M
Health Student Registration Form
Name: Age:
Street Address: City:
State/Province: Zip Code: Country:
Home Phone: Work Phone: Email:
Birth date: Birth Place: Nationality:
Marital Status: Single Married Separated Divorced Widowed
Weight: Height:
Occupation: Religion:
Educational Background: (highest grade completed)
Recreational activities:
In case of emergency contact: Phone:
Which program will you be attending? 10-Day ______ 18-Day ______
When do you plan to arrive and how?
How did you learn about Our Home Natural Health Retreat?
I want to have help dealing with:
High Blood Pressure Arthritis
Smoking Overweight
Diabetes Stress
Cancer
Other (Explain):
Date ___/___/___ Health Student Signature:
Family Health Information
(List family members (spouse, father, mother, brother/sisters, and/or children)
|Name |Relation |Present age, or age at death |If living, health (good, |If deceased, cause of death |
| | | |fair, poor) | |
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Personal History
Birthplace:
#of Pets: What kind? Any inside? Yes No
Type of Home: Past Occupations:
Habits:
Sleep: ____ hrs/night Do you have difficulty sleeping: Yes No Sometimes
Do You Smoke? Yes No If Yes, what? How Much?
Do You Drink Caffeine Containing Drinks? Coffee Tea Colas
How Much: Do You Drink: Beer Wine
Other Alcoholic Beverages? How Much of Each?
Are You on a Special Diet? Yes No What kind of diet?
Name:
Personal History (continued)
INJURIES: Head Chest Abdomen Back Broken bones Others:
Have you lost weight in the past year? No Yes
IMMUNIZATIONS: List all immunizations you have received, and the date
|Immunization |Date |
| | |
| | |
| | |
| | |
ALLERGIES: List any food or other allergies
__________________________________________________________________________________
__________________________________________________________________________________
MEDICINES (prescription or over the counter)
Are you regularly taking any medicines now? No Yes
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever taken: (Check ALL THAT APPLY)
Insulin: No Yes When: Cortisone: No Yes When:
Thyroid Med.: No Yes When: Hormones: No Yes When:
BP Medicine: No Yes When: Tranquilizers/Sedatives: No Yes When:
Birth control pills: No Yes When:
DEVICES: (Check)
Do you have any internal medical devices, (i.e. pacemaker or a defibrillator)? ________________________________________
____________________________________________________________________________________________________________________
OPERATIONS: Have you had any surgical procedure? If yes, what kind and when?
|Surgery |Date |
| | |
| | |
| | |
| | |
Please check everything on the following list that you normally use in your diet:
Fish rabbit cottage cheese kava cocoa honey
fowl white pepper yogurt molasses Postum beer
cold cuts butter cream candy artificial sweeteners cereal wine
lamb ice cream chocolate lard coffees pastries
beef milk white sugar syrup black tea nutmeg
pork ice milk brown sugar shortening margarine herb tea vinegar
shell fish non-fat milk raw sugar vegetable oil coffee catsup
cola drinks, hard liquor white bread decaffeinated coffee cookies cinnamon
white flour white rice white macaroni Tabasco Sauce black pepper pickles
Doughnuts mustard1 baking soda white spaghetti soda cracker eggs
horseradish, curry powder baking powder other carbonated drinks
Do you drink any liquids with your meals? Yes No
Do you ever eat between meals? Yes No Just before bedtime? Yes No
How many meals a day do you eat? Normal mealtimes?
Approximately how much time do you spend eating at mealtime?
Do you chew your food thoroughly, so that it is the consistency of cream? Yes No
Do you eat fruits and vegetables at the same meal? Yes No
How many glasses of water do you drink a day?
How often are you bothered with constipation? Diarrhea?
Are your bowel movements regular? Yes No How frequent?
How often do you have hard stools? Soft stools? Rectal bleeding?
How often do you urinate?
Is it normal for you to leave your arms or legs bare at times? Yes No
Do you often have cold hands or feet? Yes No Tingling sensations? Yes No
How often do you have indigestion? Gas?
What is your normal bedtime? Rising time?
Do you rest during the day? Yes No Sometimes
Do you exercise out of doors with any regularity? Yes No
What do you normally do for exercise?
