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 r r r r r r r r r r r r r r r r r r r r r r r 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