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24 Hr. Cancellation | Holistic Questionaire | Master Program | Memorandum | One Hour Vacation | Only want One Session
Name_____________________________Print:_________________________________________________
Todays Date_______________________________Birthdate: Month/day only _______________________
Address_____________________________________________________________________________
City__________________________ Zip___________________________________________________
Phone (Home)________________________________________________________________________
(Work)______________________________________________________________________________
(Cell)_________________________________ (other)___________________________________
E-mail address________________________________________________________________________
URL________________________________________________________________________________
Occupation___________________________________________
Height__________________ Weight________________________________________
Marital Status_______________ Ever had a colonic before?_________ If so, when?_________________
How did you learn of our services?______________________________________________________________
Are you now under a doctor's care?____________________________________________
If so, please explain:______________________________________________________
_____________________________________________________________________
Doctor's name___________________________________________________________
Phones________________________________________________________________
Major physical complaints______________________________________________________________
List any surgeries you have had__________________________________________________________
List all medications and supplements you now take Regularly____________________________________
List all known allergies______________________________________________________________
How many bowel movements per day do you usually have?___________________________________
Do you have to strain to have a bowel movement?________
Do you use a stool softener or laxative?_____________ Herbal laxative?_____________
Suppository?__________________________________________________________
Do you have hemorrhoids or other rectal problems?___________
Have you ever had any rectal bleeding?____________________ If so, when?___________
Have you ever had bleeding from any other bodily orifices?_________________________________
If so, please explain: _____________________________________________________________
Have you ever had a barium enema?___________________________ If so, when?____________
What would you like to receive from this appointment for hydrotherapy?_____________________________________________________________________
Signature_____________________________________________________________
Comments:____________________________________________________________
Intellectual Center |
[ ] History of gall bladder problems | [ ] Shortness of breath |
[ ] Blurred Vision | [ ] Overeating sweets upsets | [ ] Gas shortly after eating |
[ ]Excessive hair loss | [ ] History of gallstones | [ ] Appetite reduced |
[ ] Eat when nervous | [ ] Acid foods upset |
Grounding Center |
[ ] Bitter, metallic taste in mouth | [ ] Neuralgia-like pain | [ ] Buring feet |
in the morning |
[ ] Indigestoin 1/2 hr to 4 hr later | [ ] Itching skin and feet |
[ ] Dry mouth, eyes, nose | [ ] Waken after few hr, difficult to sleep | [ ] B/M's painful & difficult |
[ ] Eyelids swollen, puffy | [ ] Pulse slow, irrigular | [ ] Loss of leg energy |
[ ] Eyes or nose watery | [ ] Hoarseness frequent | [ ] Muscle/leg cramps @ night |
[ ] Difficulty remembering | [ ] Breathing irregular | [ ] Swollen ankles |
[ ] Sneezing attacks | [ ] Difficulty swallowing | [ ] Lower bowel gas after eating |
[ ] Moods of depression | [ ] Milk product distress | [ ] Skin peals on feet |
[ ] Worried, feel insecure | [ ] Dull pain in chest/left arm | [ ] Stools alternate soft/watery |
[ ] Irritable before meals | [ ] Stomach bloated after meals | [ ] Urine amount reduced |
[ ] Faintness if meals delayed | [ ] Sour stomach, frequent | [ ] Muscle cramps; worse if exercise- get "Charly-horses" |
[ ] Coated tongue | [ ] Circulation poor | [ ] Frequent urination |
[ ] Can't get rid of a thought | [ ] Tension under ribcage | [ ] Stool has foul odor |
[ ] Frequent nosebleeds | [ ] Pulse speeds after meal | [ ] Burning or itching anus |
[ ] Nightmare- bad dreams | [ ] Digestion difficult | [ ] Blood in stool |
[ ] Noises in head or ears | [ ] Butterflies in stomach, cramps | [ ] Rectal or anal bleeding |
[ ] Feeling stressed/anxious | [ ] Indigestion soon after meal |
Miscellaneous |
[ ] Susceptible to colds | [ ] Aware of breating heavily | [ ] Dizziness |
[ ] Afternoon headaches | [ ] Billiousness (gass) | [ ] Dry skin |
[ ] Get drowsy often | [ ] Heart palpitates if meals skipped or delayed | [ ] Frequent skin rashes |
[ ] Can't get to sleep | [ ] Gag easily | [ ] Hunger between meals |
[ ] Bad breath (halitosis) | [ ] Mucous colitis | [ ] Fatigue, relieved by eating |
[ ] Crave candy or coffee | [ ] "Nervous" stomach | [ ] Joint stiffness after rising |
[ ] Fevr easily raised | [ ] Susceptible to colds, asthma, bronchitis | [ ] Open window in closed room |
World Center |
[ ] Stools light in color | [ ] Laxatives used often |
[ ] Sigh often - "air hunger" | [ ] Sensitive to hot weather | [ ] Stong light irritates |
[ ] Perspire easily | [ ] Lose taste for meals | [ ] Cold sweats often |
[ ] Hands/feet cold, clammy | [ ] Get shaky if hungry | [ ] Bruse easily; black & blue spots |
[ ] Heart pounds once retired | [ ] Vomiting frequently | [ ] Buring stomach sensations |
[ ] Hands/feet go to sleep easily numbness | [ ] Greasy foods upset | |
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[ ] Pain between shoulders | |
Comments:
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