Fill out this form as completely as possible. After the form is submitted, you'll be asked for credit card information for billing purposes. You will be billed, for a limited time only $75 for your consultation. Name: Email: *Required Section 1 Jumpy nerves, easily irritated Spurts of energy, tire quickly Lack of sex drive Headaches in back of head or neck Gasp for air at night Gasp for air in daytime Susceptible to colds Infrequent urination Burning sensation when urinating Nosebleeds Momentary blackour after bending over Blood in urine Cramps in legs Breath smells of acetone Nausea Dark spots in front of eyes Night blindness Acid indigestion Sensitive to loud noises Internal "Shakes" Ravenous hunger Faintness Crying spells Dark circles under eyes Excessive mucous Allergic reactions Ankles swell Severe backaches Take diuretics Ringing or poinding in ears Take cortisone Slow in healing Excessive urination No energy Take penicillin Nervousness Sensitivity to bright light Bronchial infections Heart poinds after retiring Forgetfulness Unprovoked anxiety Cold sweats Sweet tooth Indecisiveness Hives Food rashes Headaches centered around eyes Puffiness around eyes Inability to pass urine Eat salty foods Bloodshot eyes Severe spontaneous bruising Intensive thirst Eyes water easily Huge quantities of gas Take tranquilizers Take insulin Blurred vision in dim light Weak splitting nails Section 2 Extemities cold and clammy Heart palpitations Sigh heavily, yawn Retinal hemmorrhages Dry flaky skin Halitosis Foul smelling stool Stomach swells Pulse races Feet and hands "go to sleep" Shortness of breath Pain in chest Headaches, top of head Burp bile Hemmorrhoids Gas pains Allergic to drugs Keyed up - fail to calm Dizzy spells Hard, soapy stools Drink alcohol Use tobacco Legs or arms ache Yellow fatty deposits around eyes Yellow fatty deposits elsewhere Infrequent bowel elimination Abdominal soreness Section 3 Sleep a lot Rapid pulse on exertion No interest in sex Failing vision, noticeable in close work Halos around light Needles around joints More tired when you get up than when you went to bed Cloudy vision Need more illumination Pains in eyes Soles of feet "burn" Muscular weakness Apathy Crave salty foods Narrowing of visual field Joints sore and inflamed Section 4 Sore mouth or tongue Stomach cramps Loss of hair Nose itches Underweight, eat but can't gain A feeling of rigidity Numbness Neuritis-like pains, aching, stabbing Foul odor when gas is expelled Take antibiotics Rectal itch Infrequent bowel elimination Trembling hands Unsteady gait, wobbly Double vision Convulsions Diarrhea Cold sores Coated tongue Nervous, jittery Foul body odor Tics or tremors in eyes or mouth Infections, colds etc. Difficulty in talking Drooping Eyelids Section 5 Leg cramps - "charlie horses" Kidney stones Arthritis-like pains Leg muscle ache Lost height or slumped noticeable Sun bathe Take milk of magnesia Loss in twisting and bending strength Lack of coordination Bones break easily Spontaneous fractures Drink milk Eat salads Insomnia Alternating constipation and diarrhea Aching of long bonds and thighs Tense, shoulders and neckache Low back pains Spastic constipation, elimination difficult Irritable Section 6 Female Only Premenstrual tension Very easily fatigued Painful menstruation Menstruation excessive and prolonged Decreased menstrual flow, irregular periods Vaginal discharge Vaginal inflammation or itch Pain during intercourse Menopausal hot flashes Sterile Male Only Urination difficult, dribbling Night urination Feeling of incomplete bowel evacuation Diminished sex desire Easily fatigued Inability to maintain erection Enlarged breasts Sterile Itch around genitals Loss of hair - within past five years Section 7 Please list the 5 or more main complaints you have in the order of importance, giving pertinent details (surgery, medical diagnosis, etc.) If you have had any vital organs removed by surgery which are not mentioned above, please give details Blood Pressure Height. Weight. Age Sex: Male Female Marital Status: Married Single Occupation: Do you take any type of medication? If so, please name and indication frequency and reason for use. If you have had any illness in the past which required large amounts of drugs, please list drugs taken, and indicate length of time used. Do you now use nutritional supplements? Yes No If yes, are the supplements Taken from natural sources Chemically produced Do you take them Regularly Sporadically How long have you used these supplements? A few weeks A few months A year Two years or more Please give the potency (mgs, mcgs, or units) of the following vitamins and minerals which are included in your daily supplementation. Vitamin A Vitamin C Vitamin D Vitamin E B Complex B1 B2 B6 B12 Niacinamide Biotin Pantothenic acid Paraminobenzoic acid Folic acid Choline Inositol Calcium Magnesium Iron Potassium Phosphorus Trace minerals Section 8 How often do you eat the following foods? daily occasionally seldom Milk daily occasionally seldom Cheese daily occasionally seldom Icecream daily occasionally seldom Cereal daily occasionally seldom Sweet rolls or donuts daily occasionally seldom Sandwiches daily occasionally seldom Fruit daily occasionally seldom Fruit juice daily occasionally seldom Peanut butter daily occasionally seldom Nuts daily occasionally seldom Dried peas or beans daily occasionally seldom Meat in casseroles daily occasionally seldom Red meat, fish or poultry daily occasionally seldom Cooked or raw vegetables daily occasionally seldom Potato rice or noodles daily occasionally seldom Cookies or crackers daily occasionally seldom Pie, cake or brownies daily occasionally seldom Potato chips or corn chips daily occasionally seldom Candy daily occasionally seldom Soft drinks daily occasionally seldom Koolaid By Submitting this form, you acknowledge that you understand that Eileen Renders N.D. is a Nutritional and herbal therapist, and not an M.D. She does not examine, diagnose, nor prescribe.