YEH CENTER OF NATURAL MEDICINE, INC.

195 North Second Avenue

Upland, California 91786

Phone: (909) 946-6444   Fax: (909) 946-1099

 

PERSONALIZED FOOD CONSULTATION - FORM A

PERSONAL INFORMATION
 

First Name:   Middle Initial:   Last Name:

 
Email:
 

Date of Birth (mm/dd/yyyy):

Age: Gender: Male Female
 
Height: ft in Weight: lbs  
 

Who may we thank for referring this Food Medicine book to you?

 

What is your goal and objective for health with help from this book?

 

Which statement best describes your outlook?
 If the information benefits my health, I am willing to make changes right away.
 If the information benefits my health, I will make slow and gradual changes.
 I just want to be informed about nutrition and diet.
 I am not willing to make dietary changes or give up my favorite foods.
 
MEDICAL HISTORY
 

Primary Illness:

Duration of Illness:
   

Secondary Illness:

Duration of Illness:

   
Medical History:
     
Surgeries Procedure (Please be specific) Date
 
 
 
 
 
MEDICATIONS AND SUPPLEMENTS
 
Drug Medications
Drug Name Dosage Frequency Per Day Starting Day
 
Natural Nutritional and Herbal Supplements
Supplement Dosage Frequency Per Day Starting Day
 
BIOLOGICAL EVALUATION
     
1. Do you have high blood pressure? Yes  No

high cholesterol?  Yes  No
  If yes, please explain:
     
2. Do you suffer from headaches, migraines or head pain? Yes  No
  If yes, please explain:
     
3. Do you suffer from dizziness or vertigo? Do you faint? Yes  No
  If yes, please explain:
     
4. Do you suffer from chest pains or shortness of breath? Yes  No
  If yes, please explain:
   
5. Date of EKG or stress test for the heart?
  What were the findings?
     
6. Do you suffer from pain of the hypochondriac region or rib cage? Yes  No
  If yes, please explain:
     
7. Do you suffer from upper or lower abdominal pain? Yes  No
  If yes, please explain:
     
8. Do you experience loss of appetite, nausea or vomiting? Yes  No
  If yes, please explain:
     
9. Do you suffer from anorexia, bulimia or compulsive eating? Yes  No
  If yes, please explain:
     
10. Do you have bodily aches and pains? Yes  No
  If yes, please explain:
   
11. How many times per year do you catch a cold or flu?
  How many days does it usually last?
     
12. Do you suffer from respiratory infections? Yes  No
  If yes, please explain:
   
13. Do you suffer from any of the following? Please select all that apply:
  Chronic Cough Runny Nose Sneezing Asthma
  Phlegm Post Nasal Drip Rhinitis Hay Fever
  Bronchitis Pneumonia Sinusitis Allergies
   
  The color of my phlegm/mucous is usually (Please select all that apply):
  Clear Yellow Orange  
  Green Brown With Blood  
   
  Comments:
     
14. Do you suffer from food allergies? Yes  No
  If yes, please list foods that you are allergic to:
     
15. Do you have normal bowel movements, 2-3 times daily? Yes  No
  If no, please explain:
     
16. Do you suffer from diarrhea, dysentery or constipation? Yes  No
  If yes, please explain:
   
17. Is your urine color light yellow or dark yellow? Light Yellow  Dark Yellow
     
18. Do you have blood in the urine and painful or burning urination? Yes  No
  If yes, please explain:
   
19. How many glasses of water do you consume daily?   How many ounces?
   
20. Please explain your exercise routine:
 
   
21. Please explain how you relax and cope with stress:
 
   
22. How many hours do you sleep each night?
   
  I sleep from  am pm    to    am pm
   
  I nap from    am pm     to   am pm
   
  Is your sleep disturbed? Please explain:
     
23. Do your hands and feet feel cold, numb or tingling? Yes  No
  If yes, please explain:
     
24. Do you suffer from uncontrolled movements or seizures? Yes  No
  If yes, please explain:
     
25. Do you suffer from mood swings, anxiety, anger or depression? Yes  No
  If yes, please explain:
     
26. Have you been diagnosed with cancer, tumors or cysts? Yes  No
  If yes, please explain:
     
27. Do you smoke cigarettes, drink alcohol or take drugs? Yes  No
  If yes, please explain:
     
28. Do you have hair loss or gray hair? Yes  No
  If yes, please explain:
     
29. Do you have wrinkles, dry skin, skin flaws and/or blemishes? Yes  No
  If yes, please explain:
     
30. Do you suffer from hypoglycemia or hyperglycemia? Yes  No
  If yes, please explain:
     
31. Do you suffer from hypothyroidism or hyperthyroidism? Yes  No
  If yes, please explain:
     
32. Do you have tendinitis, bursitis, arthritis or osteoarthritis? Yes  No
  If yes, please explain:
   
33. I have a tendency to feel? (please select one)
  Cool Cold Warm Hot  
   
  I enjoy the most? (please select one)
  Spring Summer Autumn Winter  
   
34. Please select all that apply to your personality:
  Aggressive Loud Talkative Fun-Loving  
  Friendly Social Organized Picky/Choosy  
  Quiet Shy Passive Generous  
   
