Symptom Survey

European Natural Health Center
World-Wide Natural Health Service
Imagine Health. Naturally

Health Assessment Questionnaire -- Electronic Filing Part 2

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Please fill the questionnaire and press SUBMIT button at the bottom of this form. Will be in contact with you shortly to setup a consultation. You must AGREE with the statement below to proceed:

CLIENT REQUEST: By answering questions in the Health Assessment Questionnaire, I request European Natural Health Centers assistance to evaluate this Health Assessment Questionnaire and/or interview me to set up my individual health-enhancement program. NATURAL HEALTH SERVICES: The natural care offered by European Natural Health Centers may be considered by some outside the current standard of care in the medical community. Such natural care is commonly referred to as complementary or alternative medicine ("CAM"), or functional, holistic or integrative care. Many of these modalities have been long practiced with great success in other countries and cultures even though they may not be considered a standard in the US. While synthetic and allopathic medicine is essential and highly effective in life support and treatment of acute/catastrophic conditions, there are alternatives that can provide the body additional support and accelerate the healing process. WHO WE ARE, OUR MISSION AND BELIEFS: We are a Christian practice. We provide health services using natural modalities and remedies proven over thousands of years to support and enhance human lives. We believe: *In God-given right to seek out health according to one’s beliefs. *In the miracle of life; we do not treat or cure, we provide the body with what it needs naturally. If the body has the elements it needs to heal itself, it usually will. *In educating and informing about health according to our beliefs, education and experience. *In assisting those whose health needs have been abandoned by others. *In assisting anyone of any faith in their quest for health without being subjected to their values and beliefs. If you agree with these principles and would like to discuss your health needs, we are at your service. CLIENT STATEMENT: I understand that if I choose to see a practitioner at European Natural Health Centers, I will discuss the status, risks, and benefits of potential health programs, supplements and remedies. Additionally, I will seek the counsel of a physician or other qualified health practitioner with any concerns regarding symptoms, a medical condition, or the use of any products if I so desire. I understand this health evaluation is in the context of nutritional deficiencies only and any subsequent health advice resulting from this evaluation will be in the form of a nutritional suggestion and/or supplementation, exercises, lifestyle improvements and the like. I understand any nutritional supplements/formulations (if needed) will be billed separately with my separate permission. **I acknowledge and understand that Andre A. Kulisz, PhD, ND(US), DNM(EU), ACN, is not a medical doctor (MD) in the territories governed by the US laws. He is a Doctor of Science (PhD) in application of science in medicine and a Naturopath (Naturopathic Doctor) registered in the District of Columbia. He is accredited to practice in the European Union as a physician specialised in natural medicine. He is also Applied Clinical Nutritionist. **Tommie R. Dahlmann, ND(US), DNM(EU), CEDS, is not a medical doctor (MD) in the territories governed by the US laws. She is a Naturopath (Naturopathic Doctor) and accredited to practice in the European Union as a physician specialized in natural medicine. She is also nationally Certified Eating Disorders Specialist (US). PRIVACY STATEMENT: European Natural Health Centers, LLC does not sell, rent, lease, or otherwise release individual identifying information to any third-party about its patients or visitors to its site, including the names of those who communicate with European Natural Health Centers staff via e-mail. European Natural Health Center, LLC treats any health information discussed with clinical staff in strict confidence. PAYMENT FOR SERVICES: Payments due when services rendered. Consultation fee is $90.00/hr, half-an-hour minimum ($45.00). Analyses, supplements and formulations extra and must be approved by you before provided. There is a charge of $75.00 for paper Health Assessment Questionnaire ($49.95 for electronic version at http://myfoodforhealth.com). We will NOT process unpaid questionnaires. Missed appointments not cancelled minimum 24 hours in advance will be billed $45.00. If cancellation is of the emergency nature and scheduling of the new appointment occurs within 48 hours of the missed appointment, there will be no charge; however, if the second appointment is missed, $90.00 will be charged. Rev. 3.1, 9/1/2010

Please provide the following information:

We do NOT share, sell or otherwise distribute any information contained in this questionnaire

First Name

Last Name

Age

Minimum age is 12

Gender

Male Female

Height

in cm (i.e. for 5 feet 2 inches write 62 inches, for 1 meter 80 centimeters write 180 centimetres)

Weight

lbs kg

Blood Pressure

Example:130/80

Cholesterol: Total/LDL/HDL

/ /

Telephone:

No hyphens, no spaces. Non US and Canadian filers, please include country code.

