Personal Health Education and Coaching
Form Instructions
Note: It may take 10-15 minutes to finish this form but Dr. Lonsdorf will be able to better comment on your lifestyle and health goals because of the valuable information you will be submitting. When you finish click on submit and you will be sent to a payment page . You will receive an email with download and other instructions after you pay.
Section 1: Wellness Personal Plan Type
Select Consultation Type
Section 2: Contact Information and Vital Statistics
First Name
Last Name
Street Address
City,State,Zip
Zip
Daytime Phone*
Please give best phone #(s) to contact you.
Cell Phone*
Evening Phone*
E-mail address
Vital Statistics
Age
Occupation
Section 3 : Disorders, Medications and Supplements
Please list any health conditions you have in order of severity.
Severity Level
Disorder
Length of time
Progress
Past Health History
Please list any past serious injury or hospitalization
Do any serious illnesses run in your family?
Prescription Drugs
How often and for about how long have you taken antibiotics in the past?
Below please list prescription drugs you take and length of time you have taken them.
Vitamins, Herbs and Food Supplements length of time you have taken them.
Section 4: Lifestyle & Health History Questionnaire
How is your sleep?
What time do you usually go to sleep?
What time do you get up?
How many bowel movements do you normally have a day?
Is the stool hard, firm, soft or loose?
Are they easy or with strain?
Do they alternate between constipated and loose?
Do you have hemmorhoids?
If yes. Do they bleed?
Do you feel now or in the past you have had an eating disorder? Please describe briefly if the answer is yes.
Do you have problems with gas or bloating?
Do you get heartburn or reflux regularly?
Do you have sour stomach or acid indigestion regularly?
Do you feel heavy after eating?
Do you feel sleepy after eating?
How is your appetite?
14. How is your energy during the day?
Have you lost or gained weight in the last 6 months and if so how much?
What percentage of your food is from leftovers?
What percentage of your food is organically grown?
percent
What percentage of your food is frozen or packaged food?
How often do you eat out in a restaurant each week?
How often do you microwave a week?
How many times do you eat meat a week?
Are there any foods you are intolerant to? Please list.
How many alcoholic beverages do you consume per day?
How many caffeinated beverages on average do you consume per day on average?
If you smoke how many cigarettes do you smoke a day?
How many diet sodas or other products containing aspartame do you drink a day?
How often a week do you exercise? (at least a brisk walk for 30 minutes or longer)
Do you practice meditation or relaxation techniques daily?
Do you have any of the following moods often? You may choose more than one.
Are you having work or family problems that are significantly affecting your health?
Which lifestyle changes are you most interested in making at this time?
What is your occupation?
What are your usual working hours?
Please list when you have breakfast and what you normally eat.
Please list when you have lunch and what you normally eat.
Please list when you have dinner and what you normally eat.
Please list when you have snacks and what you normally eat.
Environmental Health
What direction does the main entrance to your house face? North, South, East, West
Direction
What side of the house do you enter? North, South, East, West
Direction
What direction does the head of your bed point to?
Direction
Do you live near a power plant or high tension wires?
How many hours a day do you use your computer?
hours/day
How many minutes a day do you use a cell phone?
Minutes
Do you place the phone up to your ear?
Toxin Exposure and Sensitivity
Do you feel you are highly sensitive to chemicals?
Do you use mostly organic personal care products, fragrance free laundry products, and non toxic cleaning products in your home?
Are you exposed to chemicals, pesticides or toxins on a regular basis?
Have you recently renovated, or painted your home or office?
Women's Health
1. Your menstrual cycles are?
2. When was your last Pap smear?
3. When was your last mammogram ?
4. Have you reached menopause? i.e.Is it over 1 year since your last period?
5. Are you experiencing any problems with periods or menopause? Please describe.
Please comment on any question above or describe any other aspects of your health you feel
Section 5: Please describe your three major health goals
Goal 1
Goal 2
Goal 3
Section 6: Informed Consent Agreement- 11 points
1 . I understand and agree that I am involved in an Ayurvedic educational program and NOT a medical consultation and that by participation, I will not become Dr. Lonsdorf's patient. I understand the knowledge I receive is educational information and is NOT a substitute for modern medical evaluation and treatment or for preventive testing (such as blood tests, Pap smears, mammograms, and any other appropriate screening tests.)
Agree Disagree
2. I understand that Maharishi Ayurveda uses a unique system of evaluation and treatment based on the concepts of balance, doshas and overall tissue health. I understand that the educational information provided me is based on the Maharishi Ayurveda health approach to help enliven the inner intelligence of the body and restore balance to the divisions of inner intelligence.
Agree
3. I understand that the educational information I will receive is NOT for the purpose of diagnosing or treating any disease that I may have. For the treatment of any diagnosed disease that I may have, I agree to continue under the care of my family doctor and continue to seek the advice of any specialists with whom I have consulted.
Agree
Disagree
4. I agree not to modify or suspend any medical treatment program that I am now receiving, based on the information I receive.
Disagree
5. I understand that it is very important that I provide information that is as accurate and complete as possible. If I am aware of or have been advised by any physician that I am suffering from any disease or disorder, I agree that I will disclose this information to the physician in writing in this questionnaire. I also agree to disclose any medication or treatments that I am currently receiving.
Disagree
6. I understand that it is not within the scope of this Educational Program for Dr.Nancy Lonsdorf to assume responsibility for the treatment of specific health problems. I represent that no claims have been made to me that this program is for the treatment of health problems or for the diagnosis, treatments or cure of any particular health problem. I understand that what I will be receiving will be educational information as to the Maharishi Ayurveda approach to enlivening and balancing the inner intelligence of the body.
Agree
Disagree
7. I understand that the Maharishi Ayurveda programs have been developed in part by Ayurvedic scholars associated with universities or other institutions. However, I recognize and agree that any advice or recommendations to me are the sole responsibility of Dr. Nancy Lonsdorf and no other person or organization.
Agree
Disagree
8. I understand that any herbal food supplements recommended for me are not drugs and do not treat any disease. Any other programs recommended also do not treat any disease, but are alternative approaches which are for the purpose of specifically balancing the doshas, or underlying intelligece of the physiology, for the purpose for creating balance in the physiology and improving overall mental and physical well-being.
Agree
Disagree
9. I understand that any herbal food supplements and other treatments and recommendations that I may be recommended have not been evaluated by the Food and Drug Administration nor are these approved by the FDA for the prevention, diagnosis, treatment or cure of any disease condition.
Agree
Disagree
10. I understand that while the recommendations of the Maharishi Ayurveda program are usually free of harmful side-effects, I am aware that individuals can react differently to diet, spices, herbs and lifestyle changes. I understand that I am advised to consult my personal physician before implementing them or changing my diet. If I use them I am electing to adopt these suggestions at my own risk. I further understand that such suggestions and treatments are not medically necessary for my condition, and that the physician's liability insurance may not cover adverse outcomes that may occur with these treatments
Agree
Disagree
11. I recognize that no claims or guarantees have been made to me regarding specific medical benefits or improvement in my medical condition(s) that I will receive as a result of any educational information I may receive.
Agree
Disagree
When you finish click on submit and you will be sent to a payment page .
1.
If you scheduled the two visit phone session program a representative from Dr. Lonsdorf's office will call you to schedule the exact appointment time and answer any questions.