DESCRIBE YOUR PERSONALITY TRAITS:
Please check everything on the following list that applies to you:
Outgoing
withdrawn
reserved
shy
self-confident
self-conscious
quiet
enthusiastic
calm
easily excitable
friendly
optimistic
pessimistic
compassionate
practical
awkward
poised
well-coordinated
organized
disorganized
perfectionist
idealistic
dependable
undependable
efficient
economical
sensitive
moody
depressed
impetuous
excessive worry
aggressive
decisive
Do you enjoy being around other people most of the time? If so, what type of people do you prefer?
What are your main interests or hobbies?
Do you have confidence that God is the only source of true healing?
Which of your weaknesses would you like to see strengthened?
DIAGNOSED DIFFICULTIES BY ALLOPATIIIC DOCTORS
Do you have or have you ever had in the past, any of the following?
CONDITION
Migraine Headaches PRESENT PAST WHEN:
Epilepsy or Convulsions PRESENT PAST WHEN:
Stroke PRESENT PAST WHEN:
Glaucoma PRESENT PAST WHEN:
Cataracts PRESENT PAST WHEN:
Blindness (either eye) PRESENT PAST WHEN:
Deafness PRESENT PAST WHEN:
Asthma PRESENT PAST WHEN:
Hay Fever PRESENT PAST WHEN:
Chronic Bronchitis PRESENT PAST WHEN:
Emphysema PRESENT PAST WHEN:
Tuberculosis PRESENT PAST WHEN:
Abnormal Chest X-Ray PRESENT PAST WHEN:
Heart Murmur as an adult PRESENT PAST WHEN:
Abnormal Electrocardiogram PRESENT PAST WHEN:
Enlarged heart PRESENT PAST WHEN:
Heart Attack PRESENT PAST WHEN:
Rheumatic Fever PRESENT PAST WHEN:
Angina PRESENT PAST WHEN:
High Blood Pressure PRESENT PAST WHEN:
Gall Stones PRESENT PAST WHEN:
Hepatitis PRESENT PAST WHEN:
Cirrhosis of Liver PRESENT PAST WHEN:
Stomach or Duodenal Ulcer PRESENT PAST WHEN:
Abnormal Stomach X-ray PRESENT PAST WHEN:
Colon or Bowel Trouble PRESENT PAST WHEN:
Rectal Trouble PRESENT PAST WHEN:
Hemorrhoids or Piles PRESENT PAST WHEN:
Dysentery or Serious Diarrhea PRESENT PAST WHEN:
Kidney or Bladder Infection PRESENT PAST WHEN:
Kidney Stones PRESENT PAST WHEN:
Other Kidney disease PRESENT PAST WHEN:
Poor Blood Clotting PRESENT PAST WHEN:
Diabetes PRESENT PAST WHEN:
Gout PRESENT PAST WHEN:
Overactive Thyroid PRESENT PAST WHEN:
Under active Thyroid PRESENT PAST WHEN:
Goiter PRESENT PAST WHEN:
Parkinson’s PRESENT PAST WHEN:
MS PRESENT PAST WHEN:
Varicose Veins PRESENT PAST WHEN:
Arthritis PRESENT PAST WHEN:
Polio PRESENT PAST WHEN:
Phlebitis PRESENT PAST WHEN:
Venereal Disease PRESENT PAST WHEN:
Anemia - (what kind?) PRESENT PAST WHEN:
Insulin? -What kind? PRESENT PAST How much?
Recurrent boils PRESENT PAST WHEN:
Other skin disease PRESENT PAST WHEN: what kind?
Serious depression PRESENT PAST WHEN:
Serious Emotional Problem PRESENT PAST WHEN:
Nervous Breakdown PRESENT PAST WHEN:
Women
Menstrual difficulties PRESENT PAST WHEN:
Ovarian Cyst PRESENT PAST WHEN:
Other GYN Problems PRESENT PAST WHEN: what kind?
