Consultation Form

Please call our office at (888) 489‐3438 or (310) 350-5053 to schedule your consultation. The following form is to be completed at least 24 hours prior to your consultation. If you prefer to print this form and fax it to us, please print this page, or click here to download and print.

Health History Questionnaire

Personal Information

Name:

Phone:

Address:

City:

State:

Zip:

Occupation:

Email:

Age:

Height:

Weight:

Blood Type:

How long have you been on The Body Ecology Diet?

Describe your current symptoms:

What have you already tried that worked well for you?

What have you already tried without success? For what reason do you believe it was not successful?

What challenges have been getting in the way of accomplishing your recovery and health goals?

Family History

DiabetesHeart DiseaseAsthmaGallbladder DiseaseKidney DiseaseArthritisStomach DisordersCancer
If Cancer, type of Cancer:
Other:

# of Children:
# of Pregnancies:
# of Miscarriages:
# of Abortions:

Complications:

Mother History

Mother Age:
Died from:

Grandmother Age:
Died from:

Grandfather Age:
Died from:

Father History

Father Age:
Died from:

Grandmother Age:
Died from:

Grandfather Age:
Died from:

Habits

CoffeeTeaSugarChocolateAlcoholCigarettesDrugsLaxatives
Work: hrs/wk
Sleep: hrs/day
Exercise: times/wk

Please describe what you are currently eating for...

Breakfast:

Lunch:

Dinner:

Snacks:

What are the three worst foods you eat during the week?
1.
2.
3.

What are the three healthiest foods you eat during the week?
1.
2.
3.

What were your childhood eating habits? (types of foods)

List any nutritional supplements you are currently taking, including name brands and amounts:

List any prescription medication you are currently taking and dosages:

Operations/ Accidents or Injuries (what & when):

Health Check List

Digestive Tract:
NauseaDiarrheaConstipationBloatingBelchingExcess GasHeartburn

Ears:
Itchy earsEarachesEar InfectionsEar DrainageRinging in EarsHearing Loss

Emotions:
Mood SwingsAnxietyNervousnessAnger/IrritabilityDepression

Energy:
FatigueApathyLethargyHyperactivityRestlessness

Eyes:
Watery EyesItchy or red eyesBlurred VisionTunnel Vision

Heart:
Irregular heartbeatRapid heartbeatChest pains

Joint/Muscle:
Joint painArthritisMuscle painVaricose veins

Head:
HeadachesDizziness

Lungs:
Chest congestionAsthmaShortness of breath

Mind:
Poor memoryConfusionLearning

Disabilities:
StutteringPoor concentration

Mouth/Throat:
Chronic sore throatSwollen gumsCanker soresSensitive teeth‐nerves

Nose:
Stuffy noseSinus problemsHay FeverSneezingExcess Mucus

Skin:
AcneHives or rashesHair lossExcess sweating

Weight:
Binge eatingCravingsExcessive weightCompulsive eatingWater retentionUnder‐weight

Other:
Frequent illnessFrequent urinationGenital itchGenital Discharge

From the following list, what do you believe might be causing your fatigue?
Airborne?Food?Poor Sleep Habits?Thyroid?Stress?

Please list your known allergies:

Describe your hormone activity (your period as a teen/menopause difficulties):

Have you had previous Colon cleansing sessions with a professional colon Hydrotherapist?

If so, when?

How many?

Are you currently doing colonics or enemas now?

What was your Candida Questionnaire score from The Body Ecology Diet Book?

What have some other professionals told you about your health?

Metabolic Assessment Form

Please list your 5 major health concerns in order of importance:

Please choose on a scale of 1 – 4 the appropriate answer to each question below.

Category I – Colon

Feeling that bowels do not empty completely: 1234

Lower abdominal pain relief by passing stool or gas: 1234

Alternating constipation and diarrhea: 1234

Diarrhea: 1234

Constipation: 1234

Hard dry or small stool: 1234

Coated tongue of “fuzzy” debris on tongue: 1234

Pass large amount of foul smelling gas: 1234

More than 3 bowel movements daily: 1234

Do you use laxatives frequently: 1234

Category II – Hypochlorhydria

Excessive belching or aching 1‐4 hours after eating: 1234

Gas immediately following a meal: 1234

Offensive breath: 1234

Difficult bowel movements: 1234

Sense of fullness during and after meals: 1234

Difficulty digesting fruits and vegetables; undigested foods found in stools: 1234

Category III – Hyperacidity (Ulcer)

Stomach pain, burning or aching 1‐4 hours after eating: 1234

Do you frequently use antacids: 1234

Feeling hungry an hour or two after eating: 1234

Heartburn when lying down or bending forward: 1234

Temporary relief from antacids, food, milk, carbonated beverages: 1234

Digestive problems subside with rest and relaxation: 1234

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine: 1234

Category IV – Small Intestine (Pancreas)

