Natural Wellness Solutions (NWS) CONFIDENTIAL CASE HISTORY

Natural Wellness Solutions (NWS) CONFIDENTIAL CASE HISTORY

Native American Indigenous Church •NativeFireChurch.Org
Name*

First NameLast Name
Biologic Sex*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HOME PHONE:*
WORK PHONE:*
AGE: DOB:*

MonthDayYear
Date
HEIGHT: *
WEIGHT: *
MARITAL STATUS*
#of KIDS:*
OCCUPATION: *
HAVE YOU HAD Ministerial Counseling Services or Therapy Before?
WHY ARE YOU HERE? WHAT IS YOUR MAJOR AREA OF CONCERN?
WHEN DID IT START? HOW?
WHAT MAKES IT WORSE? BETTER?
IS IT GETTING WORSE?
DOES IT INTERFERE WITH WORK? PLAY? SLEEP?
HAS THERE BEEN A MEDICAL DIAGNOSIS? EXAM? BLOOD WORK? XRAYS?
DO YOU HAVE A PRIMARY CARE DOCTOR? WHO?
PREVIOUS BROKEN BONES:
PREVIOUS SURGERIES/HOSPITALIZATIONS:
PREVIOUS ACCIDENTS/INJURIES:
ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING?
MEDICATIONS:
LaxativesSedativesSleeping PillsInsulinBlood ThinnersAspirinVitaminHerbsMineralsBirth ControlBlood Pressure

INDICATE THE FOLLOWING HABITS: H = heavy M = moderate. L= light N =none

Rows	H	M	L	N
Alcohol
Coffee
Tea
Tobacco
Soda
Diet Soda
Exercise
Chips/Cookies
Sugar

HOW OFTEN DO YOU EAT THE FOLLOWING: M=every meal D=once a day 2W=2x a week R=rare (less than once/week) N=none

Rows	M	D	2W	R
Fish
Chicken/Turkey
Red Meat
Pork/Ham/Etc.
Dairy
Dark Leafy Greens
Vegetables
Packaged Foods
Restaurant Food

DO YOU EAT ORGANIC PRODUCE?
ORGANIC ANIMAL PRODUCTS?
PLEASE CIRCLE WHAT IS CURRENT AND UNDERLINE WHAT IS PAST: If you do not know issue leave blank.

HeadachesShooting Head PainsHead Feels Too HeavySinus TroubleLoss of Smell or TasteTightness in ThroatThyroid TroublesFace FlushingFace TwitchesLoss of MemoryFatigueDepressionDizziness/FaintingEar InfectionsRinging in EarsWear GlassesLight Bothers EyesMigrainesAllergiesAsthmaEpilepsyExcessive SweatingBurning During UrinationTightnessNerveCold hands and feetChest amalgamsShortness of breathHeart attackHigh Blood PressureLow Blood PressureTBAnemiaRheumaticAnxietyIBSIndigestionDigestive IssuesConstipationSkin disordersFrequent UrinationPain in the groin areaPainful hands and feetCold sweatsLiver troubleGallbladder issuesDiabetesCancerRestlessnessRestless leg syndromeBladder/kidney troublePainful/swollen jointsArthritisOsteoporosisHypothyroidism- HyperthyroidismHerniated/bulging discsPinched nervesSciaticaNumb hands & feetVaricose veinsTooth infectionsHerpesHepatitis A, B, CMalariaHIV/AIDSDiminished sex driveMercury fillingsBurning/pain during orgasmMenses scanty or missingMenopausal hot flashesMEN: prostate troubleWOMEN: PMS/depression vaginal dischargeBack PainCancerHeart DiseaseSoft Tissue PainLong CovidVaccine InjuryLow EnergyScar Tissue- Scar Tissue Contracture DisorderPhobias-fearInflammationEdemaNeurologic Pain: Hands or FeetBells PalsyLocalized PainPace MakerAny Medical ImplantsBroken BonesWeight Related IssuesSleep Issues- Insomnia
pregnancy due date:

MonthDayYear
Date
vaccination/s date:

MonthDayYear
Date
booster date:

MonthDayYear
Date
Lactation Issues

Painful BreastFertility IssuesBreast ImplantsBreast Reduction SurgeryCelluliteVaginal DischargeEndometritis
Covid Status:

Yes, I have been diagnosed with CovidNO, I have not been diagnosed with Covid
If Yes to Covid status, then when and how were you diagnosed? Also, list any treatment or hospitalizations related:
Have you experienced any post-covid or “long-covid” symptoms or health issues? If so, please explain
Vaccination Status Past & Present, Please check the appropriate answer.
Please select the statement below that accurately describes your vaccine status:

I am vaccinatedI am not Vaccinated
If Vaccinated please describe: Which Vaccine have you received? Standard childhood vaccines: Please list if possible
SARS Cov2-19 Covid Vaccine: Choose Below:

A) Pfizer.B) ModernaC) Johnson & Johnson
Date received:

MonthDayYear
Date
SARS Cov2-19 Covid Vaccine booster or boosters: If Yes: How Many and When received?
If “YES” selected for Vaccine status, Have you experienced any adverse or harmful side effects post vaccination?

YesNo
Please describe any adverse Post-vaccine symptoms
OTHER QUESTIONS: Answer all that apply.
How many bowel movements per day?
How many bowel movements per day?
Age of mattress
comfortablewaterbed
type of pillow
Do you sleep on:

sidebackstomach
Do you have Emotional, Psychological, or Spiritual Issues related to your issue?

YesNo
I understand that payment is due at the time of service unless arrangements have been made otherwise.

I understand I am responsible for payment if a third party is not made.

I understand all services and counseling rendered is private under ministerial/ communicant privilege.

I agree to give 24 hours' notice for cancellation of the appointment. If given less than 24 hours’ notice,

I agree that the practitioner may charge for the session. Cases of extreme emergency are considered exceptions. I understand that all the information on this form is true to the best of my knowledge.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Natural Wellness Solutions (NWS) CONFIDENTIAL CASE HISTORY

ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING?

Vaccination Status Past & Present, Please check the appropriate answer.

OTHER QUESTIONS: Answer all that apply.