Cystitis PRESENT PAST WHEN:
Mastitis PRESENT PAST WHEN:
Breast Cancer PRESENT PAST WHEN:
FAMILY HISTORY:
Has any blood relative ever had:
Cancer, including leukemia Yes Who:
Tuberculosis Yes Who:
Diabetes Yes Who:
Heart Trouble Yes Who:
Heart Attack Yes Who:
High Blood Pressure Yes Who:
Stroke Yes Who:
Epilepsy, Convulsions or fits Yes Who:
Bleeding tendency Yes Who:
Asthma Yes Who:
Allergies Yes Who:
Liver Disease Yes Who:
Migraine Headaches Yes Who:
Alcoholism Yes Who:
Emphysema/lung disease Yes Who:
Stomach or duodenal ulcer Yes Who:
Kidney Disease Yes Who:
Glaucoma Yes Who:
Sickle Cell Anemia Yes Who:
Other anemia Yes Who:
Arthritis Yes Who:
Gout Yes Who:
Obesity Yes Who:
Mental Illness Yes Who:
Thyroid Trouble Yes Who:
Suicide Yes Who:
Birth Defects Yes Who:
Chronic Diarrhea Yes Who:
Other Serious Disease Yes Who:
SYSTEM REVIEW
Do you have any of the following complaints: (Check all that apply)
HEAD
Blurred vision not corrected by glasses
double vision
light flashes
halos around lights
pain in your eyes
ear pain
drainage from ear
hearing difficulty or deafness
buzzing or ringing in ears
sinus trouble
difficulty swallowing
mouth or tongue problem
persistent hoarseness
Other
Explain:
SKIN
Changing mole
Rash
Yellow skin
Other skin problem
Explain:
NECK
Swelling
lumps
stiffness
other Explain:
CHEST, HEART, LUNGS
Shortness of breath
Poor exercise tolerance
Fluttering of heart
Unusual heartbeat
Chest pain or pressure attacks
Frequent cough
Coughing up blood
Wheezing swollen ankles
Other
Explain:
GASTROINTESTINAL
Poor appetite
Indigestion or heartburn
Nausea or vomiting
Vomiting blood
Abdominal pain of swelling
Blacktar-like bowel movements
Abdominal cramps
Other
Explain:
KIDNEY
Blood in urine
Difficulty passing urine
Pain or burning while urinating
Difficulty controlling urine
Getting up at night to urinate
Other Explain:
GENITALIA
WOMEN:
Breast lump
Discharge from nipple other breast problem
Vaginal bleeding or spotting (not with periods)
hot flashes
pain with intercourse
possibly pregnant
change in periods
pain not associated with periods
other Explain:
MEN:
Breast lump
Discharge from penis
Sore on penis
Lump in testicles
Difficulty having erections
Other Explain:
NEUROMUSCULAR
Weakness in arm or leg
Difficulty with balance
Dizzy spells
Fainting spells
Speech difficulty
Other Explain:
BONE/JOINTS
Painful joints
Swollen joints
Loss of muscle strength
Lump or swelling in muscle
Lump on bone
Back pain
Other
Explain:
ENDOCRINE
Thirsty all the time
Cold most of the time
Too warm most of the time
Unusually tired or sluggish
Unusually jumpy or nervous
PSYCHOLOGICAL
Do you find your life: generally unsatisfactory too demanding boring satisfactory?
Do you worry about: money job marriage home life children?
Do you:
Cry easily
Feel inferior to others
Feel shy
Feel things often go wrong
Often feel depressed
Have irrational fears
Feel anxious or upset
Have you:
Seriously considered suicide attempted suicide
CHIEF COMPLAINTS - Please list all symptoms
1. 2.
3. 4.
5. 6.
INSTRUCTIONS: Check the symptoms that apply to you. Use 1,2,3, or 4 to indicate the severity of the problem - 4 being the most severe. Answer ONLY if the symptoms apply to your case. Please note whether the problem is present, past or both.
