1. Health information

IMPORTANT: PLEASE READ THE FOLLOWING BEFORE COMPLETING THE SURVEY
The following survey is intended for first time clients who have scheduled an appointment.
If you would like to schedule a screening, please call 615-292-2313.

If you choose to fill out a survey and we have not yet spoken, please e-mail me at ( Richard@WhiteHawkHealth.com ).
As soon as I am able to review your response I will contact you to discuss your situation.

Reminder: Beginning the evening before your visit, drink an ample supply of water to insure proper hydration and refrain from using oils or lotions on your hands and feet. The first visit usually takes from two to two and a half hours. In very complicated situations, the screening time can exceed this. If you have restrictions please discuss these before hand. This is not in any way a substitution for medical care. Our goal is not to diagnose, treat, or to cure illness. If you believe you are suffering from a
medical condition, or illness, you should consider seeking the help of a medical doctor immediately. Our goal is to support the body in its own natural process through detoxification, proper diet, exercise and supplementation when necessary.
Always bring your homeopathic remedies to your follow up appointments.

Thank you

* 1. Please provide contact information below.

* 2. Please list your date of birth.

*
/
/

* 3. What are your primary health concerns?

* 4. Please give a brief medical history of any chronic illnesses, surgeries, or medical conditions past and present, that could have bearing on your current health. IMPORTANT: Do you have a pacemaker?


* 5. Please give a brief listing of any family related illnesses, and/or illnesses that you wish to be screened for.

Example: diabetes, heart disease, cancer, etc.

* 6. Are you under the care of a Medical Doctor and if so for what condition. Do you currently take prescribed pharmaceuticals?

Example: hypothyroid - synthroid ...or... heart disease - coumadin

* 7. To your knowledge, have you been exposed to moderate or high levels of environmental toxins,
either at work or home in the past twenty years (also include radiations, ie: power lines, cell towers, medical, etc.?
(Examples: pesticides, printing inks, molds, etc.)

Have you lived in an industrial community or near surface mining during your lifetime? (Ex: Goodletsville, TN and Hendersonville, TN share air and water sources with Dupont in Old Hickory, TN.

Please list all towns/cities in which you have resided since birth and travels outside of the continental U.S.

* 8. How frequently do you have difficulties with the following?

  NEVER RARELY OFTEN ALWAYS
sleep issues
fatigue
irritability
feeling depressed / lack motivation
pains or discomforts
mental clarity
dizziness or ringing in ears
frequent colds - illness
headache
joint pain
muscle pain
lower back pain
upper back pain
coughing
breathing
chills
watery eyes
sinus congestion
allergic response
swollen lymph/upper body
swollen lymph/lower body
stomach issues
diarrhea
constipation
bloating
hemorrhoids
hormones
swollen tongue (with teeth marks)
coated tongue
bad breath
body odor
skin eruptions
itching
leg cramps
blood pressure - high
blood pressure - low
F- pms
F- menstrual pain
F- heavy flow
F- hot flashes
F- female surgeries
F- sex drive
M- prostate
M- frequent urination
M- sex drive

* 9. I RECOMMEND THAT EACH CLIENT SET UP A SCHEDULE TO SCREEN FOR THE VARIOUS CANCER FREQUENCIES
RELATING TO AGE, SEX, AND OTHER RISK FACTORS.

EXAMPLES: uterine, ovarian, cervical, breast, prostate, skin, lung, etc.


Are there any other issues that you are experiencing or would like to investigate?
Examples: food allergies, heavy metals, emotional remedies, general detoxification, etc.

Report a problem

T