Client Questionnaire- Health History Step 1 of 24 4% Notice: Please allow at least 60 minutes to complete this form. You can add any additional notes by emailing us (text to request the email address at 517-409-5095). Keep in mind, no data will be submitted until you click "submit" at the end. Thank you! Today's Date(Required) MM slash DD slash YYYY Full Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Occupation Mobile Phone(Required)Work PhoneEmergency Contact(Required) Emergency Contact Phone(Required)Emergency Contact Relationship(Required) How did you learn about The Elite Health Practice?(Required) Other health care provider #1- Please list their NAME, PROFESSION & PHONE # Other health care provider #2- Please list their NAME, PROFESSION & PHONE # Other health care provider #3- Please list their NAME, PROFESSION & PHONE # Other health care provider #4- Please list their NAME, PROFESSION & PHONE # Please List Your Top 3 GoalsDescribe goal #1 and your "why" behind that goal(Required)Describe goal #2 and your "why" behind that goalDescribe goal #3 and your "why" behind that goalPlease list your health concerns (physical, emotional, psychological) in order of importance to you and date of onset.Health concern #1 (physical, emotional, psychological) in order of importance to you and date of onset.(Required)Health concern #2 (physical, emotional, psychological) in order of importance to you and date of onset.Health concern #3 (physical, emotional, psychological) in order of importance to you and date of onset.Health concern #4 (physical, emotional, psychological) in order of importance to you and date of onset. Please list your most stressful life experiences (physical and psychological) and date of onset.#1 most stressful life experience (physical and psychological) and date of onset.(Required)#2 most stressful life experience (physical and psychological) and date of onset.#3 most stressful life experience (physical and psychological) and date of onset. Supplements/ Drug MedicationsPlease list all current vitamins/ minerals, herbs or homeopathic remedies along with the daily dosage, how long you have taken it and the reason.Supplement, dose/ day, length, reason Supplement, dose/ day, length, reason Supplement, dose/ day, length, reason Supplement, dose/ day, length, reason Supplement, dose/ day, length, reason Additional supplements, dose/ day, length, reasons If you are taking more than 5 supplements, please list the rest here. Please list all medications (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects.#1 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. #2 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. #3 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. #4 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. #5 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. #6 Medication (prescription & over-the-counter), the daily dose, how long you have taken it, the reason and any adverse reactions or side effects. In the last 10 years, how many courses of antibiotics have you taken? Do you use medical cannabis?YesNoThird ChoiceIf yes, for what condition? Do you use recreational cannabis?YesNoThird ChoiceIf yes, how often? Do you use THC, CBD or combo product such as gummies or a tincture?YesNoThird ChoiceIf yes, describe the product Medical HistoryPlease indicate if you have had any of the following diagnostic tests performed in the last 12 months.Thyroid Panel:(Required) Yes No Liver Panel:(Required) Yes No Complete Blood Count:(Required) Yes No Blood Sugar Test:(Required) Yes No Colonoscopy:(Required) Yes No Cholesterol:(Required) Yes No Hormone Panel:(Required) Yes No EKG:(Required) Yes No Chest x-ray:(Required) Yes No Mammography?