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Judith G. HamidDSHOMMED, RHN
Holistic NutritionistdoTERRA Essential Oil Advocate
Intake Form
I, ______, the undersigned, understand that Judith G. Hamid is not a medical doctor, but instead a Holistic Nutritionist and doTERRA Essential Oil Advocate. As such, I acknowledge that it is my right and responsibility, at any time throughout my treatment with Judith G. Hamid, to seek medical counsel and diagnosis, if so desired, from a medical doctor, for any present and/or future condition(s). I also reserve the right to terminate treatment at any time if so inclined. I acknowledge that the state of my health is my own responsibility and that I am exercising my right to choose an alternative method of treatment, inHolistic Nutrition and Essential Oils that addresses my health in its entirety.
Fee Schedule
As Holistic Nutrition is not covered by existing government medical insurance plans, I agree to pay all incurred as presented in the current rate schedule below (rates are subject to change).
INITIALS $100.00
FOLLOW UPS $60.00
*Check yourextended health care plans,
some now cover Holistic Nutrition*
Please Note:All fees are payable at the end of each consultation (Cash, Debit, Visa, or MasterCard).
MISSED APPOINTMENT POLICY: 24 hours notice is needed if an appointment is to be missed otherwise there will be a charge for the full amount of the missed appointment.
Patient signature: ______Date: ______
(If under 18 yrs of age, a parent or guardian must sign on your behalf)
PATIENT INFORMATION
Note to patient: Determining the proper remedy involves investigating and evaluating all the subjective and objective symptoms that you are experiencing in the context of your individual life circumstances and environment. In order to develop an accurate picture of your circumstances, and to make our time spent in consultations most effective, I request that you complete the following information form as in-depth and accurately as possible. If you have any questions, feel free to ask me. Please note that all information provided is kept in confidence according to the laws of and Holistic Nutrition– patientconfidentiality.
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General Information
PATIENT’S NAME:______
ADDRESS: ______
CITY: ______POSTAL CODE: ______
PHONE: (home) ______(work) ______(cell) ______
DATE OF BIRTH: ______SEX: ______HEIGHT: ______MARITAL STATUS: ______
WEIGHT: ______WEIGHT (last year):______HAIR COLOUR: ______
EYE COLOUR: ______E-MAIL: ______
NAME AND PHONE NUMBER OF FAMILY DOCTOR:
______
HOW DID YOU HEAR ABOUT ME:
______
REFERRED BY: ______
What is the purpose of coming today?
______
Major complaints in order of importance to you:
Since Cause/Medications
______
______
______
Have you been diagnosed with an aliment related to you main health concern(s)?
______Any trauma or loss in the past 5 years? ______
Do you have any allergies or sensitivities? (please list) ______
______
What is your occupation? ______
Do you enjoy your work? Yes ______No ______Sometimes ______
How many hours each day do you work? ______Start ______End ______
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What is your level ofStress at this time?
Minimal ______Average ______
Considerable ______Unbearable ______
What are the major causes or factors of your stress?
(check all that apply)
Financial ____ Career ____ Personal ____ Marriage ____
Health ____ Family ____ Unfulfilled Expectations____
Other (please explain) ______
How does stress manifest itself? ______
Do you have any coping mechanisms? ______
How many hours on average do you sleep daily? (include naps) ______
What time do you go to sleep? ______wake up? ______
Do you awaken feeling rested? Yes ______No ______
Do you smoke? Yes ____ No ____
If yes, how much do you smoke daily and how many years for? ______
If no, does anyone smoke at home or at work? ______
Do you wish to gain weight? _____ loose weight? _____ how much? ______
On average how long do you spend on:
driving ______watching T.V ______reading ______on a computer ______
What interests and hobbies do you have? ______
What do you do for exercise? (type, frequency, time) ______
Do you vacation regularly? Yes _____ No _____ When was your last vacation? ______
Vaccinations / Childhood Illness:(If vaccinated what age? reaction to vaccine? or what age if ill with?)Any adverse affects from vaccinations? (YES or NO)
Measles: ______Mumps: ______Chicken pox: ______
Whooping Cough: ______Diphtheria: ______Polio: ______Tetanus: ______Rubella / German Measles: ______
Other: ______
(If ill from, what age?)
Pneumonia: ______
Mononucleosis: ______
Sexual Transmitted Disease:
Type: ______
Age: ______
___
What injuries or surgeries have you had during the course of your life? When? Complications?
______
What treatments have / are you receiving? (Since? Result?)
______
What medications have you taken in the past year? (Since? Any adverse effect on you?)
