1st Visit Form - Denny Waxman Macrobiotic Counselor

Personal Information

Name*

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cell Phone*

Email*

Age*

Date of Birth

Birthplace

Marital Status

Number and ages of children

Accompanied by

Relationship

Why have you decided to see me?

Occupation or previous occupation if retired

Have your read The Ultimate Guide to Longevity?

Yes
No

Days, weeks, months or years of macrobiotic practice?

What was your previous diet?

Approximate body weight

Height

How is your bowel movement?

How many times a day do you urinate?

Color of urine:

Transparent
Dark yellow
Light Yellow

Cooking & Diet

Do you cook with:

Gas
Electricity
Microwave

Please check the foods you have been eating regularly, a few times a week.

Present Symptoms (Please list)

Previous Illnesses, Accidents & Surgeries

Have you had any psychological problems? If yes, please specify the type and treatment you have had.

Have you had any previous major illnesses, miscarriages, accidents, broken bones or other surgeries including tonsils, appendix or abortions? If yes, please specify and give dates.

Present Concerns

What is the reason for your visit? Please specify such as: general dietary or lifestyle guidance; a specific health problem or illness; or a psychological problem?

If you have a particular disorder, when was it diagnosed?

Are you presently under the care of a doctor or other health professional? If yes, please specify.

Are you currently receiving any medical treatments? If yes, please specify:

Have you had any surgery and/or medical treatments such as radiation or chemotherapy for your present problem? If yes, please specify.

Are you currently taking any medications, vitamins or supplements? If yes, please list below.

For Women:

Are your menstrual cycles regular?

How many days in between periods?

How many days does it last?

Do you feel pain or discomfort? If so,when:

Before
During

Do you have vaginal discharge?

What type of birth control do you use?

If you have children, did you have normal childbirth?

Any Other Comments:

Are you comfortable with having a Scribe to take notes?*

Are you comfortable with a student-counselor being present during this consultation (Zoom-ONLY)?*

Would you like to receive monthly newsletters (blogs, upcoming events, etc)? You can unsubscribe at any time.*

Digital Signature*

By electronically signing above, I certify that I have read and agree to the Counseling Disclaimer.