I. Personal Information: Name: Street Address: Date: Phone: City, State, Zip: Referred by: Age and Sex Height Weight Blood Type (if known) (Female Only) (Date and Describe) Last Menstrual Cycle: Have you received any vaccinations in the past 5 yrs. Yes or No. If yes, did you experience any adverse effects? Yes or No. II. Diet, Nutrition and General Health Practices a. do you consume the following? (1=Very Frequently, 2 = Often, 3 = Rare, 4 = Never) Refined Sugar 1 2 3 4 Dairy 1 2 3 4 Fresh Fruits 1 2 3 4 White Flour 1 2 3 4 Pork/Shellfish 1 2 3 4 Vegetables 1 2 3 4 Alcohol 1 2 3 4 Red Meat 1 2 3 4 Green Salads 1 2 3 4 Fried Foods 1 2 3 4 Chicken/Turkey 1 2 3 4 Whole Grains 1 2 3 4 Caffeine 1 2 3 4 Artificial Sweeteners b. How much water do you drink/day? Cups d. do you exercise? Hrs per f. do you eliminate your bowels? /day /wk h. How would you rate your overall health? Poor ( 6 7 8 9 10) Great 1 2 3 4 Fresh Fish 1 2 3 4 c. How many hrs of sleep on average do you get each night? Hrs e. What is your energy level like? No energy ( 6 7 8 9 10) High energy g. What is your stress level? No stress ( 6 7 8 9 10) High stress i. Which foods do you crave? What food do you feel you would not want to do without? 1
j. Describe briefly a typical breakfast/lunch/dinner/snacks: k. Are you presently on any medications (prescription or over the counter) or dietary supplements? (Please list and include dosages.) l. List any serious illnesses or surgeries you have had in the past. m. Are you presently under a doctor s care for any condition? (If yes, please describe and give dates of onset) n. What is/are your primary health concern(s) and what do you hope to achieve through this consultation? Please indicate when the condition began. o. Name the two emotions you experience most often? (ie: Anger, irritability, sadness, worry, hopelessness, grief, fear, joy, happiness, other) p. Any additional comments which may or may not pertain to your present health. (Any odd symptoms, emotions, etc.) q. How many people live in your household? Are you happy with your living arrangements? Yes No (If No please explain) What are their names and relationship to you? 2
r. What are some of your interests? Client Intake and Health History s. What is your occupation? Do you like your job? Do you work with a lot of chemicals or pollutants? t. Have you ever been in an accident? (If yes, please explain) u. Were there any major events which may have occurred in your life just prior to the onset of your primary condition? (ie: Car Accident, Birth or Death, etc) v. Family Medical History: Mother Father Siblings Grandparents w. Do you have any known allergies or sensitivities? Specific Symptoms: a. Have you been diagnosed with any of the following? (Check all that apply) Aids Diabetes Lupus Arthritis Fibromyalgia Osteoporosis Asthma Hepatitis Multiple Sclerosis Cancer High Blood Pressure Ulcers Cirrhosis of the liver IBS/IBD Colitis Low Thyroid 3
Symptom Checklist 0. Never have the symptom 1. Rarely have the symptom 2. Occasionally have the symptom, effect not severe 3. Occasionally have the symptom, effect is severe 4. Frequently have it, effect is not severe 5. Frequently have symptom, effect is severe Head headaches faintness dizziness insomnia drowsiness Eyes watery or itchy swollen, or sticky eyelids dark circles under eyes blurred vision spots before eyes poor vision cataracts glaucoma Mouth and Throat chronic coughing frequently clearing throat frequent sore throat hoarseness metallic taste canker/cold sores dry or itching mouth grinding teeth clicking jaw Ears itchy ears ear aches, ear infections drainage from ear ringing in ears, hearing loss fullness of ears poor hearing Nose stuffy nose, smell altered sinus problems excessive mucus hay fever sneezing attacks Gastrointestinal nausea or vomiting diarrhea constipation bloated feeling belching or passing gas stomach pains or cramps difficulty swallowing black stools blood in stool hemorrhoids heart burn/reflux rectal pain loose stools Musculoskeletal neck pain back pain pains or aches in joints reduced range of motion arthritis stiffness pains or aches in muscles weakness numbness swelling in hands and feet Cardiovascular/Circulatory irregular heart beat rapid or pounding heart chest pain High blood pressure Cold hands or feet Fainting hyperactivity Low blood pressure Neuropsychological Poor sleep Depression Seizures Headaches Lack of coordination Poor memory Irritability mood swings anxiety, fears nervousness anger aggressiveness depression High stress levels Difficulty concentrating Loss of balance Numbness Migraine "Spacey"/foggy feeling poor memory poor comprehension poor concentration poor physical coordination difficulty making decisions stuttering learning disabilities 4
