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Interview Form

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The following form is used for collecting basic information regarding your current health situation by David Dancu, N.D. Data from this form will be used in analysis of various factors. Completing this form should not take more than 10 minutes. Completing the form is FREE. However, There is a fee involved for an evaluation of the intake form and credit cards are accepted. Please provide a contact address for response and cost of the evaluation. Thank you.

JavaFILE

CASE RECORD

Etiology

If you have one or more of the following, please check:

Alcoholism Anemia Arthritis Asthma Cancer Children's Illnesses Cold sores Depression Diabetes Respiratory Problems Herpes Hay fever Heart Problems Kidney Problems Liver Problems Miscarriage Cold sores Fevers Abuse Strep Skin Problems TB Tonsils Sinus Veneral Disease Warts Headaches Vertigo Vision Problems Hearing Problems Taste Problems

Please describe clearly the major complaint, the one which is
most limiting in your life, either physical, mental or both.

Any other major conditions:

Any Operations:

Past Homeopathic Treatments:

Family History of Disease:

Ill Effects from Vaccinations?

Allergies:

Weight: Lbs, Kilos
Height: Ft/In. Centimeters
Exercise regularly?Yes, No

 Coffee?
Drugs?
Alcohol?		 Tobacco?
Tea?

Can you tell us how your finger and toe nails look like? What is their appearance? Are they, for instance, brittle, soft, easily crack, etc.?


The same for your tongue: What color is it, rough or smooth?
Any aversions? (Describe)
Digestion problems? (Describe)
Sexual Functions (Describe):
Excitable? (Describe including causes)

*How do you like the temperature of your food? 		*What are your food desires: Sweet Spicy Salty Milk Fruits Fish Cheese Veggies Meat Eggs
*Body Temperature:
*Bowel: Do you have flatulence:
*Urine:
*Perspiration:
*Skin Problems: *Sleep:
Tossing/Turning
*Position:
*Type of sleep:
*Dreams:
*Where/when do you feel the "best"?
*Anger:
*Anxiety/Worry: 		*What is your appetite level:
*Thirst Level:
*Energy levels:
*Menses:


*Moods:

*Fears:
*Concentration:
*Forgetful:
*Confusion:
*Indifference:
*Words/Mistakes:
*Confidence:
Any food that causes problems? (Describe)

Specific food cravings? (Describe)

*Were you ever: Abused, Abandoned
* Do you ever feel: Abused, Abandoned
*Are you now feeling: Grief, Guilt
*Do you ever feel: 		*Do you ever have jealousy?
* Do you ever have distrust?
* Are you judgmental?
* Are you ever restless?
* Is restlessness about:
* Are you taken to weeping? 		*Do you ever have envy?
* How sensitive are you (Emotionally)?
* Have you ever considered or thought about suicide?
* Have you ever tried suicide?

Any other comments you would like to make? If so, please enter into this box: 



If you are open to additional consultation, if needed, beyond 
information in this form, check this box: Open to consultation







To complete your order please complete the following form:


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 Please make checks and money orders payable to: Larry Smith

Mail to: 3619 E Verdin road, Phoenix AZ 85044 U.S.A. 
    








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