New client Questionnaire How did you learn about me? I understand that: 1) Mineral-Nutritional Balancing is a means to reduce stress and balance body chemistry. 2) María R. de Almeida is not a medical doctor. 3) Nothing here is intended to discourage me from seeking or following the advice of a medical doctor. 4) This is not meant to diagnose, treat or cure any diseases and isn’t a substitute for standard medical care. What are your main health concerns or conditions? Write the details of your health history starting when you can remember feeling well and on from there. Include any vaccinations, illnesses, and trauma and their approximate dates What medications and/or supplements are you currently taking? Include Botox/Dyport if using now or used in the past. List any ‘out of range’ (high or low) results from recent medical tests (e.g. blood tests). List illnesses in your immediate family (e.g., heart disease, cancer, TB, diabetes, arthritis) What kind of movement/exercise do you do and how often? Approximately how many hours of sleep do you get each 24 hours and what is the quality? List therapies, diets, supplements, medications, etc. that you’ve found helpful. List therapies, diets, supplements, medications, etc. that haven’t worked well for you. What are typical examples of your meals and snacks? BREAKFAST BEVERAGE MID-MORNING SNACK BEVERAGE LUNCH BEVERAGE MID-AFTERNOON SNACK BEVERAGE DINNER BEVERAGE EVENING SNACK BEVERAGE HEALTH ISSUES & LIFE EXPERIENCES Symptons / Conditions AcneAddiction – alcoholAddiction – other substancesAddiction – otherAllergies – other than foodAnemiaAngerAnginaAnxietyArteriosclerosisArthritis – osteoArthritis – rheumatoidAsthmaAttention deficit disorderAutismBipolar disorderBladder infectionsBloatingBlood pressure – lowBlood pressure – highBody temperature – lowBrain fogBronchitisBruising – easyBursitisCataractsCholesterol – highCholesterol – poorCirrhosisCold – feeling ofColitisConfusion ConfusionConstipationCoughDepressionDermatitisDevelopment – delayedDiabetesDiarrheaDiverticulitisDizzinessDyslexiaEczemaEmhysemaEyes – glaucomaEyes – macular degenerationFatigueFearFissuresFood – allergiesFood cravings – fatsFood cravings – starchesFood cravings – sweetsFood cravings – otherFood – can't skip mealsFracturesGall stonesGoutHair lossHeadaches – migraineHeadaches – sinusHeadaches – tension Heart attackHeart – atrial fibrillationHeart -palpitationsHeart rate – rapidHeartburnHemorrhoidsHives Hunger – excessiveHunger – little to noneHyperkinesisHyperglycemiaHyperthyroidismHyperglycemiaHyperthyroidismHypoglycemiaHypothyroidsmInfection – bacterialInfection – fungal / candidaInfection – urinary tractInfection – viralInfertilityIntestinal gasIrritabilityIrritability – before mealsJoint painJoint stiffnessKidney infectionsKidney stonesLearning disabilityMemory – poorMeniere's diseaseMind racingMood swings Multiple sclerosisMuscle – crampsMuscle – painMuscle – weaknessNeuritisObsessive / CompulsiveOsteoperosisPanic attacksParkinson's diseasePostnasal dripPsoriasisSchizophreniaSclerodermaSeizuresSinus – congestionSleep – insomniaSleep – disturbanceSmokingStomach painSugar reactionsSuicidal thoughtsTeeth – decayTeeth – dental amalgamsTeeth – excessive plaqueTeeth – gum diseaseTriglycerides – highTumors / CancerUlcerUrination – frequentUrination – painfulVertigoWater rententionWeight – tend to gainWeight – tend to loseWound healing-slow Men: ImpotenceProstate problems Women: Breasts – fibrocysticBreasts – tumorsCrampsFibroid TumorsHot FlashesMenopauseMenstruation – noneMenstruation – heavyMenstruation – irregularMenstruation – lightOvarian cystsPap smear – abnormalPregnant – currentlyPremenstrual syndromeWater retentionYeast infection Trauma: Abuse – emotionalAbuse – physicalAbuse – sexual Accept policies I have read and accept the Privacy Policy Maria R. De Almeida is not a physician, and the scope of her consultation services does not include treatment or diagnosis of specific illnesses or disorders. If I, the client, suspect I may have an ailment or illness that may require medical attention, then it is my responsibility to consult with a licensed physician immediately. Only a licensed physician can prescribe drugs. Any mention of drugs in the course of consultation is only for the purpose of providing a complete history of drugs that the client is taking and not for Maria R. de Almeida to judge the appropriateness of the medication. Any change in prescription or dosage is a decision the client makes with his or her physician. Rather than dealing with treatment of disease, Maria R. de Almeida focuses on wellness and prevention of illness through the use of non-toxic, natural nutritional therapies to achieve optimal health. As a Psychoanalyst and certified Mineral Balancing practioner with functional medicine education, Maria R. de Almeida primarily educates and motivates clients to assume more personal responsibility for their health by adopting a healthy aItude, lifestyle, and diet. While people generally experience greater health and wellness as a result of embracing a healthier aItude, lifestyle, and diet, Maria R. de Almeida does not promise or guarantee protec9on from future illness. By signing below, I acknowledge that I understand that Maria R. de Almeida is a Psychoanalyst and Certified Mineral Balancing practioner with functional medicine education not a physician nor psychiatrist, and that I should see a doctor if I think I have a medical condition. Maria R. de Almeida will not be held liable for failure to diagnose or treat an illness, nor will she be liable for failure to prevent future illness. In addition, I have given Maria R. de Almeida a complete and accurate account of any medical conditions that I may have and any medications that I am taking.