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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