Whole Body Renewal Center
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Name:________________________________________
Address: _______________________________ City, State, Zip _______________________________
Home Phone: __________________
Cell Phone: __________________
E-Mail: ______________________________________
Preferred Method of Contact (circle one)
Home Phone Cell Phone Email
Who referred you? How did you hear about us? Name: _____________________
Your vitals:
Birthdate:_______ Gender: M F Height:________ Weight:____________ Blood Pressure (if known):_____ Occupation:____________
Why are you here??? What are your goals?
1. ___________________________________________________ How long? _____________________
2. ___________________________________________________ How long? _____________________
3. ___________________________________________________ How long? _____________________
4. ___________________________________________________ How long? _____________________
5. ___________________________________________________ How long? _____________________
Overall Health
Are you presently taking any medications or supplements and how long you have been taking them? Please List. (Attach sheet if necessary)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
DIET:
What foods do you eat the most? _________________________________________________
List foods you crave. __________________________________________________
What kinds of fruits and vegetables do you like? _____________________________________________
Are you the first one done at dinner table? Y N
Do you eat FAST FOOD? If so, how often? ___________
Do you eat more meat, carbs or veg/fruits? __________________________________________________
Do you drink pop/soda? Y N How often? __________________________________________________How much water do you drink per day? _________________Filtered? Y N
Please answer the following questions, be frank, no judgment here. Yes or No (Circle one)
- If you’re feeling down, does a snack make you feel better? Y N
- When you miss a meal, do you get cranky until you get food? Y N
- Do you have a hard time going to sleep without a bedtime snack? Y N
- Do you get tired and/or hungry in the mid-afternoon? Y N
- Do you get sleepy, almost “drugged” feeling after eating bread, pasta or dessert? Y N
- Do you think that now and then you’re a secret eater? Y N
- Do you experience cravings for sugar, breads, pasta and baked goods? Y N
- Do you feel shaky if you do not eat on time or have a snack? Y N
- Do you often find yourself irritable or angry? Y N
- How many bowel movements do you have in a day? _________ Color? __________ Texture? ____________
- Do you have pain or burning with urination? Y N
- Do you have any fears or anxieties? Y N ______________________________________________
- Are you missing any internal organs? Y N Please list: ________________________________________
- Do you take antacids (for reflux or indigestion)? Y N
- Do you have any allergies? Y N
- What foods give you a tummy ache? _______________________________________________
- What foods make you sleepy? ______________________________________________
- Do you have hair on the top of your toes? Y N
- Have you been on or are you on hormone replacement therapy? YES NO
Men:
- Do you struggle with the physical needs of sex? Y N
- Do you have pain during urination? Y N
- Do you have blood in your stool or urine? Y N
- Do you have any prostate issues you know about? Y N Explain______________________________________________________________________________________
Women:
- How are your cycles? ______________________________________________________________________________
- Are you, or have you ever been on birth control? Y N Fertility Treatments? Y N
If yes, give details: ________________________________________________________________________________
Are you trying to get pregnant? Y N
- Have you ever had miscarriages or stillbirths? Y N
- Do you have any reproductive issues you are aware of? __________________________________________
- Is your libido ok?? ____________________
Stress:
- How do you deal with stress? ______________________________________________________________________
- What is your main source of stress? _____________________________________________
- Are there times in the day that you feel your best? _________________ your worst?_________________
- Are you happy in your life right now? Y N
- Have you experienced any trauma in your past? Y N
Check the ones that apply to you:
| Brittle nails | Hypotension | ||
| Cold hands and feet | Inability to concentrate | ||
| Cold intolerance | Infertility | ||
| Constipation | Irritability | ||
| Depression | Menstrual irregularities | ||
| Difficulty Swallowing | Muscle Cramps | ||
| Dry Skin | Muscle Weakness | ||
| Elevated Cholesterol | Nervousness | ||
| Hypertension (unknown cause) | Poor Memory | ||
| Eyelid swelling | Puffy Eyes | ||
| Fatigue | Slower Heartbeat | ||
| Hair Loss | Throat Pain | ||
| Hoarsness | Medication for anemia | ||
| Chemotherapy or radiation | Eat soy products (directly or in processed foods) |
| Fatigue | Sweating | ||
| Goiter | Tremor | ||
| Heat intolerance | Weakness | ||
| Hyperactivity | Weight loss (unexplained) | ||
| Wandering or spotty arrhythmia (P) | Insomnia (P, T) | ||
| Menstrual disturbance | Wake up frequently (P) | ||
| Nervousness | Spinal Disk Problems (P) | ||
| Palpitations | Sexual Dysfunction (P) | ||
| Depression (severe sudden onset) (P) | Sudden on set bi-polar (P) | ||
| Cardiomyopathy (P) |
| Memory loss | Emotional Tantrums | ||
| Joint Pain | Flu symptoms | ||
| Rashes | Swollen Lymph – for a long time | ||
| Eye inflammation (red and sore) – not itchy | Extreme fatigue | ||
| Heart Palpatations | Hepatitis | ||
| Bell’s Palsy | Erythema Migrans | ||
| Red earlobes | Neck & Back Pain | ||
| TMJ |
Dental History:
Have you had any root canals? Y N Periodontal Disease? Y N
Do you have any amalgam fillings? Y N Have you had any removed? Y N
Have you received any of the following diagnosis from a medical doctor?
