| Contact Information |
| Date: | |
| First Name: | |
| Last Name: | |
| Address Street 1: | |
| Address Street 2: | |
| City: | |
| Zip Code: | (5 digits) |
| State: | |
| Daytime Phone: | |
| Evening Phone: | |
| Email: |
Client Profile |
| Age: | |
| Sex: | Male |
| Female |
| Height: | |
| Weight: | |
| Living Situation: | Alone |
| Friends |
| Partner |
| Spouse |
| Parents |
| Children |
| Pets |
| What are your major health concerns for this consultation?: | |
| Please list any other health care providers or consultants you are currently working with: | |
| Please list any current health conditions diagnosed by a medical doctor: | |
| When was your last physical exam?: | |
| Please list all herbs, vitamins, and dietary supplements you are currently taking, including dosage and frequency: | |
| List all medications you are currently taking (including aspirin, antacids, etc.) indicating whether they are over -the-counter (OTC) or Prescription, including dosage and frequency: | |
| List all medications, herbs, foods, environmental factors, to which you have a know allergy: |
|
Dietary Information
Describe below your typical meals. Please be specific as possible. For example, instead of "oil" note type of oil, such as olive, corn, etc. Instead of "bread" list whether white or whole grain, etc. Instead of "vegetables" list the type of vegetable, how prepared, canned, frozen, fresh, etc. Please include beverages, type and quantity ( two cups of orange juice, one cup of coffee-with cream/sugar, etc.) |
| Breakfast: | |
| Morning Snack(s): | |
| Lunch: | |
| Afternoon snack(s): | |
| Dinner: | |
| PM snack(s): | |
| Daily water consumption (number of glasses/day): | |
| Any recurring food cravings (such as salt, starch, sugar, chocolate, etc.) please list as many as possible including time of day or month: | |
| | Family History
Please describe any relevant or major health related issues: ( cancer, mental illness, diabetes, heart disease, etc.) |
| Mother: | |
| Father: | |
| Siblings: | |
| Maternal Grandparents: | |
| Paternal Grandparents: | |
| Medical History
List all major health problems including operations: |
| Problem/Year: |
General Health
Check all that apply to you |
Cardiovascular: | High blood pressure |
| Low blood pressure |
| Pain in heart |
| Poor circulation |
| Swelling |
| Stroke/murmur
|
| Skin | Boils |
| Bruises |
| Dryness |
| Itching |
| Varicose veins |
| Skin eruptions
|
| Muscles/Joints | Backache |
| Broken bones |
| Limited mobility |
| Arthritis |
| Bursitis |
| Weakness
|
| Respiratory | Chest pain |
| Difficulty breathing |
| Cough |
| Tuberculosis |
| Congestion |
| Itchy ears/eyes |
| Asthma |
| Coughing up blood
|
| Urinary/Kidney | Excessive urination |
| Water retention |
| Burning urine |
| Kidney stones |
| Lower back pain |
| Wheezing |
| Circles under eyes |
| Blood in urine
|
| Gastro-Intestinal | Belching |
| Colitis |
| Constipation |
| Abdominal Pain |
| Liver Disorders |
| Gallstones |
| Ulcers |
| Digestive troubles
|
| Eyes, Ears, Nose and Throat | Ear aches |
| Hay fever |
| Sore throat |
| Canker sores |
| Eyes pains |
| Sinus infections |
| Tonsils |
| Nosebleeds |
| Failing vision |
| Sinus congestion |
| Hearing loss |
| Difficulty breathing
|
| General | Fatigue |
| Excessive thirst |
| Difficulty sleeping |
| Night sweats |
| Loss of appetite |
| Irritability |
| Fever |
| Always hungry |
| Cold hands & feet
|
| Male reproductive | Burning/discharge |
| Painful testicles |
| Lumps/sweeling of testicles |
| Vasectomy |
| Female reproductive | |
| Age of first period: | |
| Heavy bleeding |
| Vaginal discharge |
| Painful intercourse |
| Breast pain |
| Infertility |
| Mood swings |
| Irregular cycles |
| Blood clots |
| Vaginal itching |
| Vaginal dryness |
| Breast lumps |
| Genitial herpes |
| PMS |
| Pre-menopausal |
| Menopause |
| Pains/cramps |
| Pelvic pain |
| Anemia |
| Hot flashes |
| Not able to conceive
|
| Contraceptive/Pregnancy History | Birth control pills/patch |
| Diaphragm |
| Cervical Cap |
| Rhythm-method |
| Condoms |
| Spermicides |
| I.U.D. |
| Mucous-method |
Please list each pregnancy you have had, including miscarriages: | Fertility lens
|
|
Current state of emotions & spiritual well-being
Please check all those describe you: |
| | I am often not able to express my emotions |
| I am dissatisfied with my job |
| I am often stressed out and not able to cope properly |
