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Submit

Therapist:______________________________________________
                     _____________________________________________
                         ________________________________________________________
                          ________________________________________________________


Please complete as much of this questionnaire as possible.  
Please read and sign the two "Understandings" on pages 5 and 6.


Name_______________________________________  Sex_____  Date_____/_____/____
Birthdate____________________  Height__________  Weight________
If you are paying by credit card:  Name on card ______________________________________
Card number _____________________________________________  Exp. date _________
Amount Over or Under Weight______  Blood Pressure_____  Pulse______
Do you wish to consult: (Check one)
_____  For a check-up
_____  For a particular concern
_____  For a particular concern with comprehensive appointment and 
health program
Do you feel that you are basically healthy?________  What are your primary health concerns?
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FAMILY HEALTH HISTORY


        Age if                    Age at                Cause of death
Member    living        State of Health    death                or poor health concerns
Father        ______    __________        ______    _________________
Mother    ______    __________        ______    _________________
Brothers    ______    __________        ______    _________________
Sisters        ______    __________        ______    _________________
Children    ______    __________        ______    _________________












Check Disease(s) Known To Have Occurred in the Family


__ Diabetes            __ Tuberculosis        __ Allergy    __ Ulcers
__ Heart Disease        __ Liver Diseases        __ Asthma    __ Migraines    
__ High Blood Pressure    __ Kidney Disease        __ Cancer    __Arthritis
__ Convulsions        __ Lung Problems        __ Others______________________________


About Yourself 


Work:             Present occupation ________________________________________________________
             Previous occupation _________________________________When:_____________


Check one:    __ Single     __ Married     __Widow(ed)     __Divorced
Live with:     __ Family    __ Alone        __ Other______________
Do you smoke tobacco? _____     Amount?_____        How long?_____
    If stopped, how long since you quit?_____________________________
Do you use caffeine? _____     Amount?_____        How long?_____
    If stopped, how long since you quit?_____________________________
Do you use recreational drugs? _____  If yes, which? ________  How often?____
    If stopped, how long since you quit?_____________________________    


PAST HISTORY


Have you had, or do you have any of the following ?  (Please circle yes or no.  If yes, indicate when)


Fever, chills, night sweats    Yes  No _____    Blood in bowel movements         Yes  No _____
Severe or frequent headaches       Yes  No _____        Diarrhea                    Yes  No _____
Periods of unconsciousness        Yes  No _____    Constipation        Yes  No _____
Complete or partial blindness    Yes  No _____    Alternating diarrhea
Frequent dizzy spells          Yes  No _____        and constipation        Yes  No _____
Hearing trouble        Yes  No _____    Frequent indigestion or gas        Yes  No _____
Eye trouble        Yes  No _____    Ulcer of stomach         Yes  No _____
Do you feel anxious,        Yes  No _____    Burning when you urinate        Yes  No _____    
   depressed, or irritable?        Yes  No _____    Blood in urine        Yes  No _____
Trouble dealing with stress        Yes  No _____    Need to urinate frequently        Yes  No _____    
Hay fever or sinus trouble        Yes  No _____    Urinate during the night        Yes  No _____
Goiter or thyroid trouble        Yes  No _____    Kidney or bladder stones        Yes  No _____
Asthma        Yes  No _____    Protein or albumin in urine        Yes  No _____
Cough        Yes  No _____    Trouble starting urine stream       Yes  No _____
Mucous in chest or                 Urinary infection        Yes  No _____
   bronchial area                               Yes  No _____    Venereal disease or Herpes        Yes  No _____
Shortness of breath        Yes  No _____    Diabetes or sugar in urine        Yes  No _____




Coughed up blood        Yes  No _____    Hypoglycemia        Yes  No _____
High blood pressure        Yes  No _____    Arthritis, Bursitis,
Heart trouble        Yes  No _____    Rheumatism        Yes  No _____
Have you ever had jaundice                Nervous breakdown        Yes  No _____
   hepatitis, or mono?        Yes  No _____    Skin rashes        Yes  No _____
Do you awaken at night                Is your appetite good?        Yes  No _____
   out of breath?        Yes  No _____    Do you exercise at least
Fast, irregular, or slow pulse        Yes  No _____         three times/week?        Yes  No _____
Pain in chest?        Yes  No _____    Do you sleep well?        Yes  No _____
Allergies        Yes  No _____    Do you feel rested in the    
Varicose veins        Yes  No _____          morning        Yes  No _____
Frequent colds or flu        Yes  No _____    Do you feel tired after eating?       Yes  No _____
Vomit blood        Yes  No _____    Tired or diminished energy        
Recent change in bowel habits     Yes  No _____       during the day?        Yes  No _____
Black bowel movements        Yes  No _____    Swollen lymph glands?        Yes  No _____


