Appendix Initial Intake Information Date: Referred by: Address: Name: Sex: M ( ); F ( ). Age: Telephone: home-( work-( Address: Initial contact: Handshake: weak ); strong ( ). cold ); warm ( ). moist ); dry ( ). Grooming: ________; posture: Demeanor/attitude: Breathing mode: High chest shallow ( ); hyperpnea ( ). 307 308 APPENDIX Sighing: frequent ( ); occasional ( ); absent ( ). Occupation: Contact with: dust ( ); fibers (); paints ( ); solvents ( ); sprays ( ); detergents ( ). Other chemicals or airborne particles: Status: Married ( ); single ( ); divorced ( ); other: children: No. Boys ( ); No. Girls ( ). Physician(s) of record: Last medical examination: _________,199__ Diagnos(e)s: 'Ireatmentts): Medication(s): Do you now have, have you ever had, or has any family member related to you by blood (mother, father, sister, brother, familial grandparents or uncles and aunts) had: ( ) High blood pressure () Heart disease APPENDIX 309 ) Low blood pressure ) Angina ) Diabetes (insulin-dependent) ) Anemia ) Diabetes (non-insulin- ) Allergies dependent) ) Dermatitis ) Colitis ) Muscle spasms ) Gastritis ) Tingling in hands and/or feet ) Ulcer ) Fainting (syncope) ) Shortness of breath ) Dizziness (vertigo) ) Asthma ) Stroke ) Emphysema ) Headache ) Hyperventilation ) TMJlbruxism ) Mitral valve prolapse ) Chronic low backache ) Other heart murmur ) EB virus (mononucl.) ) Heart arrhythmia ) PMS ) Chronic vaginal yeast ) Chronic tiredness ) Cystitis ) Menstrual irregul. ) Raynaud's disease ) Tinnitus ) Chronic pain ) Hyperthyroid ) Eating disorder ) Hypothyroid ) Cancer ) Herpes ) Depression () Other ) Migraine Health status of: Mother Father 310 APPENDIX Brother(s) Sister(s) Exercise: seldom ( ); moderately ( ); freq uently () Mode: Injuries/fractures, etc.: Do you consume: seldom moderately frequently Coffee () ( ) ( ) Tea () ( ) () Herbal tea () () ( ) Cigarettes () () ( ) Alcohol () () ( ) Aspirin ( ) () ( ) Cola ( ) ( ) ( ) Birth control pills ( ) ( ) ( ) Sedatives () () () Tranquilizers () () ( ) Antidepressants ( ) () ( ) Laxatives () () ( ) Steroids ( ) () () Hormones ( ) ( ) ( ) Vitamins/mineral suppl () () ( ) Cough/cold medicines ( ) () ( ) APPENDIX 311 Inhalants ) () ( ) Antacids ) () ( ) Diet pills ) ( ) () Sleeping pills ) ( ) ( ) Muscle relaxants ) () () Other ) ( ) () Do you have any food allergies or sensitivities? Do you suffer from: () Stress () Tension () Anxiety ( ) Panic attacks () Phobias () Depression Are you suicidal? Do you experience: seldom sometimes frequent m m s" mms mms Thirst ()()() ()()() ()()() Hunger ()()() ()()() ()()() Faintness ()()() ()()() ()()() Feeling unreal ()()() ()()() ()()() Urge to urinate ()()() ()()() ()()() Constipation ()()() ()()() ()()() Diarrhea ()()() ()()() ()()() *"m m s" = "mild," "moderate," "severe" 312 APPENDIX Blurred vision ()()() ()()() ()()() Insomnia ()()() ()()() ()()() Nightmares ()()() ()()() ()()() Sleep disturbance ()()() ()()() ()()() Sleep apnea ()()() ()()() ()()() Irritability ()()() ()()() ()()() Loss of memory ()()() ()()() ()()() Loss of work efficiency ()()() ()()() ()()() Irritability ()()() ()()() ()()() Sensation of smothering ()()() ()()() ()()() Tingling in hands and feet ()()() ()()() ()()() Other Have you been told that any of the following clinical tests showed unusual (above or below average) results or problems: Blood test ECG EEG Other Psychophysiological Profile Breathing: Mode APPENDIX 313 Rate ______ /min ETC02 ------% Rhythm Bronchitis Asthma CaPO/emphysema Other Sa02 -----_% Cardiac: Pulse rate ______ Imino RSA ECG Cardiovascular: Hand temperature [right ( ), left ( )] deg. 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