EVALUATION FORM:
CLIENT EVALUATION FORM (please print off or email a copy for your appointment)
EVALUATION PROFILE FORM
Thank you for your interest in having an evaluation completed for you. The individual who is performing your evaluation is a Consulting Analyst. Therefore, they will not only be using information regarding physical conditions and nutrition, but they will also be considering the combined effects of lifestyle, environmental and emotional stressors. This evaluation process is intended to assist in the determination of causative factors, which may be related to traumas which have been sustained from the combined effects of chemicals, diet, radiations and emotions. In order to assist in the completion of the evaluation process, please respond to the following questions in full.
Personal Information
1. Name: ______________________________ Age: ________ M[ ] F [ ]
2. Address (including city, state, zip): _______________________________________
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3. Phone number: ( ) _________-________________________
3a. Main Complaint: _____________________________________________________
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4. Blood type: A B AB 0
5. Where were you raised? _______________________________________________
6. Occupation: _________________________________________________________
7. List paternal family diseases: ___________________________________________
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8. List maternal family diseases: ___________________________________________
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9. Do you have pets?____________________________________________________
10. How often do you exercise? ____________________________________________
a. What type of exercise do you do? ________________________________________
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11. Do you experience digestive difficulties (bloating, constipation, gas,
etc...)? ________
Describe: ___________________________________________________________
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12. List any food or environmental allergies. ___________________________________
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13. Describe your symptoms and health history as completely as possible. __________
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14. Have you ever been hospitalized for surgery? _________
a. If so, what kind and how many? _____________________________________________
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15. Describe and list all supplementation you are using. _________________________
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16. List any medications you are taking and the reason you are taking it. ____________
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Diet
17. Did/do you drink coffee? ______ How many years? ______ If you quit, when? _____
18. Did/do you drink black tea? ____ How many years? _____ If you quit, when? _____
19. Did/do you drink carbonated beverages? _______ How long? _________
Diet drinks? _______ If you quit, when? _________
20. Do you consume alcohol? ______ If so, how much and how often? _____________
21. Do you eat large or regular amounts of chocolate? _____________
22. What is your water source? _____________________________
23. Do you eat organic fruits and vegetables? _________________________________
24. Write down everything you eat and drink over a typical three-day period.
Include condiments, snacks, sweeteners, etc...
Breakfast: __________________________________________________________ ___________________________________________________________________
Lunch: _____________________________________________________________
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Dinner: _____________________________________________________________
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Snacks: ____________________________________________________________ ___________________________________________________________________
Breakfast:______________________________________________________________________________________________________________________________
Lunch: _____________________________________________________________
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Dinner: _____________________________________________________________
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Snacks: ____________________________________________________________ ___________________________________________________________________
Breakfast:______________________________________________________________________________________________________________________________
Lunch: _____________________________________________________________
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Dinner: _____________________________________________________________
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Snacks: ____________________________________________________________ ___________________________________________________________________
25. Are you satisfied with your eating habits? ________________
Emotions
26. Is your occupation stressful? ____________________________________________
27. How is your relationship with your coworkers? ______________________________
28. Are your family relationships harmonious? _________________________________
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29. Are your friendships satisfying? _________________________________________
30. Are there any stressful circumstances in your life right now? _____________
Describe: ___________________________________________________________
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31. Are you traveling extensively? ___________________________________________
Chemicals
32. Are/were you a smoker? ______ How many years? _____If you quit, when? ______
33. Do you have metal dental fillings? _______ How many? _______
