MIGRAINE RELIEF COACHING CLIENT INTAKE FORM
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1 MIGRAINE RELIEF THROUGH MINERAL BALANCING 6 Coyote Canyon Dr. White Salmon, WA MIGRAINE RELIEF COACHING CLIENT INTAKE FORM First Name Last Name Address City State Zip Phone address CONSENT OF SERVICES I hereby authorize Marya Gendron, LMT, BCST to administer any services that she deems necessary in my case. I understand that Marya is not a doctor and therefore can t prescribe or treat. All information provided during health coaching sessions is educational and suggestive only, is not a replacement for medical advice, and should be brought to my primary care physician for consideration to evaluate to what extent, if any, her suggestions may be contraindicated with herbs/medications/or treatments already underway. I take full responsibility for my health and understand that Marya takes no responsibility for the outcome of such suggestions should I decide to try them. Patient/ Responsible Party signature Date
2 CANCELLATION POLICY Please give 24 hours notice if you cannot make your scheduled appointment. Cancellations without notification will be charged in full. HEALTH GOALS: What are your most important health goals? Please list in order of importance to you: CHIEF CONCERN Explain the main reason you are seeking bodywork or coaching: IN YOUR HEART OF HEARTS, DO YOU BELIEVE IT IS POSSIBLE TO HEAL FROM THIS CONDITION? ARE YOU CURRENTLY READY TO DO WHAT IT TAKES TO HEAL FROM IT (WHATEVER THAT MAY BE)? This could include but is not limited to: having the discipline to exert free will over food choices, instill new daily habits, examine emotional blocks around healing and ways that we sabotage the healing process, do deep detoxification, and/or take time off from work to rest, heal, or reset).
3 CONSTELLATION OF SYMPTOMS Check all symptoms that you experience, conditions you have been diagnosed with, or factors you suspect play a role in your overall health status. For conditions that only applied in the past, but not currently, write P. In the Other section, fill out any additional conditions or symptoms not included in the list, including any surgeries and what kind, and any genetic conditions you are aware of. brain fog headaches migraines food allergies bloating gallbladder attacks gallstones peripheral neuropathy gas heavy metal toxicity shingles infection epstein barr virus amyloid beta plaque hypothyroid hyperthyroid uterine fibroids light sensitivity cystic fibrosis kidney stones hormonal birth control hysterectomy copper IUD PMS Heavy Bleeding easy bruising low blood sugar diabetes scoliosis kyphosis candida overgrowth brittle nails nail fungus white spots on nails bulging veins varicose veins ringing or pain in ears hemmerhoids thin teeth enamel dental abscess cataracts arthritis neck and muscle tension smoking coffee addiction addiction insomnia anxiety depression constipation diarrhea belching traumatic childhood other trauma received many antibiotics salycilate sensitivity stroke received many vaccines sulfur sensitivity hyper-flexibility NSAID use other other Check any of the following conditions for how/why/when your migraines manifest menstruation with aura hemiplagic chronic at ovulation digestive (food triggers) chemical trigger light trigger sleep deprivation sinus congestion environmental allergies electromagnetic pollution emotional upset medications heat other other
4 DURATION OF PRESENT CONDITION When and how did it begin? What do you believe primarily caused/causes this condition? If you have migraines, how frequent are your migraines in a given month? What makes it better? On a scale of 0-10 (ten highest motivation), describe your motivation to better manage your condition resolve your condition for good How many hours per week would you be willing to devote to improving your health condition, above and beyond what you already do? Is there anything that you know improves your condition, that you are not doing? If so, what is preventing you from following through with what you already know you need to do? (ie, what is the elephant in the room?)
5 MEDICATION you are presently taking (pharmaceuticals only): HISTORY OF PHARMACEUTICAL MEDICATION (Very important for health coaching clients - please give as much detail as possible, including duration of medication treatment - medications of important note include antibiotics, NSAID s, and any kind of opiate-based medication). MEDICINE you are presently taking (herbs, healing plants, homeopathy, essential oils, supplements) - and dosages/frequency: HISTORY OF TRAUMA/INJURY Please describe any significant accidents, injuries, trauma, or illnesses in the past List any other hospitalizations or surgeries you have had. Include age, time and any problems since. PLEASE DETAIL ANY PHARMACEUTICAL MEDICATIONS GIVEN AT THAT TIME.
6 FLUID INTAKE How much water do you drink a day? DIET What percentage of your diet is made at home: What percentage of your diet is from processed/prepackaged food: What percentage of your diet is fresh (salads/fruit/smoothies): Describe your intake of animal products in a given week: How many pieces of fruit do you normally eat in a week? Anything else I should know about your diet/relationship to food? How many times per week do you consume: Alcohol coffee wheat cheese/yogurt/sour cream chocolate lunch meats/cured meats/bacon Dried fruit vinegar/soy sauce chilli cinnamon/nutmeg/clove pickles/sauerkraut green drinks candy
7 BODY CARE - Shampoo, lotion, makeup, face cream, deodorant Do you use body products with synthetic chemicals, fragrances, or dyes? Yes No BIRTH CONTROL method (if female, if applicable) MENSTRUATION: Is your cycle regular? (if applicable) BLOOD PRESSURE: Circle one. High Normal Low SLEEP: Describe your sleep. Do you fall asleep easily? Do you wake frequently? Do you dream? Do you wake with migraine? Do you wake with brain fog? When do you go to sleep? DIGESTION: How many bowel movements do you have in a week? How is your digestion? Please describe if you are constipated, have diarrhea, or even loose stool. Do any foods in particular cause you digestive upset or problems? EXERCISE: Describe how and to what extent you get exercise
8 CENTERING: Describe how you center yourself/what brings you joy RESOURCES: Describe where/how you feel most supported in your life: STRESS: Describe your current stressors: Additional Info: Is there anything else you feel is important that I have not asked?
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Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
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
Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA
Metro Acupuncture 6255 Barfield Road, Suite 175 Atlanta, GA 30328 404 255-8388 www.metroacupuncture.com Patient Information Last Name: First Name: Middle Initial: Street Address: City: State: Zip: Preferred
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
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
HORMONE BALANCE QUESTIONNAIRE FOR MEN
HORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal