Dr. Polly Heil-Mealey, ND, D.PSc, HHP, M.Ed., CCI

Transcription

1 Dr. Polly Heil-Mealey, ND, D.PSc, HHP, M.Ed., CCI Client Intake Form The practice of Iridology/EAV requires the understanding of clients as a whole: mind, body and spirit. Please take the time to fill out this intake form as completely as possible. This form will provide a foundation for your experience at the office, as it will help to simulate areas that may need special attention during your visit. Name: Date: Street Address/P.O. Box: City: State: Zip Code: Home Phone: Cell Phone: Address: Date of Birth: Male Female Height: Weight: Are you a Veteran? YES NO Referral Source: Self Primary Care Physician: Goals: Please list the reasons you are seeking an evaluation. Past Medical History: Check all that apply and fill in any not listed at the end. Allergies Alzheimer s Anemia Anxiety Arthritis Asthma Bleeding Disorder Blood clots Breast Disease Broken Bone Cancer Type: Chronic Fatigue Chronic Pain-Where: Chronic Sinusitis Depression Diabetes Diarrhea Diverticulitis Eczema Emphysema Endometriosis Fibromyalgia Gout Heart Disease Hepatitis High Blood Pressure High Cholesterol Hypothyroidism Impotence Irritable Bowels Kidney Disease Low Testosterone Menopause Migraines Multiple Sclerosis Osteoporosis Panic Disorder Prostate Enlargement Reflux (GERD) Seizures Stroke Urinary Tract Infection 1

2 Past Surgical History: List year performed next to surgery. Fill in those not listed at the end. Appendix Tubal Ligation Gall Bladder Cardiac Bypass Tonsils Catheterization Tubes in Ears Spinal Fusion Hysterectomy Joint Replacement Check one: Partial Total Which joint: Review of Current Symptoms: Please check any symptoms or concerns you have had in the last several months. Constitutional Gastrointestinal Musculoskeletal Good general health Loss of appetite Joint pain Recent weight change Nausea or vomiting Joint stiffness/swelling Headaches Diarrhea Weak muscles or joints Fever Painful bowel movement Muscle pain or cramps Constipation Back pain Ears/Nose/Throat Rectal bleeding Difficulty in walking Hearing loss or ringing Abdominal pain Earaches or drainage Skin/Breast Sinus problems Hematology Cold hands or feet Nosebleeds Bleeding or bruising Hives Bad breath or bad taste Anemia Rash or itching Sore throat or voice change Past transfusion Hair loss Swollen glands in neck Varicose veins Genitourinary Breast pain Eyes Frequent urination Breast lump Eye disease or injury Painful urination Wear glasses/contacts Blood in urine Psychiatric Glaucoma Change in force of urine Memory loss/confusion Double/blurred vision Incontinence Nervousness/anxiety Kidney stones Depression/mania Cardiovascular Male testicle pain Addictive behavior Chest pain or pressure Female irregular menses Palpitations Endocrine Shortness of breath lying flat Neurological Excessive thirst/urination Swelling of extremities Frequent headaches Sugar cravings Light-headed/dizzy Hot/cold intolerance Respiratory Convulsions Poor sex drive Chronic or frequent cough Numbness/tingling Dry skin Shortness of breath Tremors Asthma or wheezing Head injury Sleep Problems falling asleep Energy Problems staying asleep Forgetful Snore Poor concentration Restless legs Fatigue worst time of day: 2

3 Family Medical History: To the best of your knowledge, have any blood relatives been diagnosed with the Following? (Please state the family member(s) relationship in the space provided): Alcoholism Allergies Alzheimer s Anemia Asthma Birth Defect Bleeding Disorder Cancer: Member/Type: Member/Type: Member/Type: Depression Diabetes Epilepsy Heart Disease High Blood Pressure High Cholesterol Kidney Disease Stroke Allergies Do you have any drug allergies? Yes No If yes, please list the drugs and the reaction you had: Environmental allergies? Yes No Food allergies? Yes No Social History Number of children: Marital Status: Married Single Divorced Other Occupation: Please list what you do, approximately how many hours you work per week and your level of satisfaction with your job: Has this or any job put you around strong chemicals or smoke? Yes No Tobacco use: Yes No If yes, how many per day: How many years: Currently smoking: Yes No If you quit, how long ago: Smoke exposure at home: Yes No Alcohol use: Yes No If yes, how many drinks per week: How many years: Drug use (state which drug and if currently using): 3

