Confidential Personal History Form *Required Information. All required fields must be completed. Natural Health Counselling is a complete, holistic approach to well-being. It is not limited to specific disorders or symptoms. Complaints or symptoms uniquely manifest, from different origins, for each individual. A broad knowledge of information is required in order to establish your unique path to wellbeing. The more information that you are able to provide and the more complete the form, the easier it will be to discover the origins of your complaints and set your unique path to wellness. Part 1 - Personal Information - required for all Modalities Last Name* Street Address* Home Telephone Date of Birth* First Name* Unit Office Telephone Occupation Female Male Postal Code Cellular Province* ON PEI Email Height Weight BloodType City* Other Please describe your purpose for this visit* Please describe your main health complaint(s)/concern(s) Are you Pregnant or is there a possibility that you are pregnant? No Yes, which semester? Part 2 - Please complete this section for Massage, Reflexology, Shiatsu, and Acupressure List any condition/illness/sensitivity that the practioner should know about before proceeding?* e.g. High B/P, Cancer, Depression, Heart Disease, Warts, Skin Conditions List any medications and/or supplements that you are taking that the practitioner should know about before proceeding* *Please skip to Section 10 - Signature and Informed Consent Part 3 - Personal Health History - required for Nutrition Counselling Have you recently been diagnosed with a condition? No Yes, which one(s)? What other therapies are you currently recieving? Chiropractor Massage Reflexology Shiatsu Acupressure Therapeutic Touch Bio Feedback Homeopathy Nutrition Other Acupuncture Reiki Please list all medications you are currently taking* Name/Description Dose Frequency Purpose Please list all natural, herbal remedies, vitamins, minerals, supplements you are currently taking* Supplement Dose Frequency Year Surgery/Injury Purpose Please list all major surgeries and injuries* Surgury/Injury Caroline Richter N.H.C, C.N.C., C.I., C.R., C.S. Year Have you ever taken tetracyclines or other antibiotics for acne for one (1) month or longer? No Yes Have you ever taken antibiotics? No Yes Yes Have you ever taken antibiotics for 2 months of longer or more than 4 times in one year? No Yes Have you ever been bothered by persistant prostatitis or vaginitis? No Yes Yes Have you ever taken prednisone or other cortisone-type drugs? No Yes Have you ever had athlete's foot, ringworm, jock itch or skin or nail fungal infections? No Yes Are you sensitive to cigarette smoke, perfumes, chemicals or strong smells? No Yes Are your symptoms worse on damp muggy days or in moldy places? No Yes Have you ever been pregnant? No Yes How many times? Have you ever taken birth control pills? No Yes How Long? Part 4 - Conditions Have you ever suffered from any of the following? (check all that apply) Alcohilism Allergies Arthritis Asthma Cancer Celiac Crones/Colitis Chronic fatigue Depression Diabetes Eating disorder Epilepsy/Seizure Glaucoma Heart disease Hemophilia Hepititis Hernia Herpies High or Low B/P High Cholesterol High Fevers HIV/AIDS IBD/IBS Jaundice Kidney Stones Liver/Gallblader Lung/Bronchial Meningitis Mental Illness Obesity Osteoporosis Pneumonia Polio STDs Stroke Substance Abuse Ulcer Urinary Problems Varicose Veins Other Part 5 - Diet and Digestion How many cups/glasses/bottles do you drink? Tea Coffee Herbal Tea Soft Drinks (diet) Soft Drinks (reg) Water Milk Beer Wine Do you use artificial sweeteners? No Yes, which one(s)? Do you have any food allergies/sensitivities? No Yes, which one(s)? How many bowel movements do you have per day? Diarrhea Thin Constipated Bloody Undigested Food Other Vegetable Juice Fruit Juice Other Liquor Please describe (check all that apply) Strained Mucous Soft Greasy Hard Yellow/clay coloured Explosive Sink Loose Float Part 6 - Lifestyle How many hours of sleep do you get on average? Do you wake up feeling rested? No Yes How many hours do you work each day? Do you enjoy your work? No Yes When was your last vacation? Do you take vacations regularily? No Yes How many minutes do you exercise each day? Which types? Do you smoke cigarettes? No Yes Have you ever smoked cigarettes? No Yes Do you use recreational drugs? No Age started? Yes Which one(s)? Do you often wake up during the night? No Yes Time of day No Yes Time of day How many? Symptoms Do you often feel tired or unwell during the day? Symptoms How hours a day do you? Watch TV Read Listen to Music Sit in front of computer Practice spirituality or relaxation methods Do you use? (check all that apply) Aluminum Pots Antacids Antiperspirants Cell Phones Microwave Part 7 - Family Health History Have any of your blood relatives every suffered from any of the following? (check all that apply) Alcoholism Allergies Arthritis Asthma Cancer