Microsoft word - danquestionairre okotoks.doc

QUESTIONNAIRE
OKOTOKS NATURAL HEALTH CENTRE
29C ELIZABETH STREET
Ph:(403)995-9999 Fax:(403)995-9990
“TAKING THE TIME TO LISTEN & WORKING TOGETHER MAKES A DIFFERENCE!”
PLEASE MAKE SURE YOU HAVE ALL 30 PAGES OF THIS FORM
OUR MISSION
TO HELP IMPROVE THE ROLE IN THE RECOVERY OF CHILDREN AFFECTED BY AUTISM
SPECTRUM DISORDERS, IN COMBINING THE “DEFEAT AUTISM NOW” APPROACH WITH
HOLISTIC HEALTH. THIS INCLUDES A VARIETY OF INTERVENTIONS, CUSTOMIZED ON AN
INDIVIDUAL BASIS, WHICH HAVE BEEN SHOWN TO PRODUCE DRAMATIC RESULTS IN SOME
PATIENTS, THE FOCUS BEING ON THE WHOLE PERSON TO RESTORE OPTIMAL HEALTH.
Holistic Health is defined as a system of health care which emphasizes on personal
responsibility, and care, a cooperative relationship among all those involved, leading toward optimal harmony of body, mind, emotions and spirit. __________________________________________________________________ The following questionnaire, although somewhat long and detailed, is an invaluable source of information about you as a unique person. It will allow us to know the Total You, not just you as a collection of symptoms of an illness. PLEASE NOTE: This is a confidential record of your medical history and will be
kept in this office. Information contained here will not be released to any person without your authorization. ___________________________________________________________________ Would you be willing to sign a release to obtain medical records from your previous doctor(s) and hospital(s), if this information would be helpful for your treatment? AUTHORIZATION FOR MEDICAL INFORMATION
This will authorize (Dr.)____________________ of (Clinic)_______________ _______________________________ to provide Dr. KURT HARTMANN ND, or his/her representative, with any and all information in regards to any form of treatment applied to me, including blood tests, X - rays, findings and diagnoses. A copy of this authorization is valid as well as an original. Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS 1 Okotoks Natural Health Centre Ph: (403) 995-9999 Personal Information
Date of Initial Consultation:
Child’s First Name:
Weight: Now:
One year ago:
Maximum weight:
Height cm/ft
Siblings:
Siblings:
M.I. M.I. D.O.B.(m/d/y) D.O.B.(m/d/y) Male/Female Male/Female Siblings:
Siblings:
M.I. M.I. D.O.B.(m/d/y) D.O.B.(m/d/y) Male/Female Male/Female Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999
List diagnoses and explanations (including dates) given for your child’s condition:
Other problems to be addressed: SYMPTOMS YOUR CHILD PRESENTLY HAS:


Please bring several pictures of your child, that we may keep, specifically portraying the change he or she
has experienced i.e. if your child has regressed, bring in pictures that clearly show them before regression,
and after regression. We would also appreciate a video of before regression and after regression. You
should keep a video as he/she undergoes treatment.

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Personal Information (Continued)
Describe your child to me, including his or her history. Please be as detailed as possible.
When did you notice your child’s problem?
What did you notice?
Was the onset of your child’s problem sudden or gradual?
Was there any event or illness that you or others think brought on your child’s symptoms?
Please make note of any other event, action, etc. that you think may have some bearing/relationship to your
child’s condition. Again, be detailed as possible and do not hesitate to mention anything no matter how
small or insignificant, that you believe is related to your child’s problems.