| Even though I'm in a relationship, I often feel lonely |
| I often feel anxious & nervous for no good reason |
| I don't sleep well at night & have a hard time waking in the morning |
| I often suffer from bad dreams & nightmares |
| There are many things that I'd like to change in my life but just don't have the means |
| I have very low energy & often feel exhausted mentally & physically |
| I don't enjoy my work and would rather be doing something else |
| I find my children irritating & hard to relate to |
| | I have very few hobbies |
| I often feel depressed for no reason |
| I often become angry with people and feel guilty about it later |
| I have a hard time letting go of the past |
| I don't look towards the future with much enthusiasm |
| I am not able to concentrate for extended periods of time |
| My outlook is more negative than positive |
| I spend a great deal of time worrying about what people think about me
|
| | I tend to see the good in people |
| I have a great sense of humor and love a good joke |
| I receive great joy from my family |
| | My outlook on life is positive |
| My job uses all my greatest talent |
| I have plenty of energy to do all the things I want |
| I sleep well at night & feel rested in the morning |
| I can concentrate on the task at hand for as long as it takes |
| I have a strong spiritual faith |
| I am able to express anger constructively |
| I practice meditation or other relxation techniques |
| I try to maintain peace of mind & tranquility |
| I have many close friends that I can always count on |
| I accept full responsibility for my actions |
| I trust my intuition & believe that things happen for a reason |
| I do not harbor any resentment from the past |
| I can feel completely fulfilled even if I'm alone |
| I have many hobbies & interests to keep me preoccupied |
| How I see myself is more important than how others see me |
| I often go out of my way to help others |
| Please list the approximate dates & describe the nature of any traumatic experiences you have had in the past 7 years (divorce, surgery, end of relationship, loss of job, change of residence, injury, death of a loved one, etc.): |
|
| Lifestyle Habits |
| Do you engage in regular physical activity? | Yes |
| No |
| If yes, how often?: | |
| For how many minutes?: |
|
| Do you smoke tobacco? | Yes |
| No |
| If yes, how much (packs/cigarettes per day)?: |
|
| Do you drink alcohol? | Yes |
| No |
| If yes, how much?: | |
| How often?: | |
| Do you drink coffee and/or caffeinated beverages? | Yes |
| No |
| If yes, how much?: | |
| How often?: | |
| How many hours of television do you watch per week?: | |
| Do you use artificial sweetners? | Yes |
| No |
| Comments: | Please use the space below to add comments or any other information about yourself that you think will be helpful: |
|
STATEMENT OF CONSENT
I request that Frank Curto, MH perform a consultation and set up a program for the purpose of enhancing my health and well being. I understand that Frank Curto has a Master Herbalist certification from the Global College of Natural Medicine, an accredited school in California, board certification from the American Association of Drugless Practitioners as a Holistic Health Practitioner and is ordained in the Ministry of Herbalism by the Church of the Universal Light. I understand that this consultation is not intended as a diagnosis, prescription, or treatment for any disease, physical or mental. It is also not intended as a substitute for regular medical care.
ARTICLE IX, U.S. CONSTITUTION “The
enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.” Under the ninth Amendment to the Constitution of the United States of American, I retain the right to freedom of choice in health care (or psychological services, or educational services, etc.) This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy, or product recommended by the therapist, doctor or any practitioner of my choice. The enumeration in this declaration of these shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time.
CONSTRUCTIVE NOTICE
Notice is hereby given to any person who receives a copy of this declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the First and Ninth Amendment, as enumerated in this declaration, that they may be in violation of my civil and constitutional rights, Title 42, U.S.C. 1983 et seq. And Title 18, Section 241.
|
| | I have read the consent statement and agree with the terms |
