Name
*
Email
*
Please select the type of appointment you are requesting
*
In person
Online (video chat)
Age
Occupation and/or daily responsibilities
Marital Status
Number of Children
Main Concern
Secondary Concern
Diseases or conditions with which you have been diagnosed.
Include significant bacterial or viral infections and date of diagnosis.
List any prescription or OTC medications you are currently using.
Include dose and purpose of each
List any supplements you are currently using.
Include dose and purpose of each
List all allergies and intolerances to foods, drugs, or other substances.
List all travel outside the US
Include year
Do you use tobacco?
Yes
No
Select any skin conditions you have
Have you ever experienced shortness of breath, memory fog, fainting, or any peculiar symptoms after installing new carpet, paint, furnishings, or any other home refurbishing?
Yes
No
Not sure
How were you born?
Vaginal
Cesarean
Not sure
Did you grow up near a refinery, polluted area, or in a home with leaded paint? If so, what sort of pollution were you exposed to?
Have you had any jobs or experiences where you were exposed to solvents, heavy metals, fumes, or other toxic materials?
Do you use pesticides, herbicides, or other chemicals around your home?
Yes
No
Sometimes
Not sure
Do you have any amalgam "silver" filings? If so, how many?
Select any of the following you have had or currently have
Do you have any chronically swollen lymph nodes?
Yes
No
Not sure
Do you have any problems digesting fats?
Yes
No
Not sure
Select any of the following that apply
Have you had kidney stones?
Yes
No
Not sure
Describe the color of your urine
If you have fatigue, when is it worst?
Do you get hangry or ill if you miss a meal?
Yes
No
Sometimes
Not sure
How many bowel movements do you have per day/week?
Select the description of your typical bowel movement
Type 1 - separate hard balls
Type 2 - lumpy sausage
Type 3 - sausage with cracks
Type 4 - banana
Type 5 - soft blobs with clear edges
Type 6 - mushy
Type 6 - liquid
What time is your first meal?
Hour
Minute
Second
AM
PM
What time is your last meal/food intake?
Hour
Minute
Second
AM
PM
Describe your typical breakfast
Describe your typical lunch
Describe your typical dinner
Describe your typical snack foods
List liquids you drink and number of times per day/week
Water, coffee (regular or decaf), tea (black, green, regular, decaf), fruit juice, herbal tea, milk, soda, alcohol, etc.
Do you have indigestions?
Yes
No
Sometimes
Not sure
Do you have gas/bloating?
Yes
No
Sometimes
Not sure
Do you have stomach cramps?
Yes
No
Sometimes
Not sure
Have you had a stomach ulcer?
Yes
No
Not sure
How many rounds of antibiotics have you had and reason for antibiotics
Email 1
What is the main source of your stress?
Select any of the following that apply to you
Feel unworthy
Resistant to change
Accept defeat
Stay busy as an escape
Excessive concentration
Mental chatter
Easily overwhelmed
Grieving
Internalize emotions
Can't let go
Lack of trust
Fear/worry/anxiety
Depressed
Angry
Indecisive
Frustrated/impatient
Complaining
Timid
Feel Alone
Feel Neglected
Guilt
Have you evern been witness to or subjected to acts of physical, mental, or emotional abuse or trauma?
Yes
No
Not sure
Do you have anxiety or panic attacks?
Yes
No
Not sure
Do you have physical tics or spasms?
Yes
No
Not sure
What hobbies/interests bring you the most happiness?
How often do you make time for joy/play?
Select all that apply
List significant, stressful events/relationships/situations in your life
How many hours of sleep and the quality of sleep each night do you get?
How long does it take for you to get to sleep?
Select all that apply
List exercise or phyiscal activities you perform and how frequently
How much time do you spend outside each day?
Select all the apply
If you have headaches, describe the pain, location, and frequency?
Do you get frequent muscle cramps?
Yes
No
List all surgeries or hospitalizations and include reason and dates for each
Select all that apply
If you are on birth control, what kind?
Select which one applies to you
Pre-menarche
Menstruating
Pre/Post-Menopausal
If post-menopausal, at what age did it occur
Age at menarche?
Select all that describe your menstrual flow
Select any PMS symtoms that you experience
Do you experience pain during ovulation?
Yes
No
Not sure
Waiver
I hereby consent to and authorize Rachel Psencik to provide professional healthcare services on my behalf and/or the behalf of me or my children. I further understand that the healing therapies I am endeavoring into are based upon holistic protocols, and may involve nutrient, supplement, and/or herbal recommendations. These protocols are intended to improve my energy, alleviate pain, and restore my body, psyche, and spirit for long-term healing resolutions. I recognize that sometimes a healing response may occur at the initiation of holistic protocols. A healing response tells me that the protocols being utilized have produced changes that my body is now integrating as my health improves toward our mutual goals. As this is a voluntary endeavor, I have the right to discontinue treatments at my discretion and I will discontinue any treatments that I am uncertain of until such time as I can speak with my clinician and confirm the safety of continuation. As a new Client, I agree to: 1. Fully disclose all physical and/or psychological health conditions that may be necessary for my clinician to know in order to assure my safety, honor my emotional history, and allow my healing team to provide me with the best possible healing experience. 2. Inform my clinician immediately, via phone or email, of any physical or emotional discomfort or pain too intense to manage or that lasts for more than 2 days (48 hours) following implementation of the protocol. I hereby authorize Rachel Psencik and support staff to perform the following specific procedures as necessary to facilitate my assessment and design recommended treatments: Holistic use of nutrition: Therapeutic nutrition and nutritional supplementation. Botanical medicine: Botanical substances may be prescribed as teas, alcohol or glycerite based tinctures, capsules, tablets, creams, plasters, or suppositories. Lifestyle counseling and hygiene: Diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction, and balancing of work and social activities. I recognize the potential risks and benefits of these procedures as described below: Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes. Please notify your clinician if you experience any symptoms which may be secondary to the above procedures or if ever in doubt. Potential benefits: restoration of energy, health and the body’s maximal functional capacity without the use of pharmaceuticals or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression. Notice to pregnant women: All female clients must alert the clinician if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy, and should talk with their MD before implementing any protocol recommendations. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by this office or my clinician, therapeutic staff, or representatives regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these voluntary procedures at any time. I am responsible for all actions I take, and do not hold Hill College, the Hill College Holistic Wellness Pathway, or the students or instructors of the Hill College Holistic Wellness Pathway responsible for my actions. I understand any choices I make should be discussed with my doctor first.