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S SLEEPING HABITS:
How are your child’s sleeping habits? Good ____ Bad ______
If bad: Is your child waking at night? ____ or
Having trouble falling asleep? _____ Both_____
Other comments:_______________________________________________
CHILD’S MEDICAL HISTORY
PRIMARY DOCTOR(S)
NAME PHONE
CITY/STATE
THERAPIST(S)
SPEECH-OCCUPATIONAL-PHYSICAL-OTHER
NAME TYPE
OF PHONE CITY
HOURS/WEEK
THERAPIST
OTHER CARE GIVERS
PHONE CITY DATE
SPECIALTY
EVALUATION
SPECIALIST(S)
NATUROPATH(S)/HOMEOPATH(S)
NUTRITIONIST / OTHER
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 PRENATAL HISTORY
MATERNAL AGE AT DELIVERY: #OF PREGNANCIES / BIRTHS PRIOR______________AFTER THIS CHILD
ILLNESSES DURING PREGNANCY:
MEDICATION DURING PREGNANCY:
HEAVY METAL EXPOSURE DURING PREGNANCY (INCREASED TUNA/SWORDSFISH/SEA BASS CONSUMPTION; DENTAL
WORK: ROOT CANAL, AMALGAMS; FLUVAX; RHOGAN INJECTION
OTHER COMPLICATIONS DURING PREGNANCY:
COMPLICATIONS DURING LABOR AND DELIVERY:
MODE OF DELIVERY: C-SECTION/VAGINAL? IF C-SECTION, EXPLAIN WHY?
IF VAGINAL DELIVERY, DID YOU HAVE FORCEPS/VACUUM?
MEDICATION(S) DURING LABOUR AND DELIVERY?
FULL TERM/PREMATURE? HOW MANY WEEKS?
COMPLICATION AFTER DELIVERY?
MEDICATIONS GIVEN TO CHILD DURING HOSPITAL STAY? (INCLUDING IMUNIZATIONS)

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 DIETARY / NUTRITIONAL HISTORY
BREAST-FED? IF YES, HOW LONG? MONTHS
BOTTLE-FED? IF YES, BRAND OF FORMULA?
BOTTLE FED BEGINNING AT WHAT AGE? HOW LONG?
FOODS? BEGUN AT WHAT AGE? FIRST FOODS?
KNOW ALLERGIES TO FOOD? (PLEASE LIST)
SUSPECTED SENSITIVITIES TO FOODS? PLEASE LIST:
FOOD CRAVINGS:

FOODS MY CHILD EATS: (PLACE AN X IN APPROPRIATE COLUMN) DAILY 3-5
USED TO EAT A LOT BUT
NO LONGER DOES
SWEET FOODS
CAFFEINE
(SODA, TEA, ETC.)
CHOCOLATE
MILK: WHOLE
ICE CREAM
SALT FOODS
BREAD: WHITE
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 DIETARY / NUTRITIONAL HISTORY (CONTINUED)
PLACE AN X IN THE MOST APPORPRIATE DESCRIPTION BELOW OF YOUR CHILD’S DIET:
_________MOSTLY BABY FOOD
_________MOSTLY CARBOHYDRATES (BREAD, PASTA, ETC)
_________MOSTLY DAIRY (MILK, CHEESE, ETC)
_________MOSTLY MEAT
_________MOSTLY VEGETARIAN
_________OTHER DESCRIBE:
PLEASE DESCRIBE YOUR CHILD’S STOOL PATTERN (EXAMPLES: DAILY, FOUL, LARGE, MUSHY, ETC)
PLEASE LIST THE FOODS AND BEVERAGES NORMALLY CONSUMED BY YOUR CHILD FOR THREE TYPICAL DAYS:

BREAKFAST
MORNING SNACK
LUNCH
AFTERNOON SNACKS
DINNER
OTHER

BREAKFAST
MORNING SNACK
LUNCH
AFTERNOON SNACKS
DINNER
OTHER

BREAKFAST
MORNING SNACK
LUNCH
AFTERNOON SNACKS
DINNER
OTHER

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 FAMILY HISTORY
LIST ANY ALLERGIES, MAJOR ILLNESSES, GENERIC DISEASES, NEUROLOGIC, BIPOLAR, OBSESSIVE
COMPULSIVE, DEATHS, OR OTHER PROBLEMS FOR CHILD’S FAMILY MEMBERS.
ANY? Cancer - Tuberculosis – Diabetes - Heart Trouble -High Blood Pressure
Stroke – Epilepsy - Mental Illness - Suicide
MOTHER:
FATHER:
SIBLINGS:
MATERNAL GRANDPARENTS:
PATERNAL GRANDPARENTS:
OTHERS:

