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

    Men:

    Women:

    Trauma:

     

    Accept policies

     

    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.