CONFIDENTIAL

Date:

Pathway of Natural Health Ministry

67 Azzie Pitts Road Laurel, MS. 39443

Contact 601 577-1173 or 601 452-0852

CONFIDENTIAL

IMPORTANT: This health and nutrition evaluation is intended for educational purposes only, to assist the

individual in learning how to preserve their own health. It is not the intention of this evaluation to diagnose or to

prescribe, any medication, treatment or modality for any physical or mental disorder, disease, ailment, complaint or

anomaly.

Therefore any use of the information obtained from this health and nutritional evaluation, is at the sole discretion of, and

in response to the direct request made by the individual whose name is signed on this form.

Signature SS# Date

Please complete entire questionnaire and return it Pathway of Natural Health. to be reviewed by one of our health

educators. After careful review, specific suggestions will be outlined for you in your search for better health using

God's Plan. Please submit a $50.00 donation with questionnaire to help us cover expenses involved. Thank you!

FORWARD YOU CONSULTATION FORM TO

Pathway of Natural Health.

BY MAIL, EMAIL IF SENDING BY MAIL YOU MAY USE CHECK AS A FORM OF PAYMENT.

1. Donation payment information:

Cash ( ) or Check ( ) Billing Information:

Name:

Address:

City: State: Zip:

Phone # - Alternate Phone

HEALTH AND NUTRITION EVALUATION

Providing the following information will allow a better understanding of your condition, and enable us to help you more. Explain fully where necessary. Use separate sheets for additional information.

PLEASE PRINT

NAME: DOB:

ADDRESS: Street: City:

State: Zip: Phone: - -

Age: Sex: Height: Weight: Weight one year ago:

Nationality: Religious preference: Marital Status:

MEDICAL HISTORY

Give medical history - names and dates of past ailments, operations (anything you feel significant, including past complaints).

When did you last consult a physician?

For what reason?

What are you currently being treated for?

What specific conditions would you like this consultation to address?

List all medicine, pills, or drugs you are taking now:

List mineral and/or vitamin supplements you are taking/how many and how often:

Do you have indigestion? Yes No Gas? Yes No Bloating? Yes No How Often?

What foods tend to cause indigestion, bloating or gas?

How often do you have bowel evacuations? Yes No Color & texture:

Do you have Diarrhea? Yes No Constipation? Yes No

What color is your urine usually?

Do you wear eyeglasses? Yes No contact lenses? Yes No How many years?

Do you have or have you had any of the following? Check the appropriate box and explain fully in the space which follows.

Blank = Never 1 = Rarely 2 = Occasionally 3 = Sometimes 4 = Most of the time 5 = Always

Past

Present

Past

Present

Past

Present

Absent Minded

Excessive Hunger

Lumbago

Acne

Excessive Worry

Mental Disorder

Alcoholism

Faint When Hungry

Motion Sickness

Allergies

Fatigue

Nausea

Anemia

Feels Shaky if Hungry

Nervous Disorder

Appendicitis

Foul Smelling BM

Night Blindness

Arthritis

Foul Smelling Urine

Pain w/bowel movement

Asthma

Frequent Colds

Poliomyelitis

Bad Breath

Frequent Kidney Infections

Prostate Trouble

Cancer

Frequent Lower Bowel Gas

Respiratory Problems

Chest Pains

Frequent Urination

Rheumatic Fever

Chills/Cold Skin

Gallstones

Sexual Disorders

Cold Hands/Feet

Hay fever

Sinusitis

Constipation

Headaches

Skin Problems

Crave sweets/coffee

Heart Disease

Sluggish in the A.M.

Depression

Heart Pounds Hard

Swollen Glands

Diabetes

Hemorrhoids

Too Fast Digestion

Diarrhea

High Blood Pressure

Tuberculosis

Difficulty Breathing

Hot Most of the Time

Ulcers/Colitis

Digestive Disorders

Indigestion/Heartburn

Venereal Infection

Dizziness

Insomnia

Wake Up Tired

Eat When Depressed

Irritable before Meals

Weight Problem

Eat When Nervous

Itching of the Nose

Eating relieves fatigue

Itching of the Rectum

Eczema

Kidney Stones

Emphysema

Light-headedness

Excessive Fear

Low Blood Pressure

Explain fully the past or present ailments checked above on a separate piece of paper if needed:

GODLY TRUST

Occupations:

What hours do you work?