SOCIAL HISTORY
WHO LIVES IN THE HOME WITH YOUR CHILD?
ANY ADOPTED CHILDREN IN YOUR FAMILY?
PETS IN THE HOUSE?
CAREGIVERS BESIDES PARENTS?
LIST THE PEOPLE MOST IMPORTANT IN YOUR CHILD’S LIFE:
RECENT CHANGES, LOSSES, BIRTHS, DEATHS, DIVORCE, REMARRIAGE, OR MOVES?
RECENT TRAVEL
CHILD’S RESPONSE TO THESE CHANGES:
IS YOUR CHILD INVOLVED IN ANY SPORTS, MUSIC OR OTHER ACTIVITIES? PLEASE DESCRIBE:
HOW DOES YOUR CHILD INTERACT WITH OTHER CHILDREN?
WITH ADULTS?
WHAT MAKES YOUR CHILD HAPPY?
SAD?
ANGRY?
STRESSED?
HOW DO YOU AS A PARENT DEAL WITH THESE EMOTIONS IN YOUR CHILD?

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 ENVIRONMENTAL HISTORY
DO YOU, YOUR CHILD, OR ANY FAMILY MEMERS PRACTICE ANY RELAXATION, STRESS MANAGEMENT
TECHNIQUES? PLEASE DESCRIBE:
CIRCLE APPROPRIATE ANSWERS TO THE FOLLOWING QUESTIONS AND DESCRIBE:
1.) LOCATION OF HOME: CITY / SUBURBAN / WOODED / FARM / OTHER (DESCRIBE):
2.) WHAT TYPE OF WATER DOES YOUR FAMILY DRINK?
TAP SPRING WELL REVERSED OSMOSIS DISTILLED BRITA FILTERED FRIDGE FILTERED
DO YOU USE LEMON JUICE IN YOUR DRINKING WATER?
3.) TYPE OF HEAT: ELECTRIC / GAS / OIL / OTHER (DESCRIBE):
4.) DO YOU LIVE NEAR: POWER LINES / WOODS / INDUSTRIAL AREA / WATER
5.) IF YOU LIVE NEAR WATER, WHAT TYPE? SWAMP / RIVER / OCEAN / OTHER (DESCRIBE)
6.) DOEAS YOUR HOME HAVE A LOT OF: DUST / MOLD / DOWN / OR FEATHER ITEMS? IF SO PLEASE
DESCRIBE?
DESCRIBE YOUR CHILD’S BEDROOM:
BEDDING: SYNTHETIC / DOWN / FEATHER MATTRESS ENCLOSED: YES/NO CRIB/JR. BED / ADULT BED
FLOORING: CARPET: WALL-TO-WALL AREA RUG WOOD GLUED DOWN SYNTHETIC PAD
WINDOW TREATMENTS: SHADES BLINDS THIN CURTAINS HEAVY CURTAINS VALANCE OTHER(DESCRIBE):
OTHER ITEMS IN ROOM INCLUDING FURNITURE, TOYS, STUFFED ANIMALS, ETC.:
FLOORING IN OTHER ROOMS:
CHILD’S BATHROOM:
LIVING ROOM?
FAMILY ROOM/PLAY ROOM?
IS YOUR CHILD SENSITIVE TO OR BOTHERED BY THE FOLLOWING?
PERFUMES/COSMETICS? MOLD?
PLEASE LIST ANY OTHER KNOWN ALLERGIES:

CLEANING PRODUCTS?
POLLENS/GRASSES?
SOAPS? ANIMALS (DANDER)

DETERGENTS? GASOLINE?

