Please print out the 2 forms on this page and return them along with a check or money order for $50.00 by mail to:
631 N. Longwood Street
Suite LL03
Please allow 2 weeks for Dr. Castaneda's recommendations to be returned to you. Also be sure to include a phone number and the best time to call as she may need to contact you for further information. Answer questions with as much detail as possible.
INFORMATION
DATE:__________________
NAME:________________________________
ADDRESS:_____________________________
_______________________________________
TELEPHONE:__________________________
AGE:__________________________________
SEX: MALE_______FEMALE_____________
WEIGHT:______________________________
HEIGHT:______________________________
BLOOD PRESSURE:____________________
TEMPERATURE:_______________________
SCORE FROM SYSTEMIC YEAST TEST:______________
See Candida Questionnaire: CLICK HERE
Please list all ailments. Past and present:_________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Please list any present medications you are now taking:______________________
______________________________________________________________
______________________________________________________________
Please list all past medications:________________________________________
_______________________________________________________________
______________________________________________________________
Are you or have you taken supplements of any kind?_______________________
_______________________________________________________________
_______________________________________________________________
Are you allergic to anything that you know of?____________________________
_______________________________________________________________
_______________________________________________________________
Havehad asthma?_________________________________________________
Do you take antibiotics?________ How often throughout your lifetime?_________________________________________________________
_______________________________________________________________
_______________________________________________________________
Do you have recurrent yeast infection? If so, how often?_____________________
Do you presently have or have you had bacterial, viral, or fungal infections?______
Eplain._________________________________________________________
Do you have circulation problems?_____________________________________
_______________________________________________________________
_______________________________________________________________
Have you ever had radiation or chemotherapy treatments?________ How often?__________________________________________________________
_______________________________________________________________
_______________________________________________________________
Have you ever had x-rays?__________________________________________
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?___________Please list all?___________
_______________________________________________________________
_______________________________________________________________
Please list current symptoms?________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
When did your symptoms first occur?__________________________________
______________________________________________________________
______________________________________________________________
Are the symptoms remaining the same, diminishing or escalating?_____________
______________________________________________________________
______________________________________________________________
Do you feel pain in any particular area?_________________________________
______________________________________________________________
______________________________________________________________
Amount of processed and refined foods consumed daily?____________________
Please give example of daily food intake (i.e. fruits, vegetables, proteins, carbohydrates, nuts, grains, junk food etc...)______________________________________________
_____________________________________________________________________ _____________________________________________________________________
How many meals do you consume daily?_____________Portions?____________
What is your daily water intake?______________________________________
Purified_____City_____Well_____Spring______
Do you drink cow's milk?_______________How often?___________________
How often per week do you eat non-organic beef, chicken, or pork?___________
Do you drink from aluminum cans and plastic bottles?______________________
Amount of caffeine consumed daily?___________________________________
Do you consume foods that contain MSG (monosodiumglutamate)?____________
How much alcohol do you consume?__________________In the Past?________
_______________________________________________________________
_______________________________________________________________
Do you smoke tabacco?_________________How often?__________________
Do you use recreational drugs of any kind?_____________How often?_________
Do you exercise regularly?__________What type and how often?_____________
_______________________________________________________________
_______________________________________________________________
Do you have regular bowel movements?__________________How often?______
Do you wake up at night to urinate?____________________________________
Do you chemically process your hair with dyes or perms?____________________
Do you use personal hygiene products that contain chemicals?________________
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 a week?_________________________________
Do you do any heavy lifting?_________________________________________
Do you work with chemicals of any kind?____________If so, 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?_________________________________
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?___________________________________
If you grow a garden, do you use chemicals on your plants?__________________
Do you cook in a microwave oven?____________________________________
Have you recently installed new carpeting in your home?____________________
Have you checked your home for gas leaks?_____________________________
Have you ever checked your home for lead paint?_________________________
Do you exterminate your home for pest control?___________________________
Do you use chemical household cleaning agents?__________________________
Do you have any pets in your home?___________________________________
Have you ever been diagnosed with depression?__________________________
Do you feel depressed?____________For how long?______________________
Do you feel anger or resentment?________________If so, how do you react to these feelings?_________________________________________________________
Are you irritible?__________________________________________________
Do you feel any anxiety or nervousness?________________________________
Do you have any specific fears?_______________________________________
Do you feel stressed?________In what way?____________________________
______________________________________________________________
______________________________________________________________
Have you been under any extreme pressure?____________________________
Has there been any significant changes in your life? (divorce, death of a loved one,
or loss of employment for example).__________________________________
Have you had any traumatic experiences in your life?______________________
______________________________________________________________
______________________________________________________________
Do you feel fatigued?______________________________________________
Are your sleep habits normal or abnormal?_________ Explain_______________
How do you feel about yourself?______________________________________
Do you believe in yourself?__________________________________________
Are you a spiritual person? (in whatever way you define spirituality)____________
Do you believe in a higher self?_______________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Truth and Wellness Facilitator
I recognize that Dr. Kimberly Kaye Castaneda, ND is not an allopathic or medical doctor, nor does she represent herself as one. She does not treat, diagnose or prescribe any drugs. She does not do surgery, take X-rays or handle pregnant patients. Dr. Castaneda is a Naturopathic Doctor that researches and teaches about the benefits of natural medicines, vitamins and supplements. Her Washington D.C. registration and American Naturopathic Medical Association board certification states that she is qualified in all forms of natural healing including Acupressure, Bach Flower Remedies, Chronic Diseases, Herbology, Homeopathy, Massage, Nutrition, Reflexology, Vibrational and Polaity Healing.
I believe it is my constitutional right to seek Dr. Castaneda's counsel and wisdom concerning my well-being and the maintenance of my health.
I do hereby give Dr. Castaneda permission to counsel me concerning my health and well-being, and to recommend any supplements that she deem necessary and to recommend a proper diet. 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 Dr. Castaneda's advice, I do so at my own free will and I am under no obligation to take or purchase anything.
Signature:_______________________________Date:_________
Address:_____________________________________________
State/City:____________________________Zip:_____________
Phone:______________________________Age:_____________