Health of spouse (if applicable):

How many children do you have? Ages:

Health of children:

Recreational activities enjoyed:

Hours per week viewing TV: Do you often feel guilty about past mistakes? Yes No

Do you worry about the future? Yes No Do you have stress? Yes No Depression?Yes No

Check the following categories which cause stress: financial

job related

getting along with people

family

not happy with myself

On a scale of 1 to 10 rate your stress level (1= very little stress and 10=an extreme amt. of stress):

Do you enjoy the work that you do? Yes No If not, explain:

Are you developing your mental and spiritual capabilities by daily study, meditation and prayer?

Yes No

Are you involved in some type of activity in which you are helping others? Yes No

The following space is provided for those who would like to elaborate more on the causes of their stress, depression and other negative emotions.

OPEN AIR

How many hours daily do you spend out of doors?

Do you sleep with your windows closed? Yes No

Are you able to breathe fresh air while you are working? Yes No

Is the building where you work a none-smoking facility: Yes No

DAILY EXERCISE

How often do you exercise? Describe the exercise:

How do you feel after you exercise?

SUNSHINE

How much time daily do you spend out of doors in the sunlight?

Do you often get sunburned? Yes No Do you visit tanning beds? Yes No

Are you afraid of getting skin cancer? Yes No

PROPER REST

What time do you go to bed? What time do you awaken?

What time is your last meal before retiring? Do you snack just before bedtime? Yes No

Do you wake up during the night and snack? Yes No If so, what do you eat?

Do you have trouble sleeping? Yes No Explain:

LOTS OF WATER

How much water do you drink daily?

What type? (spring, filtered, distilled, tap):

Check below the beverages you drink and indicate how much of each:

BEVERAGE NAME BRAND # OF glasses, cans or bottles daily

Soda

Coffee

Tea

Fruit Juice

Punch

Milk

Other

What is the usual color of your urine?

Explain your understanding of the principles of hygiene:

ALWAYS TEMPERATE

Do you ingest caffeine in any form? Yes No If so, for how many years?

Have you ingested caffeine in the past? Yes No For how many years?

If so, when did you stop? Do you smoke or chew tobacco? Yes No indicate which:

If so, for how many years? Have you used tobacco in the past? Yes No

For how many years?

If so, when did you stop? Do you drink alcohol? Yes No If so, what kind?

For how many years? Have you drank alcohol in the past? Yes No For how many years?

NUTRITION

Do you overeat? Yes No Do you feel stuffed after your meals? Yes No

Do you eat between meals? Yes No Explain:

Do you drink with your meals? Yes No If so, what liquids?

Do you wear removable dentures or plates? Yes No Do you eat fast? Yes No

How long does it take you to eat? Do you have a peaceful environment at meal

times?

Do you have set meal times? Yes No Are you following any special diet? Yes No

Explain what type:

Do you eat animal products? Yes No If so, what kind?

How Often?

Do you eat dairy products? Yes No: Milk? Cheese? Egg?

Do you eat desserts, candy or other sweets regularly? Yes No Explain how often and what

Type:

What time do you eat breakfast? What foods do you usually eat?

How often do you eat a tossed green leafy salad?

How often do you eat steamed or cooked vegetables?

How often do you eat fruits?

How often do you eat soup or stew?

What time do you eat lunch (dinner)? What foods do you eat?

What time do you eat supper? What foods do you eat?

PLEASE REMEMBER TO SIGN AND DATE THE FRONT OF THIS QUESTIONNAIRE! WE CANNOT RESPOND WITHOUT YOUR SIGNATURE AND DATE: BY SIGNING YOU ARE SHOWING THAT YOU UNDERSTAND THAT THIS QUESTIONNAIRE AND THE EDUCATIONAL INFORMATION GIVEN IN THIS CONSULTATION IS BIBLICAL LIFE-STYLE EDUCATION AND IS NOT INTENDED TO DIAGNOSE OR TREAT ANY DISEASE, AILMENT OR ABNORMALITY.

FOR OFFICE USE ONLY

Consultant ____________________________ Date of response _________________

Written material given ________________________________________________________________

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Life-style suggestions: ________________________________________________________________