New Patient Registration Form

Name

First NameMiddle NameLast Name

E-mail

Sex

Date of Birth

MonthDayYear

Height (inches)

Weight (pounds)

Number of Births

Contact Number:

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

In case of emergency...

Emergency Contact:

First NameLast Name

Relationship

Contact Number

Area CodePhone Number

Please list all ailments, past and present:

Taking any medications, currently?

YesNo

If yes, please list it here

Please list all past medications:

Are you taking or have you taken supplements of any kind?

Are you allergic to anything that you know of?

Have you ever had asthma?

Do you take antibiotics?

If so, which one(s)?

How often throughout your lifetime?

Do you have recurrent yeast infections?

If yes, how often?

Do you presently have or have you had bacterial, viral, or fungal infections?

Explain:

Do you have circulation problems?

Have you ever had radiation or chemotherapy treatments?

When and how often?

Have you ever had X-rays?

When and how often?

Do you have mercury fillings in your mouth?

Have you ever had any type of serious injuries or accidents?

Have you ever had any type of surgery? If yes, let all surgeries and timeframes:

Please list current symptoms:*

When did your current symptoms occur?

Are your symptoms remaining the same, diminishing, or escalating?

Do you feel pain in a particular area? Which Area:

Amount of processed and refined foods consumed daily?

Please give examples of daily food intake (i.e. fruits, veggies, proteins, carbs, nuts, grains, junk food, etc):

How many meals do you consume daily?

How large are the portions?

Regularly scheduled meals?

What is your daily water intake?

What kind of water?

Do you drink cow's milk?

If so, how often?

How often per week do you eat non-organic beef, chicken, or pork?

Do you drink from aluminum cans? If so, often:

How much caffeine do you consume daily?

How much alcohol do you consume?

Do you consume food containing MSG?

Do you use tobacco? If so, how often?

Do you use recreational drugs of any kind?

What and how often?

Do you exercise regularly?

What type of exercise and how often?

Do you have regular bowel movements?

How often?

Do you wake up at night to urinate?

How often?

Do you use personal hygiene products that contain chemicals?

What and how often?

Job Description:

Do you enjoy your work?

What is your work environment like?

Do you get along with your peers?

How many hours do you work per week?

Do you do any heavy lifting?

Do you work with chemicals of any kind?

If yes, what?

Is your work repetitious? (same repetition of work or range of motion)

What are your hobbies?

Are you fulfilling your goals in life?

Do you have a happy home life?

Is your family loving and supportive of you?

Do you ever travel to foreign countries?

If yes, where?

Does the climate you live in agree with you?

Do you live next to any factories that may have chemical waste products?

Do you live next to fields that have been sprayed with chemicals?

Do you live close to a nuclear plant?

Do you grow a garden?

If yes, do you use chemicals?

Have you recently installed new carpeting in your home or work place? If so, when?

Do you cook in a microwave oven? If so, how often?

Do you use chemical household cleaning agents?

Do you have any pets in your home?

Have you ever been diagnosed with depression?

If so, how long ago?

Do you feel depressed? If so, for how long?

Do you feel anger or resentment?

If so, how do you express these feelings?

Are you irritable?

Do you feel anxiety or nervousness?

Do you have specific fears? If so, what are they?

Do you feel stressed? If so, in what way?

Have you been under extreme stress?

Recently?

How often?

Has there been significant changes in your life? (divorce, death of a loved one, or loss of employment for example)

When?

Have you had any traumatic experiences in your life?

Are your sleep habits normal or abnormal?

If abnormal, please explain:

How do you feel about yourself?

Are you a spiritual person (in whatever way you define spirituality)?

Do you believe in a higher self?

How did you hear about us?

Have you had COVID-19? If yes, when?

Have you had the COVID-19 vaccine? If yes, when was your first and second shot?

Discovering Wellness
Client Request and Authorization

I recognize that Kimberly Fogel, ND; Rachelle Cain, HHC are not an allopathic or medical doctor, nor do they represent their selves as such. The do not treat, diagnose or prescribe any drugs. They do not do surgery, take X-rays or handle pregnancy

I do hereby give Dr. Kimberly Fogel, and Rachelle Cain permission to counsel me concerning my health and well-being, and to recommend a proper diet, to educate me on my biological blood terrain and to apply any of the above methods of healing if they should deem necessary. I further understand that many of these natural remedies are still being researched and absolute results can not be guaranteed. If I choose to follow the advice of Dr. Kimberly Fogel, and Rachelle Cain, I do so of my own free will and I am under no obligation to take or purchase anything. In doing so, I understand that natural health care is not intended as diagaosis, treatment, prescription or cure for any disease, mental or physical, and is not intended as a substitution for regular medical care.

I also understand that the spiritual counseling provided by Kimberly Fogel, and Rachelle Cain is not part of any recognized religion nor is it intended as the practice of clinical psychology.

I, the undersigned, request that Dr. Kimberly Fogel, and Rachelle Cain may perform an evaluation and/or set up a program for the purpose of reducing stress, enhancing my health or my education concerning my health or spirituality. I understand that Dr. Kimberly Fogel, and Rachelle Cain are not an allopathic medical doctor. I understand that the therapies listed above are not intended as diagnosis, prescription or treatment for any disease, physical or mental. It is also not intended as a substitute for regular allopathic medical care.

ARTICLE IX, US. CONSTITUTION
"The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people."

Under the Ninth Amendment of the Constitution of the United States of America, I retain the right to freedom of choice in health care, spirituality and education. This includes the right to choose my diet; and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by any doctor, practitioner, nutritionist, microscopist, or minister of my choice.
The enumeration in this declaration of these rights shall not be construed to deny or disparage other rights retained by me, or my right to amend this declaration at any time.

CONSTRUCTIVE NOTICE
Notice is hereby given to any individual or persons whom receives a copy of this Declaration and who, acting under the color of law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this declaration, that they may be in violation of my Civil and constitutional rights, Title 42, U.S.C. 1983 et seq. and Title 18, Section 241

Today's Date

Date

Signature*

New Patient Registration

Symptoms

Diet

Habits

Occupation

Lifestyle

Environment

Emotional State