Email:

Such as John@mydomain.com

Address

City

State/Province

May be left blank if not the USA or Canada

Zip/Postal Code

Country

Referred by

Other (if applicable)

Primary Health Concerns

Omit the credit card information if paid by PayPal or other payment arrangements have been made.

Credit Card Number

Visa, MasterCard, Discover

Expiration Date

mmyy

Cvv (card security code)

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In the following survey please mark the answers that apply to you. If the symptom does not apply to you, leave it marked NA (default), if the symptom applies to you, click the mark 1, 2, 3, or "Major health concern" depending on its severity:

Mark 1 if the symptom occurs rarely -- every few months

Mark 2 if the symptom occurs occasionally -- few times a months

Mark 3 if the symptom occurs more than once a week

Mark "Major health concern" ONLY if the symptom persists continuously OR you are extremely concerned of the symptom/condition. Do not mark this field more than five times in this survey.

At the end, after completing the survey, click "SUBMIT". We will contact you soon.

We thank you for entrusting your needs in us.

With best wishes of good health to you,

Dr. Andre A. Kulisz (Ph.D., ND)

Health Concerns/Symptoms

Severity

1 Acid foods upset

NA 1 2 3 Major health concern

2 Get chilled often
NA 1 2 3 Major health concern

3 “Lump” in throat
NA 1 2 3 Major health concern

4 Dry mouth, eyes, nose
NA 1 2 3 Major health concern

5 Pulse speeds after meal
NA 1 2 3 Major health concern

6 Keyed up, fail to calm
NA 1 2 3 Major health concern

7 Cuts heal slowly
NA 1 2 3 Major health concern

8 Gag easily
NA 1 2 3 Major health concern

9 Unable to relax, startles easily
NA 1 2 3 Major health concern

10 Extremities cold, clammy
NA 1 2 3 Major health concern

11 Strong light irritates

NA 1 2 3 Major health concern

12 Urine amount reduced
NA 1 2 3 Major health concern

13 Heart pounds after retiring
NA 1 2 3 Major health concern

14 “Nervous” stomach
NA 1 2 3 Major health concern

15 Appetite reduced
NA 1 2 3 Major health concern

16 Cold sweats often
NA 1 2 3 Major health concern

17 Fever easily raised
NA    X 1 2 3 Major health concern

18 Neuralgia-like pains
NA 1 2 3 Major health concern

19 Staring, blinks little
NA 1 2 3 Major health concern

20 Sour stomach frequent
NA 1 2 3 Major health concern

GROUP TWO

21 Joint stiffness after arising

NA 1 2 3 Major health concern

22 Muscle-leg-toe cramps at night
NA 1 2 3 Major health concern

23 “Butterfly” stomach, cramps
NA 1 2 3 Major health concern

24 Eyes or nose watery
NA 1 2 3 Major health concern

25 Eyes blink often
NA 1 2 3 Major health concern

26 Eyelids swollen, puffy
NA 1 2 3 Major health concern

27 Indigestion soon after meals
NA 1 2 3 Major health concern

28 Always seem hungry; feels “lightheaded”
NA    X 1 2 3 Major health concern

29 Digestion rapid
NA 1 2 3 Major health concern

30 Vomiting frequent
NA    X 1 2 3 Major health concern

31 Hoarseness frequent

NA 1 2 3 Major health concern

32 Breathing irregular
NA 1 2 3 Major health concern

33 Pulse slow; feels “irregular” sensitive to cold
NA 1 2 3 Major health concern

34 Gagging reflex slow
NA 1 2 3 Major health concern

35 Difficulty swallowing asthma, bronchitis
NA 1 2 3 Major health concern

36 Constipation, often diarrhea alternating
NA 1 2 3 Major health concern

37 “Slow starter”
NA 1 2 3 Major health concern

38 Get “chilled” infrequently
NA 1 2 3 Major health concern

39 Perspire easily
NA 1 2 3 Major health concern

40 Circulation poor
NA 1 2 3 Major health concern

41 Subject to colds

NA 1 2 3 Major health concern

GROUP THREE

42 Eat when nervous
NA 1 2 3 Major health concern

43 Excessive appetite
NA 1 2 3 Major health concern

44 Hungry between meals
NA 1 2 3 Major health concern

45 Irritable before meals
NA 1 2 3 Major health concern

46 Get “shaky” if hungry
NA    X 1 2 3 Major health concern

