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(Note: if you arrived here via a search engine -- all symptoms listed below respond positively to a strict regime of detoxification and nutrition. Click here.) Application & Registration Registration To reserve your space and get started on the program, please first call us (808-933-4400) to consult with Dr. Baylac. If you decide to become a patient with us, you will probably be instructed to follow these steps: 1. Fill out the questionnaire below 2. Write an essay about the problems or health issues you would like to address during your stay. Please mention all events that preceded the onset of the problems. Include any emotional or mental issues. Describe your stress level, the nature of the stress and how you deal with it. Review any sexual, familial, professional and social issues. Write about your relationship to food. Write about what you would like to accomplish with your life or in your life. 3. Keep track of what you eat and drink for the next 3 or 4 days. This food and drink diary needs to include all the following information: Where the food is eaten, Hours when it is eaten, State of mind while eating, quantities, hunger and satiety issues, quality of the food (organic, can, unknown), cooked (method) raw, oils used. Nature of salad dressing used. Mention how often do you eat in a restaurant and what type of restaurant 4. Choose some dates for your visit, check with airlines and with us for availability. To reserve your space, send a $300 check to MInd Your Body Retreat Center Inc., attn. Dr. Baylac, - see address below. Click here for credit card payment. This application fee is non refundable and covers emails and phone calls for preparatory work at home. It also includes a physical exam at your arrival and departure and post treatment recommendations. 5. Return the questionnaire (below) and essays by e-mail, or fax them at 808 443 0313, email, or send by mail to the address below (under payment). Email: click here 6. If applicable - fax your recent lab work and a copy of the diagnosis to 808 443 0313, or email them. Payment You may pay your reservation fee ($300) by check or Paypal. To pay by credit card click here or call us (808-933-4400) with your credit card information. Please make any check to Hawaii Naturopathic Retreat Center Inc., and send it to Hawaii Naturopathic Retreat Center Inc., attn. Dr. Baylac - see address below. Money order must be made to Dr. Baylac and sent to the same address. You will be billed for the full amount of your therapy within 24 hours of your arrival and payment in full will be due within 3 days of arrival. Patients who terminate their therapy due to a medical emergency will be reimbursed for the remaining unused portion of the program. For the reservation fee there is no refund in case of cancellation, unless there is a medical emergency. INSTRUCTION Either print this application webpage and fill in the requested information below - or click here for another page to print, without instruction text. You can fax or mail (or scan & email) it to us. Or copy the text and paste in a wordfile, where you can type your answers, and email it. Note: You can alternatively download a wordfile with the same content - like this: right-click here, and choose "save (link) target as". APPLICATION FORM & QUESTIONNAIRE GENERAL INFORMATION Today's date ___________ Name _______________________________________________ Age _____ Sex (M,F) ______ Place of birth ____________________________ Birth date ____________ Marital status ________________________ Number of children _____ Living situation (alone, family, friends) ____________________________ Occupation _________________________________________ Address _____________________________________________________________ City _______________________________________ State/Zip/Country __________________ E-mail address _____________________________________ Fax_____________________ Phone (home) _____________________ Phone (work/cell) ______________________ OPTIONAL (sometimes it can help explain your health problem) Religion _________________________ Race ______________ COMPREHENSIVE HEALTH HISTORY YOUR CURRENT HEALTH PROBLEMS What is your major health problem? What are the symptoms? (Location, quantity, quality, or severity, timing, setting in which they occurred, factors that aggravate them or relieve them and associated manifestations.) When did it start for the first time and setting in which it developed? Describe any factors that you suspect may have played a role in its onset and continuation. Is it becoming better or worse? Be specific in your description. Describe past treatments for this problem. Drugs: How long and what dosage taken? Surgeries: Natural treatments: What treatment worked the best? What treatment worked the least? Do you have any other health problems? Please list in order of importance and describe. Do you have any emotional issues that you would like to address? Do you have any sexual issues that you would like to address? Do you have any social issues that you would like to address? Do you have any family issues that you would like to address? Are you currently working with a doctor of conventional medicine ___ yes ___ no a naturopathic doctor ___ yes ___ no a counselor, pastor, or other therapist ___ yes ___ no Today's weight __________ Today's height ____________ As an adult what has been your maximum ________ and minimum _______ weight? Any recent weight change? Do you feel weakness or fatigue? Explain. Do you have an exercise routine? Describe. YOUR HEALTH HISTORY: Is your present state of health ___ excellent, ___good, ___average, ____fair, ___ poor. General state of health: rate today's state compared to the past. (Rate from 1 to 10; 1 is the lowest, 10 is highest.) Now _____ In the past ______ Please comment. When during the day is your energy the best? ____________ Worst? ____________ Rate your energy level: Now ________ In the past ___________ Childhood illnesses: ___measles ___rubella ___mumps ___whooping cough ___chicken pox ___rheumatic fever ____scarlet fever ___polio Childhood immunizations and age at immunization: ___tetanus ___pertussis ___diphteria ___polio ___measles ___rubella ___mumps ___influenza ___hepatitus B ___hemophilus influenza ___pneumococcal vaccine List adult illnesses, psychiatric illness, accidents, and injuries, operations,and hospitalizations by date of onset, starting with the oldest first: Do you have any allergies to drugs, herbs, foods, animals, dust or other? Have you been exposed to environmental hazards at home or on the job? (Please read "Where do you find heavy metal toxicity?" at the end of this questionnaire and mention situations where you may have been exposed to mercury, cadmium, or lead.) Do you live in a new place or an old one? ________________ How long have you lived there? ________________ Is it damp and moldy, or dry? _____________________ Do you have new wall to wall carpeting? _______ Do you use aluminum cook pots? __________ Do you have an air filter at home? _____ At your job? ______ Do you live in a city, a suburban area, or in the country? _______________________ Do you live near a golf course or any area that is heavily sprayed with pesticides?