Health and Lifestyle History
Your insightful answers to these questions will assist me in understanding what nutritional changes, lifestyle changes or alternative health protocols I would select to assist you. You understand I am an alternative medical solution researcher and any ideas I present are not endorsed by anyone from organized medicine or any government organization. Further, many resources I have recommended to others have been banned, hounded and otherwise harassed by FTC, FDA, AMA and others. Please think for yourself, gather every bit of information you can on any possible solutions and make your own choices regarding your health.
Dale Maxwell, CHT, NLP, Personal Coach and Montor.
I am authorized under Cal BP2068; "State law allows any person to provide nutritional advice or give advice concerning proper nutrition--which is the giving of advice as to the role of food and food ingredients, including dietary supplements."
Please give as detailed and verbose information as you can and fax these pages to me. Any other test results such as stool tests; blood tests, etc. may be faxed to me also.
If you do not want to put your name on the document please use any alias you choose and let me know in a separate fax how to communicate with you.
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Age |
Height |
Weight |
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Blood Type |
Vision |
Hearing |
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Skin (dry, oily, normal, bumps, etc.) |
Body Temperature |
Bowel Movements (easy, hard) frequency |
Any time you experience an accident your body may contract. This is not unusual and you will usually recover from the contraction in a short while. However in some cases your body may stay in contraction and this can result in disease. For instance, contraction of the pancreas can cause digestion problems.
Injuries
Stress
Root Canals
Metal
Fillings
Appliances
Crowns
Pulled teeth: COULD THERE BE HIDDEN INFECTION IN YOUR JAW?
Pain: Do you have chronic pain of unknown origin? This pain is usually from the arms up, but it can even be back or leg pain. Does this pain increase with stress or exhaustion?
Tenderness: Do you have tenderness in the gum area where a tooth has been removed or behind your last molar?
Skin lesion: Do you have a chronic skin lesion, dry skin patch, or keratotic tissue on the face?
Fatigue: Do you have some type of chronic fatigue or tiredness?
Infections: Do you have numerous sinus or upper respiratory infections?
Gum disease: Do you have periodontal (gum) disease in posterior teeth?
Spasms: Do you have muscle spasms in your head or face?
Tooth extraction: did you have complications from the extraction of your wisdom teeth? Did your symptoms begin soon after a tooth was extracted?
Note that these symptoms are numerous causes and may be unrelated.
Jawbone cavitations are cavities or infections within the jawbone.
A rather significant aspect of such lesions is that they cannot be easily seen on x-rays, although they often have an irregular fuzzy margin.
A recent published study of 224 biopsied tissue samples from alveolar bone cavities in 135 patients with "trigeminal neuralgia" or "atypical facial neuralgia" demonstrated common features of these lesions: intra-osseous cavity formation; long-standing bone necrosis (tissue death); chronic facial neuralgia (pain).
We are not sure how all of these lesions develop; however, it is obvious that many patients with chronic pain can trace the onset of their pain back subsequent to one or more tooth extractions. Generally, even though the surgical site appears to heal normally, a problem remains in the bone that antibiotics are not able to remedy.
Days in Hospital
Drugs
Now
Before
What
How much
Timing
Do you have a model that you can now notice that does not serve you for the good emotional and physical health you deserve?
A common survival technique that you may have adopted as a child is to bottle up your opinions, emotions, and feelings so that you will gain acceptance from the people who have power over you. These patterns served you well and allowed you to grow up safely. However, these behaviors may not be appropriate for you now. Notice how you answer the questions and examine whether some changes may assist you in your pursuit of emotional and physical health.
Answer these questions for each emotional area; be as verbose as you can, as more detail will assist in clarifying:
How do you handle it? Please comment and add detail.
With Acceptance and joy
With anger
Outwardly quiet - inside upset
(Add your own statement)
How do you handle it?
With Acceptance and joy
With anger
Outwardly quiet - inside upset
Hazards
Worked In Building
Closed System?
Did you have widows that would open? Were they open?
Time
How many People
Duration
How often, many, transitions?
Support for alternative health solutions
Financial
Emotional
Please examine the dynamics between family members, as well as any facts you feel are relevant.
Mother
Father
Siblings
Schooling
How do you handle it?
With Acceptance and joy
With anger
Outwardly quiet - inside upset
Full understanding of money management
Feeling in control
Sex
Vasectomy
When
One partner
How long
Ejaculation frequency
Sex
Difficult or Enjoyable
Children
When
How Many
Easy birth
Difficult birth
C-section
Nursed - How Long
One partner
How long
Orgasm frequency
List each of your physical and emotional complaints When did they start and are they more or less intense at certain times? (Use an additional piece of paper for other complaints.)
Copper
Galvanized
PVC
Trailer
Motor home with inside access to motor (most)
Used how long and how recently?
Remember any funny smells or discomfort?
How many
With meals
Other times
Distilled
City
Well
Mineral
How much each day?
How often, how many ounces and what fruits or veggies? Details please (homemade, store bought, unpasteurized, pasteurized, etc)
Fruit
Veg
Pollen?
Mold (seasonal?)
Chemical Sensitivity?
Drugs?
Items you avoid?
When did this start?
What supplements or drugs are you taking for these symptoms?
What have you done to clean out toxins?
Bulking programs? (Psyllium, Clays, Herbs)
Colonics - How many
Last year
Prior
Enemas
Coffee
How often
Other: (herbs, Friendly Bacteria, chlorophyll, etc?)
When?
What did you use?
When was the last one?
Flush
When?
When was the last one?
What did you use?
How often?
Cleanse (herbs)
When?
When was the last one
What did you use
How often
Candling
When
When was the last one
What did you use
How often
Oil
When
When was the last one?
What did you use?
How often?
Results? Explain
Written goals and the active movement toward their accomplishment is an important component in mental health. If you do not have these goals, please work on them now (suggestions follow).
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6 Months |
1 Year |
2 years |
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5 Years |
10 Years |
20 Years |
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Health |
Spiritual |
Financial |
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Education |
Vacation and hobbies |
Career |
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Charitable |
Family |
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Fill out this document to the best of your ability and fax to 800-868-7298.
If you are uncomfortable with putting your name on this document use a pen name.
If you prefer you may mail to:
Dale Maxwell, CHT, Personal Mentor and Coach
1547 Palos Verdes Mall Suite 314
Walnut Creek, CA 94597
The activity of completing this document will allow me to understand your needs, both in the physical and emotional areas. The traditional medical approach disconnects the physical and emotional and often overlooks the power that is inherent within you to. Use this power to obtain swift and permanent relief form your physical complaints, your emotional state (beliefs and attitudes) muse be addressed as well (a belief intervention.)
To guide me in the way you would like to proceed, please answer the following questions:
Choose:
Professional fee based assistance:
[ ] I would like this information reviewed and then schedule a telephone mentoring session, including a belief intervention. $255.00 flat fee.
[ ] I would like this information reviewed and then call me for a telephone mentoring session $50.00 for each 20 minutes with no belief intervention.
Or:
Volunteer
Order the suggestions in the following order:
Please review this information and send me your ideas.
[ ] Most likely to assist protocols or supplements first
[ ] Cheapest first