> What's happening over the next few months? <
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> What's happening over the next few months? <
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| Michele will give you advise over the telephone on a full personalized health program to follow , including diet, exercise, herbs, supplements, and life counseling accompanied by appropriate written information sheets by email. First email the completed questionnaire and an appointment time will be emailed back to you when you must telephone. If this is not convenient, please let us know and a new appointment can be given. This initial consultation is £25. Please send cheque made payable to Michele Claiborne to Oak Tree House Healing Center, 18 Elm Grove, Wivenhoe, C07 9AY which must be received before the telephone Consultation appointment. QuestionnaireInstructions
Alternatively, print the page and circle or write the appropriate answers, then send it, together with your cheque, to: Michele Claiborne, Oak Tree House Healing Centre, 18 Elm Grove, Wivenhoe, Essex, CO7 9AY, UK.
Please write reason for needing a consultation, include a brief description of any symptoms.
Please give a brief list about your medical history, include any operations or organs missing and previously prescribed drugs that you can remember with approximate dates.
What age are you? (Enter number)
What is your occupation? (Type here)
What build are you? Slight; Medium; Heavy.
What sex are you? Male; Female.
How many children do you have? (Enter number)
What hobbies, do you primarily participate in? None; Physically active hobbies; Inactive hobbies.
How often do you participate in cardiovascular exercise? Never; Occasionally (once a week or less); Regularly (at least twice a week).
Do you smoke tobacco? No; Yes. (How many?)
Do you drink 2 liters of filtered water a day? No; Yes.
Do you drink coffee, tea or cola? Indicate which. Never; Yes but seldom: ___ a day Yes, often: ____a day.
Do you drink alcohol? Never; Only a maximum of one glass of wine/beer or measure of spirits a day; More: ____ glasses of alcohol per day.
Do you like sweet tasting foods? (e.g. biscuits, cakes, sweets, sugar in hot drinks, soda drinks, chocolate ) No; Yes. Indicate how many of the above do you have each day.
Do you like salty tasting foods? (e.g. extra salt on meals, crisps, peanuts, crackers, soy sauce) No; Yes.
Do you eat at fast-food restaurants or snack bars? No; Regularly; Yes but rarely.
Do you eat 50%+ organic foods? No; Yes.
Do you eat dairy products most days? (e.g. milk, eggs, cheese, yogurt) No; Yes.
Do you eat red meat? No; Yes.
Do you eat poultry or fish? No; Yes.
Do you eat some raw salad/vegetables every day? No; Yes.
Do you eat wholegrain (e.g. whole meal bread, brown rice, whole wheat pasta) or refined grain (e.g. white or brown bread, white rice, pasta) products mostly? I eat Refined grains; I eat Whole grains.
Do you eat fresh vegetables every day? No; Yes.
Do you eat nuts? No, I am allergic to nuts Yes.
Do you include sunflower, sesame, and pumpkin seeds in your every day use? Never, or only very occasionally; Often.
Do you eat a piece of fresh fruit every day, or most days? No; Yes.
Which spreads and cooking oil do you use mostly? Butter; Margarine; Pure virgin olive oil; Vegetable oils.
What saucepans do you use? Stainless steel; Aluminum; Teflon.
Do you often cook your pepper (including chilly powder) with your food or add it on afterwards? Cook the pepper; Add pepper afterwards; Never use it.
Do you often cook your salt with your food or add it on afterwards? Cook the salt; Add salt afterwards; Never use it.
How many anti- biotic courses have you had in the last 10 years? 1 - 5 times; 5 times plus.
Do you take aspirin or parecetemol quite often? No; Yes.
Do you take nutritional supplements? No; Yes. (Give a list)
Do you take any prescription or non prescription drugs on a regular basis? No; Yes. (Give a list)
Do you dry skin brush or exfoliate? No; Yes.
Do you practice yoga? No; Yes.
Do you practice any form of meditation on a regular basis? No; Yes.
Do you sing or play a musical instrument? No; Yes.
Do you feel you have a purpose in life? No; Yes.
Do you have a spiritual belief? No; Yes.
Would you say you are happy and at peace with your life? No; Yes.
Do you have a situation at this moment in your life that you feel would benefit from some guidance in how to handle it? Elaborate if yes. No; Yes.
Do you find forgiving easy? No; Yes.
Do you find giving easy? (this includes your love, time as well as material things) No; Yes.
Do you find receiving easy? (this includes love, affection as well as material things) No; Yes.
Do you feel lonely? No; Yes.
Do you feel you are or have followed your dreams? No; Yes.
Do you worry easily? No; Yes.
