Integrative Health and Fitness

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1 Integrative Health and Fitness Robert Guiel, M.S., A.C.N North Road, Westfield, MA (413) Health History Questionnaire of 1 st visit: / / Name: of Birth: Age: Address: City: State: Zip: Phone: (home) (cell) Single Partnered Married Separated Occupation: Employer: How did you hear about us? Has any other family member already been a client here? Y N - Who? Emergency Contact: Relationship: Phone: Address: If under 18, name of parent: Phone: WE UNDERSTAND THIS FORM IS LENGTHY AND TEDIOUS. HOWEVER, PLEASE UNDERSTAND, SUCCESSFUL HEALTH CARE IS ONLY POSSIBLE WHEN THE PRACTITIONER HAS A COMPLETE UNDERSTANDING OF THE CLIENT, BOTH PHYSICALLY AND EMOTIONALLY. THEREFORE, WE ASK THAT YOU PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. THE MORE WE KNOW THE MORE WE CAN HELP. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK. Are you currently receiving healthcare? Y N If yes, where and from whom? What was the reason? If no, when and where did you last receive medical or health care? List, in order of importance, your health concerns that are most important to you. 1) 2) 3) 4) 5) 6)

2 Current State of Health Allergies: Do you currently know if you are hypersensitive or allergic to...? Any drugs? Any foods? Any environmental? Current Medications Prescription Medications 1) 4) 2) 5) 3) 6) Over the counter medications 1) 3) 2) 4) Supplements and Vitamins 1) 6) 2) 7) 3) 8) 4) 9) 5) 10) Habits Yes No In past Additional Information Do you exercise? If yes please fill in below How many hours of sleep do you get per night? ( ) Do you sleep well? Do you wake rested? Fall asleep easily? Wake in the night? Do you enjoy your work? Do you have a supportive relationship? Do you have a history of being abused? Do you use recreational drugs? Have you been treated for drug dependence? Have you been treated for alcoholism? Do you use tobacco products? How many packs per day? ( ) How many years? ( ) Exercise Days per week:, Length of workouts:, Types of Activities: Meals per day:, Snacks:, Caffeinated Drinks:, Alcohol/week: Interests/Hobbies:

3 Hospitalizations and Surgeries Traumas (including accidents, situations of abuse, etc.) Family History Father Mother Brothers Sisters Spouse Children Age if still living Health P=Poor, G=Good Age at Passing Check ( ) all that apply Cancer Heart Disease Diabetes High Blood Pressure Stroke Mental Illness Dementia Autoimmune Disease Asthma / Hay Fever Other Cause of Death if other Please check any conditions or symptoms you currently have now with a ( C ) and any you have had in the past with a ( P ). Diagnostic History Heart Disease Stroke Cancer Autoimmune Disease Thyroid Disease Arthritis Gastritis/Pancreatitis General Poor Appetite Poor Sleeping Fatigue Fevers Chills Liver Disease Gallbladder Disease Kidney Disease Food Allergies Diabetes Chronic Fatigue Anemia Night Sweats Sweats Easily Tremors Cravings Localized Weakness Head, Eyes, Ears, Nose and Throat Headaches Poor/ Blurred vision Dizziness Spots in front of eyes Difficulty swallowing Night Blindness Migraines Color Blindness Glasses Cataracts Eye Strain/Pain Earaches Infertility / Impotence Hypo/Hyperglycemia Hepatitis Raynaud s Disease Respiratory Allergies Lyme s Disease Chronic Pain Condition Poor Balance Change in appetite Bleed/Bruise easily Weight loss Weight Gain Ringing in ears Poor hearing Sinus problems Nose bleeds Sore throats/colds Grinding Teeth Emphysema Alcoholism Drug Abuse Depression/Anxiety Psychotic Disorder Other: Peculiar tastes/smells Dental/gum problems Muscle weakness/fatigue Sudden energy drops Strong thirst Facial pain Sores on lips/tongue Dental problems Jaw clicks/lock

4 Skin and Hair Rashes Ulcerations Itching Hives Cardiovascular Low blood pressure High blood pressure Irregular heart beat Palpitations at rest Respiratory Asthma Bronchitis Pneumonia Gastrointestinal IBS Crohn s Disease Colitis Acid reflux/gerd Indigestion Nausea Gas Genito-Urinary Pain on urination Frequent urination Blood in Urine Urgent urination Unable to hold urine Scanty Flow Eczema/Psoriasis Dandruff Loss of hair Recent moles Blood Clots Phlebitis Shortness of breath Chest pain or pressure Emphysema COPD Pain on inhalation Belching Bloating/Distension Abdominal pain/cramps Constipation Chronic laxative use Diarrhea Loose stools Copious flow Kidney Stones Impotence Sores on Genitals Urinary Tract Infection Burning urination Skin discoloration Acne Face flushing Change in skin/hair texture Fainting Cold hands/feet Swelling of hands/feet Varicose/spider veins Cough/Wheezing Coughing Blood Tight sensation in chest Vomiting Hemorrhoids Rectal pain Black stools Blood in stool Bad breath Changes in appetite Premature ejaculation Nocturnal emission Decreased Libido Excessive libido Prostatitis Dribbling after urination Night urination What time? How often? Gynecological/Reproductive Ovarian cysts Endometriosis Uterine Fibroids PMS Menopause Fibrocystic breast tissue Painful intercourse Vaginal dryness Vaginal sores Irregular Menstrual Cycles of last menses of last PAP/Pelvic Musculoskeletal Neck pain Shoulder pain Rotator Cuff Elbow Pain Hand/wrist pain Carpal Tunnel Hip pain Sciatica Knee pain Foot/ankle pain Sprains/Strains Muscle pain Back pain Low Middle Upper Neuropsychological Anxiety/Panic attacks S.A.D Vertigo/Dizziness Nervousness Bad temper/irritable Loss of balance Easily Over Stressed Bi Polar Poor Coordination Depression Seizures Concussion Areas of numbness: Warts Dermatitis Fungal Infection Weak or ridged nails Spontaneous sweating Elevated Cholesterol Other: Difficult inhale/exhale Production of phlegm What color? Poor appetite Excessive appetite Significant thirst Hernia Other: Pain in testicles Herpes STD Infections Vaginal discharge Infertility Use Birth Control Muscle weakness Tendonitis Bursitis ADD/ADHD Dyslexia Poor memory Have you ever; been treated for emotional problems?, or considered / attempted suicide? How much change and effort are you willing to make to improve your health? MINIMAL SOME COMPLETE Signature Signature of Parent or Guardian

5 INTEGRATIVE AND COMPLEMENTRY Robert Guiel, M.S., A.C.N North Road, Westfield, MA (413) As a client of Robert Guiel s M.S., I clearly understand that I am not being treated for any specific disease. I understand that the treatment received at this office is for the purpose of rebalancing both the structure and bio-electric reflexes of the body. The nutritional supplements received at this office or recommended from this office are not drugs or medicines. They are vitamins, amino acids, mineral food complexes, herbal formulations and homeopathy. The Reflex Analysis used at this office is only used to find increased bio-electric points, which may indicate a deficiency. This work is not and cannot be used to render a physical diagnosis, nor is this work linked to any type of diagnosis. As with all health care treatment, a guarantee cannot be given that such treatment will result in a restoration of health. I have read the above paragraphs and understand them fully Signature Print Name

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