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Holistic Questionnaire


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:____________________________________________________________

 

 

 

 
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:

 

 

   

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