HFM Spring Detox and Rejuvenation Assessment
advertisement
Holistic Family Medicine Healthy Lifestyle & Prevention Center Spring Detox and Rejuvenation 2008 This is _________________________________________’s Initial Assessment. Age__________ Health Goals (what would you like to achieve by participating in this Spring Detox & Rejuvenation?): PLEASE NOTE! YOU MAY WANT TO DO THIS LAST AFTER COMPLETING THE REST OF THE ASSESSMENT FIRST. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _________ Health Challenges (current medical diagnosis and any diseases you have had in the past). e.g. hypertension, prostate cancer _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ________ Familial Genetic Predispositions you would like to reduce your risk(s) for? e.g. hypertension, diabetes, cancer, arthritis _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _____ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ What is your current exercise regimen ? e.g. walk for 40 min 2x/week _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ If you feel your exercise regimen needs improving, how so? e.g. I need to increase it to daily for at least 20 minutes to reduce my risk of heart disease _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ______ In what ways do you want to improve the nourishment you give your physical body? e.g. stop eating fried foods and eat vegan 3x per week _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _________ In what ways do you want to improve the nourishment you give your mental body? e.g. be more conscious of my thoughts, reduce negativity, do exercises to improve my memory _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______ In what ways do you want to improve the nourishment you give your emotional/feeling body? e.g. to release the worry, do HeartMath emwave sessions daily for 15 minutes and practice the stress reduction exercises when tension mounts. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ In what ways do you want to improve the nourishment you give your spiritual body? e.g. read an inspirational book or sacred text daily, have daily prayer and meditation _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _____ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ In what ways do you want to improve the nourishment you give your planetary body, a cell in the Universe? e.g. I am going to perform energy fast for 1 hour every night, join the food buying club, start a garden, recycle, bicycle, speak only positively or not speak at all _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _________ Please list current medications, herbs, supplements you are taking and for what. (attach a list or use the back if this space is not enough) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______ Holistic Review of Systems Please list your health concerns, observations and health projections for every organ system: e.g. head concerns and observations: headaches, hair keeps breaking off, Health Projections: headache free, for my hair to grow back without breaking off. Head Concerns/observations ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______ Concerns/observations ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______ Eyes, Ears, Nose, Mouth, Sinuses Cardiovascular Concerns/observations ________________________________ _ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ _____ Concerns/observations ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ _____ ________________________________ _ Respiratory Health Projections ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______ Health Projections ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ______ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Musculoskeletal/Connective Tissue Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Skin/Lymphatics Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Metabolic/Endocrine Systems Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Gastrointestinal Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Nervous System Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Reproductive System Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Mental/Psychological Body Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Immune System Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Spiritual Body Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Planetary Body Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Post additional areas here (career, finances, business, family life) Concerns/observations _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Emotional/Feeling Body Concerns/observations _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Health Projections _________________________________ _________________________________ Use this section to summarize all of the concerns you have and health projections to finalize your health goals and you commitments to better nutrition on all levels. This will be the bases of your personalized detox and rejuvenation program ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Use this space to make pictures or diagrams if you will.