4 Medications and Supplements: Please list all medications and supplements you are currently taking: Stress: Stress and the management of stress is very important to you overall health. Describe your recreation activities: Describe your relaxation activities: You are happiest when: Spiritual Life: Having an active spiritual life is an important part of your overall health. Describe your current religious practice. (Please provide details as to how often and what you do. For example, do you attend church or other ceremonies? Any small group study?): Previous Complimentary Medicine Experiences: Acupuncture Homeopathy Naturopathy Biofeedback Hypnotherapy Reflexology Chiropractic Iridology Relki Guided Imagery Massage Psychological Counseling Healing Touch Meditation Yoga Additional Dietary Information: Please provide honest answers to these questions based usage on a typical day. Cups of regular coffee: Cups of decaf coffee: Cups of regular tea: Cups of decaf tea: Regular soda: Diet soda: Crystal Light: Artificial Sweetener packs (Splenda or others): Flavored water or Propel: Meals per day: Meals made at home: 4

5 Exercise: Please answer questions based on an average week. How many times per week do you exercise? List the specific exercises that you do, and how long you typically do them: Exercise Duration Preventative Services: Please list the date of your most recent screening procedures: Breast Cancer: Cervical Cancer: Mammogram Pap Smear Colposcopy Colon Cancer: Colonoscopy Three stool test Prostate Cancer: PSA Digital Rectal Exam Diabetes: Fasting blood sugar Heart Disease: Fasting lipid panel Osteoporosis: DEXA scan Carotid Artery Disease: Carotid Doppler 5

6 I fully understand that P. Heil-Mealey, ND, CCI, M Ed., and is not a Medical Doctor, nor Medical Practitioner, and I attest that I am not here for medical diagnostic or treatment procedures. Further, I have been advised that if I have a medical problem, I should seek the advice of a licensed Medical Doctor for my state of condition. The services performed by P. Heil-Mealey are at all times restricted to consultation on the subject of nutritional matters, and do not involve the diagnosing, prognosticating, treatment or prescribing of remedies for treatment of condition or disease, or any act which will constitute the practice of medicine in this state. Member Share Member Share Agreement (MSA) Member Share is a name given the membership program of the Pastoral Medical Association TM, a private ecclesiastical association and tribunal with a mission to further a more natural form of health care and to do so inpart by providing members with a constitutionally protected private gathering place to exercise the desires and rights specified herein. As members we declare the right to select other members of the Association to give us counsel and advice for our physical, mental and spiritual health, and to request member assistance in facilitating for us the actual performance and delivery of the therapies, treatments and care we so choose for ourselves and our families. As members we proclaim the freedom to select for ourselves the types of health care we think best for treating and preventing illness and disease of our minds and bodies, including but not limited to any and all treatment modalities and therapies practiced or used by any type of healers, therapists or practitioners the world over, whether conventional or unconventional. I understand that members of the Association come together to help each other achieve better health and live longer with good quality of life, and that members accept the goals of helping their body function better and choosing options that are both very safe and have a reasonably good chance to succeed, realizing that no diagnostic technique is foolproof. I understand that members have freely chosen to change their legal status as a public person and/or patient, to a private member of the Association. With my signature I agree that all of my questions have been answered fully to my satisfaction and with these understandings, I wish to become a member and herby request and agree to join the Association. In Witness Whereof I set my hand this day of, 20 Printed Name:(Please print legibly) Signature: Legal Guardian Signature: (if client under 18 years of age) Date: 6

7 BioEnergetic Health Survey Name: Age: M/F Date: Instructions: Indicate the symptoms which apply to you using the following scale: (0) if "never" (1) if "rarely" (2) if "time to time" (3) if "often" DIGESTIVE Lower bowel gas several hours after eating Burning stomach sensation, eating relieves Coated tongue Indigestion 1/2-1 hr after eating (may be up to 3/4 hrs Carbonated drinks 3+ per week? Difficult bowel movements Ulcers? Colitis? Gastritis? Stomach bloating after eating Excessive belching/burping Bad breath Alternating diarrhea/constipation Have pet e.g. dogs, cats, farm animals etc. Rectal itching Can't gain weight International travel Stomach/intestinal cramping/diarrhea SUGAR HANDLING PROBLEMS Afternoon headaches Get "shaky" if hungry Faintness if meals delayed Heart palpitates if meals missed or delayed Eat when nervous Awaken after a few hours of sleep Hard to get back to sleep Crave candy or coffee in the afternoon Abnormal craving for sweets or snacks Thirsty much of the time History of diabetes Excessive frequent urination Blurred vision/failing eyesight Breath smells sweet Tingling, numbness, prickling sensation in extremities CARDIAC Bruise easily, "black & blue spots" Sigh frequently Aware of "breathing heavily" Open window in closed room Susceptible to colds & fevers Swollen ankles, worse during night Muscle cramps, worse during night Shortness of breath on exertion Nosebleeds Ringing in ears Heart palpitations Dull pain in chest or radiating into left arm, worse during exertion Hands & feet go to sleep easily Numbness in extremities Tendency to anemia Tension under breastbone or feeling of tightness, worse during exertion Blushing with no apparent cause Black stool (no iron supplementation) Poor concentration Slurred speech Headaches Weakness/fatigue Out of breath frequently e.g., going up stairs Nervousness 7

