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IMPORTANT
Please Note: The health information received during this consultation is for general education and is not intended to be specific medical advice. No medical care, diagnosis, or treatment is provided during this consultation. It is advisable to consult with ones personal health care provider before implementing any lifestyle changes.
I release 3Angels’ Health Ministry; Lifestyle counselors / staff from any and all liability. Participation in this consultation indicates acceptance of these terms.
Signature: ______________________________________________________ Date: ___________
General Information
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Telephone: Home (___) ___________________ Cell: (______) ____________________
Email Address: _____________________________________
Date of Birth ________________ SEX:(Circle ) Male Female Height ________ Weight ________
Church Affiliation: ______________________ How long have you been a member? ______________
Marital Status – (circle) Single, Married (1st / 2nd / 3rd or more), Divorced (1st /2nd or more), Widowed married (1st,2nd, 3rd) widowed divorced
How long have you been married or divorced __________
List any health concerns you have: (physical, mental, social or spiritual): ____________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
When did you last consult a physician? __________________
Are you currently being treated for any ailments? Yes / No
If yes, which ones? ________________________________________________________________________________________________________________________________________________________________________
Please list any surgery that you have had (along with the date): ________________________________________________________________________________________________________________________________________________________________________
What diseases have you been diagnosed with? (please list all) ________________________________________________________________________________________________________________________________________________________________________
Are you presently experiencing any of the following: (please circle)
Dizziness Numbness Bad body odor
Fainting Clammy skin Excessive sweating
Nausea Cold hands or feet Hair loss
Pain Constipation Fever
Heart palpitations Diarrhea Infections
Fatigue Indigestion / Acid Reflux Bleeding
Headaches Cold / Flu Weight loss
Memory loss Blurred vision Weight gain
Insomnia Swelling anywhere Sexual dysfunction
Difficulty breathing Parasites / Worms Anemia
Do you suffer from any of the following emotional / mental disorders: (please circle)
Depression Chronic anxiety Bipolar
Co-dependency Manias Schizophrenia
Phobias Obsessive compulsive disorder Neurosis
What specific condition(s) would you like this consultation to address? ________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
Blood Pressure: ____/____ Pulse _______
Glucose: _____ Postprandial (2 hours after meal): ______
Cholesterol: _____ HDL: ___ LDL: ____ Triglycerides ______
How often do you have bowel evacuations? ___________ Do you have diarrhea? _____ Constipation?________
Please list all medicines or pills you are currently taking: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Please list all supplements and / or herbs that you are taking (vitamins, minerals, nutritional drinks etc…) ________________________________________________________________________________________________________________________________________________________________________
Circle One where needed
1. Do you eat any meat or flesh items (chicken, turkey, pork, fish, shrimp etc…)? Yes / No
2. Do you eat any dairy items or eggs (i.e. milk, cheese, yogurt, chocolate etc…)? Yes / No
3. Which ones? _______________________________________________________________________
4. Do you eat refined white products (i.e. white bread, white rice, white flour products, etc…)? Yes / No
5. How many servings of fruit per day? ____ How many servings of vegetables? ____
6. Do you use condiments (i.e. ketchup, mustard, mayonnaise, barbeque sauces, veggienaise, nayonaise, salad dressings, pickles, vinegar, etc…)? Yes / No
7. Do you add any of the following spices to your foods: cinnamon, nutmeg, cloves, curry, hot sauces, and cayenne peppers, black and white peppers and etc? Yes / No
8. Do you eat fried foods? Yes / No If so, how often? _______
9. Do you use margarine or butter? Yes / No If so, how often? _______
10. Do you use baking powder or baking soda? Yes / No
11. Do you eat fresh bread? (bread eaten less than 48 hours after baking) Yes / No / Sometimes
12. Do you eat or drink any cocoa, chocolate or ice cream? Yes / No How often? __________
13. Which oils do you cook with? __________________
14. Do you read the labels of food items that you buy from the store? Yes / No
15. List any sweeteners you consume (i.e. sugar, honey, splenda, sweet & low, equal or additional artificial sweeteners, etc…) ___________________________________________________
16. How much & often do you eat nuts? _________________ Which ones? ____________________
17. Do you eat any canned items (beans, veggies, fruits, veggie meats etc…)? Yes / No
18. Which ones? _________________________________________________________
19. Are you on any special diet? Yes / No
20. If so, please list: ________________________________
21. Do you eat out? Yes / No If so how often: _________
22. Do you use salt? Yes / No Does the salt contain iodine? Yes / No
1. Do you exercise? Yes / No
2. How many times per week? _________ How many minutes per day? _________
3. How would you rate your exercise? (circle one) Mild Moderate Vigorous
4. What are your favorite exercise sessions? ______________________________________________________________________________
