Chadwell Method Online Intake Form

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Chadwell Method Intake Form

Patient’s Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Email

Phone home

Phone Cell

Phone work

May we contact you?

Referred By:

Date of Birth

(month/date/year)

Age:

How old do you feel:

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Occupation:

Do you enjoy what you do?

Marital Status:

Childern:

Childern names and ages:

Are you under a doctor’s care? If yes, please give name, reason, and date of last visit.

Are you currently taking any Medications? If yes, please list and indicate why and how long you have been on medication

Are you currently taking any Vitamins/ Supplements?

Ever visit a chiropractor? Who, when, why, and what was your experience?

Is there any physical pain anywhere in your body right now? Where and for how long?

Any known allergies or sensitivities?

Any foods you don’t eat?

Please list any accidents and dates.

Please list any surgeries and dates

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Have you been to a counselor/therapist before? How long ago was that? What did you enjoy most about it? How could it have been better for you?

Have you tried any of the following techniques? If yes, when? And how successful were they for you?

Muscle testing

Hypnosis

Meditation

Prayer

Neuromuscular Therapy or massage

Cranial Sacral Therapy

Visualization

Yoga

What would your ideal outcome of today’s visit be?

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Please carefully read and select the following:

I am 18 years old or older. If not, I have provided written permission from my parents or legal guardian to participate in treatment.

I understand that my success is directly related to my readiness to change and my level of commitment to my personal growth.

I understand that payment is expected at the time of service. I may choose to submit a receipt of this visit to my insurance company for reimbursement but that it is my responsibility to secure whatever reimbursement, if any, according to the policies and procedures of my insurance carrier.

I understand that Anthony Chadwell is not a Physician and does not Diagnose or Treat Disease.

Name

Date

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Metabolic Assessment Form

PART 1
Please list your 5 major health concerns in order of importance

PART II

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely

Lower abdominal pain relieved by passing stool or gas

Alternating constipation and diarrhea

Diarrhea

Hard, dry, or small stool

Coated tongue or “fuzzy” debris on tongue

Use laxatives frequently

More than 3 bowel movements daily

Category II

Increasing frequency of food reactions

Unpredictable food reactions

Aches, pains, and swelling throughout the body

Unpredictable abdominal swelling

Frequent bloating and distention after eating

Abdominal intolerance to sugars and starches

Category III

Intolerance to smells

Intolerance to jewelry

Intolerance to shampoo, lotion, detergents, etc.

Multiple smell and chemical sensitivities

Constant skin outbreaks

Category IV

Excessive belching, burping, or bloating

Gas immediately following a meal

Offensive breath

Difficult bowel movement

Sense of fullness during and after meals

Difficulty digesting fruits and vegetables; undigested food found in stools

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Category V

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

Use antacids

Feel hungry an hour or two after eating

Heartburn when lying down or bending forward

Temporary relief by using antacids, food, milk, or carbonated beverages

Digestive problems subside with rest and relaxation

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI

Roughage and fiber cause constipation

Indigestion and fullness last 2-4 hours after eating

Pain, tenderness, soreness on left side under rib cage

Excessive passage of gas

Nausea and/or vomiting

Stool undigested, foul smelling, mucous like greasy, or poorly formed

Frequent urination

Increased thirst and appetite

Category VII

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

Burpy, fishy taste after consuming fish oils

Difficulty losing weight

Yellowish cast to eyes

Unexplained itchy skin

Stool color alternates from clay colored 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?

