Confidential Personal History Form

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.