|PAST |NOW | |PAST |NOW | |
| | |abnormal thirst | | |highly emotional |
| | |acid Foods | | |hoarseness, frequent |
| | |Acne | | |hunger between meals |
| | |Adenoids | | |impaired hearing |
| | |afternoon headaches | | |increased amount of urine |
| | |afternoon “yawner” | | |can’t decide easily |
| | |aging rapidly | | |can’t gain weight |
| | |air (swallow air) | | |can’t start in AM before coffee |
| | |allergies-asthma tendency | | |can’t work under pressure |
| | |aluminum cooking utensils | | |cataracts |
| | |ankles swell in evening | | |chemical or spray poisoning |
| | |ankles swell in morning | | |chemicals in environment |
| | |appetite excessive | | |chronic fatigue |
| | |appetite reduced | | |cigarette cough |
| | |Armed Forces Syndrome | | |circulation poor |
| | |arthritic tendencies | | |sensitive to cold |
| | |awaken after few hours asleep | | |cloudy urine |
| | |hard to get back to sleep | | |coated tongue |
| | |bad breath | | |cold sweats often |
| | |bad dreams | | |color blind |
| | |bitter, metallic taste in mouth in AM | | |constipation, common |
| | |black or bloody stools | | |constipation, diarrhea -alternating |
| | |bleeding gums | | |convulsions |
| | |bloating of intestines | | |crave candy or coffee in afternoon |
| | |blurred vision | | |crave salt |
| | |blushes easily | | |crave sweets or snacks |
| | |body odor bad | | |crawling sensation of skin |
| | |bottle fed | | |cries easily/no apparent reason |
| | |bowel movements painful | | |cuts heal slowly |
| | |breathing irregular | | |damp weather bothers |
| | |brittle fingernails | | |dandruff |
| | |brown spot or bronzing of skin | | |dark glasses |
| | |bruise easily “black & blue spots” | | |day dreamer |
| | |burning feet | | |daytime sleepiness |
| | |burning or itching anus | | |decreased amount of urine |
| | |burning on urination | | |decrease in appetite |
| | |burning stomach sensations | | |dental caries |
| | |relieved by eating | | |depressed |
| | |“butterfly” stomach, cramps | | |difficulty swallowing |
| | |dwell on past | | |digestion rapid |
| | |increased appetite | | |dizziness |
| | |eat often or get hunger pains or | | |drug reaction |
| | |Faintness | | |dull pain in chest or radiating to |
| | |eat rapidly | | |increase in weight |
| | |eat slowly | | |indigestion 1/2-1 hour after eating |
| | |eat when nervous | | |indigestion 3-4 hrs after eating |
| | |eyelids and face twitch | | |indoor occupation |
| | |eyelids swollen, puffy | | |smoky urine |
| | |eyes bulge | | |intestinal trouble |
| | |eyes or nose watery | | |intolerance to heat |
| | |eye strain | | |inward trembling |
| | |exhaustion-muscular and nervous | | |irritable and restless |
| | |extremities cold, clammy | | |irritable, annoyed easily |
| | |fainting spells | | |itching skin and feet |
| | |faintness if meals delayed | | |joint stiffness in evening |
| | |falling hair excessive | | |joint stiffness in morning |
| | |fatigue easily | | |keyed up, fail to calm |
| | |fatigue, eating relieves | | |lack energy |
| | |fearful | | |laxatives used often |
| | |fever easily raised | | |light colored stools |
| | |fluoridated toothpaste | | |loud talker |
| | |fluoridated water | | |loses temper easily |
| | |food poisoning history | | |low back pain, flank |
| | |frequent urination | | |low blood pressure |
| | |gag easily | | |lower bowel gas several hrs after eating |
| | |gas shortly after eating | | |magnifies insignificant events |
| | |get drowsy often | | |mentally alert, quick |
| | |going crazy sensation | | |mentally sluggish |
| | |goose flesh common | | |moods of depression, “blues” / melancholy |
| | |goose flesh seldom | | |mucous colitis |
| | |greasy food intolerances | | |muscle cramps, worse during exercise/ |
| | | | | |“charley horses” |
| | |gum chewer | | |muscle-leg-toe cramps at night |
| | |hair coarse, falls out | | |muscle twitching |
| | |hair treatments, sprays, etc. | | |nails weak, ridged, split |
| | |hallucinations | | |Nausea |
| | |hands and feet go to sleep easily; | | |nerve pains |
| | |Numbness | | |nervousness |
| | |hand tremor | | |opens windows in closed room y |
| | |hard to awaken | | |overeating sweets upset |
| | |hate to be criticized | | |overexertion reactions |
| | |headaches upon arising -wears off during | | |overwork |
| | |the day | | | |
| | |nose bleeds frequently | | |pain between shoulder blades |
| | |heart palpitates for no reason | | |perfectionist |
| | |hiccups frequently | | |perspiration increases |
| | |high altitude discomfort | | |perspiration decrease |
Do you represent any food and Drug, Medical or Government Organization? Yes No
I hereby give my permission and consent that my case records may be used for research and educational purposes.
NAME: DATE:
LIFE SCRIPT WORKSHEET
Describe yourself:
Describe your father:
Describe your mother:
What makes you feel most happy, loved, successful and glad to be alive?
What makes you feel most unhappy, unloved, mad, disgusted, etc.?
When you were little, who did you go to with your biggest troubles?
Why?
When you were little, what did the family usually talk about at the dinner table?
Nowadays, what is your main bad feeling?
What is wrong with your life?
Which parent had the same thing wrong?
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