Holistic Questionnaire

Name_____________________________Print:_________________________________________________

Todays Date_______________________________Birthdate: Month/day only _______________________

Address_____________________________________________________________________________

City__________________________ Zip___________________________________________________

Phone (Home)________________________________________________________________________

(Work)______________________________________________________________________________

(Cellularr)_________________________________ (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:____________________________________________________________

**Mark (P) for Present Conditions**
**Mark (X) for Past Conditions**
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
	[ ] Pain between shoulders
Comments:

Holistic Questionnaire

Intellectual Center

Grounding Center

Miscellaneous

World Center