Are you often disappointed with people and situations? No; Yes.
Do you laugh a lot, at least every day? No; Yes.
Do you make the most of your talents and gifts? No; (you may not even know what they are) Yes.
Are you ever envious or jealous of others? No; Yes.
Do you fast on a regular basis, at least one day, four times a year? (eat no solid food, consume only liquid, water or juices) No; Yes.
Do you ever use seaweed in your cooking? No; Yes.
Have you ever made your own sprouted seeds or beans? No; Yes.
Do you suffer from general skin disorders? No; Yes, dry or oily skin; Yes, acne, boils, psoriasis or eczema; Yes, warts; Yes, dandruff' Yes, herpes simplex.
Do you suffer from allergies? No; Yes.
Do you suffer from aching muscles? No; Yes, rheumatism or arthritis; Yes, cramps; Yes, sciatica.
Are you either: Overweight; Underweight.
Do you often suffer from respiratory problems? No; Yes, congestion or cough; Yes, asthma or short of breath; Yes, bronchitis or pleurisy. Yes, excess mucus.
Do you often suffer from fungal infections? No; Yes, athletes foot or ringworm; Yes, thrush.
Do you suffer from bad body odor or breath? No; Yes, body odor; Yes, bad breath.
Have you moved, lost a loved one, lost your job or divorced in the last 2 years? No; Yes.
Do you suffer from any urinary problems? No; Yes, infections in the urinary system; Yes, water retention; Yes, kidney stones; Yes, incontinence. Yes, prostrate problems.
Do you often suffer from headaches? No; Yes, migraines or tension headaches; Yes, sinus headaches; Yes, but unsure of what kind.
Do you suffer from anxiety, insomnia or depression? No; Yes, anxiety; Yes, depression; Yes, insomnia.
Do you often suffer from bleeding from, or ulcers on, the gums? No; Yes bleeding from the gums; Yes ulcers on the gum or tongue.
Do you suffer from constipation, diarrhea or excessive flatulence? No; Yes, constipation; Yes, diarrhea; Yes, flatulence. Please state how often you do have a bowel movement.___________
Do you often suffer from indigestion or bloated stomach? No; Yes, indigestion; Yes, bloated stomach.
Do you often suffer from colds, flu, sore throat or earache? No; Yes, colds or flu; Yes, sore throat; Yes, earache.
Do you often suffer from swollen glands? No; Yes.
Do you suffer from high or low blood pressure? No; Yes high blood pressure; Yes low blood pressure.
Do you suffer from poor circulation or varicose veins? No; Yes.
Do you suffer with your menstrual cycle? Elaborate if yes. No; Yes.
Do you suffer from menopause? Elaborate if yes. No; Yes.
Are you pregnant? No; Yes.
Do you have any reproductive problems? No; Yes, infertility; Yes, impotency; Yes, lack of sex drive; Yes, suspect you have a sexually transmitted disease.
Do you suffer from any heart problems? No; Yes.
Are you concerned about osteoporosis? No; Yes.
Are you concerned about hormone treatment? (e.g. the pill or hormone replacement) No; Yes.
Do you suspect you have worms? No; Yes.
Are you losing your hair and is it very fine or breaks easily? No; Yes.
Is your tongue very red or red at the tip, sore or very sensitive to heat? No; Yes.
Have you a poor sense of taste or smell? Do your nails have white flecks? No; Yes.
Are you pale, easily tired, and are the whites of you eyes slightly blue? No; Yes.
Do you get cramps at night? No; Yes.
Do you have trouble seeing in moderate darkness? No; Yes.
Do you have very rough, dry skin on the elbows or knees? No; Yes.
Does it take a long time for your cuts to stop bleeding, or do you have frequent nosebleeds? No; Yes.
Where do you live? In the town, city; or next to a busy road; In the county or a quiet area.
Do you take a walk outside for more than 10 minutes every day? No; Yes.
Do you have cancer? No, not to my knowledge; Yes, I have been diagnosed of cancer.
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Dear Colleges, I will be going to India in November to explore more the Ayavedic medicine principles and Kriya Yoga, so the December lodge may be interesting if you would like to visit India for yourselves, so hope to see many of you at Oak Tree House. Until then walk in light and beauty, Love and Light Michele Contact the Oak Tree House Healing Centre on (+44) (0)1206 827766, or send mail to michele.claiborne@ntlworld.com with questions or comments about this web site.Mailing address: Oak Tree House Healing Centre, 18 Elm Grove, Wivenhoe, Essex, CO7 9AY, England.
Copyright © 2001 Michele Claiborne
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