47 Fatigue, eating relieves
NA 1 2 3 Major health concern

48 “Lightheaded” if meals delayed
NA 1 2 3 Major health concern

49 Heart palpitates if meals missed or delayed in afternoons
NA 1 2 3 Major health concern

50 Afternoon headaches

NA 1 2 3 Major health concern

51 Overeating sweets upsets
NA 1 2 3 Major health concern

52 Awaken after few hours sleep - hard to get back to sleep
NA 1 2 3 Major health concern

53 Crave candy or coffee
NA 1 2 3 Major health concern

54 Moods of depression “blues” or melancholy
NA 1 2 3 Major health concern

55 Abnormal craving for sweets or snacks
NA    X 1   X 2 3 Major health concern

GROUP FOUR

56 Hands and feet go to sleep easily, numbness
NA 1 2 3 Major health concern

57 Sigh frequently, “air hunger”
NA 1 2 3 Major health concern

58 Aware of “breathing heavily”
NA 1 2 3 Major health concern

59 High altitude discomfort

NA 1 2 3 Major health concern

60 Opens windows in closed room
NA 1 2 3 Major health concern

61 Susceptible to colds and fevers
NA 1 2 3 Major health concern

62 Afternoon “yawner”
NA 1 2 3 Major health concern

63 Get “drowsy” often
NA 1 2 3 Major health concern

64 Swollen ankles, worse at night
NA 1 2 3 Major health concern

65 Muscle cramps, worse during exercise; get “charley horses”
NA 1 2 3 Major health concern

66 Shortness of breath on exertion
NA 1 2 3 Major health concern

67 Dull pain in chest or radiating into left arm, worse on exertion
NA 1 2 3 Major health concern

68 Bruise easily, “black and blue” spots
NA 1 2 3 Major health concern

69 Tendency to anemia

NA 1 2 3 Major health concern

70 “Nose bleeds” frequent
NA 1 2 3 Major health concern

71 Noises in head, or “ringing in ears”
NA 1 2 3 Major health concern

72 Tension under the breastbone, or feeling of “tightness”, worse on exertion
NA 1 2 3 Major health concern

GROUP FIVE

73 Dizziness
NA 1 2 3 Major health concern

74 Dry skin
NA 1 2 3 Major health concern

75 Burning feet
NA 1 2 3 Major health concern

76 Blurred vision
NA 1 2 3 Major health concern

77 Itching skin and feet
NA 1 2 3 Major health concern

78 Excessive falling hair

NA 1 2 3 Major health concern

79 Frequent skin rashes
NA 1 2 3 Major health concern

80 Bitter, metallic taste in mouth in mornings
NA 1 2 3 Major health concern

81 Bowel movements painful or difficult
NA 1 2 3 Major health concern

82 Worrier, feels insecure
NA 1 2 3 Major health concern

83 Feeling queasy; headache over eyes
NA 1 2 3 Major health concern

84 Greasy foods upset
NA 1 2 3 Major health concern

85 Stools light-colored
NA 1 2 3 Major health concern

86 Skin peels on foot soles
NA 1 2 3 Major health concern

87 Pain between shoulder blades
NA 1 2 3 Major health concern

88 Use laxatives

NA 1 2 3 Major health concern

89 Stools alternate from soft to watery
NA 1 2 3 Major health concern

90 History of gallbladder attacks or gallstones
NA 1 2 3 Major health concern

91 Sneezing attacks
NA 1 2 3 Major health concern

92 Nightmares, bad dreams
NA 1 2 3 Major health concern

93 Bad breath (halitosis)
NA 1 2 3 Major health concern

94 Milk products cause distress
NA 1 2 3 Major health concern

95 Sensitive to hot weather
NA 1 2 3 Major health concern

96 Burning or itching anus
NA 1 2 3 Major health concern

97 Crave sweets
NA 1 2 3 Major health concern

GROUP SIX

98 Loss of taste for meat
NA 1 2 3 Major health concern

99 Lower bowel gas several hours after eating
NA 1 2 3 Major health concern

100 Burning stomach sensations, eating relieves
NA 1 2 3 Major health concern

101 Coated tongue
NA 1 2 3 Major health concern

102 Pass large amounts of foul-smelling gas
NA 1 2 3 Major health concern

103 Indigestion ½ hour to 1 hour after eating; may be up to 3-4 hours
NA 1 2 3 Major health concern

104 Mucous colitis or “irritable bowel”
NA 1 2 3 Major health concern

105 Gas shortly after eating
NA 1 2 3 Major health concern

106 Stomach “bloating” after eating
NA 1 2 3 Major health concern

GROUP SEVEN (A)