Have you had any removed? _______ When? _______________
34. Do you have root canals? ________ How many? _____________
35. Do you have crowns or other metals (braces, "flippers", partials, retainers. etc.) in your mouth? _____________
Describe: ___________________________________________________________
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36. Do or have you used aluminum cookware? __________________
37. Do you use spray deodorants or antiperspirants? _____________
What kind? _________________________________________________________
38. Do you use antacids? ___________
39. Are you now on or have you ever taken birth control pills? ___________ How many years? _______ What year did you begin? ______________
40. Are you now or have you ever been on estrogen replacement therapy? __________
41. Have you had inoculations? _________
42. What drugs have you taken during your life? (include prescription, over the-counter, and recreational") ____________________________________________________
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___________________________________________________________________ 43. Have you ever been on antibiotics? ________ When? _________
For how long? ________________ For what reason _________________________
44. Do you live near any farms or large agricultural projects? ________
If so, what kind (dairy, vegetable, orchard, etc...)? ___________________________
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45. Do you live in preconstructed housing, such as a mobile or modular home? _______
How old is the home? ____________________
46. Has there been any kind of remodeling/construction in your home recently (sheet rock, paint, new carpets)? ______________________________________________
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47. What type of heating do you have in your home:
Wood burning stove? _______ Gas? _______ Electric ________Other? ________
48. What cosmetics do you use regularly? ____________________________________
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Radiations
49. Do you live near any nuclear reactors or military bases? ________________
If so, how many miles away is the facility? ____________
50. Are there any high-tension lines or step-down transformers near your home or work? _________________
51. Do you use a micro-wave oven? _____ Electric blanket? ____Water bed? ___
52. Do you have fluorescent lights? ____________________________________
53. Do you use a computer? _____ If so how often? _______________________
54. Do you use a cell phone? _____ If so, how many hours per day? __________
55. List any other information you think might be relevant. ___________________
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Declaration of Informed Consent to Services, Contract and Stipulations Regarding All Employees of Natura Vitoria
I understand and acknowledge neither that Natura Vitoria, nor any employees of said clinic do or can guarantee that the protocols will cure me of any disease or affliction. I believe it is within my constitutional rights to seek any form of diagnosis or treatment whether orthodox or unorthodox (not recommended by the CMA or AMA). It is my choice whether or not to accept such diagnosis and treatment. By my signature I attest that I have not engaged the services of this clinic to file a malpractice suit or to further any investigation or prosecution by any government entity or medical association or pharmaceutical company. My sole purpose and intent in seeking the services of Natura Vitoria is to get information and help for my personal health problems.
I understand that Natura Vitoria protocols and assessments may include :
Live/Dry Blood Analysis and other healing modalities as made available by the clinic staff. I also understand that such treatments may be unconventional or experimental in nature and as such accept all risks and liabilities for such decisions. I agree to hold Natura Vitoria and all its employees harmless and blameless from any untoward results. I acknowledge that my acceptance of the clinic services binds me to pay the fees and that such fees reflect both the expertise of the professionals as well as the intensity of the protocols involved.
Payment for services is due at time of administration of services rendered.
I understand that I have the right to choose the doctor/practitioner of my choice to address my health issues. I also have the right to discontinue the care and treatments of that doctor/practitioner at any time, but I agree that I will promptly pay to date any and all outstanding balances due for services rendered.
If you are unable to honor an appointment and fail to provide 24 hours notice. A full appointment fee of
$ 60.00 will be charged. Courtesy calls are appreciated.
I have read or had read to me the Declaration of Informed Consent to Services and agree to be bound by the terms therein. I have not signed this declaration without reading it or having it read to me and I may ask questions useful in helping me to understand it. I further understand my agreement to the provision of this declaration is an entirely voluntary and informed choice to which my signature attests.
I understand that the advice and treatment protocols of the professionals at Natura Vitoria. are based upon their training, experience and personal judgment as to how to help me to the fullest. In good faith, I accept and engage the services of those employed by Natura Vitoria, and do hold them harmless for the services they have or will render.
I understand that Natura Vitoria. is not a Medicare, Ohip, or Medicaid provider and that my receipt is not to be submitted to them for financial reimbursement.
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CLIENT SIGNATURE WITNESS SIGNATURE
NAME _______________________ DATE_______________
ADDRESS _______________________ HOME PHONE _______________
PROV/STE_______________________ WORK PHONE _______________
PC/ZIP _______________________ E-mail _______________________
AGE _______________________