Name:  E-mail:

    Spouse’s Name:  Emergency Contact Phone Number:

    If client is Minor - Parents’ Names:

    Home Address:

    City:  State:  Zip:



    Mailing Address:

    City:  State:   Zip:


    Home Phone (with area code):  Work Phone (with area code):

    Employer:  City:  Profession:

    Height: | Weight:

    Ethnic Origin:

    Birth Date:  Referred by:

    Primary Care Physician:  City:  Phone Number (with area code):

    Check any of the following medications you are taking or have taken within the last 90 days:

    Antacids

    Cortisone/Anti-inflammatories

    Lithium


    Antibiotic/Antifungal

    Heart Medications

    Oral Contraceptives


    Antidepressants

    High Blood Pressure

    Radiation


    Antidiabetic/Insulin

    Hormones

    Relaxants/Sleeping Pills


    Aspirin/Tylenol

    Inhalers


    Thyroid


    Chemotherapy

    Laxatives


    Ulcer Medications

    Recreational Drugs

    Specify:

    Other Specify:


    List ALL Surgeries of Medically-diagnosed Conditions

    Check if you eat, drink, or use:

    Alcohol

    Distilled water

    Refined sugars

    Candy

    At fast food restaurants regularly

    Saccharine (Sweet and Low)

    Carbonated beverages

    Fried foods

    Chew Tobacco

    Cigarettes

    Luncheon meats

    Vitamins and/or Minerals

    Coffee

    Margarine

    Check if you:

    Diet often

    Salt food without tasting

    Exposed to chemicals at work

    Do not exercise regularly

    Under excessive stress

    Exposed to cigarette smoke

    List all medications taken within the past 90 days:


    List all supplements:


    Do you have a history of any of the following:

    High blood pressure


    Yes


    No

    Low blood pressure


    Yes


    No

    Elevated blood sugar levels


    Yes


    No

    Low blood sugar levels


    Yes


    No

    Family history of diabetes:



        Father’s side:


    Yes


    No

        Mother’s side:


    Yes


    No

        Both:


    Yes


    No

    Family history of cancer. If yes, what type:



    Yes


    No

    Any hereditary condition. If yes, describe.



    Yes


    No

    Heart problems. If yes, what type:



    Yes


    No

     Please list below the five main complaints you have in the order of importance:

    1.

    2.

    3.

    4.

    5.

    List any allergies (food, chemicals, medications, supplements, environmental, pets):



    Form 2: Contract of Authorization Form

    Gloria Gilbère, D.A.Hom., Ph.D., D.S.C.

    EcoErgonomist©, Wholistic Rejuvenist©, Health Detective

    Please read carefully before submitting or signing:

    I hereby authorize Gloria Gilbère, and her representatives, to act on my behalf concerning the corrective, non-drug programs offered to achieve holistic health. I specifically authorize her to evaluate my health concerns and to recommend the appropriate nutritional and detoxification programs, lifestyle and environmental modifications necessary.

    I warrant that all information submitted for evaluation is submitted by me and is true to the best of my knowledge. I also attest that I am disclosing all medical information including any medical diagnosis, physicians’/therapists’ names and contact information, any drugs, herbs, supplements, allergies, or therapies I am currently having or have had within the past 90 days.

    I recognize that the approach (s) recommended by Gloria Gilbère are non-medical. I also recognize that she will evaluate my condition so she can make appropriate personalized wellness protocols suited specifically for me. I, and any family members, heirs, or other parties, hereby hold Gloria Gilbère, et al harmless in any way. I understand it is my responsibility and choice to follow the wellness protocols recommended. The programs recommended by Gloria Gilbère are designed to allow the body to have the necessary natural means to promote health and healing and boost my body’s immune system by implementing nutrition-based medicine, alternative therapies as appropriate, lifestyle modifications and nutraceuticals or other natural healing modalities. I also understand that as a client of Gloria Gilbère, division of Gloria E. Gilbère, LLC, twenty dollars of my consulting fee will be applied to a one-time membership fee as part of a Private Healthcare Membership Association of The Institute for Wholistic Rejuvenation, of which Gloria Gilbère is the health care director