DUST? PAINT?
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S DEVELOPMENTAL HISTORY
PLEASE LIST THE AGE WHEN THE FOLLOWING SKILLS WERE MASTERED AND ANY PROBLEMS
ASSOCIATED WITH THESE SKILLS:
1.) FIRST WORDS:
2.) PHRASES OR SENTENCE:
3.) SITTING UP:
4.) CRAWLING:
5.) PULLING UP TO A STAND:
6.) WALKING:
7.) RUNNING:
8.) WALKING UP AND DOWN STEPS WITHOUT HELP:
9.) JUMPING:
10.) PUT ON CLOTHING
11.) LEARNED TO PEDAL:
12.) RODE 2-WHEELED BICYCLE:

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S MEDICAL HISTORY
PREVIOUS DIAGNOSTIC STUDIES – PLEASE LIST DATES AND RESULTS:

PREVIOUS STUDY
DATE(S) RESULTS
PHYSICAL EXAM
Stomach or colon
Gall bladder
Extremities
HEARING TESTS
CT SCAN (BRAIN)
CT SCAN (OTHER)
ATTACH RESULTS IF AVAILABLE
ANY ABNORMAL RESULTS
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 CHILD ILLNESSES – PLEASE LIST APPROPRIATE DATES AND ANY COMPLICATIONS:
COMPLICATIONS
EAR INFECTIONS
SINUS INFECTIONS
BRONCHITIS
PNEUMONIA
CHICKEN POX
SEIZURES
YOUR CHILD’S MEDICAL HISTORY (CONTINUED)
MAJOR SURGERIES – PLEASE DESCRIBE AND GIVE DATES:
DATE(S) RESULTS
Has your child ever been advised to have any operations, which have not been done?

MAJOR INJURIES – PLEASE DESCRIBE AND GIVE DATES:
DATE(S) RESULTS
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 IMPORTANT – PLEASE PROVIDE COPIES OF MOST RECENT RESULTS OF THE
FOLLOWING: 1. BLOOD WORK 2. URINE TESTS 3. STOOL TESTS
IMMUNIZATIONS: PLEASE LIST DATES AND ANY COMPLICATIONS:
DTP/DTaP
HIB (HEMOPHILUS)
HEPATITIS B
OPV/IPV (POLIO)
VARIVAX (CHICKEN POX)
MMR (MEASLES)
ROTAVIRUS VACCINE
PREVNAR:

ANY OTHER COMMENTS:

