ࡱ > T W S j, bjbjVV j\ < < j$ ~ ~ $ \ A d " O" Q" Q" Q" Q" Q" Q" $ :' d Q" Q" f" R O" O" V @ W! dv` ;" |" 0 " x ' ' W! ' W! Q" Q" $ " ' ~ : Name____________________________ Date of visit _______
Reasons for coming____________________________________ ____________________________________________________
Health goals __________________________________________
Medical history ________________________________________
____________________________________________________Diseases, Surgeries, Traumas ___________________________
____________________________________________________ ________________________________________________________________________________________________________
List vitamins and herbs consumed_________________________
____________________________________________________
Weekly Exercise habits _________________________________
____________________________________________________
What do you drink on a normal day________________________ ____________________________________________________
How much coffee do you drink daily _______________________
How much alcohol do you drink daily ______________________
Describe your activity level forty hours a week _______________
Do you smoke? How many daily? _________________________
What is your major cause of stress? _______________________
What do you do to relax? ________________________________
How do you feel on a normal day? And today? ______________ How do you usually feel after eating? (bloated, energized, sleepy)
Blood type? ____ Name the last book you read ______________
Do you believe you can make a difference in your health? _____
Describe your bowel movements and frequency______________
____________________________________________________
How much and how well do you sleep?_____________________
How many times do you eat fish a week?____Raw nuts/seeds___
List all foods eaten in the last 3 days on back or attach food diary.
Consent to Services Agreement
THE BELOW DISCLAIMERS APPLY TO EVERY PART OF THE INFORMATION PROVIDED BY RENEE DETKY CONCERNING BODY CHEMISTRY ANALYSIS AND INTERPRETATION.
If you have a named disease, I do not cure diseases. I am not a medical doctor.
The purpose of bio-chemistry testing is to help teach you how to live a healthier life.
The purpose of bio-terrain testing and blood nutrition analysis are to help you understand your individual metabolic imbalances and teach how to correct them.
It is also my purpose to encourage all clients to do their own research. I hope that each client would learn to listen to their own body, and give each person an understanding of You are what you eat.
The DANGER of taking over-the-counter drugs, prescribed medications or even mega doses of vitamins, minerals and herbs should never be ignored.
I DO NOT ADVOCATE ANYONE FROM DISCONTINUING MEDICATIONS PRESCRIBED BY THEIR DOCTOR. IF YOUR HEALTH IMPROVES AND YOU CHOOSE TO DO THIS, CONSULT WITH THE PRESCIBING MEDICAL DOCTOR BEFORE ANY CHANGES ARE MADE.
I have read and understand all the above information and consent to services.
Name ___________________________
Signed__________________________ Date______
____________ ____________________ ___________ ______________
Last Name First Name Middle Initial (Mr./Mrs./Miss)
______________________________________ _____________
Street address E-mail address
____________________________________________________________
City State Zip Home Phone Cell Work
____ _____ ________ _______ _______ ____ ______ _________
Sex Age Birth Date Height Weight Race Religion Occupation
Please check once anything that pertains to you, twice in areas that you experience more strongly.
Category I Colon
__Feeling that bowels do not empty completely
__Lower abdominal pain relief by passing stool or gas
__Alternating constipation and diarrhea
__Diarrhea
__Constipation
__Hard, dry or small stool
__Coated tongue or fuzzy debris on tongue
__Pass large amount of foul smelling gas
__More than 3 bowel movements daily
__Do you use laxatives frequently?
Category 2 Hypocholorhydria
__Excessive belching, burping or bloating
__Gas immediately following a meal
__ Offensive breath
__Difficult bowel movements
__Sense of fullness during and after meals
__Difficulty digesting fruits and vegetables; undigested foods found in stool
Category 3 Hyperacidity (Ulcers)
__Stomach pain, burning or aching 1 4 hours after eating
__Do you frequently use antacids?
__Feeling hungry an hour or two after eating
__Heartburn when lying down or bending forward
__Temporary relief from heart burn with: antacids, food, milk, or soda
__Digestive problems subside with rest and relaxation
__Heartburn due to spicy food, chocolate, citrus, peppers, alcohol, caffeine
Category 4 Small Intestine (Pancreas)