107 Insomnia
NA 1 2 3 Major health concern

108 Nervousness
NA 1 2 3 Major health concern

109 Can’t gain weight
NA 1 2 3 Major health concern

110 Intolerance to heat
NA 1 2 3 Major health concern

111 Highly emotional
NA 1 2 3 Major health concern

112 Flush easily
NA 1 2 3 Major health concern

113 Night sweats
NA 1 2 3 Major health concern

114 Thin, moist skin
NA 1 2 3 Major health concern

115 Inward trembling
NA 1 2 3 Major health concern

116 Heart palpitates

NA 1 2 3 Major health concern

117 Increased appetite without weight gain
NA 1 2 3 Major health concern

118 Pulse fast at rest
NA 1 2 3 Major health concern

119 Eyelids and face twitch
NA 1 2 3 Major health concern

120 Irritable and restless
NA 1 2 3 Major health concern

121 Can’t work under pressure
NA 1 2 3 Major health concern

GROUP SEVEN (B)

122 Increase in weight
NA 1 2 3 Major health concern

123 Decrease in appetite
NA 1 2 3 Major health concern

124 Fatigue easily
NA 1 2 3 Major health concern

125 Ringing in ears

NA 1 2 3 Major health concern

126 Sleepy during day
NA 1 2 3 Major health concern

127 Sensitive to cold
NA 1 2 3 Major health concern

128 Dry or scaly skin
NA 1 2 3 Major health concern

129 Constipation
NA 1 2 3 Major health concern

130 Mental sluggishness
NA 1 2 3 Major health concern

131 Hair coarse, falls out
NA 1 2 3 Major health concern

132 Headaches upon arising, wear off during day
NA 1 2 3 Major health concern

133 Slow pulse, below 65
NA 1 2 3 Major health concern

134 Frequent urination
NA 1 2 3 Major health concern

135 Impaired hearing

NA 1 2 3 Major health concern

136 Reduced initiative
NA 1 2 3 Major health concern

GROUP SEVEN (C)

137 Failing memory
NA 1 2 3 Major health concern

138 Low blood pressure
NA 1 2 3 Major health concern

139 Increased sex drive
NA 1 2 3 Major health concern

140 Headaches, “splitting or rendering” type
NA 1 2 3 Major health concern

141 Decreased sugar tolerance
NA 1 2 3 Major health concern

GROUP SEVEN (D)

142 Abnormal thirst
NA 1 2 3 Major health concern

143 Bloating of abdomen

NA 1 2 3 Major health concern

144 Weight gain around hips or waist
NA 1 2 3 Major health concern

145 Sex drive reduced or lacking
NA 1 2 3 Major health concern

146 Tendency to ulcers, colitis
NA 1 2 3 Major health concern

147 Increased sugar tolerance
NA 1 2 3 Major health concern

148 Women: menstrual disorders
NA 1 2 3 Major health concern

149 Young girls: lack of menstrual function
NA 1 2 3 Major health concern

GROUP SEVEN (E)

150 Dizziness
NA 1 2 3 Major health concern

151 Headaches
NA 1 2 3 Major health concern

152 Hot flashes

NA 1 2 3 Major health concern

153 Increased blood pressure
NA 1 2 3 Major health concern

154 Hair growth on face or body (female)
NA 1 2 3 Major health concern

155 Sugar in urine (not diabetes)
NA 1 2 3 Major health concern

156 Masculine tendencies (female)
NA 1 2 3 Major health concern

GROUP SEVEN (F)

157 Weakness, dizziness
NA 1 2 3 Major health concern

158 Chronic fatigue
NA 1 2 3 Major health concern

159 Low blood pressure
NA 1 2 3 Major health concern

160 Nails, weak, ridged
NA 1 2 3 Major health concern

161 Tendency to hives

NA 1 2 3 Major health concern

162 Arthritic tendencies
NA 1 2 3 Major health concern

163 Perspiration increase
NA 1 2 3 Major health concern

164 Bowel disorders
NA 1 2 3 Major health concern

165 Poor circulation
NA 1 2 3 Major health concern

166 Swollen ankles
NA 1 2 3 Major health concern

167 Crave salt
NA 1 2 3 Major health concern

168 Brown spots or bronzing of skin
NA 1 2 3 Major health concern

169 Allergies - tendency to asthma
NA 1 2 3 Major health concern

170 Weakness after colds, influenza
NA 1 2 3 Major health concern

171 Exhaustion - muscular and nervous

NA 1 2 3 Major health concern

172 Respiratory disorders
NA 1 2 3 Major health concern

GROUP EIGHT

801Acoustic hallucinations
NA 1 2 3 Major health concern

802 Anorexia
NA 1 2 3 Major health concern

803 Anxiety
NA 1 2 3 Major health concern

804 Apprehension
NA 1 2 3 Major health concern

805 Confusion
NA 1 2 3 Major health concern

806 Craving for sweets
NA 1 2 3 Major health concern

807 Depression
NA 1 2 3 Major health concern

808 Distraction

NA 1 2 3 Major health concern

809 Dizziness
NA 1 2 3 Major health concern

810 Fatigue
NA 1 2 3 Major health concern

811 Feeling something dreadful will happen
NA 1 2 3 Major health concern

812 Forgetfulness
NA 1 2 3 Major health concern

813 Headache
NA 1 2 3 Major health concern

814 Hypochondria
NA 1 2 3 Major health concern

815 Indigestion
NA 1 2 3 Major health concern

816 Insomnia
NA 1 2 3 Major health concern

817 Instability
NA 1 2 3 Major health concern

818 Irritability

NA 1 2 3 Major health concern

819 Morbid fears
NA 1 2 3 Major health concern

820 Muscular soreness
NA 1 2 3 Major health concern

821 Nervousness
NA 1 2 3 Major health concern

822 Neuralgia
NA 1 2 3 Major health concern

823 Neuritis
NA 1 2 3 Major health concern

824 Noise sensitivity
NA 1 2 3 Major health concern

825 Poor appetite
NA 1 2 3 Major health concern

826 Tendency to cry without reason
NA 1 2 3 Major health concern

827 Weakness
NA 1 2 3 Major health concern

FEMALE ONLY

173 Very easily fatigued
NA 1 2 3 Major health concern

174 Premenstrual tension
NA 1 2 3 Major health concern

175 Painful menses
NA 1 2 3 Major health concern

176 Depressed feelings before menstruation
NA 1 2 3 Major health concern

177 Menstruation excessive and prolonged
NA 1 2 3 Major health concern

178 Painful breasts
NA 1 2 3 Major health concern

179 Menstruate too frequently
NA 1 2 3 Major health concern

180 Vaginal discharge
NA 1 2 3 Major health concern

181 Hysterectomy/ovaries removed
NA    X 1   X 2 3 Major health concern

182 Menopausal hot flashes

NA 1 2 3 Major health concern

183 Menses scanty or missed
NA 1 2 3 Major health concern

184 Acne, worse at menses
NA 1 2 3 Major health concern

185 Depression of long standing
NA 1 2 3 Major health concern

MALE ONLY

186 Prostate trouble
NA 1 2 3 Major health concern

187 Urination difficult or dribbling
NA 1 2 3 Major health concern

188 Night urination frequent
NA 1 2 3 Major health concern

189 Depression
NA 1 2 3 Major health concern

190 Pain on inside of legs or heels
NA 1 2 3 Major health concern

191 Feeling of incomplete bowel evacuation
NA 1 2 3 Major health concern

192 Lack of energy
NA 1 2 3 Major health concern

193 Migrating aches and pains
NA 1 2 3 Major health concern

194 Tire too easily
NA 1 2 3 Major health concern

195 Avoids activity
NA 1 2 3 Major health concern

196 Leg nervousness at night
NA 1 2 3 Major health concern

197 Diminished sex drive
NA 1 2 3 Major health concern

Other specifics not mentioned above:

Additional information

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