Patient Performa

Dr. Vinu Kumar
Detox and Wellness Clinic
Phone : +91-98150 00925

Consultation Date:*

Consultation Time:*

* Required Feilds.

Please call us to schedule your consultation.
The following form is to be completed 24 hours prior to your consultation and emailed to
dr.vinukumar21@yahoo.com or printed out and faxed to the clinic.

Health History Questionnaire
If you have any test results, etc. please feel free to attach copies along with any pertinent
information not covered here. All client information is kept strictly confidential

Personal Information

Name:

Phone:

Address:

City:

State:

Pin Code:

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 notsuccessful?

What challenges have been getting in the way of accomplishing your recovery and health goals?
 
Family History
Diabetes
Heart Disease
Asthma
Gallbladder Disease
Kidney Disease
Arthritis
Stomach Disorders
Cancer
If so, type of Cancer:   
Others:
# of Children:
# of Pregnancies:
# of Miscarriages:
# of Abortions:
Complications:

Mother Age:

Died From:

Grandmother Age:

Died From:

Grandfather Age:

Died From:

Father Age:

Died From:

Grandmother Age:

Died From:

Grandfather Age:

Died From:

Coffee
Tea
Sugar
Chocolate
Alcohol
Cigarettes
Drugs
 
Laxatives
 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 (that you think are not healthy!) you eat during the week?

1

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

1

2
3
Snacks: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 and when):
Digestive Tract
Nausea
Diarrhea
Constipation
Bloating
Belching
Excess Gas
Heartburn
Ears
Itchy ears
Earaches
Ear Infections
Ear Drainage
Ringing in Ears
Hearing Loss
Emotions
Mood Swings
Anxiety
Nervousness
Anger/Irritability
Depression
Energy
Fatigue
Apathy
Weight
Binge eating
Cravings
Excessive weight
Compulsive eating
Water retention
Under-weight
Lethargy
Hyperactivity
Restlessness
Eyes
Watery Eyes
Itchy or red eyes
Blurred Vision
Tunnel Vision
Heart
Irregular heartbeat
Rapid heartbeat
Chest pains
Joint/Muscle
Joint pain
Arthritis
Muscle pain
Varicose veins
Head
Headaches
Dizziness
Lungs
Chest congestion
Asthma
Shortness of breath
Other
Frequent illness
Frequent urination
Genital itch
Discharge
Mind
Poor memory
Confusion
Learning
Disabilities
Stuttering
Poor concentration
Mouth/Throat
Chronic
Sore throat
Swollen gums
Canker sores
Sensitive teeth-nerves
Nose
Stuffy nose
Sinus problems
Hay Fever
Sneezing
Excess Mucus
Skin
Acne
Hives or rashes
Hair loss
Excess sweating
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):
Dinner:
Have you had previous colon cleansing sessions with a professional colon hydro therapist?
Yes
No
If so, when?How many?
If so, when? Are they currently doing colonics or enemas now?
What have some other professionals told you about your health?
Metabolic Assessment Form
Please list your 5 major health concerns in order of importance

1

2
3
4
5
Please choose on a scale of 1 – 4 the appropriate answer to each question below.
1 = Least/Never 4 = Most/Always
Category I – Colon
1234

Feeling that bowels do not empty completely

Lower abdominal pain relief by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard dry or small stool
Coated tongue of "fuzzy" debris on tongue
Pass large amount of foul smelling gas
More than 3 bowel movements daily
Do you use laxatives frequently
Category II – Hypochlorhydria 

Excessive belching or aching 1-4 hours after eating

Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested
foods found in stools
Category III – Hyperacidity (Ulcer) 

Stomach pain, burning or aching 1-4 hours after eating

Do you frequently use antacids?
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk,
carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers,
alcohol and caffeine
Category IV – Small Intestine (Pancreas) 

Roughage and fibere cause constipation

Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under
rib cage bloated
Excessive passage of gas
Nausea and /or vomiting
Excessive passage of gas
Stool undigested, foul smelling mucous-like,
greasy or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight
Category V – Biliary Insufficiency and/or stasis 

Greasy or high fat foods cause distress

Lower bowel gas and or bloating several
hours after eating
Bitter metallic taste in mouth,
especially in the morning
Unexplained itchy skin
Yellowish cast to eyes
Stool colour alternates for clay coloured to
normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
   
Category VI - Hypoglycemia 

Crave sweets during the day

Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded and if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitates, easily upset, nervous
Poor memory, forgetful
Blurred vision
Category VIII – Adrenal Hypofunction 

Cannot stay asleep

Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon Headaches
Headaches with exertion or stress
Weak nails
Category IX – Adrenal Hyperfunction 

Cannot fall asleep

Perspire easily
Under high amounts of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with
little or no activity
Category X - Hypothyroid 

Tired/Sluggish

Feel cold – hands, feel, all over
Require excessive amounts of sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals or
excessive falling hair
Dryness of skin and/or scalp
Mental sluggishness
Category XI – Thyroid Hyperfunction 

Heart palpations

Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night Sweats
Difficulty gaining weight
Category XII – Pituitary Hypofunction 

Diminished sex drive

Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
Category XIII – Pituitary Hyperfunction 

Increased sex drive

Tolerance to sugars reduced
"Splitting" type headaches symptoms
Category XIV (Males Only) - Prostate 

Urination difficulty or dribbling

Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night
Category XV (Males Only) - Andropause 

Decrease in libido

Decrease in spontaneous morning erections
Decrease in fullness of erections
Difficulty in maintain morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decrease in physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
Category XVI (Menstruation Females Only) 

Are you a menopausal?

   
Alternating menstrual cycle lengths?
   
Extended menstrual cycle, greater than 32 days?
   
Shortened menses, less than every 24 days?
   
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne break outs
Category XVII (Menopausal Females Only) 
How many years have you been menopausal?
Did you ever have uterine bleeding since menopause?
   
Hot Flashes Mental
Fogginess
Disinterest in Sex
Mood Swings
Depression
Painful intercourse
Shrinking breast
Facial hair growth
Acne
Increased vaginal, pain, dryness or itching
Do you smoke?
How many times a week do you eat raw nuts and seeds?
How many alcohol 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.
Antacids
Antibiotics
Antidepressants
Antifungals
Antihistamines
Anti-Inflammatory
Anxiety Medication
Diuretics
High Blood Pressure
High Cholesterol
Hormones Replacements
Hydrocortisone Cream
Oral Contraceptives
Thyroid Hormones
  
Others
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