    Client’s Name:   E-mail:  Date:

    If client is minor, parent/guardian must acknowledge below:

    Name of Minor:

    Name of Parent/Guardian 

    By clicking submit, you are confirming that the information contained above is true and correct, and acknowledge that you are providing an electronic signature. You also attest that you are submitting this document solely as a client, on this and any subsequent visits (in person, by e-cam or telephone), and solely on your own behalf and not as an agent of any agency, people, organization or parties. You also attest that any person or persons with you at this time and any future consultation by any means are strictly present to accompany you at your request and not as an agent or other representative in any way whatsoever.



    Before you submit online or mail, print all your forms, you will need to upload or email us a close up photo taken within the past 30 days.



    ©2020 Gloria E. Gilbère, LLC, Institute for Wholistic Rejuvenation, a Private Healthcare Membership Association


    Form 3: Status Form

    Please read carefully before submitting or signing:

    I, Gloria Gilbère, am neither a medical or naturopathic physician, and do not hold myself out as one. I am trained as a doctor of natural health and wholistic nutrition, a certified dietary supplement counselor, and as a clinical and classical homeopath.

    As a client, you will be informed of the natural approaches necessary for a lifestyle of healthy living**. The recommendations given are not a substitute for conventional medical treatment; they are natural, non-drug protocols. I do not diagnose, treat or cure, but rather work within holistic, integrative natural protocols to achieve health. It is my goal to assist you in dealing with the underlying causes of your condition, not merely the effects – accomplishing a natural overall approach to your health and quality of life. For any medical problem, it is important that you disclose to my office the name of your physician, any allergies, and any medications you are taking, or have taken within the past 90 days.

    At this time, most insurance companies do not pay for nutritional, environmental or wellness healthcare consulting. Please SAVE ALL YOUR RECEIPTS, we do not bill or deal with insurance companies or year end summaries. It is your responsibility to submit or deal with your insurance carrier if your policy covers nutritional and wellness services. Payment is due at time of service, no exceptions – we accept Visa and Master Card.

    If we should have to use legal or collection means to collect on your account, you agree that you will be responsible for all charges/fees incurred by us. A finance charge of 2.5 percent per month will be added to all balances beyond 15 days.

    Client’s Name:  E-mail:   Date:

    If client is minor, parent/guardian must acknowledge below:

    Name of Minor:  Age:

    Name of Parent/Guardian:  Date:

    A doctor of natural health recognizes the healing power of nature, incorporating diet, exercise, pure water, rest, sunlight and fresh air. A doctor of natural health prepares each student to educate and empower the public to actively choose a healthy lifestyle. A doctor of natural health does not perform invasive procedures, diagnose, treat illness, or prescribe drugs. He / She focuses the clients attention through education to attain, fine-tune, and maximize his / her own homeostasis. This holistic approach incorporates health promotion by giving equal consideration to body, mind and spirit. It is a proactive model rather than a reactive (allopathic) model of health care.

    Holistic Nutrition, natural health and rejuvenation focuses on health through education rather than diagnosis. The training prepares each practitioner with a solid foundation in nutrition counseling including nutraceuticals, minerals, homeopathic, and herbals, as well as organic "living foods". Wholistic Rejuvenation counseling includes natural detoxification methodologies to assist the body in reducing its overall toxic burden; facilitating natural healing processes at a return to homoestasis by implementing nutrition-based medicine principles.

    Copyright 2020 Gloria E. Gilbere, LLC, Institute for Wholistic Rejuvenation, a Private Healthcare Membership Association


    Form 4: Metabolic Screening Questionnaire


    Patient Name:   Email:   Date:

    Weight:  Height:  Eye Color:

    Rate each of the following symptoms based upon your typical health profile for the past 30 days.

