TLC HYGIENE AND NUTRITION QUESTIONNAIRE
Please fill out to best of your ability.
IMPORTANT 1. I am seeking information, education, and practical hands on application relating to God's Biblical Lifestyle Restoration Plan from individuals and or organization(s) not licensed to diagnose, prescribe, treat disease or legally practice medicine. 2. My participation in the supervised or unsupervised Christian Lifestyle restoration program in all of its phases is to be a willful, voluntary act on my part without force or coercion. 3. All responses to this form and assistance in applying the principles and practice of lifestyle change whether written, typographic, verbal, via water or plant based restorative regimens, or any other means of assistance, are not to be construed as practicing medicine but rather as obedience to God's command to heal the sick using Biblically approved methods of lifestyle change. 4. I believe that God is responsible for the results of obedience to His lifestyle plan and not the individual(s) or organization(s) which shared the information, or assisted in its proper application. 5. I understand that in harmony with the law, I am free to seek medical attention, advice, treatment and diagnosis from licensed medical personnel and that my choice to pursue a course of lifestyle change does not prohibit or discourage me now or at any future time from seeking traditional treatment.
Fields marked with an asterisk (*) are required.
I AGREE WITH 5 STATEMENTS ABOVE *
Must be 18+
DATE *
FULL NAME *
Last, First, M
DATE OF BIRTH *
FULL ADDRESS *
Street, City, State, Zip
HOME PHONE *
WORK PHONE
AGE *
GENDER *
Female
Male
HEIGHT FT/IN
Ft. and Inches
CURRENT WEIGHT
In lbs
WEIGHT YEAR AGO
NATIONALITY
RELIGIOUS PREFERENCE
MARITAL STATUS
Married
Divorced
Widowed
Single
MEDICAL HISTORY
Name of past ailments and operations with dates
When (date) did you last consult a physician?
What was the nature of this doctor visit?
Are you currently being treated for any of the above ailments?
Yes
No
If yes, which one?
What specific condition(s) would you like this consultation to address?
List all medicines, pills, or drug you are taking now, how many you are taking of each and how often you take them? (Example “2 Zantac capsules, 3 times daily with each meal”)
Medicines pills/drugs? How many taken each day? How often taken? each day
List mineral, herbs and /or vitamin supplements are you taking, how many you are taking and how often you are taking them?
Mineral/herbs/vitamin(s)? How many taken each day? How often each day?
Do you have indigestion?
Yes
No
Do you have gas?
Yes
No
Do you have bloating?
Yes
No
What type of foods tends to cause indigestion, bloating or gas in your body? (List as many as you can)
How often do you have bowel evacuations?
Describe your stool color and texture?
Color and Texture
Do you have Diarrhea?
Yes
No
Sometimes
Often
Constipation?
Sometimes
No
Yes
Often
Do you wear eyeglasses?
Yes
No
Contact lenses?
Yes
No
For the following, please state how many years or months. (Indicating Y for years and M for months?)
ACNE
ALCOHOLISM
ALLERGIES
ANEMIA
APPENDICITIS
ARTHRITIS
ASTHMA
CANCER
CHILLS/COLD SKIN
DEPRESSION
DIABETES
DIGESTIVE DISORDERS
ECZEMA
EMPHYSEMA
GALLSTONES
HAY FEVER
HEADACHES
HEART DISEASE
HEMORRHOIDS
KIDNEY STONES
LUMBAGO
MENTAL DISORDER(S)
NERVOUS DISORDER
POLIOMYELITIS
RESPIRATORY PROBLEMS
RHEUMATIC FEVER
SKIN PROBLEMS
SINUSITIS
TUBERCULOSIS
TUMORS
ULCERS OR COLITIS
SEXUAL DISORDER
VENEREAL INFECTION
As much as possible, please explain the past or present ailments checked above. Name ailment and explain.
GODLY TRUST
What is your occupation?
What hours do you work?
Health of Spouse (If applicable, check one of the following)
Excellent
Adverage
Poor
Very Poor
Do you have any children?
Yes
No
If your answer is yes, how many children do you have and ages?
How many and their ages.
Health of your children?
Excellent
Adverage
Poor
Very Poor
What types of recreational activities do you enjoy?
How many hours of television do you watch per week?
Do you often feel guilty about past mistakes?
Yes
Do you worry about the future?
Yes
No
Do you have stress?
Yes
No
Depression?
Yes
No
On a scale of 1 to 10 rate your stress level relating to each of following items (1= very little stress and 10 = an extreme amount of stress).
Financial
Job Related
Getting Along With People
Family (Spouse or Children)
Not Happy With Self
Do you enjoy the work that you do?
Yes
No
Are you developing your mental and spiritual capabilities by daily study, meditation and prayer?
Yes
No
Are you involved in some type of activity in which you are helping others?
Yes
No
The following space is provided for those who would like to elaborate on the causes of their stress, depression and other negative emotions.
OPEN AIR
How many hours daily do you spend out of doors?
Do you sleep with your windows closed?
Yes
No
Are you able to breathe fresh air while you are working?
Yes
No
Is the building where you work constructed in such a way that the windows cannot be opened?
Yes
No
Do you know how to do deep breathing exercises?
Yes
No
If yes, please explain the method in which you practice.
DAILY EXERCISE
How often do you exercise per week?
Describe the form of exercise.
How do you feel after you exercise (if applicable)?
SUNSHINE
How much time daily do you spend out of doors in the sunlight?
Do you often get sunburned?
Yes
No
Do you visit tanning beds?
Yes
No
Are you afraid of getting skin cancer?
Yes
No
PROPER REST
What time do you go to bed?
What time do you awaken?
What time is your last meal before retiring?
Do you snack just before bedtime?
Yes
No
Do you wake up during the night and snack?
Yes
No
If yes, what do you eat?
Do you have trouble sleeping?
Yes
No
If yes how long have you being experiencing this.
LOTS OF WATER
How much water (8 onz glasses) do you drink daily?
What type of water do you drink?
Spring
Distilled
Tap
Other
Give brand name of the beverages you drink and indicate how much of each.
Soda
Coffee
Tea
Fruit Juice
Punch
Milk
Other
What is the usual color of your urine?
Explain your understand the principles of hygiene?
ALWAYS TEMPERATE
Do you ingest caffeine in any form?
Yes
No
If yes, for how many years?
Have you ingested caffeine in the past?
Yes
No
If yes, for how many years?
If no, when did you stop?
Do you smoke or chew tobacco? (Indicate which)
Smoke
Chew
If so, for how many years?
If you have quit, how long has it been?
Do you drink alcohol?
Yes
No
If you have quit, how long has it been?
If so, for how many years?
Do you overwork?
Yes
No
How many hours of television do you watch each week?
NUTRITION
Do you overeat?
Yes
No
Do you feel stuffed after your meals?
Yes
No
Do you eat between major meals?
Yes
No
If yes, please explain.
Do you drink with your meals?
Yes
No
If so, what form of liquids?
Do you wear removable dentures or plates?
Yes
No
Do you eat fast?
Yes
No
How long does it take you to eat?
Do you have a peaceful environment at meat times?
Yes
No
Do you have set meal times?
Yes
No
Are you following any special diet?
Yes
No
Do you eat animal products?
Yes
No
Dairy Products?
Yes
No
Do you eat desserts, candy or other sweets regularly?
Yes
No
If yes, please explain.
What time do you eat breakfast?
What foods do you usually eat for breakfast?
What time do you eat lunch (dinner)?
What foods do you usually eat for lunch?
What time do you eat supper?
What foods do you usually eat for supper?
Email *
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