Client Form IWHB

Client Form

Gordons Bay, Cape Town
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
ID number*
Gender?*

MaleFemale
Martial Status*
Medical Aid*

YesNO
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Sign in to Innovative Wellness Helderberg email list*

YESNO
Please list below your 4 main health concerns in order of importance:
*
Please list below your 4 main health goals in order of importance:
*
Do you have any surgical implants or dental, including metal rods, birth control implants, breast or other body parts implants, dental fillings, caps, etc?


*
Gallbladder: Stress/Imbalance?*

tension headacheInsomnia - waking up suddenly or very early in the morning and being unable to go back to sleep is asign of under energy in the Gall Bladder meridian.Nausea, vomiting, motion sicknesship pain, sciaticaPain behind the kneeright-sided shoulder pain, pain between the shoulder bladesacid reflux, gas, indigestion, heartburn, dull/sharp abdominal pain, stomach detentionpain that worsens after fatty mealsclay or light colored stooljaundice (yellowing eyes/skin)None
Kidneys: Stress/Imbalance?*

frequent urination, foamy urineswelling in hands, legs, feet, ankleslower back painkidney stonesmetallic taste in mouth, bad breathpoor concentrationdark circles under eyes, eye puffinesspuffy or swollen facedry itchy skinconstipationfatigueNone
Liver: Stress/Imbalance?*

skin problems (acne, eczema, skin itchiness)chemical sensitivity (headaches, nausea, from perfumes, paints, gasoline, cleaning products, etc.)Nausea, vomiting, motion sicknesshormone imbalancechronic body order, bad breathpain or tenderness over right rib cagebloating, gas, leaky gut, heartburn, chronic indigestion, food sensitivitiespain that worsens after fatty mealsclay or light colored stooljaundice (yellow eyes/skin), clay or light colored stoolpoor vision or eye problemsanger, irritability, easily annoyed difficulty unwindingexcessive fatigueswelling and edemaNone
Brain: Stress/Imbalance?*

memory loss or lapsesloss of smellNausea, mental exhaustionsleep disturbances, insomniamood issues, anxiety, depressionbrain fogpoor concentrationlearn difficultiespoor vision or eye problemsless than 6 hours of sleep at nightheadaches, migrainesNone
Colon: Stress/Imbalance?*

Constipation, diarrheaGas, bloating, indigestion, refluxNauseaBody orderBad breathIBSIntestinal crampingFoul-smelling bowel movementBowel movement least than twice a dayHemorrhoidsFood intolerance, sensitivitiesNone
Lymphatic: Stress/Imbalance?*

Digestive issuesChronic fatigueAllergiesLower immunityCelluliteEnlarged lymph nodes, swollen glandsFood/chemical sensitivitiesChronic sinus infection, flu, sore throat, ear issues or coldSwelling in fingersInability to sweatSkin issuesHeadaches, brain fogNone
Skin: Stress/Imbalance?*

Rashesblackheads, whiteheadsRosaceaDrynessItchy skinPsoriasis, dermatitis, eczemaClogged pores, enlarged poresInability to sweatNone
Eyewear*

contact lensprecription glassesNone
Urination: How are your daily urinations? How often?*

every2-3 hourstoo frequentsense of urgencytoo small amounttwo large amountburningdribblingurinate several times in the nightNormal or None of the above
Sleep: How is your sleep?*

restfulrestlesshard to get to sleepwake up oftenget up during the nightbad dreamsother
Stress*

complications with hearthigh blood pressureirritabilityfatiguedecrease in muscular strengthdepressive moodfeeling burned outdecreased libidotire easily(Men Only) prostate troubleNone
Stress Level*

minimal stressmoderate stressexcessive stressfamily stresswork stressNone
WOMAN ONLY

pregnantbreast feedingmenopausehysterectomy or partialregular monthly cycle(28 days)5 days of menstrual flowless than 3 days of menstrual flowmore than 5 days of menstrual flowhave taken birth control pillsbone losscrampingbloatingfeeling weakmood swingscravingsheavy metalsheadachesbright red blooddark clotty bloodpainful breastspain with menses
Check any areas that apply*

classes/contactsOther skin conditionsImmune dysregulationArthritisInfectious diseaseTMJ DysfunctionHigh blood pressureSwollen jointsChronic Neck painEpilepsyCold sore/herpesChronic Joint painAsthmaClaustrophobicConcussionEczema or psoriasisHepatitisNone
Sunlight Exposure*

daily sunlight (outside)daily sunlight (through windows)fluorescent lighting in home/work mostlyNone
Chemical Exposure*

work with and around chemicals(hair styles, carpenter, engineer, dentist, artist(painter), industrial)live in city, heavily congested, near factoriessmoker, around smoker, live near smoke industrtyrecreational drug use, past or presentprescriptive medicationsuse conventional household body and cleaning productsuse fluorinated toothpaste, other dental careuse unfiltered water for cooking, bathing and brushing teethany medical devices in the body such as, implants, surgical plates, screws, any objects placed in the bodyNone
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Do you smoke, how often?*

DailyWeeklyMonthlyOccasionallyNever
Do you exercise, how regularly?*

DailyWeeklyMonthlyOccasionallyNeverOther
Following a special diet?*
Please explain.
Have you had COVID?*

YESNO
Have you been vaccinated?*

YESNO
Any reactions to the vacine?*
Please list medications or supplements you are currently taking:
*
Please list any surgeries, operations, trauma, car accidents, etc:



Type a label
Are you currently under the care of a physician? Yes or No. If so, for what condition(s)?



Type a label
Emotional history*
If unstable, please explain.
Family history (mom, dad, grandpa, grandma)*
Signature

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