(CHILD IF AVAILABLE) WOMEN ONLY-MENSTRUAL HISTORY
Age at onset _________
Cycle ________ days (from start to start)
FLOW: Heavy
Any clots passed
Pains or cramps
Date of last period
Date of last pelvic exam
Date of last Pap test
Results:
Any discharge from vagina? No Yes
If so, what color?
Any itching of vaginal area No Yes
Do you take birthcontrol pills? No Yes
How long have you taken them?
Pregnancies:
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S MEDICAL HISTORY (CONTINUED)
PLEASE LIST APPROXIMATE DATES AND ANY REACTIONS TO ANY MEDICATIONS TAKEN BY YOUR CHILD IN THE PAST. IF THE DATES ARE TO NUMEROUS, JUST LIST THE NUMBER OF TIMES THE MEDICATION WAS GIVEN PER YEAR. REACTION(S)
NAME OF DRUG
MEDICATIONS
ANTIBIOTICS:
MEDICATIONS:
ANTIHISTAMINES:
STEROIDS:
ANTIFUNGAL I.E.
NYSTATIN,
DIFLUCAN, LAMISIL
NAME DOSAGE
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S MEDICAL HISTORY (CONTINUED)
VITAMINS, MINERALS, SUPPLEMENTS OR OVER THE COUNTER PRODUCTS – PLEASE LIST
MULTIVITAMINS
VITAMIN C
VITMAIN B
MAGNESIUM
HERBAL/HOMEOPATHIC/HOMOTOXICOLOGY AND OR OTHER THERAPIES.
PLEASE LIST ANY OTHER MEDICATION OF THIS TYPE(S) YOUR CHILD HAS USED.
MEDICAL/THERAPY
TIME WHEN TAKEN
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S SIGNS AND SYMPTOMS
PLACE AN (X) NEXT TO ANY SIGNS/SYMPTOMS YOUR CHILD MAY DEMONSTRATE AND NOTE DURATION AND DETAILS IS APPROPRIATE. SNAPS, OR ZIPPERS PROCESSING PROBLEMS – VISUAL, MOTOR, LANGUAGE, SENSORY, ETC. SENSITIVE TO CROWDS Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Has your child ever had?
Please check yes or no.
German measles
Chicken pox
Whooping cough
Scarlet fever or Scarlentina
Diphtheria
Small pox
Pneumonia
Influenza
Pleurisy
Rheumatic Fever
Any bone or joint disease
Neuritis or neuralgia
Bursitis
Sciatica
Polio or Meningitis
Nephritis
Gonorrhea or Syphilis
Gallbladder disease
Jaundice
Bladder disease
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Has your child ever had? Continued.
Please check yes or no.
Epilepsy
Migraine headaches
Tuberculosis
Diabetes
High or low blood pressure
Colitis or other bowel diseases
Hemorrhoids or any rectal dis.
Nervous breakdown
Food, chemical or drug
poisoning
Hay fever or asthma
Hives or Eczema
Frequent infections or boils
INJURIES: have you had any?
Broken or cracked bones
Lacerations
Dislocations
Concussion, or head injuries
Ever been knocked unconscious
Frequent or severe headaches
Fainting spells
Dizziness on movement
Unconscious spells
Blurred vision
Double vision
Spots in front of the eyes
Infected eyes
Pain behind eyes
Any change in vision
Do you wear glasses?
When was your last check up?
Earaches
Discharge from ears
Ringing in ears
Diminishing of hearing
Recurrent nose bleed
Recurrent head colds
Sinus trouble
Hay fever
Strange persistent odors
Persistent hoarseness
Difficulty on swallowing
Has your child ever had? Continued.
Please check yes or no.
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Enlarged glands
Recurrent sore throats
Recurrent mouth sores
Soreness or bleeding of
gums during brushing.
Has your child ever had in the last year? Please check yes or no.
OTHER COMMENTS
Chest pain
Angina pectoris
Coughed up blood
Pain in arm(s)
Night sweats
Chronic or frequent
cough
Chronic or frequent
cough on lying
down

Wake up short of
breath
Shortness of breath
on:
Walking several
blocks
One flight of stairs
On lying down
Purple lips or
fingers
Palpitations,
fluttering of heart
High blood pressure
Swelling of hands,
feet or ankles.
At what time of day
Leg cramps on
walking or at night
Enlarged veins in
legs
Recurrent stomach
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999
Has your child ever had in the last year? Please check yes or no. Continued.
OTHER COMMENTS
Belching or heartburn
Relieved by food or
medication.
Appetite: good
fair poor
Nausea or vomiting
Avoid some foods
What kinds?
Avoid spices
Like some foods
very much
What kinds?
Abdominal
cramping
Color of bowel
movement.
Consistency of
stools
Frequency of BM a
day/week
Any blood in bowel
movement
Rectal pain with
B.M.
Change in size
shape or texture
of B.M.
Do you get up at
night to urinate
How many times?