Serious illnesses as a child:  (Check appropriate one(s))
        ___ Rheumatic Fever                 ___ Kidney Trouble              ___ Prolonged Fever    
        ___ Heart Trouble                 ___ Other__________________________________
Serious illnesses as an adult:_____________________________________________________
Allergies:     Medicines __________________________  Other__________________________
Operations/Injuries:
        __________________________________________________ When? ________________
        __________________________________________________ When? ________________
        __________________________________________________ When? ________________


Have you ever been in the hospital for other reasons? (Please indicate when & why)
        _____________________________________________________________________________
        _____________________________________________________________________________
Has your weight changed in the past year?     ___ Yes     ___ No
If yes, how much? ________________    Current weight: _____________________
Weight 1 year ago: (approx.) _________    Weight 5 years ago: (approx.) ____________


FOR WOMEN
Number of pregnancies: __________     Miscarriages: __________     Abortions: __________
Number of living children: ________    Ages: ___________________________________


Age when menstrual periods began: __________________ Ended: ___________________
How frequent are periods? _________________________ How long: _________________
Excessive flow? _____ Yes  _____ No        Spotting between periods? _____ Yes _____No
Pain/cramps during period?  _____ Yes  _____ No
Blood clots during periods? _____ Yes  _____No              If yes, color _______________
Sharp pain in ovaries?  _____ Yes  _____No    If yes, which side? ___________
Lumps in _____ Breast  _____ armpit  _____ groin area
Hysterectomy? _____ Yes  _____ No    If yes, when? ________________________  
Have you taken birth control pills? _____ Yes  _____No    For how long?___________
    If you have since stopped taking birth control pills, when did you stop? _________________
Have you worn an IUD? _____ Yes  _____ No          If yes, for how long? _______
    If you no longer wear an IUD, when did you stop? ________________________________
FOR MEN
Lumps in groin area or just above and to the side of the penis    _____ Yes  _____ No
Has the quality of your orgasm, or force of release, diminished?    _____ Yes  _____ No
Troubles concerning erection or ejaculation?            _____ Yes  _____ No
Prostatitis?                        _____ Yes  _____ No
FOR ALL CLIENTS
Please use this space to write in any other important health considerations you may have.
The more specific, yet descriptive, your information is, the more we will be able to help you.


________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________


________________________________________________________________________________________
      Thank you very much for your cooperation.  We wish you abundant well-being and happiness.


Agreement & Understanding Prior To Consultation With:


Therapist:______________________________________________________________


Graduates from any of our programs do not qualify as a licensed medical doctor.  One cannot diagnose, prescribe, treat symptom, defect, injury, or disease pursuant to California Business and Professional Code 2052. You can do health counseling or therapies as a licensed Holistic Health Practitioner (H.H.P.) or therapist. Please call us should you have questions.


Prior to retaining the services of Therapist:___________________________________________, I certify that I clearly understand the following:


I understand that Therapist:_________________________________________, is not providing medical services.  I will not consider anything he says to substitute in any way for consultation, diagnosis, and treatment by a licensed primary health care provider, such as an M.D.  Therapist:_____________________________________ is not a licensed medical doctor (M.D.) or licensed primary health care provider.  He does not diagnose, prescribe, or treat symptom, defect, injury, or disease.  This appointment is for educational purposes only.  If I want medical advice or treatment, Therapist:___________________________________ encourages me to consult with a licensed primary health care provider.  I consult with Therapist:_____________________________________ in his capacity as a holistic health counselor who conveys self-help information that people can use to increase their own health and well-being.  I affirm my right to self-health and I take full responsibility for my healing process.


Signature: ___________________________________  Date: __________________


Address:     _____________________________________________
             _____________________________________________
Telephone:     (home)______________________ (work)_____________________


            (cell) _______________________
AGREEMENT AND UNDERSTANDING PRIOR TO CONSULTATION WITH:
Therapist:__________________________________________________________________
Prior to retaining the services of (Therapist):__________________________________, I certify that I clearly understand the following:


Graduates from any of our programs do not qualify as a licensed medical doctor.  One cannot diagnose, prescribe, treat symptom, defect, injury, or disease pursuant to California Business and Professional Code 2052. You can do health counseling or therapies as a licensed Holistic Health Practitioner (H.H.P.) or therapist. Please call us should you have questions.


