Multistep Form – Back2Eden Lifestyle

General Information

Name:

Address:

Telephone:

Home

Work

Cell:

Email Address:

Church Affiliation:

How long have you been a member?

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 one’s personal health care provider before implementing any lifestyle changes. I release B2EL Counselors or associated organizations from any and all liability. Participation in this consultation indicates acceptance of these terms.

Signature:

Date:

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?YesNo

which ones?

Please list any surgery that you have had (along with the date):

What diseases have you been diagnosed with? (please list all)

What specific condition(s) would you like this consultation to address?

Age(yrs):

Sex:MaleFemale

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How long have you been married or divorced

Weight:

Height:

Sedimentation Rate (ESR):

Blood Pressure:

Pulse

Glucose:

Postprandial (2 hours after meal):

Cholesterol:

HDL:

LDL:

Triglycerides

Vitamin: D

B12

Allergies:

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…)

PURE AIR

1. Where do you live?CitySuburbsCountry

2. Do you sleep with your windows open?YesNo

3. Do you open your windows / doors daily to air out the home?YesNo

4. Do you live or work in a smoke-filled environment?YesNo

5. Do you have any smokers living in your home?YesNo

6. Do you have live plants throughout your home?YesNo

7. Are there any environments that you are in that do not have a good supply of fresh air?YesNo

8. If so what are they?

9. Do you wear tight fitted clothing that restricts your lung expansion?YesNo

SUNLIGHT

1. How much sun exposure do you get per day?

2. Do you sunbathe?YesNo

If so how long?

3. Do you wear short sleeves?YesNo

4. Do you use sun block?YesNoSometimes

5. Do you have any abnormal sensitivity to the sun naturally or due to any medications?YesNo

6. Do you take vitamin D supplements?YesNo

7. Do you have any family history of skin cancer?RadioYesNo

TEMPERANCE

1. What is your current occupation?

2. Please list your last five jobs and the years of service:

3. Do you smoke / use tobacco products in any form (i.e. chewing tobacco)?YesNo

4. Did you use tobacco in the past?YesNo

If so how much and for how long?

5. Do you use alcohol in any form?YesNo

If so, how much and for how long?

6. Do you ingest caffeine in any form?YesNo

7. If so, please list

8. Do you overeat?YesNoSometimes

9. Do you eat too fast?YesNoSometimes

10. Do you chew your food thoroughly?YesNo

11. Do you snack between meals? (this includes any food items and juice)YesNoSometimes

12. List any desserts you eat? (include candies, cakes, or pies)

13. Do you eat at set meal times?YesNo

Breakfast

14. Please list times for all meals:

Lunch

Supper

15. Would you say that your dress is healthful and modest?YesNo

16. Please list your leisure activities (i.e. watching TV, reading, sports, dancing, board games etc…)

17. How much time do you spend on leisure activities?

18. Do you overwork?YesNoSometimes

19. Please list any addictions

20. Have you been involved with substance abuse?YesNo

If so please list:

21. Do you read novels, science fiction, pornography, fashion magazines, computer games?YesNo

22. If so, which ones?

23. Do you attend cinemas, dances, night clubs, house parties and amusement parks?YesNo

24. If so, which ones?

25. Do you play any competitive sports?YesNo

26. If so, what sports are they?

27. Please list all types of music that you listen to?

REST

1. What is your usual bedtime?

2. Do you wake up during the night?YesNosometimes

3. Do you snack before you go to bed?YesNoSometimes

4. Do you sleep with the lights on?YesNoSometimes

5. Do you work the night shift or swing shift?YesNoSometimes

6. Do you wake up early in the morning and find it difficult to get back to sleep?YesNoSometimes

7. Do you take sleeping pills?YesNo

8. Do you make it a practice to get to bed at a certain time?YesNo

9. Do you rest from labor at least one day per week?YesNo

EXERCISE

1. Do you exercise?YesNo

2. How many times per week?

How many minutes per day?

3. How would you rate your exercise?MildModerateVigorous

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?YesNo

PROPER DIET

1. Do you eat any meat or flesh itemsYesNo

2. Do you eat any dairy items or eggsYesNo

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i.e. milkcheeseyogurtchocolate etc

Which ones?

3. Do you eat refined white productsYesNo

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i.e. white breadwhite ricewhite flour products, etc

4. How many servings of fruit per day?

How many servings of vegetables?

5. Do you use condiments - circle answerYesNo

6. Do you add any of the following spices to your foodsYesNo

7. Do you eat fried foods?YesNo

If so, how often?

8. Do you use margarine or butter?YesNo

If so, how often?

9. Do you use baking powder or baking soda?YesNo

10. Do you eat fresh bread? (bread eaten less than 48 hours after baking)YesNosometimes

11. Do you eat or drink any cocoa, chocolate or ice cream?YesNo

How often?

12. Which oils do you cook with?

13. Do you read the labels of food items that you buy from the store?YesNo

14. List any sweeteners you consume (i.e. sugar, honey, splenda, sweet & low, equal or additional artificial sweeteners, etc…)

15. How much & often do you eat nuts?

Which ones?

16. Do you eat any canned items (beans, veggies, fruits, veggie meats etc…)?YesNo

17. Which ones?

18. Are you on any special diet?YesNo

19. If so, please list:

20. Do you eat out?YesNo

If so how often:

21. Do you use salt?YesNo

Does the salt contain iodine?YesNo

USE OF WATER

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?YesNo

4. At what temperature do you drink your water?HotColdRoom temp

5. Do you eat ice?YesNo

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?YesNoSometimes

10. What is the usual color of your urine?clearpaleslight yellowyellow and dark yellow

12. Does it involve any of the following?No urgencystrainingbleedingincomplete evacuation?

TRUST IN DIVINE POWER

1. Do you have a daily devotional time?YesNo

2. If no, would you like to have one?YesNo

3. Do you spend time reading the Bible daily?

4. Do you return a faithful systematic tithe, plus offerings?YesNo

5. Do you have difficulty in trusting the Lord with your problems?YesNoSometimes

6. Do you suffer any remorse, guilt, worry or fear at present?YesNo

7. Do you believe that you have experienced the forgiveness of God in your life?YesNo

8. Do you struggle with knowing God’s will for your life?YesNo

9. Would you consider your family to have good relations with each other?YesNo

10. Do you have a spiritually strong immediate family?YesNo

11. Do you have peace with God and your fellow men?YesNo

12. Have you broken any vows or promises to God that is within your power to fulfill?YesNo

13. How has the Lord been treating you?

14. How have you been treating the Lord?

If the Lord were to come today, knowing the life that you are currently living, would you be saved? Please answer this question within yourself.YesNo

Meal plan questions

1. How much time do you spend cooking per day?

2. Which meals do you eat warm and which cold?

3. Do you usually make more than you need? If s what do you do with the leftovers?

4. Do you like baking?

5. Do you cook longer on the weekend?

6. Which kitchen equipment do you own? blender, food processor, pressure cooker, etc.

Are you presently experiencing any of the following: (select all that applies to you)?

Do you suffer from any of the following emotional/mental disorders: (please select)?