Naturopathic Consultation Nutra-Kol Clinic Judith Kolkovski

Judith Kolkovski
Nutra-Kol Clinic
Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065
Ph 1300 228 843 www.nutrascan.com.au
Preventative Screening &
Wellness Management
Naturopathic Consultation
Name_____________________________________________________Date_________________________
Address________________________________________________________________________________
Phone__________________Mob_____________________E-mail_________________________________
Occupation______________________________________ Date of birth________________ Age________
Marital status_________________ Children _________
Blood Group
O
A
B
AB (Please circle)
Where did you hear about us? ______________________________________________________________
EIS Measurement and Calculation Limitation Restrictions (check all that apply)
I have an absence of one or more limbs <STOP> Scan can not be conducted
I am unable to be held upright or seated <STOP> Scan can not be conducted
I am in my 6th month or later of pregnancy <STOP> Scan can not be conducted
I have an implanted electronic device (pacemaker) <STOP> Scan can not be conducted
I preformed intense physical activity within the last 8 hours
I have dermatological lesions on my hands, feet or forehead
I am experiencing excessive accumulation of body fluid (edema)
I consumed alcohol or stimulants (amphetamines) with the last 12 hours
I have metal pins or prostheses on the level of the extremities or joints <STOP> Scan can not be conducted
I have diarrhoea
I am taking non prescription drugs
I am wearing metal objects
I have fever
I am wearing an electromagnetic field (EMF) protection disk or device (remove now)
Primary reason(s) for scan (issue, complaint,
Illness, pain):
I am taking medication(s)
1-
1-
2-
2-
3-
3-
4-
4More on attached…
I am a smoker of tobacco
More on attached…
I am suffering from an addiction: __________________________________
EIS Questionnaire
Please read thoroughly and check all that apply in all of the following categories
GENERAL SYMPTOMS
r Abscess or Boil
r Allergy
r Anaemia
r Anorexia (Loss of appetite)
r Confusion
r Convalescence
r Drowsiness in the daytime
r Excessive weight
r Fasting hypoglycaemia
r Geriatric disorders
r Hyperactivity
r Infectious disease
r Injuries
r Insomnia
r Masculine sexual deficiency
r Nail or hair changes
r Obesity
r Post-operative or post-traumatic oedema (fluid
retention)
r Premature ejaculation
r Recent emotional
r shock
r Smoker
r Stress
r Vertigo
r Pregnancy
DENTAL DISORDERS
r Amalgams
r Gingival bleeding
r Halitosis
r Periodontal problems
CARDIOVASCULAR DISORDER
r Cardiac insufficiency
r Cholesterol or Triglycerides elevated
r Coagulation problem
r Congenital malformation
r Coronary Artery Disease
r Heart murmur
r Hypertension
r Hypotension
r Infarction (Heart Attack)
r Isehemic cardiac disease (angina)
r Left ventricular hypertrophy
r Loss of breath
r Lower limbs arteritis
r Taste disorders
r Tongue bright red and smooth
r Tongue Inflammation
HAVE YOU HAD ANY OF THESE CANCERS
r
r
r
r
r
r
r
r
r
r
r
r
r
r
Acute lymphocytic leukaemia - as a child
Bladder cancer
Bone cancer
Brain cancer
Breast cancer
Colon cancer
Colorectal cancer
Gastric (stomach) cancer
Leukaemia
Liver cancer
Lymphoma
Melanoma
Oral cancer
Ovarian cancer
r Pancreatic cancer
r Prostate cancer
r Lung cancer
r Testicular cancer
CARDIOVASCULAR DISORDER cont.
