PMS Menopause Hot Flashes Overwhelm Tremors Rashes / skin conditions Sexually Trans. Dis. Pains Hyperactive Low Energy Tense / Uptight Unable to Relax Difficulty Concentrating
3 Allergies: Other: Please list any medical or psychological conditions you have been diagnosed with: Have you ever been hospitalized? If so, please describe: Have you ever had any operations? yes, no. If yes explain: Did you have your tonsils out?: yes, no If yes, when?: List all prescriptions and medications you have taken regularly: List vitamins, minerals, etc. that you presently take and dosages: Are you currently under the care of a medical doctor?yes, no. If so, list doctor s name:phone: Have you been in psychotherapy previously?: yes, no. Do you have any scars on or inside your body?: ie.. operations, teeth removed, deep cuts, episiotomy, c-sections, etc.: yes, no. If yes, where:
4 Do you know of any viruses, toxins, bacteria, fungus, etc. that you may have or contacted?: yes, no, If yes, explain: Do you have any mercury (silver fillings) amalgams?: yes, no. Did you have silver fillings removed?: yes, no. If yes, when?: Did you do a detox after removal of the fillings?: yes, no. Do you have any metal lined caps or bridges in your mouth?: yes, no Do you have any root canals?: yes, no How many: List any other problems with your teeth?: Do you smoke? yes, no. If yes, how many packs a day? cigarettes a day? WHAT TO YOU TYPICALLY EAT FOR: Breakfast: Lunch: Dinner: Snacks: Do you crave any specific foods?: COFFEE/CAFFEINE: 8 oz. Cups caffeine per day: Coffee, Chocolate, Tea ALCOHOL: How many drinks per day? wine, beer, hard liquor. Have you had a problem with abusing alcohol?:yes, no. How long?: Is it a problem now?:yes, no.
5 Timeframe: DRUGS: Have you ever taken drugs?:yes, no. If so, what type?: How often?: How much?: How long?: Is it a problem now?:yes, no EATING DISORDER: Have you experienced any of the following?: AnorexiaBulimiaOther: Is it a problem now?: yes, no. If so, when?: DO YOU HAVE ANY COMPULSIVE OR ADDICTIVE BEHAVIORS?: Workaholism Sex Hand washing Rage addiction Phobias Constantly checking things Over-thinking (obsessing) Relationship addiction Stuck on thoughts Other: What health issues do you want to address: What alternative treatments have you had: PLEASE LIST ANY OTHER CONDITIONS OR SITUATIONS THAT MIGHT BE PERTINENT FOR ME TO KNOW:
6 By signing below you provide permission to contact your medical doctor to obtain any verbal or written information, which would be related to your treatment if necessary. This will be in force throughout the duration of your treatment in our office. Signature: Date:
HEALTH HISTORY FORM. (Please fill out thoroughly and print clearly) Name: Date: Age: Male/female: Height: Weight: Weight one year ago:
HEALTH HISTORY FORM (Please fill out thoroughly and print clearly) Name: Date: Age: Male/female: Height: Weight: Weight one year ago: Would you like your weight different? If so, what? Street Address:
Minor Intake Form. Child s Name DOB
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1 Last Name: First Name: Middle Initial: Address: Apartment #: City: State: Zip: Home #: Cell #: Email: How did you find us? Patient (who) : Doctor (who) : Staff (who) : Date of Birth: / / Gender (circle
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What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)
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Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age
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Date Time Dietary consultation involves a health profile whose purpose is not to establish a diagnosis, but rather to determine a client's health status in order to guide his or her weight loss plan. A
Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
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