Pain on urinating?
Difficulty in starting
urination?
Urinate more than
before?
Urinate less than
before
Any blood in urine
How much water do
you drink a day
How many times per
day do you urinate?
Full feeling of
bladder but only
Small amount of
urination
Lose urine on
coughing or sneezing
Discharge from
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 Has your child ever had in the last year? Please check yes or no. Continued.
OTHER COMMENTS
Recurrent back
pains
Backaches
Joint pains
Swelling of any
joints
Redness or heat of
any joint
Tingling or
weakness of hands
or feet
Muscle spasm
Loss or change in
sensation of hands
or feet
Trembling of any
extremity
Growth in neck or
throat
Hot flashes
Tiredness without
apparent reason?
Brittleness of nails
Dryness of skin
Easy bruising
Inability to stand
heat
Inability to stand
cold
Change in hair
texture
Change in skin
texture
Any skin rash
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 YOUR CHILD’S SIGNS AND SYMPTOMS
DESCRIBE ANY OTHER SYMPTOMS YOU WOULD LIKE ME TO KNOW ABOUT YOUR CHILD:
LIST ANY OTHER HISTORY, PERTINENT THOUGHTS OR QUESTIONS THAT YOU
WANT TO ADDRESS:
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 NUMBER OF COMMON PROBLEMS THAT CHILDREN HAVE.
MARK AN X IN THE RATE ACCORDING TO THE LAST MONTH:
0-NONE 1&2- IN BETWEEN 3-FREQUENTLY
IS ALWAYS “ON THE GO” OR ACTS AS IF DRIVEN BY A MOTOR AVOIDS, EXPRESSES RELUCTANCE ABOUT, OR HAS DIFFICULTIES ENGAGING IN TASKS THAT REQUIRE SUSTAINED MENTAL EFFORT (SUCH AS SCHOOLWORK OR HOMEWORK) HAS DIFFICULTY SUSTAINING ATTENTION IN TASKS OR PLAY HARD TO CONTROL IN MALLS OR WHILE GROCERY SHOPPING KEEPS CHECKING THINGS OVER AND OVER AGAIN DOES NOT SEEM TO LISTEN TO WHAT IS BEING SAID TO NEEDS CLOSE SUPERVISION TO GET THROUGH ASSIGNMENTS RUNS ABOUT OR CLIMBS EXCESSIVELY IN SITUATIONS WHERE GETS ACHES AND PAINS OR STOMACHACHES BEFORE SCHOOL DOES NOT FOLLOW THROUGH ON INSTRUCTIONS AND FAILS TO FINISH SCHOOLWORK, CHORES OR DUTIES IN THE WORKPLACE (NOT DUE TO OPPOSITIONAL BEHAVIOR OR FAILURE TO UNDERSTAND INSTRUCTIONS HAS DIFFICULTY ORGANIZING TASKS AND ACTIVITIES THINGS MUST BE DONE THE SAME WAY EVERY TIME DOES NOT GET INVITED OVER TO FRIENS HOUSES Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 ACTIVELY DEFIES OR REFUSES TO COMPLY WITH ADULTS FAILS TO GIVE CLOSE ATTENTION TO DETAILS OR MAKES CARELESS MJISTAKES IN SCHOOLWORK, WORK OR OTHER ACTIVITIES HAS DIFFICULTY WAIING IN LINES OR AWAITING TURN IN DISTRACTIBILITY OR ATTENTION SPAN A PROBLEM COMPLAINS ABOUT BEING SICK EVEN WHEN NOTHING IS GETS DISTRACTED WHEN GIVEN INSTRUCTIONS TO DO INTERRUPTS OR INTRUDES ON OTHERS (E.G. BUTTS INTO WILL RUN AROUND BETWEEN MOUTHFULS AT MEALS FIDGETS WITH HANDS OR FEET OR SQUIRMS IN SEAT HAS DIFFICULTY PLAYING OR ENGAGING IN LEISURE BLAMES OTHERS FOR HIS/HER MISTAKES OR BEHAVIOUR GETS UPSET IF SOMEONE REARRANGES HIS/HER THINGS DELIBERATELY DOES THINGS THAT ANNOY OTHER PEOPLE DEMANDS MUST BE MET IMMEDIATELY-EASILY FRUSTRATED ONLY ATTENDS IF IT IS SOMETHING HE/SHE IS VERY LOSES THINGS NECESSARY FOR TASKS OR ACTIVITIES (E.G. SCHOOL ASSIGNMENTS, PENCILS, BOOKS, TOOLS OR TOYS) Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 LEAVES SEAT IN CLASSROOM OR INOTHER SITUATIONS IN BLURTS OUT ANSWERS TO QUESTIONS BEFORE THE OTHER QUESTIONS WE FEEL ARE IMPORTANT TO ASK?
PLEASE LIST ANY HOBBIES YOUR CHILD HAS, RECREATIONAL OR LEISURE ACTIVITIES /
EXERCISE HE/SHE PERFORMS:
DOES YOUR CHILD MEDITATE OR DO RELAXATION EXERCISES REGULARLY? NO YES
Does your child have any pets?
IF YES, WHAT TYPE OF PETS DO YOU HAVE?
IS YOUR CHILD A VEGETARIAN? NO____ YES_____
DIET: Is your CHILD’S diet primarily of typical North American food NO___ YES___

