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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