11285 Elkins Road Suite J1, Roswell GA Tel: CONSULTATION FORM. Parent/Guardian s Name (if under 18) Address.
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1 11285 Elkins Road Suite J1, Roswell GA Tel: CONSULTATION FORM Name Date Parent/Guardian s Name (if under 18) Address City State Zip Home Phone Work Phone Cell Phone Birth date Occupation Referred by List every health problem you currently have in the order of its importance to you: What desires do you have with regards to your health & well-being? In other words, what would be your ideal health scene? Are you ready to make a change in your lifestyle to reach these desired goals? What are your expectations with regards to how naturopathic medicine will work to relieve your conditions and help you toward your ideal scene? Please list any major illnesses that any of your family members has a history of:
2 Consultation Symptom Survey Please put a check mark by any that you've experienced in the last 3 months: Never Occasionally Often Lower energy and/or stamina Loss of flexibility (stiffness or tight muscles) Don't get a fully sound sleep Experience nervousness or anxiousness Experience depression Loss of luster in hair or nails Skin dryness, breakouts or rashes Darkness or bags under the eyes Irregular, painful or heavier/lighter menstrual periods Swelling, receding or bleeding gums Dental decay or dental work Fungus in nails or periodic yeast infections Digestion or elimination not quite right (or taking meds for this) Sinus pressure Headaches Weight gain Water retention/ swelling Joint irritation
3 DISCLAIMER I,, understand and acknowledge that: Debra MacIntyre is a naturopath, licensed in Washington, DC and board certified by the American Naturopathic Medical Association. She does not represent herself as being licensed by the state of Georgia in any branch of the healing arts (The state of Georgia does not license naturopaths). She does not engage in the practice of medicine, and does not recommend or dispense any prescription drugs, or utilize surgery, x-rays, or radiation therapy. She also does not represent herself as a registered dietician. If you are seeking medical services, you are urged to seek them from a qualified medical practitioner. I further understand and acknowledge that: Debra MacIntyre provides naturopathic services to private persons by contract. Article 1 of the Constitution of the United States of America guarantees the right to contract. Naturopathic services do not involve any diagnosis or treatment of physical or mental ills. Debra MacIntyre s naturopathic services do not diagnose, treat, prevent or cure any diseases. Naturopathic services strictly involve supporting the healthy function of the body s own systems. Additionally, she provides non-prescription health products for sale to private persons with whom she contracts. I further understand and acknowledge that: Many naturopathic techniques come from philosophies that were outgrowths from religious philosophies, such as Traditional Chinese Medicine, which has its roots in Taoism. This naturopathic office utilizes techniques from Traditional Chinese Medicine, German Homeopathic philosophy, and research from L. Ron Hubbard, who is the founder of Scientology. My participation in naturopathic healing does not imply any attempt to change my religious beliefs. These naturopathic techniques are not religious in and of themselves. I have read the above and understand it. I have chosen to have naturopathic services provided to me by Debra MacIntyre and her staff. Further, I understand that naturopathy is a system of healthcare that supports the body s ability to heal and regenerate itself. I understand that Debra MacIntyre has not made any promises regarding a diagnosis, treatment, cure or prevention for any disease. Signed: Date: If under 18, parent or guardian s signature: Natural Health Solutions, Inc. All rights reserved. I/A # L. Ron Hubbard and Scientology are trade marks and service marks owned by RTC and used with its permission. Printed in USA.
4 Consultation Key Word List During your consultation, you might hear words that you are unfamiliar with. For you to get the most out of your consultation, please review the following explanations: Free radical damage- This is damage that occurs because of exposure to environmental toxins. The easiest way to think of it is as a speeded up aging process. One obvious example is to think of two people age 20 years old. One takes up smoking and the other doesn't. Fast forward to these people in their 40's. Who looks older? The smoker, and this is because of the free radical damage he experienced from the cigarette smoke. We all experience this damage to a greater or lesser degree, because our environment contains many damaging toxins. Toxin- Any substance you take into your body (by breathing, eating/drinking, or absorbing through the skin) that is foreign to you. This includes chemicals like air and water pollution, additives, preservatives, and colorings in our food, viral, bacterial, or yeast infections, radiation from x-rays, flame retardants in our clothing, carpeting, and furniture, etc. Anti-oxidant- A vitamin which helps to protect your cells from free radical damage. Some common antioxidants include Vitamin C and Vitamin E. ph- ph stands for percent hydrogen and is an indicator of your acid/alkaline balance. If you are too acidic or alkaline, it leads to health problems. Inflammation- This is a defense mechanism of your body and occurs when you have more toxins built up in your tissues than you can release through sweating, urinating or having bowel movements. Inflammation is a rushing of blood and immune resources to the area of toxic load in an attempt to handle it. Some conditions that are associated with inflammation include arthritis, asthma, allergies, lupus, diabetes, heart disease, cancer, headaches, fever, and swelling. In fact, research is showing that nearly all non-optimal health conditions have an inflammatory component. Homeopathy- A system of healing which uses extreme dilutions of herbs to stimulate your body to repair itself. These remedies are so dilute, that if a young child drank a whole bottle, there would be no problem! Homeopathy is safe for all ages and can be taken alongside any necessary medication. Homeopathy has been in use for well over 200 years, and was quite popular in the US before the advent of the pharmaceutical industry. It never lost popularity in Europe (in fact, the Queen of England uses it) and is enjoying a resurgence of popularity in the United States.
5 Directions to Natural Health Solutions From GA 400 going north: Exit Roswell exit 7B (toward Roswell). Follow Holcomb Bridge Rd. to Alpharetta Hwy (Hwy 9). Go right on Alpharetta Hwy. Go left at fifth light Elkins Rd. From Roswell Rd. going north: Go through Historic Roswell. Cross over Holcomb Bridge Rd. - continue straight. Cross over Mansell Rd. - continue straight. Go left at third light Elkins Rd. From Marietta: Take Hwy 120 E/Roswell St. into Roswell. (Will change names to Roswell Rd. then Marietta Hwy.) When you come to the T intersection with Atlanta St./Hwy 9/120 E at the Roswell Mill, take a left. In about half a mile you will take the fork to the right to continue onto Hwy 9/120 E/Alpharetta Hwy. Cross over Holcomb Bridge Rd. - continue straight. Cross over Mansell Rd. - continue straight. Go left at third light past Mansell Rd. Elkins Rd. From Hwy 120 (Duluth): Take 120 W./Abbotts Bridge Rd. (Changes names to 120 W./Kimball Bridge Rd.) Slight right onto 120 W./State Bridge Way. Keep right at fork to continue on 120 W. As you get into Alpharetta it turns into Old Milton Pkwy. Go past Haynes Bridge Rd. When Old Milton intersects with Alpharetta Hwy/Hwy 9/S. Main St., go left onto Alpharetta Hwy. Follow Alpharetta Hwy south take a right at Elkins Rd. (5 th traffic light) Go right onto Elkins Rd. If you have any questions about these directions or to make an appointment, please call the office at
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