(Required) Yes No Please list all past surgeries or hospitalizations and approximate dates.Surgery/ hospitalization/ dateSurgery/ hospitalization/ dateSurgery/ hospitalization/ date Add RemovePlease list all past injuries and dates (i.e.broken bones, joint sprains, burns, falls, car accidents, etc.).Injury and dateInjury and dateInjury and date Add RemovePlease list all current and past health conditions/ challenges (suspected and diagnosed)Condition/ challengeCondition/ challengeCondition/ challenge Add RemoveAre you currently under the care of a mental healthcare provider? Yes, I am currently receiving care and it is helping. Yes, I am currently receiving care but it is NOT helping No, I am not currently under care Were you previously under the care of a mental healthcare provider? Yes, I received care in the past and it helped Yes, I received care in the past but it did NOT help No, I have never received this type of care Dental History: Please list all dental work and the approximate date of each procedure (root canal, mercury or ceramic fillings, implants, caps, dentures).Procedure type/ dateWhat is your blood type? A+ B+ AB+ A- B- O- O+ AB- Not Sure Family History: Please indicate whether any close family members have had any of the following:Family History of: Alcoholism Alzheimer's Disease Arthritis Asthma Cancer Depression Other Mental Illness Diabetes Drug Abuse Heart Disease High Blood Pressure Kidney Disease Osteoporosis Stroke Thyroid Condition If you have a family history of cancer, please list what type(s). LifestylePlease list or explain all allergies or sensitivities (foods, medications, environment, etc.).Do you consume any of the following? Water Coffee Beer Wine Liquor Select AllDo you do any of the following? Smoke Chew gum Use a cell phone with protective case Have exposure to animals Have exposure to toxins (heavy metals, mold, etc.). Please list any dietary restrictions. Please describe the emotional climate of your home.On a scale of 1-10, rate your stress level (10=high):On a scale of 1-10, rate the importance of your everyday spiritual/ faith practices (10= very important):On a scale of 1-10, rate your level of motivation to improve your health (10= very motivated):On a scale of 1-10, rate your level of motivation to prevent illness (10= very motivated): BioEnergetic Health Survey: Section A- DigestiveInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per week Lower bowel gas several hours after eating:Never =0Rarely =1Time-to-time =2Often =3Burning stomach sensation, eating relievesNever =0Rarely =1Time-to-time =2Often =3Coated tongueNever =0Rarely =1Time-to-time =2Often =3Indigestion 30-60 minutes after eatingNever =0Rarely =1Time-to-time =2Often =3Carbonated DrinksNever =0Rarely =1Time-to-time =2Often =3Difficult bowel movementsNever =0Rarely =1Time-to-time =2Often =3Ulcers/ Colitis/ GastritisNever =0Rarely =1Time-to-time =2Often =3Stomach bloating after eatingNever =0Rarely =1Time-to-time =2Often =3Belching/ burpingNever =0Rarely =1Time-to-time =2Often =3Bad breathNever =0Rarely =1Time-to-time =2Often =3Alternating diarrhea/ constipationNever =0Rarely =1Time-to-time =2Often =3Have petsNever =0Rarely =1Time-to-time =2Often =3Rectal itchingNever =0Rarely =1Time-to-time =2Often =3Can't gain weightNever =0Rarely =1Time-to-time =2Often =3International travelNever =0Rarely =1Time-to-time =2Often =3Stomach/ intestinal cramping/ diarrheaNever =0Rarely =1Time-to-time =2Often =3Add your totals from the above questions and enter your total here: Section B: Sugar Handling ProblemsInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per week Afternoon headachesNever =0Rarely =1Time-to-time =2Often =3Get "shaky" if hungryNever =0Rarely =1Time-to-time =2Often =3Faintness if meals delayedNever =0Rarely =1Time-to-time =2Often =3Heart palpitates if meals missed or delayedNever =0Rarely =1Time-to-time =2Often =3Eat when nervousNever =0Rarely =1Time-to-time =2Often =3Awaken after a few hours of sleepNever =0Rarely =1Time-to-time =2Often =3Hard to get back to sleepNever =0Rarely =1Time-to-time =2Often =3Crave candy or coffee in the afternoonNever =0Rarely =1Time-to-time =2Often =3Abnormal craving for sweets or snacksNever =0Rarely =1Time-to-time =2Often =3Thirsty much of the timeNever =0Rarely =1Time-to-time= 2Often= 3History of diabetesNever =0Rarely =1Time-to-time =2Often =3Excessive frequent urinationNever =0Rarely =1Time-to-time =2Often =3Blurred vision/ failing eyesightNever =0Rarely =1Time-to-time =2Often =3Breath smells sweetNever =0Rarely =1Time-to-time =2Often =3Tingling, numbness, prickling sensation in extremitiesNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section B questions and enter your total here: Section C: CardiacInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekBruise easily, "black and blue spots"Never =0Rarely =1Time-to-time =2Often =3Sigh frequentlyNever =0Rarely =1Time-to-time =2Often =3Aware of breathing heavilyNever =0Rarely =1Time-to-time =2Often =3Open window in closed roomNever =0Rarely =1Time-to-time =2Often =3Susceptible to colds and feversNever =0Rarely =1Time-to-time =2Often =3Swollen ankles, worse at nightNever =0Rarely =1Time-to-time =2Often =3Muscle cramps, worse during nightNever =0Rarely =1Time-to-time =2Often =3Shortness of breath on exertionNever =0Rarely =1Time-to-time =2Often =3NosebleedsNever =0Rarely =1Time-to-time =2Often =3Ringing in the earsNever =0Rarely =1Time-to-time =2Often =3Heart PalaitationsNever =0Rarely =1Time-to-time =23Often =3Dull pain in chest or radiating into left arm, worse on exertionNever =0Rarely =1Time-to-time =2Often =3Hands & feet go to sleep easilyNever =0Rarely =1Time-to-time =2Often =3Numbness in extremitiesNever =0Rarely =1Time-to-time =2Often =3Tendency toward anemiaNever =0Rarely =1Time-to-time =2Often =3Tension under breastbone or feeling of tightness, worse with exertionNever =0Rarely =1Time-to-time =2Often =3Blushing with no apparent causeNever =0Rarely =1Time-to-time =2Often =3Black stool (no iron supplementation)Never =0Rarely =1Time-to-time =2Often =3Poor concentrationNever =0Rarely =1Time-to-time =2Often =3Slurred speechNever =0Rarely =1Time-to-time =2Often =3HeadachesNever =0Rarely =1Time-to-time =2Often =3Weakness/ fatigueNever =0Rarely =1Time-to-time =2Often =3Out of breath frequentlyNever =0Rarely =1Time-to-time =2Often =3NervousnessNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section C questions and enter your total here: Section D: Liver and GallbladderInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per week Pain under right side of rib cageNever =0Rarely =1Time-to-time =2Often =3Frequent skin rashesNever =0Rarely =1Time-to-time =2Often =3Bitter metallic taste in mouth in morningNever =0Rarely =1Time-to-time =2Often =3Bowel movements painful and difficultNever =0Rarely =1Time-to-time =2Often =3Low energy, weakness, exhaustionNever =0Rarely =1Time-to-time =2Often =3Upset from greasy/ fatty foodsNever =0Rarely =1Time-to-time =2Often =3Bruises easilyNever =0Rarely =1Time-to-time =2Often =3Frequent headachesNever =0Rarely =1Time-to-time =2Often =3Pain between shoulder bladesNever =0Rarely =1Time-to-time =2Often =3Stools light colouredNever =0Rarely =1Time-to-time =2Often =3Laxatives used oftenNever =0Rarely =1Time-to-time =2Often =3History of gallbladder attacks or gallstonesNever =0Rarely =1Time-to-time =2Often =3History of hepatitisNever =0Rarely =1Time-to-time =2Often =3History of jaundiceNever =0Rarely =1Time-to-time =2Often =3Sneezing attacksNever =0Rarely =1Time-to-time =2Often =3Itchy skin, worse at nightNever =0Rarely =1Time-to-time =2Often =3Dry flaky skin, hairNever =0Rarely =1Time-to-time =2Often =3General feeling of poor healthNever =0Rarely =1Time-to-time =2Often =3Aching musclesNever =0Rarely =1Time-to-time =2Often =3Swollen feet and/or legsNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section D questions and enter your total here: Section E: ThyroidInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekImpaired HearingNever =0Rarely =1Time-to-time =2Often =3Decrease in