Aromatherapy

Similar documents
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

Natural Balance strives to offer efficacious, holistic, natural health-care, in a personalized, caring and supportive manner.

Aromatherapist: CLIENT RECORD. Personal Information: Name: D.O.B Occupation: Address: Telephone: Marital Status: Dependents: Doctor: Doctor Informed?

PATIENT INFORMATION FORM (WOMEN ONLY)

WELLNESS HISTORY. Patient s Name: Date

Essential Oils. Katherine Jury Hopkins County Agent For Family & Consumer Sciences

Pharmacy Prep. Qualifying Pharmacy Review

Adult Health History Summary

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

Complementary Therapies

Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?

Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male

What do you believe is causing your most important health concern?

The Wellness Lounge Staff

New Patient Intake Form

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

c o m m u n i t y o u t r e a c h

PATIENT MEDICAL HISTORY INTAKE FORM

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Acupuncture for Well Being

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Have you ever been diagnosed with any of the following? The patient has a history of the following conditions: Glaucoma

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form

Patient Medical History

Acupuncture for Well Being

Luck has nothing to do with it. Complementary & Alternative Medicine Guide

The Food Intolerance Institute of Australia

WELCOME TO OUR FAMILY!

Laser Vein Center Thomas Wright MD Page 1 of 4

Naturopathic & Acupuncture Intake Form (Age 14+)

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

TOUCHMATTERS MANUAL THERAPY Health History Form NAME: DATE: ADDRESS: (street and number) (city) (postal code) TELEPHONE: (home) (work) (cell)

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP

LECOM Health Ophthalmology

stoneburner acupuncture

Patient History Form

Inner Balance Acupuncture

EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)

Nutrition Consultation Intake Form Please write or print clearly

A longwinded way of saying that stress is subjective and stress is different for everyone. What may be stressful for one person may not be for

Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me

UnityPoint Clinic - Cardiology

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Symptom Review (page 1) Name Date

New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

MALDIVES RANGALI ISLAND H OLISTIC H E ALTH

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

l.com The gy or foodintol COPYRIGHT: Copyright of the

Client Name: Date: Birthdate: Age: Gender: F M Address: City State Zipcode phone # home: cell: work:

Dear Valued Patient, Thanks for allowing me to be a part of your healthcare team! Sincerely, Mary Mees, LAc, DAOM

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Functional Blood Chemistry & CBC Analysis

Patient Health History Questionnaire

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

UWSP Medical History Form

Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042

New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4

the nccaom certif ication in oriental medicine

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC

Medication Allergies

T HE NC C AO M OR I E NTAL ME D IC IN E

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:

Avery Acupuncture & Natural Medicine New Patient Registration

Honduras New Hope Clinic Weekly Reports, August Weekly Report August 3-7, 2015

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

OKANAGAN HEALTH & PERFORMANCE Inc.

Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #

Medical History Form

MGH Beacon Hill Primary Care New Patient Form

intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:

Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information

Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.

WELCOME TO FALLS CHIROPRACTIC AND INJURY!

Traditional Chinese Medicine

NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)

Headache Follow-up Visit Form

Johanna M. Hoeller, DC PS

ABA Chiropractic Holistic Health Center Nutritional Assessment

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

HEALTH PARTICIPATION CLIENT INTAKE FORM (Please Print) CLIENT INFORMATION

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

Welcome to About Women by Women

Emotional Relationships Social Life Sexually Recreation

If you have any questions, feel free to contact us at 475- WLNS (9567) or

Morris Medical Center, P.A.

WOODLANDS FAMILY CHIROPRACTIC

PLAS/RECON SURGERY PATIENT HEALTH HISTORY

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

WELCOME to Naturopathic Medicine at Vivo!