    Point Scale:

    0 =
    Never or almost never
    have the symptom

    1 =
    Occasionally
    have it; effect is
    not severe


    2 =
    Occasionally
    have it; effect is
    severe


    3 =
    Frequently
    have it; effect is
    not severe


    4 =
    Frequently
    have it; effect is
    severe

     





    HEAD

    Headaches:

    01234

    Faintness:

    01234

    Dizziness:

    01234

    Insomnia:

    01234

    Total:


    EYES
    :

    Watery or itchy eyes:

    01234

    Swollen, reddened or sticky eyelids:

    01234

    Bags or dark circles under eyes:

    01234

    Blurred or tunnel vision

    (Does not include near- or far-sightedness):

    01234

    Total:


    EARS
    :

    Itchy ears:

    01234

    Earaches, ear infections:

    01234

    Drainage from ear:

    01234

    Ringing in ears, hearing loss:

    01234

    Total:








    NOSE
    :

    Stuffy nose:

    01234

    Sinus problems:

    01234

    Hay fever:

    01234

    Sneezing attacks:

    01234

    Excessive mucus formation:

    01234


    Total:


    MOUTH/THROAT
    :

    Chronic coughing:

    01234

    Gagging, frequent need to clear throat:

    01234

    Sore throat, hoarseness, loss of voice:

    01234

    Swollen or discolored tongue, gums, lips:

    01234

    Canker sores:

    01234

    Total:


    SKIN
    :

    Acne:

    01234

    Hives, rashes, dry skin:

    01234

    Hair loss:

    01234

    Flushing, hot flashes:

    01234

    Excessive sweating:

    01234

    Total:







    HEART
    :

    Irregular or skipped heartbeat:

    01234

    Rapid or pounding heartbeat:

    01234

    Chest pain:

    01234


    Total:


     


    LUNGS
    :

    Chest congestion:

    01234

    Asthma, bronchitis:

    01234

    Shortness of breath:

    01234

    Difficulty breathing:

    01234

    Total:


    DIGESTIVE TRACT
    :

    Nausea, vomiting:

    01234

    Diarrhea:

    01234

    Constipation:

    01234

    Bloated feeling:

    01234

    Belching, passing gas:

    01234

    Heartburn:

    01234

    Intestinal/stomach pain:

    01234

    Total:






    JOINTS/MUSCLE
    :

    Pain or aches in joint:

    01234

    Arthritis:

    01234

    Stiffness or limitation of movement:

    01234

    Pain or aches in muscles:

    01234

    Feeling of weakness or tiredness:

    01234


    Total:


    WEIGHT
    :

    Binge eating/drinking:

    01234

    Craving certain foods:

    01234

    Excessive weight:

    01234

    Compulsive eating:

    01234

    Water retention:

    01234

    Underweight:

    01234

    Total:


    ENERGY/ACTIVITY
    :

    Fatigue, sluggishness:

    01234

    Apathy, lethargy:

    01234

    Hyperactivity:

    01234

    Restlessness:

    01234

    Total:





    MIND
    :

    Poor memory:

    01234

    Confusion, poor comprehension:

    01234

    Poor concentration:

    01234

    Poor physical coordination:

    01234

    Difficulty in making decisions:

    01234

    Stuttering or stammering:

    01234

    Slurred speech:

    01234

    Learning disabilities:

    01234


    Total:


    EMOTIONS
    :

    Mood swings:

    01234

    Anxiety, fear, nervousness:

    01234

    Anger, irritability, aggressiveness:

    01234

    Depression:

    01234

    Total:


    OTHER
    :

    Frequent illness:

    01234

    Frequent or urgent urination:

    01234

    Genital itch or discharge:

    01234

    Total:


    List ALL Surgeries of Medically-diagnosed Conditions





    ENVIRONMENTAL
    :

    Are you sensitive/allergic to fragrances (perfume, air fresheners, fabric softeners, candles, etc.)?

    If so, list:


    Do you use a self-cleaning oven?      YesNo

    Do you color your hair?      YesNo

    Do you permanent wave your hair?      YesNo

    Do you wear acrylic nails?      YesNo

    Do you use clothes dryer fabric softener sheets?      YesNo

    Do you use conventional window/glass cleaners?      YesNo

    Are you sensitive/allergic to refueling your car?      YesNo

    How old is your car?  How old is your home?