appetiteNever =0Rarely =1Time-to-time =2Often =3Ringing in earsNever =0Rarely =1Time-to-time =2Often =3ConstipationNever =0Rarely =1Time-to-time =2Often =3Puffy hands/ faceNever =0Rarely =1Time-to-time =2Often =3Tired/ sluggishNever =0Rarely =1Time-to-time =2Often =3MiscarriagesNever =0Rarely =1Time-to-time =2Often =3InfertilityNever =0Rarely =1Time-to-time =2Often =3Mental sluggishness/ forgetfulnessNever =0Rarely =1Time-to-time =2Often =3Headache upon rising; wears off during dayNever =0Rarely =1Time-to-time =2Often =3Slow pulse, below 65Never =0Rarely =1Time-to-time =2Often =3Cold hands and feetNever =0Rarely =1Time-to-time =2Often =3Gains weight easilyNever =0Rarely =1Time-to-time =2Often =3Weight gain around hipsNever =0Rarely =1Time-to-time =2Often =3Outer third eyebrow thinningNever =0Rarely =1Time-to-time =2Often =3EmotionalNever =0Rarely =1Time-to-time =2Often =3Flush easilyNever =0Rarely =1Time-to-time =2Often =3Night SweatsNever =0Rarely =1Time-to-time =2Often =3Hair LossNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section E questions and enter your total here: Section F: Bone Development/ Minerals, etc.Instructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekHip and joint painNever =0Rarely =1Time-to-time =2Often =3Receding gums and/ or dental cavitiesNever =0Rarely =1Time-to-time =2Often =3Tendency towards slouching/ weakNever =0Rarely =1Time-to-time =2Often =3Bone loss/ osteoporosis in familyNever =0Rarely =1Time-to-time =2Often =3Crunching , creaking jointsNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section F questions and enter your total here: Section G: EnvironmentalInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekExposure to fumes e.g., paint, salon, carNever =0Rarely =1Time-to-time =2Often =3Use pesticides on gardenNever =0Rarely =1Time-to-time =2Often =3Live near power lines/ high tension wiresNever =0Rarely =1Time-to-time =2Often =3Have mercury amalgams (silver) in mouthNever =0Rarely =1Time-to-time =2Often =3Skin disorders e.g., psoriasis, eczema etc.Never =0Rarely =1Time-to-time =2Often =3Loss of hairNever =0Rarely =1Time-to-time =2Often =3Hormone disordersNever =0Rarely =1Time-to-time =2Often =3History of cancer/ personal or familialNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section G questions and enter your total here: Section H: Muscle and LigamentInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekMuscle aches, stiffness, cramping and painsNever =0Rarely =1Time-to-time =2Often =3Chiropractic adjustments do not holdNever =0Rarely =1Time-to-time =2Often =3Whiplash and/or ligamental trauma/ strainNever =0Rarely =1Time-to-time =2Often =3Fatigue, sluggishnessNever =0Rarely =1Time-to-time =2Often =3Upper or lower back painNever =0Rarely =1Time-to-time =2Often =3Stiff neck and shouldersNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section H questions and enter your total here: Section I: AdrenalInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekLow blood pressureNever =0Rarely =1Time-to-time =2Often =3Chronic fatigueNever =0Rarely =1Time-to-time =2Often =3Low energy, lack of staminaNever =0Rarely =1Time-to-time =2Often =3General malaise, unhappinessNever =0Rarely =1Time-to-time =2Often =3Tendency to hivesNever =0Rarely =1Time-to-time =2Often =3Arthritic tendencyNever =0Rarely =1Time-to-time =2Often =3Excessive perspirationNever =0Rarely =1Time-to-time =2Often =3Colds/ flu oftenNever =0Rarely =1Time-to-time =2Often =3Weakness after illnessNever =0Rarely =1Time-to-time =2Often =3Dark circles under eyesNever =0Rarely =1Time-to-time =2Often =3Crave salty foodsNever =0Rarely =1Time-to-time =2Often =3Feeling unrefreshed upon awakeningNever =0Rarely =1Time-to-time =2Often =3AllergiesNever =0Rarely =1Time-to-time =2Often =3Exhaustion - muscular & nervousNever =0Rarely =1Time-to-time =2Often =3Respiratory disordersNever =0Rarely =1Time-to-time =2Often =3Swollen anklesNever =0Rarely =1Time-to-time =2Often =3Dizzy when stand up "too fast"Never =0Rarely =1Time-to-time =2Often =3Decreasing appetiteNever =0Rarely =1Time-to-time =2Often =3IrritibleNever =0Rarely =1Time-to-time =2Often =3Bright lights irritateNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section H questions and enter your total here: Section J: Male and FemaleInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekFemale OnlyPainful mensesNever =0Rarely =1Time-to-time =2Often =3Premenstural tensionNever =0Rarely =1Time-to-time =2Often =3Very easily fatiguedNever =0Rarely =1Time-to-time =2Often =3Depressed feelingNever =0Rarely =1Time-to-time =2Often =3Mensturation excessive and prolongedNever =0Rarely =1Time-to-time =2Often =3Painful breasts (monthly)Never =0Rarely =1Time-to-time =2Often =3Lumpy breasts/ worst at mensesNever =0Rarely =1Time-to-time =2Often =3Have taken birth control pillsNever =0Rarely =1Time-to-time =2Often =3Menopause, hot flashes, etc.Never =0Rarely =1Time-to-time =2Often =3Menses scanty or irregularNever =0Rarely =1Time-to-time =2Often =3Acne, worse at mensesNever =0Rarely =1Time-to-time =2Often =3Vaginal discharge/ yeast, etcNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section I Female questions and enter your total here:Male OnlyTired too easilyNever =0Rarely =1Time-to-time =2Often =3Urination difficultNever =0Rarely =1Time-to-time =2Often =3Night urination frequentNever =0Rarely =1Time-to-time =2Often =3Pain on inside of legs or heelNever =0Rarely =1Time-to-time =2Often =3Feeling of incomplete bowel evacuationNever =0Rarely =1Time-to-time =2Often =3Prostate troubleNever =0Rarely =1Time-to-time =2Often =3Legs nervous at nightNever =0Rarely =1Time-to-time =2Often =3Diminished sex driveNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section I Male questions and enter your total here: Section K: LungInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekChronic coughNever =0Rarely =1Time-to-time =2Often =3Pain around ribsNever =0Rarely =1Time-to-time =2Often =3Shortness of breathNever =0Rarely =1Time-to-time =2Often =3Chest painNever =0Rarely =1Time-to-time =2Often =3Difficulty breathingNever =0Rarely =1Time-to-time =2Often =3Post nasal dripNever =0Rarely =1Time-to-time =2Often =3Sinus and nasal congestionNever =0Rarely =1Time-to-time =2Often =3Coughing up phlegmNever =0Rarely =1Time-to-time =2Often =3Coughing up bloodNever =0Rarely =1Time-to-time =2Often =3Bronchitis (frequent)Never =0Rarely =1Time-to-time =2Often =3Infections settle in lungsNever =0Rarely =1Time-to-time =2Often =3Sensitive to smogNever =0Rarely =1Time-to-time =2Often =3AsthmaNever =0Rarely =1Time-to-time =2Often =3WheezingNever =0Rarely =1Time-to-time =2Often =3SmokerNever =0Rarely =1Time-to-time =2Often =3Chronic lung congestionsNever =0Rarely =1Time-to-time =2Often =3Breathes through mouthNever =0Rarely =1Time-to-time =2Often =3Shallow breatherNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section K questions and enter your total here: Section L: ImmuneInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per week Throat infectionsNever =0Rarely =1Time-to-time =2Often =3Poor wound healingNever =0Rarely =1Time-to-time =2Often =3Slow to recover from colds or fluNever =0Rarely =1Time-to-time =2Often =3Gets boils or stiesNever =0Rarely =1Time-to-time =2Often =3Swollen lymph glandsNever =0Rarely =1Time-to-time =2Often =3Catch colds or flu easilyNever =0Rarely =1Time-to-time =2Often =3Bumpy skin on armsNever =0Rarely =1Time-to-time =2Often =3Inflamed or bleeding gumsNever =0Rarely =1Time-to-time =2Often =3Cough with mucusNever =0Rarely =1Time-to-time =2Often =3Swollen tongueNever =0Rarely =1Time-to-time =2Often =3Dark areas under eyes/ cheeksNever =0Rarely =1Time-to-time =2Often =3Sore throatNever =0Rarely =1Time-to-time =2Often =3Post nasal dripNever =0Rarely =1Time-to-time =2Often =3Earaches and infectionsNever =0Rarely =1Time-to-time =2Often =3Herpes/ cold soresNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section L questions and enter your total here: Section M: KidneyInstructions: Indicate the frequency of the symptoms or events. Add the total of your score at the end and enter it into the section total. NEVER= 0-1 time per month at most, RARELY= 2-3 times per month, TIME-TO-TIME= 1-2 times per week, OFTEN= 3 or more times per weekFrequent urinationNever =0Rarely =1Time-to-time =2Often =3Rose=coloured (bloody) urineNever =0Rarely =1Time-to-time =2Often =3Dripping after urinationNever =0Rarely =1Time-to-time =2Often =3Difficulty passing urineNever =0Rarely =1Time-to-time =2Often =3Cloudy urineNever =0Rarely =1Time-to-time =2Often =3Rarely need to urinateNever =0Rarely =1Time-to-time =2Often =3Frequent bladder infectionsNever =0Rarely =1Time-to-time =2Often =3Painful burning when urinatingNever =0Rarely =1Time-to-time =2Often =3Urination when cough or sneezeNever =0Rarely =1Time-to-time =2Often =3Strong smelling urineNever =0Rarely =1Time-to-time =2Often =3Mild back painNever =0Rarely =1Time-to-time =2Often =3Interrupted urine streamNever =0Rarely =1Time-to-time =2Often =3Tingling in jointsNever =0Rarely =1Time-to-time =2Often =3Joint and muscle pain/ crampingNever =0Rarely =1Time-to-time =2Often =3Can't hold urineNever =0Rarely =1Time-to-time =2Often =3Dark circles under eyesNever =0Rarely =1Time-to-time =2Often =3Frequent urge to urinate but pass only small amountsNever =0Rarely =1Time-to-time =2Often =3Add your totals from the Section M questions and enter your total here: Section N: OtherInstructions: Select YES or NO for the following questions.Reactions to vaccinations? Yes No Allergies? Yes No Are you experiencing bone loss or osteoporosis? Yes No Diagnosed for parasites? Yes No Diagnosed or history of candida? Yes No Exposure to pesticides? Yes No Hormone replacement medications? Yes No Have you had your gallbladder removed? Yes No ACE ResiliencePrior to your 18th birthday, please answer YES or NO to the following questions. To learn more about this portion of the questionnaire, visit: https://acestoohigh.com/got-your-ace-score/ Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? Or act in a way that made you afraid that you might be physically hurt? Yes No Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured? Yes No Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes No Did you often or very often feel that … No one in your family loved you or thought you were important or special? Or your family didn’t look out for each other, feel close to each other, or support each other? Yes No Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No Was a biological parent ever lost to you through divorce, abandonment, or other reason Yes No Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Yes No Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No Did a household member go to prison? Yes No SEEDSPlease answer the following questions. S – SOCIAL SUPPORT (describe your social life with friends, family, colleagues, etc).(Required)E – EDUCATION (how often do you read, learn, grow your mind?)(Required)E – EXERCISE (how often do you exercise, what kind, how often, how long…running, weight lifting, walking, etc.)(Required)D – DIET (describe your daily food and beverage intake; breakfast, lunch, dinner, snacks, desserts and indicate if you typically skip any of the above main meals).(Required)S – SLEEP (how many hours per night, sleep aids? Bedtime ritual, etc)(Required) Lab Work or Report FindingsPlease upload any lab work or report findings below. If you prefer to fax or email: Fax=517-208-4001, Email= getwell@drjasonnd.comUpload any lab-work or report findings here.Max. file size: 36 MB.Upload any lab-work or report findings hereMax. file size: 36 MB.Disclosure/ Release Waiver of Liability AgreementDISCLOSURE AND RELEASE AND WAIVER OF LIABILITY AGREEMENT I undersigned and acknowledge that I have read and understand the contents of this agreement. Elite Health Practice (EHP) makes no representations, claims, or guarantees regarding the efficacy of the recommendations. The recommendations are based upon a combination of naturopathic health and holistic knowledge and education. 