Healing Ways Holistic Health

Healing Ways Holistic Health

207 Oakdale Rd. Suite C

Jamestown NC, 27282

336-885-2948

Confidential Client History

Email this completed document to:

If you prefer to print and mail a hard copy, please mail to the address above.

General Information:

Name: ______

Address: ______

City: ______State: ______Zip: ____

Telephone Numbers: Cell: ( ) ______Other: ( ) ______

E-mail ______

Occupation______

__ Full Time __Part Time __ School __Retired __Unemployed __Other______

Status: __Single __Married __Divorced __Widowed

Pets: ______

In Case of Emergency Notify: ______Phone #: ______

Blood Type (if know): ______

Height: ______

Weight: ______

Date of Birth: ______

How did you hear about Healing Ways? ______

Financial Agreement:

I claim full financial responsibility for services rendered by Healing Ways and understand that payment is required in full at the time of service. Insurance is not accepted. The sessions with our Naturopath are billed at rate of $150 per hour. We require 24 hours notice before cancelling or changing an appointment. If less notice is given, we will charge half the value of the scheduled appointment.

Name and Date: ______

Current Health:

What are your current health concerns? ______

If you have a specific condition, when did it first begin? ______

______

Has your condition been getting progressively worse?

Do you have a reaction to missing meals? ______

Have you found anything that makes your condition better? ______

Have you found anything that makes your condition worse? ______

Exercise: ______

Relaxation: ______

Creative Outlet: ______

What are the major stress factors in your life? ______

Are you currently under the care of a Medical Doctor or licensed health care professional? ______

If so, who?

General: (Please check all that apply)

[ ] Poor appetite [ ] Heavy appetite [ ] Hard to wake [ ] Poor sleep

[ ] Light sleep [ ] Heavy sleep [ ] Insomnia [ ] Fatigue

[ ] Tremors [ ] Vertigo [ ] Cold hands [ ] Cold Feet

[ ] Hot Flashes [ ] Fevers [ ] Chills [ ] Sweat easily

[ ] Localized weakness [ ] Poor coordination [ ] Change in appetite [ ] Cravings ______

[ ] Peculiar tastes/smells [ ] Strong thirst (hot, cold drinks) ______

[ ] Bleed or bruise easily (where) ______

[ ] Sudden energy drop at ______(times)

How often do you eat? ______

Habits:

[ ] Cigarettes ______per day [ ] Coffee ____ cups Caffeinated/day ___ Decaf/day

[ ] Soda _____cups/day [ ] Iced Tea ____ glasses/day [ ] Salt [ ] Sugar [ ] Water ____glasses/day [ ] Drugs [ ] Alcohol

How many glasses of alcohol do you drink per day, week?

______

Nutrition:

Please indicate your typical eating habits:

Breakfast: ______

Lunch: ______

Dinner: ______

Snacks: ______

Misc.: ______

Additional Comments: ______

______

Family Medical History: (please check all that apply)

[ ] Diabetes [ ] Cancer [ ] High Blood Pressure [ ] Heart Disease

[ ] Strokes [ ] Seizures [ ] Asthma [ ] Allergies [ ] Alcoholism

[ ] Other ______

If your parents or siblings have passed, what was the cause of death and at what age did it occur

Medical History: (please include date)

Diagnosed illnesses:

[ ] Cancer [ ] Diabetes [ ] High Blood Pressure [ ] Cardiovascular Disease [ ] Hepatitis

[ ] Thyroid dysfunction [ ] Rheumatic Fever [ ] Seizures

[ ] Environmental Toxicity ______

[ ] Allergies: (Drugs, Chemicals, Foods) ______

[ ] Other (explain) ______

Teeth:

When was your last dental appointment? ______

Do you have any mercury/silver amalgam fillings? [ ] yes [ ] no

Do you have root canal fillings? [ ] yes [ ] no How many? ______

Removable bridge [ ]

Fixed bridge [ ] Implanted tooth or teeth [ ] Periodontal (gum) disease [ ]

Other ______

Surgeries: ______

Significant Trauma: (also accidents, falls, etc.) ______

______

Birth History:

[ ] Prolonged labor [ ] forceps delivery [ ] Other ______

[ ] Occupational Stresses: (chemical, physical, psychological, etc.)