    Does your home have standing water or visible mold?     YesNo

    Have you recently painted any room in your home or office?     YesNo

    Is the carpet in your home or office newer than 2 years?      YesNo

    What type of cook stove do you have?  (check which one)

    Natural gas, Electric, Wood, Propane, Solar power

    What type of heat do you have in your home? (check which one)

    Natural gas, Electric, Radiant, Wood, Propane, Solar power, Hot water, Baseboard heat

    Do you use a microwave oven at home or office?      YesNo

    Are your mattresses newer than 4 years? YesNo      If so, when were they purchased?

    Do you use fragranced spray room fresheners or plug-in fresheners?      YesNo

    Do you use carpet sprays for cleaning or deodorizing?      YesNo

    How many times per year do you travel by air?

    Have you traveled outside the U.S.? YesNoIf so, when was last trip:

    Do you get symptoms of any of the following when exposed to any environmental factors?      YesNo     (If yes, check those that apply):

    Headaches

    Cortisone/Anti-inflammatories Stuffy nose

    Lithium

    Antibiotic/Antifungal Muscle aches

    Heart Medications Blurred vision

    Oral Contraceptives Trouble concentrating

    Antidepressants

    High Blood Pressure

    Cough

    Sneezing

    Are you exposed to chemicals in your work/profession?      YesNo      If so, what type? 

    Has your home or office been remodeled within the past 4 years?      YesNoIf so, when:

    If you use a computer, how many hours average per day do you use it?


    If you commute to your office or place of business, how long is your commute in time? in miles round trip per day or total miles per week.


    DENTAL HEALTH:

    How often do you regularly get your teeth cleaned by either a dentist or hygienist?

    When was the last time you had a professional teeth cleaning? Month: Year:

    Do you have any root canals?   YesNoIf so where:

    Do you have any silver (amalgam) fillings? YesNo

    If you’ve had silver (amalgam) fillings replaced, give Month: Year:

    Do you wear, or have you ever worn a night-guard? YesNo

    Are you allergic to epinephrine in local anesthetic? YesNo

    If so, what type of anesthetic can you tolerate?

    Does your tongue have a definite white coating? YesNo

    Have you had any extractions? YesNo

    If so, describe location of teeth and approximate year of extraction:

    Do you wear a partial or dentures?  YesNo If so, which: Partial Denture

    Have you been diagnosed with TMJ syndrome? YesNo

    Are you overly apprehensive about going to the dentist? YesNo

    Do you experience headaches, depression, anxiety or emotionally fragile systems after local anesthetic? No

    (If yes, check those that apply):

    Headaches
    Depression
    Anxiety
    Emotionally Fragile

    Have you had any dental implants? YesNo

    Have you ever had an allergic reaction either in the dental office or as a result of a dental procedure? YesNo

    If so, explain:

    Does your biological father have dentures? YesNo

    If so, at what age approximately did they receive them?

    Does your biological mother have dentures? YesNo

    If so, at what age approximately did they receive them?

    Did you have a lot of cavities as a child and adolescent? YesNo

    What type of product do you use to brush your teeth? Describe:

    Do you floss daily? YesNo

    Do you use toothpicks? YesNo

    Have you been told you have any form of gum (periodontal) disease? YesNo

    If so, describe:

    Have you ever had I.V. sedation? YesNo

    Was your experience positive? YesNo

    If not, explain:

    Does heart disease run in your family? YesNo

    Do inflammatory disorders fun in your family (Arthritis, Fibromyalgia, Gout, Lupus etc.) YesNo

    If so, describe condition and relationship:

    When was your last dental visit for restorative work? Month: Year:

    Do you have difficulty swallowing pills? YesNo

    Do you gag easily? YesNo

    Do you get nausea easily? YesNo

    Do you experience sinus infections? YesNoHow Often? 

    Do you experience migraine-type headaches? YesNo How Often?

    Who is your dentist? Dr.: City: State: 

    Country:

     

    Institute for Wholistic Rejuvenation, a subsidiary of Gloria E. Gilbere, LLC - A Private Healthcare Membership Association

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