1. A natural health and life coaching consultation as provided by Jason McCammon does not constitute a medical service or health care treatment. 2. The title of “Licensed Practitioner” is used to indicate the achievement of naturopathic and integrative holistic qualifications as licensed through the Guardian Ecclesiastic Medical Association. 3. Individualized recommendations are offered and applied as an educational and informative consultation. Any action taken as a result of the consultation is done at the sole discretion of the client. Therefore, it is strongly recommended that in addition to any health consultation that you maintain a relationship with one or more physicians qualified to care for bodily or mental health condition(s). 4. By agreeing to this informed consent you agree to forever release Jason McCammon, his officers and employees from any and all actions, claims or demands that you, your heirs, next of kin, spouse and legal representatives now have, or may have in the future related in your participation of a natural health consultation. You agree to be responsible for all legal costs and fees that may result from action(s) on your part or on the part of your representative(s) against us. If a legal case is brought against us, you agree that we shall be judged by the standards and principles of complementary, alternative, and/or holistic medicine and not the standards and principles of consensus conventional medicine. You have the right to have this consent reviewed by your lawyer. 5. Your agreement verifies that you have not been told to discontinue treatments with any other medical specialists or other health care providers. Your agreement is being given prior to rendering any service, advice, and/or recommendations whatsoever. 6. Supplements. Jason McCammon makes nutritional supplements and other health products available. You are in no way obligated to purchase these products from my office or any other specific location or company. You may freely choose to purchase such products from any source(s) as you wish. Jason McCammon may profit from the sale of supplements and other products that are made available to his clients. 7. Licensing/Payment Natural health consultations provided by Jason McCammon are NOT covered by insurance plans. By agreeing, you accept full financial responsibility for costs associated with the consultation including laboratory tests and treatment procedures provided by others. No refunds on services and EHP holds the right to refuse to accept personal checks. 8. Follow up It is the responsibility of the client to follow up for results of all testing and laboratory procedures. It should not be assumed on the part of the client that if they are not contacted by EHP, or if the client does not schedule or keep a consultation, that test results are normal (or without abnormalities), and may not require further medical treatments or advice. Health recommendations and/or possible referral and additional follow-up may be warranted based upon laboratory testing and evaluations. 9. Missed Appointments Cancellations must be made at least 24 hours prior to the scheduled appointment. Clients that fail to cancel prior to 24 hours in advance will be charged $25 after their first offense. By agreeing, you are acknowledging that you understand all terms, verbiage (language) and concepts herein. I understand and agree: Name(Required) First Last My typed name constitutes a signature. I have read and agree to the above Disclosure/ Release Waiver of Liability Agreement.Date(Required) MM slash DD slash YYYY Untitled PhoneThis field is for validation purposes and should be left unchanged.