____ Do you work in the presence of toxic fumes or chemicals? ______ Do any of your hobbies involve toxic materials? ______ Are you presently exposed to secondhand smoke? ______ In the past? ______ If yes, for how long? ___________ What is the source of your drinking water?__________________________________ Do you have any silver-mercury fillings? _____ How many? __________ What are your leisurely activities? Describe type and frequency. What is the quality of your sleep? How many hours of sleep do you get on average? Current medications, amount and dosage: Vitamins, herbal remedies, and supplements: Do you smoke tobacco? ____ Have you smoked in the past? ____ How long? _________________________How much? _______________________ Do you drink alcohol? ___ Have you drunk in the past?____ How long? _________________________How much? _______________________ FAMILY HISTORY: Age and health of parents, and if deceased, cause of death Mother ___________________ Father ____________________ Brothers ___________________ Sisters ____________________ Mother's mother ____________________ Mother's father ______________________ Father's father ______________________ Father's mother _____________________ Family history of (indicate family member, severity, or death) __diabetes __arthritis __mental illness __allergies __tuberculosis __anemia __drug addiction __high BP __heart attack __headache __alcoholism __hypoglycemia __cancer __epilepsy __depression __stroke Health of your children? DIGESTION AND ELIMINATION: Gastrointestinal Do you have any problem with gas, bloating, or fullness after eating? __Yes __No How Often? ____________ How severe is the problem? (rate 1 to 10) _____ How long have you had this problem? ___________ How often do you have a bowel movement? _____________ Do you ever have blood, mucous, undigested food, or black stools? _________ Any rectal itching? _______________ Do your stools tend to be formed or loose? _________________ Do you have diarrhea, constipation, alternating diarrhea and constipation? ________ Do you have thin, long, narrow stools? _____ How often? _____________ Do you have small, hard stools? ______ How often? _________________ How often do your stools have a strong disagreeable odor? _______________ Have you ever fasted? _____ For how long? ____________ Was it supervised, or did you fast by yourself? __________________ Have you traveled outside the USA in the last 5 years? ___________ Have you gone camping in the last 5 years? __________________ Kidneys and Bladder Have you had recurrent bladder infections? _____ How were they treated? ________________________________ Do you have any burning sensation during or after urination? ____ Is your urine dark yellow, bright yellow, pale yellow, cloudy, or clear? (circle) Does your urine have a strong odor to it? ______ Do you perspire when you exercise? ____ Lightly, moderately, heavily. (circle) Does your perspiration have a strong odor to it?_______ MEDICAL SYMPTOMS RATING SCALE: Rate each of the following symptoms according to the following scale: 0 never or almost never have this symptom 1 occasionally have it, effect is not severe 2 occasionally have it, effect is severe 3 frequently have it, effect is not severe 4 frequently have it, effect is severe HEAD ___ headaches ___ faintness ___ dizziness ___ insomnia Total ____ EYES ___ watery or itchy ___ swollen, reddened, or sticky eyelids ___ bags or dark circles under eyes ___ blurred or tunnel vision Total ____ EARS ___ itchy ears ___ earaches or ear infections ___drainage from the ears ___ringing or hearing loss Total ____ NOSE ___ stuffy nose ___ sinus problems ___ hay fever ___ sneezing attacks ___ excessive mucus formation Total ____ MOUTH AND THROAT ___ chronic coughing ___ gagging, frequent need to clear throat ___ sore throat, hoarseness, loss of voice ___ swollen or discolored tongue, gums, or lips ___ canker sores Total ____ SKIN ___ acne ___ hives, rashes, dry skin ___ hair loss ___ flushing, hot flashes ___ excessive sweating Total ____ HEART ___ irregular or skipped heart beat ___ rapid or pounding heart beat ___ chest pain Total ____ LUNGS ___ asthma and/or bronchitis ___ chest congestion ___ shortness of breath ___ difficulty breathing Total ____ DIGESTIVE TRACT ___ nausea and/or vomiting ___ diarrhea ___ constipation ___ bloated feeling ___ belching, passing gas ___ heartburn ___ intestinal and/or stomach pain Total ____ JOINTS AND MUSCLES ___ pain or aches in joints ___ arthritis ___ stiffness or limitation of movement ___ pain or aches in muscles ___ feelings of weakness or tiredness Total ____ ENERGY AND ACTIVITY ___ feelings of fatigue or sluggishness ___ feelings of apathy or lethargy ___ hyperactivity ___ restlessness Total ____ MIND ___ poor memory ___ confusion, poor comprehension ___ poor concentration ___ poor physical condition ___ difficulty making decisions ___ stuttering or stammering ___ slurred speech ___ learning disabilities Total ____ EMOTIONS ___ mood swings ___ anxiety, fear, nervousness ___ anger, irritability, aggressiveness ___ depression Total ____ OTHER ___ frequent illness ___ frequent or urgent urination ___ genital itch or discharge Total ____ GRAND TOTAL ____ NOTE: DON'T FORGET TO FILL IN YOUR NAME, ADDRESS, EMAIL & PHONE AT THE TOP. THANK YOU! Note: You can alternatively download a wordfile with the same content - like this: right-click here, and choose "save (link) target as", to download a word-file (applicationform.rtf) that you can type your answers in and then attach in an email to us. (Or copy the text from and paste in an email.) Note: All payments should be made to Hawaii Naturopathic Retreat Center Inc. |
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HAWAI'I NATUROPATHIC RETREAT CENTER 885 Kilauea Ave, Hilo, HI 96748 Tel 808 982 8202 Fax 808 443 0313 www.mindyourbody.info |
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