5. How do you feel after you exercise? ______________________________________________________________________________
6. Do you experience any pain while you are exercising? Yes? No
1. How many glasses of water do you usually drink per day? ___________
2. What kind of water do you commonly drink? __________________________________________
3. Is your water filtered? Yes / No
4. At what temperature do you drink your water? (circle one) Hot Cold Room temp.
5. Do you eat ice? Yes / No
6. How many glasses of juice do you drink per day? ____
7. How many cans / bottles of soda per day? ___________________________
8. What other liquid do you drink (i.e. tea, wine, alcohol, beer, soda, milk, vitamin water, etc…)?
_____________________________________________________
9. Do you drink with your meals? Yes / No / Sometimes
10. What color is your urine normally? (clear, pale, slight yellow, yellow and dark yellow)
1. How much sun exposure do you get per day? _______________
2. Do you sunbathe? Yes / No If so how long? ______________
3. Do you wear short sleeves? Yes / No
4. Do you use sun block? Yes / No / Sometimes
5. Do you have any abnormal sensitivity to the sun naturally or due to any medications? Yes / No
6. Do you take vitamin D supplements? Yes / No
7. Do you have any family history of skin cancer? Yes / No
1. What is your current occupation? _____________________________________________________
2. Do you smoke / use tobacco products in any form (i.e. chewing tobacco)? Yes / No
3. Did you use tobacco in the past? Yes / No If so how much and for how long? ____________
4. Do you use alcohol in any form? Yes / No If so, how much and for how long? ___________
5. Do you ingest caffeine in any form? Yes / No (e.g. coffee, teas, mate, colas, energy drinks, etc.)
6. If so, please list _____________________________________________________.
7. Do you overeat? Yes / No / Sometimes
8. Do you eat too fast? Yes / No / Sometimes
9. Do you chew your food thoroughly? Yes / No
10. Do you snack between meals? (this includes any food items and juice) Yes / No / Sometimes
11. List any desserts you eat? (include candies, cakes, or pies) _________________________________
12. Do you eat at set meal times? Yes / No
13. Please list times for all meals: Breakfast _______ Lunch _________ Supper __________
14. Would you say that your dress is healthful and modest? Yes / No
15. Please list your leisure activities (i.e. watching TV, reading, sports, dancing, board games etc…) ________________________________________________________________________________
16. How much time do you spend on leisure activities? _________
17. Do you overwork? Yes / No / Sometimes
18. Please list any addictions _______________________________________________________________
19. Have you been involved with substance abuse? Yes / No If so please list: _______________
20. Do you read novels, science fiction, pornography, fashion magazines, computer games? Yes / No
21. If so, which ones? __________________________________
22. Do you attend cinemas, dances, night clubs, house parties and amusement parks? Yes / No
23. If so, which ones? ___________________________________________
24. Do you play any competitive sports? Yes / No
25. If so, what sports are they? _________________________________________________
26. Please list all types of music that you listen to? ___________________________________________
1. Where do you live? (Circle one) City Suburbs Country
2. Do you sleep with your windows open? Yes / No
3. Do you open your windows / doors daily to air out the home? Yes / No
4. Do you live or work in a smoke-filled environment? Yes / No
5. Do you have any smokers living in your home? Yes / No
6. Do you have live plants throughout your home? Yes / No
7. Are there any environments that you are in that do not have a good supply of fresh air? Yes / No
8. If so what are they? ____________________
9. Do you wear tight fitted clothing that restricts your lung expansion? Yes / No
1. What is your usual bedtime? ________
2. Do you wake up during the night? Yes / No / Sometimes
3. Do you snack before you go to bed? Yes / No / Sometimes
4. Do you sleep with the lights on? Yes / No / Sometimes
5. Do you work the night shift or swing shift? Yes / No / Sometimes
6. Do you wake up early in the morning and find it difficult to get back to sleep? Yes / No / Sometimes
7. Do you take sleeping pills? Yes / No
8. Do you make it a practice to get to bed at a certain time? Yes / No
9. Do you rest from labor at least one day per week? Yes / No
1. Do you have a daily devotional time? Yes / No
2. If no, would you like to have one? Yes / No
3. Do you spend time reading the Bible daily? ________
4. Do you return a faithful systematic tithe, plus offerings? Yes / No
5. Do you have difficulty in trusting the Lord with your problems? Yes / No / Sometimes
6. Do you suffer any remorse, guilt, worry or fear at present? Yes / No
7. Do you believe that you have experienced the forgiveness of God in your life? Yes / No
8. Do you struggle with knowing God’s will for your life? Yes / No
9. Would you consider your family to have good relations with each other? Yes / No
10. Do you have a spiritually strong immediate family? Yes / No?
11. Do you have peace with God and your fellow men? Yes / No
12. Have you broken any vows or promises to God that is within your power to fulfill? Yes / No
13. How has the Lord been treating you? ______________________________________
14. How have you been treating the Lord? _____________________________________
15. If the Lord were to come today, knowing the life that you are currently living, would you be saved? Yes / No “Please answer this question within yourself.”
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