If no, please list anything unusual about your diet _____________________

Does your child have any Religious Affiliations to food?
NO___ YES___ If yes, what?___________________________________
OR
Medical Procedures?
NO___ YES___ If yes, what?___________________________________
DOES YOUR CHILD PREFER DIET DRINKS OR POP WITH ARTIFICIAL SWEETENERS?
NO YES If yes, what sort of sweeteners?
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 OTHER QUESTIONS WE FEEL ARE IMPORTANT TO ASK? Cont’d
PLEASE LIST ALL YOUR CHILD’S MAJOR SOURCES OF STRESS OR THINGS THAT CAUSE
HIM/HER ANXIETY.
HAS YOUR CHILD EVER SMOKED?
DOES YOUR CHILD DRINK COFFEE, TEA OR ALCOHOL?
IS THERE ANYTHING ELSE THAT YOU FEEL IS IMPORTANT; AND HAS NOT
BEEN ASKED?
IF SO, PLEASE FEEL FREE TO SHARE IT WITH US:
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 ABOUT THE VISIT
At the first visit the practitioner will meet with the parent(s) / caregiver first. The
practitioner needs the time and concentration to speak to the parents first. There will be
a second visit with the child, so that the practitioner can really take some one on one time
with your child and do an evaluation. Thank you for choosing Okotoks Natural Health
Centre for your child’s health needs, please do not hesitate to call if you have any
questions or concerns. Please call the office for the pricing and length of time for the
visits.
When the practitioner meets with the child and then takes time to start the Healing Program we ask that after you start your plan you should come in 10-14 days for a follow-up visit to verify the healing process. We will then evaluate how everything is going and talk about the success of the plan. IRIDOLOGY