Immune System frequent illness frequent infections poor wound healing Urinary System Painful urination Urinary urgency Incontinence Frequent urination Kidney stones Inability to hold urine Blood in urine Irregular flow Decreased flow Difficulty starting/stopping slow Reproductive (women only) Heavy cramping Bloating PMS Irritability/Moody Heavy bleeding Light bleeding Vaginal odor Vaginal discharge Vaginal itching Frequent Yeast infections Breast tenderness Is your cycle longer than 28 days? Yes or No Is your cycle shorter than 28 days? Yes or No Is your libido (desire for intercourse) low, medium or strong? Energy and Activity restless fatigue, sluggishness apathy, lethargy Respiratory chronic cough (dry or phlegm) chest congestion asthma, bronchitis pneumonia coughing up blood shortness of breath difficulty breathing difficulty breathing when laying down Skin acne hives, rash, or dry skin hair loss flushing or hot flashes excessive sweating change in color Weight binge eating/drinking water retention crave sweet foods crave salty foods purging/laxative use 5
Mens Prostate Health Screening IN THE PAST MONTH 1. Incomplete Emptying have you had the sensation of not emptying your bladder? 2. Frequency have you had to urinate less than every two hours? 3. Intermittency have you found you stopped and started again several times when you urinated? 4. Urgency have you found it difficult to postpone urination? 5. Weak Stream have you had a weak urinary stream? 6. Straining have you had to strain to start urination? NOT AT ALL LESS THAN 1-5 TIMES LESS THAN HALF THE TIME ABOUT HALF THE TIME MORE THAN HALF THE TIME ALMOST ALWAYS 7. Nocturia How many YOUR SCORE 6
times did you typically get up at night to urinate? Total I-PSS Score Score: 1-7: Mild 8-19: Moderate 20-35: Severe Are there any other concerns that have not been addressed? 7
Client Statement I understand that I am here to learn about holistic nutrition and better health practices and that I will be offered information about food supplements and herbs as a guide to general good health and this is considered to be for educational purposes only. I fully understand that those who counsel me are not medical doctors and I am not here for medial-diagnostic purposes or treatment procedures. I am not on this visit or any subsequent visit as an agent for federal, state, or local agencies or on a mission of entrapment or investigation. The services performed by NATALIE VICKERY are at all times restricted to consultation on the subject of nutritional matters intended for the maintenance of the best possible state of nutritional health and do not involve the diagnosing, treatment or prescribing of remedies for disease. I also understand that it is my responsibility to discuss any and all information provided during this consultation with my primary health care provider or any other health care providers/specialists whose care I may be under. Due to HIPPA privacy regulations, your information will be held confidential and not shared with anyone. Initial here to indicate that you have been advised of all consultations fees. Initial here to indicate that you have received a copy of the handout, Natural Health Consultation What to Expect. Initial here to indicate that you are aware that these services are not covered by insurance and that you are responsible for all fees incurred. Date. Signature: Signature of Guardian for minor child: Natalie B. Vickery Traditional Naturopath/Herbalist www.thefamilyherbalist.com Email: family_herbalist@yahoo.com (904)613-2738 For Correspondence only: 4171 Dowling Rd Middleburg, Fla. 32068 8