______
Usage of nutritional supplements? (please list vitamins, herbs, etc)
______
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Have you suffered from any of the following conditions?(circle all that apply)
Abscesses, Abortion, AIDS / HIV, Alcoholism, Anemia, Anxiety Disorder, Arthritis, Asthma, Cancer, Chicken Pox, Cold Sores, Colitis, Depression, Diabetes, Drug Abuse, Ear Infections, Eating Disorder, Eczema, Emphysema, Epilepsy, Frequent Colds, Gallstones, Goitre, Gonorrhea, Gout, Hay Fever, Heart Disease, Hepatitis, Herpes Genitialia, High/Low Blood Pressure, IBS,Influenza, Kidney Disease, Leukemia, Lyme Disease, Malaria, Measles, Miscarriage, Mononucleosis, Mood Disorder, Multiple Sclerosis, Mumps, Parasites, Pelvic Inflammatory Disease, Pleurisy, PMS, Pneumonia, Post – partum Depression, Prostatitis, Psoriasis, Rheumatic Fever, Rubella, Scarlet Fever, Schizophrenia, Schizoid-affected Disorder, Sexual Abuse, Skin Ailments, Strep Throat, Sinusitis, Stroke, Sunstroke, Syphilis, Thrush, Tonsillitis, Travel Sickness, Tuberculosis, Typhoid Fever, Venereal Warts, Warts, Whooping Cough, Worms,
Other: ______
Are there any conditions that you have never been totally well from again? Which ones?
______
How much of the following do you use?
Alcohol: ______Coffee: ______Tobacco: ______“Recreational Drugs”: ______
Can you trace the origin of any present condition to any particular circumstance (e.g. accident, illness, incident, mental upset, etc.)
______
Any serious shock, grief, disappointment, fright, depression, etc?
______
Do you have mercury filling? Yes _____ No _____Have you ever had periodontal issues? Yes ______No ______
How often do you have bowel movements?______
Do you strain to have a bowel movement? Yes _____ No _____ Sometimes _____
Is straining related to eating particular food? ______
Is there undigested food in your stool? Yes _____ No _____In general what colour is the stool?______
What is the consistency of the stool? ______
Is there any mucus, blood, etc, in the stool? ______
Female
What was the age of your first menses:______
Method of Birth Control (if used)? ______Length of time on birth control?______
Previous pregnancies/miscarriages/abortions or complications: ____________Could you be pregnant or menopausal? ______
Male
Any history or impotence/erectile dysfunction/prostate/urination problems? ______When? ______
Treatment for any of the above: ______
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How many times a day do you eat? (# of meals & snacks)______
Do you eat: with family ______home alone ______on the run ______restaurants ______fast food ______
Are there any restrictions to your diet (family, roommates, etc)? ______
Do you eat or use: (“1” for rarely, “2” for regular, “3” for often)
aluminum pans ____margarine ____candy ____ microwaves ____fried food ____ refined foods ____
luncheon meats____cigarettes ____fast food ____Nutra sweet/aspartame ______
Please indicate if you drink the following daily: (if yes, approx how many cups each day)
bottled or spring water ______tap water______milk ______coffee______tea______fruit juices ______
soft drinks (regular) ______soft drinks (diet)______alcoholic beverages ______other ______
Are you a: meat eater? ______vegetarian? ______vegan? ______
How often do you eat meat a week? daily ______4-5 days ______2-3 days ______1 or less ______
How often do you have dairy products a week? Daily ______3-5 days ______1 or less ______
What are your favourite foods? ______How often do you eat them? ______
Do you avoid certain foods?(if so, why?)______
Do you experience any symptoms if meals are missed? Explain: ______
Do you experience any symptoms after meals? Explain: ______
Family Health History
Alcoholism, Allergies, Arthritis, Asthma, Cancer, Depression, Diabetes, Epilepsy, Gonorrhea, Gout, Hay Fever, Heart Disease, Mental Illness (specific type), paralysis, Pneumonia, Skin Disease, Syphilis, Tuberculosis, Other: ______
Age if aliveAlimentsCause of deathAge at death
(if applicable)(if applicable)
Mother:______
Father:______
Brothers: ______
Sisters: ______
Children: ______
Maternal Grandmother: ______
Maternal Grandfather: ______
Maternal Aunts/Uncles: ______
Paternal Grandmother: ______
Paternal Grandfather: ______
Paternal Aunts/Uncles: ______
Is there anything else you feel is of importance to mention?
Thank you for taking the time to complete this form.
All information contained herein will remain strictly confidential.