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.