Iridology identifies inherited predispositions that negatively or positively can affect one's health,
as the iris shows, which systems of the body are the least and which are the most resilient.
Iridology is a diagnostic tool that helps the Practitioner see certain signs out of the iris, every
bodily organ corresponds to a location on the iris, which then makes is possible to find out where
the problems are originating.
Iridology is an invaluable tool for prevention; we need to identify our strongest functioning parts
of the body, so we can depend upon them to carry us through periods of stress, and to keep the
body balanced and in harmony!
Homeopathy: is a system of medicine that uses highly diluted doses from the plant, mineral
and animal kingdoms to stimulate natural defenses in the body. Homeopathic remedies are
based on the theory that "like cures like," and uses remedies that cause symptoms of a certain
illness in one who is healthy in order to stimulate the body's natural defenses to heal those same
symptoms in one who is ill. The word homeopathy comes from the Greek word 'homeos'
meaning similar, and 'pathos' meaning suffering.
Herbal Medicine: is the therapeutic use of plants, and is the most ancient form of health care
known to humankind. A herb is a plant or plant part valued for its medicinal, savory or aromatic
qualities. Herb plants produce and contain a variety of chemical substances that act upon the
body. Herbs have been used to treat virtually every disease and condition. The use of herbology
ranges from pain relievers, hormone balancers, energizers, sleep aids, stomach soothers, skin
soothers, and treatment of everything from allergies to cancer, from depression to hysteria.
Herbs are used for both prevention and treatment.
Homotoxicology: In homotoxicology, homotoxins are all of those substances, which can cause
ill health in humans. They can be introduced from the exterior or originate in the body itself. In
Homotoxicology, homeopathically manufactured combination products are designed to work
with the body's defense mechanisms and facilitate the body's elimination of toxic substances. VERY IMPORTANT NOTICE:
WE WOULD LIKE TO HEAR HOW YOU FEEL DURING THE TREATMENT, PLEASE CALL US A WEEK AFTER
YOU HAVE STARTED THE TREATMENT.
THIS SUGGESTION PLAN IS NOT INTENDED TO REPLACE YOUR MEDICATION FROM YOUR GENERAL
MEDICAL PRACTITIONER.
DO NOT TAKE ANY OTHER SUPPLEMENTS OR DO NOT CHANGE THE RECOMMENDED DOSAGE IN OUR
PROGRAM UNLESS DISCUSSED WITH THE PRACTITIONER(S).
Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS Okotoks Natural Health Centre Ph: (403) 995-9999 FINANCIAL POLICY
THANK YOU FOR CHOOSING US AS YOUR HEALTH CARE PROVIDER. THE
FOLLOWING IS A STATEMENT OF OUR FINANCIAL POLICY, WHICH WE
REQUIRE THAT YOU READ AND SIGN PRIOR TO ANY SUGGESTIONS. ALL
PATIENTS MUST COMPLETE OUR “QUESTIONAIRRE” BEFORE BEING SEEN AT
OUR OFFICE(S). FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE
ACCEPT CASH, DEBIT, VISA OR MASTERCARD.
PLEASE NOTE THAT WE DO NOT FILE FOR INSURANCE. THE BILL IS YOUR
RESPONSIBILITY, WHETHER YOUR INSURANCE COMPANY PAYS OR NOT. PLEASE BE
AWARE THAT SOME, PERHAPS ALL, OF THESE SERVICES PROVIDED MAY BE “NON-
COVERED” SERVICES AND NOT CONSIDERED REASONABLE AND NECESSARY UNDER
YOUR INSURANCE PLAN. YOU ARE RESPONSIBLE FOR PAYMENT IN FULL,
REGARDLESS OF YOUR INSURANCE COVERAGE.
CANCELLATION POLICY
UNLESS APPOINTMENTS ARE CANCELLED AT LEAST 72 HOURS IN ADVANCE,
OUR POLICY IS TO CHARGE FOR MISSED APPOINTMENTS AT NORMAL OFFICE
RATES. IF CANCELLED ON A FRIDAY AFTER 1:00 PM OR OVER THE WEEKEND
YOU WILL ALSO BE CHARGED AT NORMAL OFFICE RATES.
THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICY. PLEASE LET US
KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS. I HAVE READ THE
FINANCIAL POLICY ABOVE. I UNDERSTAND AND AGREE TO THIS FINANCIAL

___________________________________________ _________________
SIGNATURE PATIENT/RESPONSIBLE PARTY DATE (m/d/y)

Dr. Kurt Hartmann US Cert. ND, & Dr. Wendy Poole US Cert. ND, (HP, CKTP) REGISTERED DEFEAT AUTISM NOW PRACTITIONERS

Source: http://www.okotoksnaturalhealthcentre.info/DANQUESTIONAIRRE_OKOTOKS.pdf