The Natural Path Alternative Health Questionnaire

Please help us provide you with the most appropriate and effective service by completing the following questions. All information is kept confidential.

Personal Data: (please print)                                                                                                                                 Date:

First Name Last Name

Address City /State /Zip

Phone: HomeWork_Cell_e-mail_

Occupation Date of Birth_Gender

Your Physician’s NamePhysician’s address__

Physician’s Telephone number  Did your physician recommend colon hydrotherapy?  Yes     No

Emergency ContactNumber

How did you find out about us?

Boston Yellow Pages	Practitioner (name & specialty) Purpose of Visit/Main Complaint/
Spirit of Change Ad	Our client (client’s name)_
Internet/Website	Market Street Health Advertising
Other	Diagnosis

Health History:  Do you currently have, or have you had in the past, any of the following:  C for Current   P for past

General Symptoms:

Allergies Anxiety Convulsions Depression

Dizziness Extreme weight loss Extreme weight gain Fainting

Fatigue Fever/chills Fissure Headache

High or low blood pressure Loss of sleep Skin Condition Sweats

Gastro-Intestinal:

Abdominal Gas/pain Appendicitis Bad Breath Belching  Bloating  Blood in stool

Constipation Crohn’s Diverticulitis Diarrhea  Gallstones Hemorrhoids

Hernia Indigestion Nausea Parasites/worms in stool Polyps Poor appetite

Rectal/GI hemorrhaging Urinary Tract Infections Vomiting

Intestinal Procedures:

Please list any intestinal-related procedures you have had, along with the year it took place and your age at the time:

Other:

AIDS/HIV Anal discomfort Anemia Anorexia Arthritis Asthma Auto Immune Disorder Blood clot/vessel disorder Bulimia

Cancer Candida Albicans Chemical Toxicity Currently months pregnant Diabetes Edema Environmental Sensitivities Epstein-Barr Eczema

Fibromyalgia Heart Condition Hepititis Irregular menstrual cycle Kidney Stones Liver disease Low blood sugar Mental disorder Other

Nerve Disorder  PMS  Renal insufficiency Spleen/pancreas Thyroid problems Toxicity Tumor Ulcer Venereal

1. If your appointment is for Colon Hydrotherapy, is this your first Colon Hydrotherapy session? Yes    No             

    .If not, where and when was your most recent visit?

2. If your appointment is for acupuncture, is this you first session? Yes    No

    If not, where and when was your most recent visit?

3. Are you currently fasting? Yes    No      Are you currently cleansing? Yes    No         

     a. If yes, type of fast or cleanse program:

4. Have you had surgery in the past?  q Yes    No     Please list history of surgical procedures/hospitalizations (include the year and your age at the time): 

5. Have you had any significant physical/emotional traumas or injuries?  Please list:        

6. Do you use any of the following? How frequently?  antibiotics      over-the-counter drugs        steroids

recreational drugs ______	prescribed birth control		herbs__________ other __________________
prescription drugs (please list)		anti-depressants (please list)		supplements (please list)

7. Do you use an electronic medical device (i.e. Pacemaker)? Yes    No

Diet: Using the following key, please indicate your dietary usage.

H = Heavy (5 - 7 times a week)         L = Light (once a week or less)        M = Moderate (2 -4 times a week)     N = Never (really, never!)

Alcohol Antacids Baked goods Beans Caffeinated Coffee Caffeinated Tea Carbonated Water Cheese Chocolate Dairy Products

Eggs Fast Foods Fatty Foods Fish  Flax Fiber Fried Foods Fruit  Green leafy vegetables Gum Junk Food

Nuts / Seeds Organic Foods Pasta Popcorn Poultry Processed foods Protein Shakes Psyllium Fiber Red Meat/Animal Products  Salt

Smoothies Soda Soy       Sugar   Tobacco Water Wheat products White bread Whole Grains Yogurt

Briefly describe your typical dietary intake for the following meals:

        Breakfast        

        Lunch

        Dinner

       Snacks  

How many bowel movements do you usually have?                   # Per day                       # Per week

Do you strain to have a movement? Yes      No

Does the movement feel complete? Yes      No

Please check applicable responses. The stool . . .

? Shows signs of mucus	Usual Color
? Shows signs of blood	Usual Shape
? Has a strong odor	Usual Consistency

Do you exercise? Yes      No    How often?  What type of exercise do you enjoy?

Height Weight       Cigarette per day   Alcohol per week  Meals per day   Urine Color/Amt   

Sweat Day/Night Sleep Sound/Hours            Cup Coffee per day                   Mouth Taste/Smell/Dry

Family History indicate relationship

Cancer              Diabetes      Seizures      High Blood Pressure 

Heart DiseaseStroke           Asthma        Overweight                  Other      

I have read and agree to these policies of The Natural Path Alternative, Inc:

§          Please be on time. If you are late, a shortened session will be charged at the full rate.

§          We request payment in full at the time of your visit.  We accept cash, Visa, MasterCard, and personal checks.  All

returned checks are subject to a $20 handling fee.

§          A referral from your primary health care provider or our supervising physician is required if you have a condition or are

following a prescribed treatment.

§          We require 48 hours notice for all cancellations or postponements; otherwise a $60 fee will be charged.  As a courtesy, we

give clients a telephone reminder a day or two before an appointment; however, appointments are considered confirmed when they are made.

·          All series must be used within 1 year.  Any refunds within a year are subject to a $10 processing fee  and all sessions will be charged at the regular rates.  No refunds are given after the 1 year  expiration date.

·          Please remember any detox can be discontinued at any time and the price will be prorated to services and products received along with a 20% cancellation fee.

·          Herbal Sales are final

Client Signature: ________________________________________________________           Date: __________________________

Additional Page for Acupuncture

For Women

Menstruation

Age of first period  Duration of period (range and lastest period)

No. of Days between period Date of last period

Pre-Menstrual Syndrome (PMS)

Vaginal Discharge

Quantity: HeavyMediumLight        Clot

Quality: ThickMediumThin             Color

Breast

Lumps  YesNo                                           Birth ControlDuration

Pregnancy

Dates and No.Births dates and NoMiscarriages

Abortions    IU’s    IVF’s  

Client Signature: ________________________________________________________           Date: __________________________