Assessment Form
(All information maintained strictly confidential)Name______________________________________
Address ____________________________________
City__________ State____ Zip_________
Contact Phone_________________ Times ________________
Birth date___________ Email___________________________
Occupation(s)_____________________________________________________
Primary Care Physician___________________ PCP Phone ________________
What were your results on the Candida Questionnaire? _____________________
(There is a link to this questionnaire on the "How I work" page)
List other medical & alternative care currently used (e.g. acupuncture, chiropractic , etc)
________________________________________________________________
List all current medications
and how long taken. Identify side-effects you are
experiencing .
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Circle the following supplements, essential oils, medicinal
foods, etc that you use
and indicate how much per week:
| Essential Oils | Peppers | Garlic |
| Ginger | Ginseng | Tea |
| Coffee | Tea Tree Oil | Swedish Bitters |
| Sunrider Products | KM Products | Pau d'Arco tea |
List other supplements medicinal foods, herbs & spices used and how
much:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Now Check above, the medicines & supplements that you know really help.
Identify applicable health factors either at home or at work, now or in the past:
Exercise: under or over-exertion, forms: __________________________________
Sleep: Adequate? (Yes/No), Sleep time:_____ Wake time:_____
Any sleep problems?:________________________________________________
Pets:____________________________________________________________
Hobbies:_________________________________________________________
Addictions: drugs, sex, alcohol, other:____________________________________
"Recreational" drugs taken & frequency:__________________________________
Physical or mental abuse: ____________________________________________
Over-work: ________________________________________________________
Travel: ___________________________________________________________
Hot springs: _______________________________________________________
Dental work, "silver" fillings, stainless "steel": _____________________________
Economic stress: ___________________________________________________
Other stress: ______________________________________________________
Circle any of the following toxins that are present in your environment:
| chemicals (household & other) | pesticides | paints |
| construction materials | water contamination |
strong odors |
| camphor (e.g. Tiger balm), | mothballs | mold or dampness |
other toxins:________________________________________________________
Circle any of the following sources of EMF (electromagnetic field) in your environment:
| microwaves | cell phone | electric blanket |
|
power cables next to bed |
electric clock near bed | high power lines |
| tattoo parlor machines | portable phone |
Circle any of the following factors in your
diet: processed or hydrogenated oils,
fried foods, sugar, excess salt, highly spicy,
highly processed foods, fast foods.
Family Health History
List major diseases and cause of death for the following members of your family.
Father_____________________________________________________
Mother_____________________________________________________
Siblings ____________________________________________________
___________________________________________________________
___________________________________________________________
Father's mother__________________________________________________
Father's father___________________________________________________
Mother's mother__________________________________________________
Mother's father___________________________________________________
Health Time-line:
Please
create a timeline of your health from conception to the present. Include anything that may
possibly have had an impact on your health including adverse vaccinations,
illnesses, injuries, physical or emotional crises, dental work, operations,
birth trauma, parental conflict, etc. Contacting your parents may be helpful.
On a separate sheet of unlined paper please hand-write a full page narrative about your current health condition.
Leave the following blank until you meet with me:
I understand that when undertaking to improve my health it can be difficult to determine what factors are affecting the results. Therefore I commit to ______ months (usually 6 months minimum) of care without making changes to my supplements & medications or adding in other forms of care unless mutually agreed upon or approved by my doctor.
Signed _____________________________________ Date ______________
Please bring this filled-out form with you to the initial interview or return it to:
Roger Barr, POB 1427, North Fork, CA 93643-1427
Tel: (559) 877-7233
Email:
you@canhealyourself.comHow I Work | Home İcanhealyourself.com