        I, _________________________________________, the undersigned, do hereby acknowledge that (Therapist):___________________________________ states to me that he is an educator and a holistic health counselor and that he is not a licensed (allopathic) medical doctor or licensed primary health care provider.


        I state that I come to (Therapist):_________________________________ with the purity of purpose of seeking more information.  I state that I do not come with any forethought or desire for entrapping Therapist:__________________________________ into an illegal statement.  If I am a member of the AMA, the F.D.A., or any law enforcement agency, or any city, county, state or federal regulatory agency, then I will identify myself as such before the appointment begins.


        I understand (Therapist's): ______________________________________sole intention is to offer to me general educational information I request.  If I choose to use this information to work on myself then I affirm that the responsibility is mine.


        I understand (Therapist):_______________________________________ to state one should never use his information in any way that contradicts, conflicts, or opposes a course of treatment recommended by a primary health care provider such as a licensed medical doctor.  If I ever perceive or feel that information given by (Therapist):____________________________________ opposes a licensed doctor's treatment or recommendations, (Therapist):_____________________________ strongly advises me to follow the advice and instruction of my licensed primary health care provider.


        I live in a country founded on freedom and self-determination, and dedicated to life, liberty, and the pursuit of happiness.  I affirm my right to self-health and the ability of my own innate intelligence (my body-emotions-intellect-spirit) to control my self-healing process.  I can heal myself, and maintain holistic health solely through myself/my God/or my own personal use of other "greater" powers of life that help me to help myself, or through such legal channels as my licensed doctor.


        I, the undersigned, do hereby voluntarily state to understand and acknowledge as accurate all the above comments.


Date: ___________       Signature: _____________________________________
                                    Name: ________________________________________
                                    Address: _______________________________________
                                         _______________________________________
                                    Telephone: (home) _____________________  (work) _____________________
                                    (cell) ________________________________
















Copyright © 1972  Steven R. Schechter, N.P. , Copyright @ 1997 Natural Healing Institute, Inc.                    Health Questionnaire P.  PAGE 5






Here are a few questions that I think are pertinent for your trial:


How much weight do you want to lose
Outside of your weight, what would you say is your current health status? Excellent____ Good____ Fair____ Poor_____


Are you currently on any particular diet?


If so, what is the diet that you are on?


How long have you been trying to lose weight?


How many meals do you eat a day?


How many snacks do you eat a day?


What type of beverages do you drink every day and how many servings?  Coffee _____  Tea _____ Soda/Juice___ Water _____


Would you be willing to stop any diet you are on for the length of the Thunder God Vine weight loss trial?




Beginning Wight  _______        Midpoint Weight________   End Weight




Weigh in: ______    Date: ______  (This will be a chart)


Disclaimer about toxicity and their understanding that beginning, midpoint, and ending labs will be done. If any adverse effects are seen, participant can drop out of trial.


This is the main points I would cover, but I am not a doctor, so if you have one willing to do the weigh ins, you might run this by him/her and see what else they would add, or how they would word it.

​



Timothy Telymonde
​253 Main Street

Suite 355
Matawan, NJ 07747
+1-(740) 352-9594
Policies:​
Because we make every effort to ensure the quality of our products, all sales are final and we do not accept returns.

Deliveries are normally made within 3 business days. 

Under rare circumstances, products may be delivered within 30 working days.

*Disclaimer: 

All information discussed/printed herein and/or by our business affiliates do not constitute medical advice. We recommend that you consult your physician and/or health care professionals to determine if this product or products are right for you before consumption, especially if you are taking medications for any medical conditions, and to avoid any possible side effects. These statements have not been evaluated by the Food and Drug Administration. Further, this product is not intended to diagnose, treat, cure or prevent any disease. Expressly, all information supplied within our website or related public domains or during verbal discussion with any owner, owners, affiliates, or users’ testimonials have no warranty whatsoever. Since our product has not been tested in peer-reviewed double-blind controlled studies, all testimonials associated with this product should not provide assurance that you will have a similar outcome and/or similar side effects. You should clearly understand the above statements and fully accept total responsibility for what you do with the information and the resulting outcomes from your actions.  

If you are pregnant, lactating or are planning a pregnancy do not use this product. While on this product you may temporarily have a lower sperm count. Do not use if seal is broken. Keep out of reach of children, For adults only . store in a cool dry place.


 ​
  • Home
  • Flawless Defense Plus
  • Tripterygium Wilfordii Thunder God Vine
  • contact us
  • side effects
  • Testing
  • Affiliated sites
  • Tree of life