Celiac Diabetes Epilepsy Heart Disease High or Low B/P High Cholesterol Kidney Disease Liver Disease Mental Illness Nervous disorders Obesity Osteoporosis Stroke Substance abuse Other Caroline Caroline Richter Richter N.H.C, N.H.C, C.N.C., C.N.C., C.I., C.I., C.R., C.R., C.S. C.S. Part 8 -Symptoms Frequency: 1 = Occassionally 2 = Often 3 = Always Severity: 1 = Mild 2 = Moderate 3 = Severe Frequency Severity Frequency Fatigue Shortness of breath Feeling of being "drained" Urinary frequency or urgency Poor Memory Burining on urination Feeling "spacey" or "unreal" Blood in Urine Inability to make decisions Bladder/urinary infections Numbness, burning, tingling Water retention Insomnia Bronchial infections Muscle aches Lung congestion Muscle weakness or paralysis Wheezing Joint pain and/or swelling Pain or tightness in chest Abdominal pain Heart palpitations Constipation Racing heart Diarrhea Spider or varicose veins Bloating, belching, or intestinal gas Nose bleeds Vaginal burning, itching, or discharge Bleeding or receeding gums Prostatitis Bruise easily Impotence Cold sores/cankers Loss of sexual desire or feeling Boils or abscesses Endometriosis or fibroids or infertility Hemorrhoids or fissures Cramps or menstrual irregularities Spots in front of eyes Premenstrual Syndrome Erratic vision Attacks of anxiety or crying Burning or tearing of eyes Cold hands or feet Psoriasis or eczema Chilliness Acne Shaking or irritable when hungry Dry skin Drowsiness Oily skin Irritability or jitteriness Nausea or vomitting Incoordination Loss of appetite Inability to concentrate Heaviness after eating Frequent mood swings Tired after eating Headache or migraines Gallstones Dizziness/loss of balance Ear infections or ear aches Feeling of head swelling Recurrent fluid in ears Bruise easily easily Bruise Ear pain or deafness Chronic rashes or itching Frequent colds/flues Indigestion or heartburn Throat infections or irritation Food insensitivity or intolerance Throat constriction Mucous in stool Sinus Congestion Rectal itching Fever Dry mouth or throat Joint pain or stiffness Rash or blisters in mouth Back pain Bad breath Disc problems Nasal congestion or post nasal drip Foot, hair, body odour not relieved by washing Nasal itching Muscle cramps, pains, twitches Calcium deposits Neck pain Soar throat Anemia Laryngitis or loss of voice Hypoglycemia Cough or recurrent bronchitis Weight loss/gain Pain or tightness in chest Intense thirst Caroline CarolineRichter RichterN.H.C, N.H.C,C.N.C., C.N.C.,C.I., C.I.,C.R., C.R.,C.S. C.S. Severity Part 9 - Dietary Habits **Please do not take anything by mouth, except water, two (2) hours prior to your appointment Please describe what you typically eat and drink in a day Breakfast Snack Lunch Snack Dinner Snack Part 10 - Signature and Informed Consent Please read the following carefully and check which treatment(s) you wish to give consent for: NUTRITION COUNSELLING IRIDOLOGY SHIATSU is a form of body massage/treatment that uses a variety of different kinds of pressure and stretches to stimulate the flow of "life energy" or "qi" in the body. The therapist is constantly "reading" the body throughout the treatment in order to ascertain which areas of the body have stagnant energy or which areas are blocked. Throughout the session, no physical adjustments are made to the body. Healing occurs at an energetic level. The therapy is not intended as a substitute for medical advice. It is however complementary to western medicine and may lead to a diminished requirement for medical attention. REFLEXOLOGY is a form of foot, hand, face, or ear massage that uses pressure and therapeutic touch to stimulate reflexes to major organs, glands, and body parts. Through the treatment, no physical adjustments area made to the body. The therapy is not intended as a substitute for medical advice. It is however complementary to western medicine and may lead to a diminished requirement for medical attention. RELAXATION MASSAGE is a gentle, relaxing full body massage. Throughout the massage no physical adjustments are made to the body. - I understand the risks and benefits associated with the elected therapy(s). - It has been explained to me the specific areas to be treated, and/or those areas to be omitted. - I have fully disclosed all medical conditions that I am aware of and understand that it is my responsibility to update my treatment file of any changes in my health status. - I acknowledge that information provided in this form and during all consultations is confidential and that no personal data shall be released to anyone. I, the undersigned, understand the above statements. I consent to the selected treatment(s) and confirm that the information in this document is correct and true to the best of my knowledge. Date (yyyy-mm-dd) Signature Caroline Richter N.H.C, C.N.C., C.I., C.R., C.S. Caroline Richter N.H.C, C.N.C., C.I., C.R., C.S.
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