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Health Services of Carmel

Phone: 831-262-9799 * Fax: 831-763-9251

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Iridology Client Form

IIPA Iridology Client Form Date: _______

Name:________________________________________________________________

Address:_______________________________________________________________

Phone: Home:________________Cell:______________ Office: __________________

Male: _____ Female: _____ Birth date: _________________

Height:______________ Weight: ___________

Any weight troubles [loosing or gaining]? _____________________

Are you under a Physician’s care now?___________________________________ Primary Care Physician: ______________________________________________

Occupation: ________________________________________________

What is your main complaint physically? __________________________________________________

Surgeries: (List type, and approximate date and age) including Eye surgeries.

______________________________________________________________________

Any Medically Diagnosed Disease or Disorders:

______________________________________________________________________

Name of Medications, supplements, Over the counter meds that you are currently taking:

______________________________________________________________________

Covid:

Were you evaluated positive for Covid? _____________________________

did you have the Covid Swab Test? _____________ How many times?_______________________

Did you have the completed Covid Vaccine? _________________________When? __________________

Did you have the booster? _____________________________________

What Essential Oils do you use? _________________________________________________________

______________________________________________________________________

Family History of Disease or Medical Condition: ______________________________________________________________________

______________________________________________________________________

Genealogy Traits:

Are you more similar to your mother of your father? Explain why?

______________________________________________________________________

Have you had any trauma, injury, artificial equipment?

______________________________________________________________________

_____________________________________________________________________

Personal History:

Allergies: Foods, Pollens, etc. _____________________________________________________________

Acid Reflux: ______ Do you eat raw fish?_________How many Tattoos? __________

Emotions: __________________________Ear issues: ________________________

Stomach/ Digestive Issues: ______________________________________________________________

Abdominal Pain: (location) ______________________________________________________________

Back Problems: (location) _______________________________________________________________

Muscle Aches & Joint Pain: (location) ______________________________________________________

Other Pain: (location) ___________________________________________________________________

Eczema/ Psoriasis/ other Skin problems: _____________________________________________________

Bowel Problems: _____________ Constipation: _______ Diarrhea: ______________ Memory Issues: _________________ For how long? _________________

Edema/Swelling: (location) ______________________________________________________________

Have you ever had hepatitis? ______Type: (if known) ______________________

Have you ever had a blood transfusion? __________________________________

Heart Issues: _________________________________________________________

Breathing Problems: ____________________________________________________

Blood Pressure:_________________________________________________

Sinus Issues: _________________________________________________________

Do you Smoke? _____ If yes, how many a day? __________ How long? _______ Have you quit smoking? _________________________ If yes, when? ____________

Do you drink alcohol? __________________ How often? ______________ Sleep Issues?: ____________ Exercise: how often? ____________________

Female Issues: __________________________________________

Menstrual cycle: ________________________ Menopause: _____________________

Have you ever been on the pill? _____________________________ How long? ____________________

Number of pregnancies: __________________ Number of children: _________

Are you pregnant? ____________________________________________________________________

Male Issues:

Prostate gland problems: ________________________________________________________________

Urinary frequency: _________________________ Difficult urination: ____________________________

Other problems: ______________________________________________________________________

Do you have any implants? ___________________________________________________________

Other problems: ______________________________________________________________________

Complaints or Symptoms:

___ Fatigue ___ Depression ___ Poor Digestion ____Headaches

___ Memory Loss ___ Hearing Problems ___ Indigestion

___ Crave Sweets ___ Tire Easily ___ Vision Problems

___ Headaches ___ Cold Hands/Feet ___Dizziness ___ Burping/Belching

___ Earaches ___ Hemorrhoids ___ Bloating/Gas ___ Anxiety ___ Lack Patience

___ Nagging Cough ___ Nervousness ___ Shortness of Breath

___ Temper Problems ___ Hernias ___ Sinus Problems ___ Difficulty Sleeping

___ Varicose Veins ___ Sore Throat ___ Dental Problems

___ Low Blood Sugar ___ Bad Breath ___ Low Blood Pressure

___ Diabetes ___ Blood Clots ___ High Blood Pressure

Childhood History:

___ Asthma ___ Tonsillitis ___ Tuberculosis

___ Chicken Pox ___ Measles ___ Mumps

___ Colds ___ Pneumonia ___ Scoliosis

___ Earaches/tubes ___ Scarlet Fever ___ Hay Fever/Allergies

Other:_________________________________________________________________

Childhood Immunizations: _______________________________________________________________

Other Immunizations: ___________________________________________________________________

Dietary Information: What percentage of meals are from restaurants? __________Sushi? ___________

Are you a Vegetarian? ________________ Vegan? _____________________ Do you eat animal Meats?____________ Do you have a water softener?_____________

Food Habits: Write down what you typically eat for meals & snacks.

Breakfast: ______________________________________________________________________

Lunch: ______________________________________________________________________

Snacks. _________________________________________________________

Dinner: ______________________________________________________________________

Night time snacking: ____________________________________________________________________ How much water do you drink daily?________________

What are you goals or expectations? ______________________________________________________

______________________________________________________________________

****All of the information above is held 100% confidential through the Health Service of Carmel. ._____________________________________________________________________

Please send this sheet to:

Fax: 831-763-9251,

Email to: elkhorng@earthlink.net

Mail to: p.o. 1149, Carmel, Ca 93921