8 LIVER AND GALL BLADDER Pain under right side of rib cage Frequent skin rashes Bitter metallic taste in mouth in morning Bowel movements painful and difficult Low energy, weakness, exhaustion Upset from greasy/fatty foods Bruises easily Frequent headaches Stools light colored Pain between shoulder blades Laxatives used often History of gall bladder attacks or gallstones History of hepatitis History of jaundice Sneezing attacks Itchy skin, worse at night Dry flaky skin, hair General feeling of poor health Aching muscles Swollen feet and/or legs THYROID Impaired hearing Decrease in appetite Ringing in ears Constipation Puffy hands/face Tired/sluggish Miscarriages Infertility Mental sluggishness/forgetfulness Headache upon rising; wears off during day Slow pulse, below 65 Cold hands and feet Gains weight easily Weight gain around hips Outer third of eyebrows thinning "Emotional" Flush easily Night sweats Hair loss BONE DEVELOPMENT/MINERALS, ETC. Hip & joint pain Receding gums and/or dental cavities Tendency towards slouching/weak Bone loss/osteoporosis in family Crunching, creaking joints ENVIRONMENTAL Exposure to fumes e.g. paint, salon, car Use pesticides in garden Live near power lines/high tension wires Have mercury amalgams (silver) in mouth Skin disorders e.g., psoriasis, eczema etc Loss of hair Hormone disorders History of cancer/personal or familial MUSCLE AND LIGAMENT Muscle aches, stiffness, cramping and pains Chiropractic adjustments don't hold Whiplash and/or ligamental trauma/strain Fatigue, sluggishness Upper or lower back pain Stiff neck and shoulders 8

9 ADRENAL Low blood pressure Chronic fatigue Low energy, lack of stamina General malaise, unhappiness Tendency to hives Arthritic tendency Excessive perspiration Colds/flu often Weakness after illness Dark circles under the eyes Crave salty foods Feeling unrefreshed upon awakening Allergies Exhaustion--muscular and nervous Respiratory disorders Swollen ankles Dizzy when stand up "too fast" Decreasing appetite Irritable Bright lights irritate FEMALE & MALE Female Only Painful menses Premenstrual tension Very easily fatigued Depressed feeling Menstruation excessive and prolonged Painful breasts (monthly) Lumpy breasts/worst at menses Have taken birth control pills Menopause, hot flashes, etc. Menses scanty or irregular Acne, worse at menses Vaginal discharge/yeast, etc. Male Only Tired too easily Urination difficult Pain on inside of legs or heel Feeling of incomplete bowel evacuation Prostrate trouble Leg nervous at night Diminished sex drive Female Male LUNG Chronic cough Pain around ribs Shortness of breath Chest pain Difficulty breathing Post nasal drip Sinus and nasal congestion Coughing up phlegm Coughing up blood Bronchitis (frequent) Infections settle in lungs Sensitive to smog Asthma Wheezing Smoker Chronic lung congestion Breathes through mouth Shallow breather 9

10 IMMUNE Throat infections Poor wound healing Slow to recover from colds or flu Gets boils or styes Swollen lymph glands Catch colds or flu easily Bumpy skin on arms Inflamed or bleeding lungs Cough with mucus Swollen tongue Dark areas under the eyes/cheeks Sore throat Post nasal drip Ear aches and infections Herpes/cold sores KIDNEYS Frequent urination Rose-colored (bloody urine) Dripping after urination Difficulty passing urine Cloudy urine Rarely need to urinate Frequent bladder infections Painful/burning when urinating Urination when cough or sneeze Strong smelling urine Mild back pain Interrupted urine stream Tingling in joints Joint and muscle pain/cramping Can't hold urine Dark circles under eyes Frequent urge to urinate but passes only small amounts How often do you take (or have taken) antibiotics? # Y / N Reactions to vaccinations Y / N How many silver amalgams do you have in your mouth? Root canals? Crowns/bridges? Y / N Were your wisdom teeth impacted? Y / N Other dental problems? Y / N Allergies? Y / N (List main) Are you experiencing bone loss or osteoporosis? Y / N Do you smoke? Y / N Diagnosed for parasites? Y / N Diagnosed history of Candida? Y / N Exposure to pesticides Y / N Drink 6-8 glasses of water daily Y / N Hormone replacement medications Y / N 10