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Category VIII

Acne and unhealthy skin

Excessive hair loss

Overall sense of bloating

Bodily swelling for no reason

Weight gain

Poor bowel function

Excessively foul-smelling sweat

Category IX

Crave sweets during the day

Irritable if meals are missed

Depend on coffee to keep going/get started

Get light-headed if meals are missed

Eating relieves fatigue

Feel shaky, jittery, or have tremors

Agitated, easily upset, nervous

Poor memory/forgetful

Blurred vision

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Category X

Fatigue after meals

Crave sweets during the day

Eating sweets does not relieve cravings for sugar

Must have sweets after meals

Waist girth is equal or larger than hip girth

Frequent urination

Increased thirst and appetite

Difficulty losing weight

Category XI

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 XII

Cannot fall asleep

Perspire easily

Under high amount 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 XII

Edema and swelling in ankles and wrists

Muscle cramping

Poor muscle endurance

Frequent urination

Frequent thirst

Crave salt

Abnormal sweating from minimal activity

Alteration in bowel regularity

Inability to hold breath for long periods

Shallow, rapid breathing

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Category XIV

Tired/sluggish

Feel cold―hands, feet, all over

Require excessive amounts of sleep to function properly

Increase in weight 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 hair loss

Dryness of skin and/or scalp

Mental sluggishness

Category XV

Heart palpitations

Mental sluggishness

Inward trembling

Increased pulse even at rest

Nervous and emotional

Insomnia

Night sweats

Difficulty gaining weight

Category XVI

Diminished sex drive

Menstrual disorders or lack of menstruation

Increased ability to eat sugars without symptoms

Difficulty gaining weight

Category XVII

Increased sex drive

Tolerance to sugars reduced

“Splitting” – type headaches

Difficulty gaining weight

Category XVIII (Males Only)

Urination difficulty or dribbling

Frequent urination

Pain inside of legs or heels

Feeling of incomplete bowel emptying

Leg twitching at night

Category XIX (Males Only)

Decreased libido

Decreased number of spontaneous morning erections

Decreased fullness of erections

Difficulty maintaining morning erections

Spells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decreased physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

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Category XX (Menstruating Females Only)

Perimenopausal

Alternating menstrual cycle lengths

Extended menstrual cycle (greater than 32 days)

Shortened menstrual cycle (less than 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

Facial hair growth

Hair loss/thinning

Category XXI (Menstruating Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Hot flashes

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness, or itching

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PART III

How many alcoholic beverages do you consume per week?

Rate your stress level on a scale of 1-10 during the average week:

How many caffeinated beverages do you consume per day?

How many times do you eat fish per week?

How many times do you eat out per week?

How many times do you work out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

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PART IV

Please list any medications you currently take and for what conditions

List the three healthiest foods you eat during the average week:

Please list any natural supplements you currently take and for what conditions

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Permission and Authorization Form G2G Health Systems Inc. and Chadwell Center for Health

PLEASE READ BEFORE SIGNING:
I specifically authorize the natural health practitioners at Chadwell Center for Health. to perform a nutritional health analysis and to develop a natural, complimentary health improvement program for me. My program may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or “cure” of any disease.

I understand that the analysis used are a safe and non-invasive natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems.

I understand that the analysis used is not a method for “diagnosing” or “treating” any disease, including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated.

No promise or guarantee has been made regarding the results of any analysis performed or any natural health, nutritional or dietary programs recommended. I understand that the analysis performed is a means by which to determine possible nutritional imbalances, so that safe,natural programs can be developed for the purpose of bringing about a more optimal state of health.

Furthermore, I understand that I am fully responsible for all aspects of my own healthcare, and will not hold Chadwell Center for Health, its employees, or agents, liable for any actions I take based on the information provided.

I have read and understand the above.

This permission form applies to all visits and consultations.

Date

Print Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Signature:

(If minor, signature of parent or guardian)

Witness:

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Chadwell Method Intake Form

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Metabolic Assessment Form

PART II

Category I

Category II

Category III

Category IV

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Category V

Category VI

Category VII

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Category VIII

Category IX

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Category X

Category XI

Category XII

Category XII

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Category XIV

Category XV

Category XVI

Category XVII

Category XVIII (Males Only)

Category XIX (Males Only)

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Category XX (Menstruating Females Only)

Category XXI (Menstruating Females Only)

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PART III

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PART IV

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Permission and Authorization Form G2G Health Systems Inc. and Chadwell Center for Health

New Year New You

Postpartum Depression

Prescription Drug Use and Addiction