Roughage and fiber cause constipation: 1234

Indigestion and fullness last 2‐4 hours after eating: 1234

Pain, tenderness, soreness on left side under rib cage bloated: 1234

Excessive passage of gas: 1234

Nausea and /or vomiting: 1234

Stool undigested, foul smelling mucous‐like, greasy or poorly formed: 1234

Frequent urination: 1234

Increased thirst and appetite: 1234

Difficulty losing weight: 1234

Category V – Biliary Insufficiency and/or stasis

Greasy or high fat foods cause distress: 1234

Lower bowel gas and or bloating several hours after eating: 1234

Bitter metallic taste in mouth, especially in the morning: 1234

Unexplained itchy skin: 1234

Yellowish cast to eyes: 1234

Stool color alternates for clay colored to normal brown: 1234

Reddened skin, especially palms: 1234

Dry or flaky skin and/or hair: 1234

History of gallbladder attacks or stones: 1234

Have you had your gallbladder removed? 1234

Category VI ‐ Hypoglycemia

Crave sweets during the day: 1234

Irritable if meals are missed: 1234

Depend on coffee to keep yourself going or started: 1234

Get lightheaded if meals are missed: 1234

Eating relieves fatigue: 1234

Feel shaky, jittery, tremors: 1234

Agitated, easily upset, nervous: 1234

Poor memory, forgetful: 1234

Blurred vision: 1234

Category VII – Adrenal Hypofunction

Cannot stay asleep: 1234

Crave salt: 1234

Slow starter in the morning: 1234

Afternoon fatigue: 1234

Dizziness when standing up quickly: 1234

Afternoon Headaches: 1234

Headaches with exertion or stress: 1234

Weak nails: 1234

Category VIII – Adrenal Hyperfunction

Cannot fall asleep: 1234

Perspire easily: 1234

Under high amounts of stress: 1234

Weight gain when under stress: 1234

Wake up tired even after 6 or more hours of sleep: 1234

Excessive perspiration or perspiration with little or no activity: 1234

Category IX ‐ Hypothyroid

Tired, sluggish: 1234

Feel cold – hands, feet, all over: 1234

Require excessive amounts of sleep to function properly: 1234

Increase in weight gain even with low‐calorie diet: 1234

Gain weight easily: 1234

Difficult, infrequent bowel movements: 1234

Depression, lack of motivation: 1234

Morning headaches that wear off as the day progresses: 1234

Outer third of eyebrow thins: 1234

Thinning of hair on scalp, face or genitals or excessive falling hair: 1234

Dryness of skin and/or scalp: 1234

Mental sluggishness: 1234

Category X – Thyroid Hyperfunction

Heart palpitations: 1234

Inward trembling: 1234

Increased pulse even at rest: 1234

Nervousness and emotional: 1234

Insomnia: 1234

Night Sweats: 1234

Difficulty gaining weight: 1234

Category XI – Pituitary Hypofunction

Diminished sex drive: 1234

Menstrual disorders of lack of menstruation: 1234

Increased ability to eat sugars without symptoms: 1234

Category XII – Pituitary Hyperfunction

Increased sex drive: 1234

Tolerance to sugars reduced: 1234

“Splitting” type headaches: 1234

Category XIII (Males Only) ‐ Prostate

Urination difficulty or dribbling: 1234

Urination frequent: 1234

Pain inside of legs or heels: 1234

Feeling of incomplete bowel evacuation: 1234

Leg nervousness at night: 1234

Category XIV (Males Only) ‐ Andropause

Decrease in libido: 1234

Decrease in spontaneous morning erections: 1234

Decrease in fullness of erections: 1234

Difficulty in maintain morning erections: 1234

Spells of mental fatigue: 1234

Inability to concentrate: 1234

Episodes of depression: 1234

Muscle soreness: 1234

Decrease in physical stamina: 1234

Unexplained weight gain: 1234

Increase in fat distribution around chest and hips: 1234

Sweating attacks: 1234

More emotional than in the past: 1234

Category XV (Menstruation Females Only)

Are you menopausal? 1234

Alternating menstrual cycle lengths? 1234

Extended menstrual cycle, greater than 32 days? 1234

Shortened menses, less than every 24 days? 1234

Pain and cramping during periods: 1234

Scanty blood flow: 1234

Heavy blood flow: 1234

Breast pain and swelling during menses: 1234

Pelvic pain during menses: 1234

Irritable and depressed during menses: 1234

Acne break outs: 1234

Category XVI (Menopausal Females Only)

How many years have you been menopausal?

Do you ever have uterine bleeding since menopause? 1234

Hot Flashes: 1234

Mental Fogginess: 1234

Disinterest in Sex: 1234

Mood Swings: 1234

Depression: 1234

Painful intercourse: 1234

Shrinking breast: 1234

Facial hair growth: 1234

Acne: 1234

Increased vaginal, pain, dryness or itching: 1234

Do you smoke?

How many times a week do you eat raw nuts and seeds?

How many alcoholic beverages do you consume per week?

How many times do you eat out per week?

How many times a week do you schedule for workouts?

How many caffeinated beverages do you consume per day?

How many times a week do you eat fish?

Rate your stress levels on a scale of 1‐10 during the average week.

Medications

Check any of the following medications that you are currently taking.

AntacidsAntibioticsAntidepressantsAntifungalsAntihistaminesAnti‐InflammatoryAnxiety MedicationAspirin/TylenolDiureticsHigh Blood PressureHigh CholesterolHormones ReplacementsHydrocortisone CreamOral ContraceptivesThyroid Hormones

Others: