EVALUATION FORM:

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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): _______________________________________

___________________________________________________________________

___________________________________________________________________

3. Phone number: ( ) _________-________________________

3a. Main Complaint: _____________________________________________________

___________________________________________________________________

___________________________________________________________________

4. Blood type: A B AB 0

5. Where were you raised? _______________________________________________

6. Occupation: _________________________________________________________

7. List paternal family diseases: ___________________________________________

___________________________________________________________________

8. List maternal family diseases: ___________________________________________

___________________________________________________________________

9. Do you have pets?____________________________________________________

10. How often do you exercise? ____________________________________________

a. What type of exercise do you do? ________________________________________

___________________________________________________________________

11. Do you experience digestive difficulties (bloating, constipation, gas,

etc...)? ________

Describe: ___________________________________________________________

________________________________________________________________________

________________________________________________________________________

12. List any food or environmental allergies. ___________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Describe your symptoms and health history as completely as possible. __________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

14. Have you ever been hospitalized for surgery? _________

a. If so, what kind and how many? _____________________________________________

________________________________________________________________________________________________________________________________________________

15. Describe and list all supplementation you are using. _________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. List any medications you are taking and the reason you are taking it. ____________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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: _____________________________________________________________

___________________________________________________________________

Dinner: _____________________________________________________________

___________________________________________________________________

Snacks: ____________________________________________________________ ___________________________________________________________________


Breakfast:______________________________________________________________________________________________________________________________

Lunch: _____________________________________________________________

___________________________________________________________________

Dinner: _____________________________________________________________

___________________________________________________________________

Snacks: ____________________________________________________________ ___________________________________________________________________


Breakfast:______________________________________________________________________________________________________________________________

Lunch: _____________________________________________________________

___________________________________________________________________

Dinner: _____________________________________________________________

___________________________________________________________________

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? _________________________________

___________________________________________________________________

29. Are your friendships satisfying? _________________________________________

30. Are there any stressful circumstances in your life right now? _____________

Describe: ___________________________________________________________

______________________________________________________________________________________________________________________________________

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: ___________________________________________________________

___________________________________________________________________

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") ____________________________________________________

___________________________________________________________________

___________________________________________________________________ 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...)? ___________________________

___________________________________________________________________ ___________________________________________________________________

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)? ______________________________________________

___________________________________________________________________

___________________________________________________________________

47. What type of heating do you have in your home:

Wood burning stove? _______ Gas? _______ Electric ________Other? ________

48. What cosmetics do you use regularly? ____________________________________

___________________________________________________________________





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.

 

 

 

______________________________________ _____________________________________

CLIENT SIGNATURE WITNESS SIGNATURE

 

NAME _______________________ DATE_______________

ADDRESS _______________________ HOME PHONE _______________

PROV/STE_______________________ WORK PHONE _______________

PC/ZIP _______________________ E-mail _______________________

AGE _______________________