Life Strength & Health Holistic HEALTH HISTORY INTAKE FORM

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Transcription:

Life Strength & Health Holistic HEALTH HISTORY INTAKE FORM Name: Date: Address: Town/City: State: Zip Code: Home Phone: Work Phone: Mobil/Pager: Email: Occupation: Employer: DOB: Sex: Marital Status: Spouse's Name: In case of emergency contact: Relationship: Please Check the services that you will be receiving today? ( ) Detoxification Program ( ) 3 Month Program ( ) One Time Consultation ( ) Colon Hyrdotherapy ( ) Massage Therapy ( ) Personal Training ( ) Colon Health Program How did you hear about us? ( ) Brochure ( ) Business Card ( ) Internet ( ) Email ( ) Other ( ) Advertisement ( ) Refer By Whom: May I contact you with Brochures, Specials and Notices? ( ) Yes ( ) No If you are a Federal, State or Local Agent, upon entering the premises, you MUST declare same or under BivensAct - Article 42, be held personally or individually liable.

Are you presently under a physician's care? Y / N For what condition? List medications you are taking: Are you allergic to any medications? Serious illness / hospitalizations / injury? What is your chief health concern? Other concerns? Are there any other healers, helpers, pets, or therapies with which you are involved? Y / N If so please list: How many glasses of water do you drink daily? Do you eat a lot of dairy? Y / N Do you often get tired after eating? Y / N Do you shake, get light headed or anxious when you miss a meal? Y / N Do you wake-up in the middle of the night in a cold sweat or feeling hungry? Y / N Current Weight: Weight six months ago: One Yr Ago: Would you like your weight to be different? Y / N If so what? Do you sleep well? Y / N Do you wake up at nights? Y / N What time(s)? What time do you generally get up in the morning? What's your food like these days? Breakfast Lunch Dinner Snacks Liquids Circle the foods you eat on a daily basis: Starchy Vegetable Rice Meat Fish Eggs Green Vegetables White Flour Fruits Nuts Butter Beans / Legumes Whole Grains Seeds Fowl Vegetable Oils Are you allergic to any foods? What % of your foods is home cooked? % Where do you get the rest from? How many meals do you eat a day? Do your hands often tingle? Y / N Do your feet often burn? Y / N Do you often get leg cramps Are your hands and feet usually cold? Y / N Do you often feel cold when others are warm? Y / N What conditions or diseases run in your family

Women Are your periods regular? Y / N How Frequent? How many days is your flow? Painful or symptomatic? Please explain: Do you presently use birth control? Y / N Have you used birth control in the past? Y / N How long? Have you had a tubal ligation? Y / N Grade your sypmtoms for your last menstrual cycle. If it is unusual, grade according to a typical cycle. Use the following Key. 0 = None 1 = Mild 2 = Moderate (symptoms present and interfere, but you can function) 3 = Severe ( cannot function without medication, disabling) Symptoms Week Before Week After Menses Ends PMT - A Nervous tension Mood swings Irritability Anxiety PMT - H Swelling of extremities Weight gain (1 to 4 lbs) Breast tenderness Abdominal bloating PMT - C Headaches Crave Sweets Increased appetite Heart pounds Fatigue Dizziness or fainting PMT - D Depression Forgetfulness Crying Confusion Insomnia

Do you drink coffee, smoke cigarettes, or have any major addiction? What role does exercise play in your life? Describe your daily / weekly exercise: Are you under a lot of stress? Y / N Do you use any stree reduction techniques? Y / N Is so what? Is your sex drive: Poor Fair Good Very Good? Is your appetite: Poor Fair Good Very Good? Is your mood usually: Poor Fair Good Very Good? Have you been diagnosed as AtherosclerosWhat is you Blood Pressure? Arteriosclerosis Angina What are your blood levels of CholestHDL LDL Triglycerides How often do you have a bowel movement(bm)? What is the usual color of your stool? What is the consistency of your stool? ( ) Hard & Dry ( ) Loose, Like Pudding ( ) Firm & Moist ( ) Watery, Diarrhea Do you use laxatives? Y / N If so what brands? Do you have? Hemorrhoids: Y/N Rectal Bleeding: Y/N Strain when you have a BM: Y/N Have you had? Recent Barium Enema: Colonoscopy: Colon Surgery: Rectal Surgery: If you have ever had any of these procedures please list the type and when it was performed