r A.A.R. (acute articular rheumatism)
r Arrhythmia
r Arterial stenosis
r Arterial Thrombosis
r Arteriosclerosis (hardening of the arteries)
r Auricular fibrillation
r Bradycardia
SKIN DISORDERS
r Acne
r Alopecia
r Angiomas
r Cellulite
r Cracked skin
r Cyanosis
r Dermatitis
r Dry skin
r Eczema
r Erythematous Lupus
r Haematoma
r Herpes
r Hyperkeratosis
Nutrakol Clinic, Preventative Screening & Wellness Management
Judith Kolkovski Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065 Ph 1300 228 843 www.nutrascan.com.au
Page 2 of 6
r Myocarditis
r Pericarditis
r Raynaud’s Disease
r Right ventricular hypertrophy
r Stroke
r Chest pains
r Venous thrombosis
PAIN
r Axillary pain
r Cervical pain
r Chronic pain
r Digestive pain
r Eye pain
r Face pain
r Headache
r Left arm, left wrist or left hand pain
r Left foot, left knee or left leg pain
r Liver pain
r Right arm, right wrist or right hand pain
r Breast pain
r Right foot, right knee or right leg pain
r Bladder or genital pain
ENDOCRINE DISORDERS
r Pituitary dysfunction
r Insulin-resistant diabetes
r Menopause
r Menopause disorders
r Painful menstruation
r Sterility
r Thyroid nodules
r Thyroid dysfunction (function change)
r Type I insulin-dependent diabetes
r Type II non insulin-dependent diabetes
GASTRO-INTESTINAL DISORDERS
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
Anal fissure
Appendicitis
Cirrhosis
Colitis
Constipation
Diarrhoea
Digestion disorders
Hepatitis
Drug related hepatitis
Duodenal ulcer
Dysentery
Dyspepsia
Gastro-enteritis
Gastro-oesophageal reflux (Hiatus hernia)
Haemorrhoids
r Icterus
r Impetigo
r Interdigital mycosis
r Keloidal scars
r Neurodermatitis
r Petechiae
r Pruritus
r Psoriasis
r Purpura
r Scleroderma
r Sunburn (recent)
r Ulcerations
r Urticaria
r Vesicles
r Zoster
ENDOCRINE DISORDERS cont.
r Amenorrhea
r Andropause (male ‘menopause’)
r Dysmenorrhoea
r Endometriosis
r Goitre
r Growth disorders
r Vomiting
r
IMMUNE DISORDERS
r AIDS
r Autoimmune disease
NEUROLOGICAL DISORDERS
r Extremely cold hands & feet
r Alzheimer disease
r Attention-Deficit / Hyperactivity Disorder ADHD
r Behavioural disorders
r Concussion
r Convulsions
r Depression
r Encephalitis
r Facial paralysis
r Memory disorders
r Multiple sclerosis
r Neuralgia
r Paralyses
r Paraplegia
r Pins & Needles constantly in one area
r Parkinson Disease
r Schizophrenia
r Trigeminal neuralgia
NEUROMUSCLAR DISORDERS
r Leg cramps
r Lumbago
Nutrakol Clinic, Preventative Screening & Wellness Management
Judith Kolkovski Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065 Ph 1300 228 843 www.nutrascan.com.au
Page 3 of 6
r Hiatal hernias
r Intestinal spasms in children
r Intestinal stasis (ileus) or occlusion
r Polyps
r Pancreatitis
r Rectal Prolapse
r Spasmodic colitis
r Stomach ulcer
r Ulcer
EYE PROBLEMS
r Eye dryness
r Troubles with the retina
r Floaters
EAR NOSE OR THROAT PROBLEMS
r Allergic rhinitis
r Balance disorder
r Decrease in hearing ability
r ENT Allergies
r External otitis (such as itchy ears)
r Sinusitis
r Middle ear otitis
r Pharyngitis
r Tonsillitis
r flu
BONE DISEASES
r Muscular weaknesses
r Tendonitis
r Muscular ache
r Sciatica — write Right or Left
r Tendonitis
r Torticollis
r Other
r
r
LUNG DISORDERS
r Asthma
r Bronchiectasis
r Chronic bronchitis
r Chronic recurrent cough
r Loss of breath with effort
r Pleurisy
r Pneumonia
r Pneumothorax
r Pulmonary abscess
r Rapid breathing
r Tuberculosis
KIDNEY & UROGENITAL PROBLEMS
r
r
r
r
r
r
r
r
r
r
r
r
Benign hypertrophy of the prostate
Gall Bladder Disease
Cystitis
Effort urinary incontinence
Endometritis
Glomerulonephritis
Gynaecological disorders
Hydronephrosis
Leucorrhoea
Renal colic
Nephritis
Prostatitis
r Bone pains
r Spinal arthritis
r Rheumatoid polyarthritis
r Disc problems
r Osteochondrosis
r Osteomalacia
r Osteomyelitis
r Osteoporosis
r Paget’s disease
r Polyarthritis
r Sacroiliac problem
VEINS
r Shoulder-hand syndrome
r Spontaneous fractures
r Oedema
r Sprains or dislocations
r Painless lymphadenopathy (enlarged glands)
r
r Thrombophlebitis
r
r Varicose Veins
HAVE YOU BEEN TOLD YOU HAVE AN ABNORMLITY IN THE URINE OR BLOOB?