CAM Dr Monem Alshok

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

Medical History Form

Transcription:

Holistic Health Practitioner and Aroma Therapist. 650-321-5600 naturaltraditions@gmail.com, jaya@naturaltraditionshealth.com Natural Traditions, 115 El Camino real, Menlo Park, CA 94025 www.naturaltraditionshealth.com Jaya Pancholy is the Founder and CEO of Natural Traditions, Inc., Menlo Park, CA, a company promoting Holistic Health, Mind Body wellness with the use of Smart Nutrition, Optimal Digestion, Antioxidant Protection, Body Efficiency, Prevention instead of Treatment for a healthier you, help with balancingrestoring-normalizing health and wellness and help with Stress by proper guided tools. Her practice is located at 115 El Camino real, at Stanford Inn, Menlo Park, California, where she provides consulting services for Holistic Health & Aroma Therapy. Jaya has a BSc in Psychology, MBA from National University USA, Holistic Health Practitioner Graduate from Global Institute of Alternate Medicine, Aroma therapist graduate from Pacific Institute of Aromatherapy, certification in Kinesio Taping KT 1-2-3, Pranic Healing Certificate Basic-Advanced-Psychotherapy, Reiki, Acupressure. Jaya has experience of running 3 successful Gloria jeans Gourmet Coffees franchises, and was consultant for holistic retail set up for Body Scanning Company in Southern California. Jaya is also CEO of KIN Healthcare in India. As a Holistic Health Practitioner (HHP) Jaya is trained in various areas of holistic healing, including Herbal Medicine, Nutrition, Body-Mind Medicine, Ayurveda, Yoga, Meditation etc. As an Aroma therapist Jaya uses plant oils, including essential oils, for psychological and physical well-being. Jaya recommends healingwellness-preventive modalities for health that works on the 5 aspects Mind, Emotions, Body, Spirit and environment. Holistic medicine treats the whole person and works on strengthening the body s innate healing ability thru the use of herbs, nutrition, aromatherapy, homeopathy, ayurveda, yoga, meditation and other healing modalities. Jaya is Board certified Holistic Health Practitioner from American Association of Drugless Practitioners (AADP) and holds International Certification in Aroma Therapy. She has published many articles and has been invited as speaker at International Conferences, such as the MBB Expo at Los Angeles Convention Center, California, USA (2007), where she spoke on Aromatherapy, (AICOG) All India Obstetrics & Gynecology Conference, New Delhi, India (2008), where she spoke on Holistic Approach to Women s Health issues, and is part of International Faculty. (AICOG) All India Obstetrics & Gynecology Conference, 2009 January, Jaipur, India, where She spoke on Holistic Approach to women s Health and Wellness, Jaya is part of core faculty at Indian Society for Sleep Research and presented course on Holistic Approach to Better Sleep at India Habitat Center, New Delhi, December 12-13, 2009. From Jaya Pancholy: My Work can help anyone who is seeking *Integrative, complimentary, and alternate ways to Healthy living, health and healing the natural way, *Positive balance between, Mind, Body and Spirit, *. If you need help with Arthritis, Acne, Allergies, Anemia, Asthma, Anxiety, Athlete s foot, Adhd, Autism, Back Pain, Blood Pressure, Bronchitis, burns, Carpal Tunnel, Candida, Canker Sores, Cancer management, Colds, Cough, Cholesterol, Constipation, Cardiovascular Disorders, Depression, Dermatological Disorders, Diabetes, Diarrhea, Ear infections, Eczema, Fever, Fibromyalgia, Gastrointestinal, Gingivitis, Headaches, Hepatitis, Hemorrhoids, High Blood Pressure, Hives, Hypertension, Insomnia, Immune Dysfunctions, Jet Lag, Menopause, Menstrual problems, Muscle Cramps-Pain, Pinched Nerves, Slipped Disc, Sinus, Snoring, Sore Throats, Sprains, Stress, Migraine, Neurological Disorders, Osteoporosis, Poison Ivy, Sinusitis, Thyroid Please make an appointment at Natural Traditions 650-321-5600. Promoting Health & Wellness the natural way! Jaya Pancholy