Please check if you currently have or have ever had any of the following, or been diagnosed as having problems with any of the following: ( ) Bad Breath ( ) Sigmoidoscopy ( ) Colds / Flu ( ) Coated Tongue ( ) Diverticulosis ( ) Hay Fever ( ) Vomiting ( ) Diverticulitis ( ) Nerves ( ) Blood in stool ( ) Chron's Disease ( ) Depression ( ) Frequent use of laxatives ( ) Severe Hemorrhiods ( ) Anxiety ( ) Indigestion after meals ( ) Severe cardiac disease ( ) Phobias ( ) Gas after eating ( ) Cirrhosis ( ) Ulcers ( ) Painful / Difficult BMs ( ) Carcinoma of the colon ( ) Alzheimer's ( ) Burning stomach sensations ( ) Fissures / Fistulas ( ) Epilepsy ( ) Acid food upset ( ) Aneurysm ( ) Fainting ( ) Greasy food upset ( ) Advanced Pregnancy ( ) Impotence ( ) Frequent sour stomach ( ) Severe Anemia ( ) Headaches ( ) Hunger between meals ( ) Abdominal Hernia ( ) Migraine ( ) Early pregnancy ( ) GI Hemorrhage ( ) Arthrititis ( ) Constipation ( ) Recent Colon Surgery ( ) Edema ( ) (Ulcerative) Colitis ( ) Abdominal Distension ( ) Menopause ( ) Diarrhea ( ) Flatulence ( ) Circulation ( ) Atonic Colon ( ) Barium enemas ( ) Thyroid ( ) Fatigue ( ) Parasites ( ) Diabetes ( ) Aids ( ) Hypoglycemia ( ) Bladder ( ) Rashes ( ) Acne / Boils ( ) Asthma ( ) Bruising ( ) Eczema ( ) Sinuses ( ) Throat ( ) Cysts / Tumors ( ) Ovaries ( ) Eyes ( ) Spine Back ( ) Breasts ( ) Ears ( ) Osteoporosis ( ) Prostate ( ) Cancer ( ) Yeast Infections ( ) Vaginitis ( ) Heart ( ) Blood Pressure ( ) Memory ( ) Liver ( ) Gallbladder ( ) Kidneys ( ) Spleen ( ) Urinary Infections ( ) Pancreas ( ) Lungs ( ) Varicose Veins

Answer Only If You Are Receiving A Colonic Why have you chosen to have a Colon Hydrotherapy Session(s)? ( ) 9th Amendment Right to Self-Prescribe ( ) Doctor's Referral ( ) Other: If there is any other information you would like to share with the Colon Hydrotherapist, please use this space to do so: Answer Only If you Are Receiving A Massage Is this your first professional massage If not, how frequent do you get a massage and what types? What do you want to accomplish from todays massage? Do you have any injuries or conditions that would interfy/n Do you have any skin rashes Y/N If so where? Do you have uncontrolled high blood pressure? Y/N Do you have any broken bones or spraif so where? Do you have any varicose veins? Y/N If so where? Are you aware of any health issues that would prohibit you from receiving a massage? Y/N If so what? Please follow the instructions of the Therapist. You must be draped/covered at all times. Absolutely NO sexual activity is permitted during the session! PLEASE READ FULLY AND SIGN BELOW The above information is accurate and true to the best of my knowledge. I understand that the health practitioners at Life Strength & Health Holistic Center do not diagnose disease, prescribe medication or minipulate bones. I further understandthat the holistic serivices offered at Life Strength & Health Holistic Center is not a substitute for medical attention or examination. I take full responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointments without 24 hours notice (medical emergencies excluded) may be charged 50% of the price of the missed session. Signature: Date:

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