| Chronic Fatigue | Multiple Sclerosis (P) | ||
| Crohn’s | Polymyalgia Rhemutica | ||
| Fibromyalgia | Polymyositis | ||
| PTSD | Psoriatic Arthritis | ||
| Grave’s Disease | Reiter’s | ||
| Hashimotos | Rheumatoid Arthritis | ||
| Juvenile Arthritis | Scleroderma | ||
| Lupus | Sjogrens | ||
| Ulcerative Colitis | Vasculitis | ||
| CMV | Herpes | ||
| Mono | Lyme’s Disease | ||
| Other: | |||
Have you had any of the following that you are aware of – or do you suspect issues with any of these?
| Brucella | Mycoplasm | ||
| Candida | Neisseria | ||
| Chlamydia | Parovirus B19 | ||
| Coxiella | Staphylococcus Aureus | ||
| Fungi | Streptococcus | ||
| Hepatitis A/B/C | HIV | ||
| Other: | Other Viruses: list below | ||
| Other: |
Have you had any traumas such as:
Whiplash or Motor Vehicle Accident (esp. with air bag deployment)? ____________
Concussion or head injury? ___________
Serious fall where your head or neck may have been injured, damaged or thrown around? ________
Mild to moderate blow to the head? _______
Sexual abuse as a child? -_________
Radiation exposure? _________
Huffing or snorting drugs? _______
Prolonged high stress?? ________
What diagnosis have you received in the past:
____________________________________________________________________________________________
____________________________________________________________________________________________
Health History
Do you presently, or in the past ever have any of the following conditions? (Circle those that apply)
Anemia Frequent Headaches Chronic cold/flu symptoms Skin Conditions
Arthritis Heartburn Thyroid Condition Asthma Chest Pains Diabetes
Depression Chronic Fatigue Osteoporosis Liver Problems Hypoglycemia
Kidney Problems High Cholesterol High Blood Pressure Unexplained Weight Changes
What was your childhood health and emotional experience like? ____________________________________________________
Were you born c-section? Yes No
Did you have antibiotics, anti-inflammatories, or immune suppressing medications? ______________________
Have you ever had eczema, psoriasis or any other Skin conditions? _______________________________
Surgeries, starting with most recent: __________________________________________________Hospitalizations:_________________________________________
__________________________________________________Hospitalizations:_________________________________________
__________________________________________________Hospitalizations:_________________________________________
Circle any of the following that have applies to you within the last 90 days:
Nauseous Bloating Heartburn Constipation Belch after meals Gas Diarrhea
Bloated after meals abdominal/intestinal pain Travel outside US Gurgles in Stomach
Alternate constipation/diarrhea Stool compact/hard to pass
Physical Body
How do you feel when you get up in morning? (Example, stiff)_______________________________________________
How many hours of sleep do you get on average? ____________________
Do you get up in the night? Y N If yes – what time approximately? __________
For what reason? _________________________Do your feet hurt a lot? Y N
Do you have difficulty concentrating? Y N Do you feel fuzzy headed? Y N
Of this list, what changes are you willing to make to improve or get rid of your symptoms?
Diet/Food Hydration Exercise Healthy Supplements
Client Signature:_____________________________________________________Date: _________________
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