__Roughage and fiber cause constipation
__Indigestion and fullness lasts 2 4 hours after eating
__Pain, tenderness, soreness on left side under rib cage, bloated
__Excessive passage of gas
__Nausea and/or vomiting
__Stool undigested, foul smelling, mucous-like, greasy, or poorly-formed
__Stool floats
Category 5 Biliary Insufficiency and /or Stasis
__Greasy or high fat foods cause distress
__Lower bowel gas and/or bloating several hours after eating
__Bitter metallic taste in mouth, especially in the morning
__Unexplained itchy skin
__Yellowish cast to eyes
__Stool color alternates from clay colored to normal brown
__Reddened skin, especially palms
__Dry flaky skin and/or hair
__History of gallbladder attacks or stones
__Have you had your gallbladder removed?
Category 6 Hypoglycemia
__Crave sweets during the day
__Irritable if meals are missed
__Depend on coffee to keep yourself going or get started
__Get lightheaded if meals are missed
__Eating relieves fatigue
__Agitated, easily upset, nervous
__Poor memory, forgetful
__Blurred vision
Category 7 Insulin Resistance
__Fatigue after meals
__Crave sweets during the day
__Eating sweets does not relieve cravings for sugar
__Must have sweets after meals
__Waist girth is equal or larger than hip girth
__Frequent urination
__Increased thirst and appetite
__Difficulty losing weight
Category 8 Adrenal Hypo function
__Cannot stay asleep
__Crave salt
__Slow starter in the morning
__Afternoon fatigue
__Dizziness when standing up quickly
__Afternoon headaches
__Headaches with exertion or stress
__Weak nails
Category 9 Adrenal Hyper function
__Cannot fall asleep
__Perspire easily
__Under high amounts of stress
__Weight gain when under stress
__Wake tired even after 6 or more hours of sleep
__Excessive perspiration or perspiration with little or no activity
Category 10 Hypothyroid
__Head hair loss
__Headaches / migraines
__Loss of outer eyebrow
__Decreased memory
__Depression
__Insomnia or needing lots of sleep
__Anxiety attacks
__Easy weight gain
__Low motivation
__Dry skin & hair
__Slow growing or brittle nails
Category 11 Thyroid Hyper function
___Heart palpitations
___Inward trembling
___Increased pulse even at rest
___Nervousness and emotional
___Insomnia
___Night sweats
___Difficulty gaining weight
Category 12 Pituitary Hypo function
___Diminished sex drive
___Menstrual disorders
___Increased ability to eat sugars without symptoms
Category 13 Pituitary Hyper function
___Increased sex drive
___Tolerance to sugars reduced
___Splitting type headache
Medications Circle any that you are currently taking.
Antacids
Antibiotics
Antifungal
Antihistamines
Antidepressants
Aspirin / Tylenol
Anti-Inflammatory
Anxiety Medication
Diuretics
High Blood Pressure Medicine
High Cholesterol
Oral Contraceptives
Hormone Replacement
Thyroid Hormones
Laxatives
Hydrocortisone Cream
Prescription Pain Reliever
Other
Please list all other medications and reasons for taking them on the back.
Category 16 Menstruating only
__Peri-menopausal?
__Irregular menstrual cycle length
__Menstrual cycle less than 24 days
__Cycle longer than 32 days
__ Pain & cramping during periods
__Scanty blood flow
__Heavy blood flow
__Breast pain/swelling with mense
__Pelvic pain during menses
__Irritable/depressed during cycle
__Acne breakouts
__Facial hair growth
__Hair loss, or thinning hair
Category 17 Menopausal Only
__How many years
__Uterine bleeding
__Mental fogginess
__Hot flashes
__Disinterest in sex
__Mood swings
__Depression
__Painful Intercourse
__Shrinking breasts
__Facial hair growth
__Acne
__Increased vaginal pain, itch, dry
Category 14 Prostate
(Men only)
__Urination difficulty or dribbling
__Frequent urination
__Pain inside of legs or heels
__Feeling of incomplete
bowel evacuation
__Leg nervousness at night
Category 15 Andropause
(Men only)
__Decrease in libido
__Decrease in spontaneous
morning erections
__Decrease in fullness of erection
__Difficulty maintaining erections
__Spells of mental fatigue
__Inability to concentrate
__Episodes of depression
__Muscle soreness
__Decrease in physical stamina
__Unexplained weight gain
__Increase in fat around chest/hip
__Sweating attacks
__More emotional than in the past
__Varicose veins or Hemorrhoids
__Changes in visual acuity
Category 18 Toxic burden
__More than 10 lbs overweight
__Allergies or Asthma
__Eczema or Psoriasis
__Headaches
__Brain fog
__Depression / Anxiety
__Chemically sensitive
__Fatigue
__Chronic pain
__Fibromyalgia / CFS
__Autoimmune disease
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