Skin and Hair

[ ] Rashes [ ] Ulcerations [ ] Hives [ ] Itching [ ] Eczema

[ ] Pimples [ ] Dandruff [ ] Loss of hair [ ] Change in hair/skin texture

[ ] Other hair or skin problems

Head, Eyes Ears, Nose and Throat

[ ] Dizziness [ ] Concussions [ ] Migraine [ ] Glasses [ ] Cataracts

[ ] Eye Strain [ ] Eye Pain [ ] Poor Vision [ ] Night Blindness [ ] Color Blindness

[ ] Blurry Vision [ ] Earaches [ ] Poor hearing [ ] Ringing in ears [ ] Nose Bleeds

[ ] Mucus [ ] Dry Throat [ ] Dry Mouth [ ] Copious Saliva [ ] Sinus Problems

[ ] Jaw Clicks [ ] Facial Pain [ ] Teeth Problems [ ] Grinding Teeth

[ ] Headaches (where and when) ______

[ ] Other head or neck problems ______

Cardiovascular:

[ ] High Blood Pressure [ ] Low Blood Pressure [ ] Chest Pain [ ] Dizziness

[ ] Irregular Heartbeat [ ] Cold Hands and Feet [ ] Fainting [ ] Phlebitis

[ ] Difficult Breathing [ ] Swelling Hands/Feet [ ] Blood Clots

[ ] Other ______

Respiratory:

[ ] Cough [ ] Pneumonia [ ] Asthma [ ] Bronchitis [ ] Coughing Blood

[ ] Tight Chest [ ] Difficulty breathing when lying down

[ ] Production of phlegm (what color?) ______

[ ] Other lung problems ______

Gastrointestinal:

[ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Gas [ ] Bloating [ ] Heartburn

[ ] Belching [ ] Black Stools [ ] Bad Breath [ ] Rectal Pain [ ] Hemorrhoids [ ] Constipation

[ ] Bloody Stools [ ] Pain [ ] Cramps [ ] Sensitive Abdomen

[ ] Laxative use (weekly) ______Type ______

[ ] Bowel movement (frequency) ______

[ ] Other ______

Genito – Urinary:

[ ] Painful Urination [ ] Frequent urination [ ] Blood in urine [ ] Urgency to urinate

[ ] Kidney Stones [ ] Unable to hold urine [ ] Venereal Disease [ ] Impotency

[ ] Wake up to urinate (How often) ______[ ] Day [ ] Night

[ ] Other G/U problems ______

Musculoskeletal:

[ ] Neck Pain [ ] Muscle Pain [ ] Back Pain (where) ______

[ ] Joint Pain (where) ______

[ ] Other joint or bone problems ______

Neuropsychological:

[ ] Seizures [ ] Poor Memory [ ] Anxiety [ ] Depression [ ] Easily Stressed

[ ] Concussion [ ] Bad Temper [ ] Areas of Numbness [ ] Treated for emotional problems

[ ] Considered/Attempted suicide

[ ] Other neurological or psychological problems ______

Environmental Exposure

Have you used the following or had a situation where you might have been exposed to any of the following? :

[ ] Pesticides [ ] Herbicides [ ] Fungicides [ ] X-rays (qty. ____) [ ] Fertilizer

[ ] High Voltage lines [ ] Well water [ ] Orchards [ ] Cleaning Solvents

[ ] Insect sprays [ ] Glues [ ] Insulation [ ] New carpets [ ] New Home

[ ] Industrial toxins [ ] Other ______

Pregnancy and Gynecology:

[ ] Pregnancies [ ] Number births [ ] Premature Births [ ] Miscarriages

[ ] Age at 1st menses ______[ ] Period duration ______

[ ] Irregular Periods [ ] Clots [ ] Last PAP ______

[ ] Last Menses [ ] Vaginal Sores [ ] Vaginal Discharge [ ] PMS symptoms

[ ] Breast lumps [ ] Menopause [ ] Hysterectomy [ ]

[ ] Birth Control (type and duration) ______

[ ] Changes in body/ psyche prior to menstruation ______

______

[ ] Heavy Flow [ ] Light Flow [ ] discomfort [ ] Long menses [ ] Short menses

Medication and Supplements:

Please list any supplements and medications you currently take. List the reason you take the substance, what the effect, if any, you notice from taking it, and the dosage.

Health Timeline

Please list below, in chronological order, events in your life that have possibly had an impact on your health. These could include not only occurrences of disease or injury, but also events in which you were subjected to emotional or psychological stress such as the loss of a loved one, failure in work or a relationship, or a radical change in your circumstance.

Symptoms

Please list all your current symptoms and medical diagnoses.

Health Goals

What specific results would you like to achieve by working with Healing Ways?

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