Nutrakol Clinic, Preventative Screening & Wellness Management
Judith Kolkovski Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065 Ph 1300 228 843 www.nutrascan.com.au
Page 4 of 6
CURRENT TREATMENT-LIST
LIFESTYLE
r Beer less than 2
r Broccoli less than 2 times per week
r Butter every day
r Butter more than 2 times per week
r Carrots every day
r Coffee every day
r Coffee more than 2 times per week
r Dairy products : less than 2 times per week
r Dairy products every day
r Dairy products more than 2 times per week
r Fish grilled more than 2 times per week
r Fish grilled occasionally
r Fish grilled every day
r Fish raw every day
r Fish raw more than 2 times per week
r Fish raw occasionally
r Fish smoked every day
r Fish smoked more than 2 times per week
r Fish smoked occasionally
r Ovo-vegetarian
r Oil Nut
r Oil: Olive
r Oil: Sunflower r Oil: Vegetable
r Pork grilled every day
r Pork grilled more than 2 times per week
r Pork grilled occasionally
r Pork raw
r Pork raw every day
r Pork raw more than 2 times per week
r Pork smoked every day
r Pork smoked more than 2 times per week
r Pork smoked occasionally
r Red meat grilled every day
r Sauce tomato every day
r Sauce tomato less than 2 times per week
r Sauce tomato more than 2 times per week
r Smoking less than 20 cigarettes per day
r Smoking more than 20 cigarettes per day
r Strict vegetarian
r Sports activity: 2 times per week
r
r
r
r
r
r
Beer more than 2
Broccoli more than 2 times per week
Butter less than 2 times per week
Carrots less than 2 times per week
Carrots more than 2 times per week
Coffee less than 2 times per week
r
r
r
r
r
r
r
r
r
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r
r
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r
r
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r
r
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Grapefruit and juice every day
Grapefruit and juice less than 2 times per week
Grapefruit and juice more than 2 times per week
High consumption of bread
Low consumption of bread
Medium consumption of bread
High consumption of salt
Low consumption of salt
Medium consumption of salt
High level athletes (professionals)
Ketchup every day
Ketchup less than 2 times per week
Ketchup more than 2 times per week
Red meat grilled more than 2 times p/wk
Red meat grilled occasionally
Red meat raw every day
Red meat raw more than 2 tunes per week
Red meat raw occasionally
Red meat smoked every day
Red meat smoked occasionally
Diet after medical consultation
Personal diet
Diet after medical consultation
Exposure to neurotoxins or pesticides
Passive smoking (environment)
Vegetarian eating eggs and fish
Vegetarian eating fish but not eggs
White meat grilled every day
White meat grilled more than 2 times /wk
White meat grilled occasionally
White meat raw every day
White meat raw more than 2 times /wk
Nutrakol Clinic, Preventative Screening & Wellness Management
Judith Kolkovski Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065 Ph 1300 228 843 www.nutrascan.com.au
Page 5 of 6
r
r
r
r
r
r
r
r
r
Sports activity: every day
Sports activity: less than 2 times per week
Strong Alcohol less than 2 glasses p/d
Strong Alcohol more than 2 glasses p/d
Tomato every day
Tomato less than 2 times per week
Tomato more than 2 times per week
Vegetables / fruits less than 6 times per/day
Vegetables / fruits more than 6 times p/day
r
r
r
r
r
r
White meat raw occasionally
White meat smoked every day
White meat smoked more than 2 times/wk
White meat smoked occasionally
Wine less than 2 glasses per day
Wine more than 2 glasses per day
Client Name_________________________________
Weight (Kg) ________________________________
Height (cm) ______________________________
Date ofBirth ______/_______/________ Address______________________________________________________
_________________________________________________________________________Post Code_____________
Phone __________________Mobile___________________ email_________________________________________
Disclaimer according to the results of select tissue parameters, microcirculation and inverse problems ’ issues from
clinical tests, the software proposes some statistical possibilities of diseases and/or dysfunction with degrees of
specificity and sensitivity. These possibilities are not diagnostic. They are designed to help regulate more specific and
sensitive supplementary examinations. These possibilities are not available for a patient under medications (drugs
or chemotherapy) or certain medical treatments (radiotherapy or surgery). In such cases, the Statistical Functional
Risk Analysis is done as a follow up to study the effects of the medications and/or medical therapies.
I understand and accept that the examination using this EIS scanner is therefore a diagnostic aid to assist the
practitioner at arriving at a conclusion based on his/her experience and knowledge plus the information gained
from any diagnostic aids he/she considers necessary to come to a diagnostic conclusion.
Signed by the above named client ______________________________________Date________________________
Witness’s Name______________________________
Witness Signature__________________________________
Nutrakol Clinic, Preventative Screening & Wellness Management
Judith Kolkovski Naturopath, B.H.Sc Nut Med, Adv Dip of Naturopathy
Unit 39, 110 Inspiration Drive, Wangara WA 6065 Ph 1300 228 843 www.nutrascan.com.au
Page 6 of 6
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