35. Please select all that apply to your lifestyle:
  Prefer Outdoor Athletic Active Prefer Indoor Sedentary
   
36. Please select the emotion that most applies to you:
  Anger Sadness Fear Joy Worry
   
37. How many hours a day do you engage in... (24 hours total)?
  studying? working? sleeping/napping?
  playing? exercising? resting/relaxing?
 
WOMEN ONLY
   
Do you have reoccurring yeast, bladder or urinary tract infections? Yes  No
If yes, please explain:
   
Have you ever been pregnant? Yes  No
If yes, please explain any difficult pregnancies or complications during childbirth:
   
Number of total pregnancies: Number of children:
 
MENSTRATING WOMEN ONLY
   
Are you currently pregnant? Yes  No
If yes, how many months:
   
Do you suffer from abnormal menstrual cycles? Yes  No
If yes, please explain:
   
During menstruation, do you have cramps? Yes  No
If yes, please explain:
   
Do you suffer from PMS? Yes  No
If yes, please explain:
   
Are you on birth control pills? Yes  No
If yes, for how long? Please explain:
 
MENOPAUSE WOMEN ONLY
   
Have you had hormone replacement therapy in the past? Yes  No
If yes, please explain:
 
How long have you experienced absence of menstruation?
   
Do you suffer from menopause symptoms? Yes  No
If yes, please explain:
 
HYSTERECTOMY PATIENTS ONLY
 
What were the reasons for the hysterectomy?
 
Was it a partial or complete hysterectomy?
 
When did you have the hysterectomy?
   
Have you had hormone replacement therapy? Yes  No
If yes, please explain how many years you have received it?
 
MEN ONLY
   
Do you have prostatitis or prostate enlargement? Yes  No
If yes, please explain:
   
Have you had a vasectomy? Yes  No
If yes, please explain:
   
Do you suffer from impotence or sterility? Yes  No
If yes, please explain:
   
Do you have nocturnal emissions? Yes  No
If yes, please explain:
   
Do you have painful ejaculation or premature ejaculation? Yes  No
If yes, please explain:
 
I would like more information on:
 
Additional comments:
 

 

 

YOU WILL RECEIVE THE FOLLOWING 5 BOOKS

1. FOODS OF FOOD MEDICINE TM

Foods of Food Medicine TM is a unique food encyclopedia with knowledge of food biology, chemistry, and physics. This book also provides food effects for health. Keep it in your kitchen for references or for a guide while you are shopping foods. Always remember: "Eat what you should not what you like."

 

2. SEASONAL FOOD MEDICINE TM

Specific foods required by the body and vital organ systems during the changing seasons. This is your guide through spring, summer, autumn and winter foods and related systems. This book is one of the textbooks for the weekly seminars.

 

3. BALANCED FOOD MEDICINE TM

It takes an in-depth look at the importance of food, the major determinants of health, the balance of chemistry, physics and biology, and special care for specific illnesses. It is a comprehensive guide for your health and wellness. This book is one of the textbooks for the weekly seminars.

 

4. NATURAL MEDICINE WORKS

It is the complete collection of inspirational recoveries and patient testimonials
that will touch your heart, mind and soul. This book also includes history, theory and use of natural medicine. This book is one of the textbooks for the weekly seminars.

 

5. TAI CHI EXERCISES

Classical Tai Chi exercises from China to benefit the mind and body. Tai Chi is good for the nervous, cardiovascular, digestive, metabolic, respiratory systems as well as skeletal, muscle and joint activities. This book illustrates and explains 24 forms and 174 movements carefully and precisely.

The information I have provided is true and accurate to the best of my knowledge. I understand that this information will be held in strict confidentiality between the medical staff at Yeh Center of Natural Medicine, Inc. and myself. 

The purpose of "Food Consultation" is to familiarize the patient with food medicine, nutrition, and diet on an individualized basis. The "Food Consultation" does not make any health claims, and the information introduced does not take the place of physician's care, medical procedures, lab tests, or any necessary medication. 

Yeh Center of Natural Medicine, Inc. also does not in any way encourage any person to try to heal themselves or to stop their current medical care and supervision, as all medical treatment requires the knowledge and skill of a trained professional. Due to the personalized nature of this food medicine program, long hours are spent putting it together. Therefore, there is no exchange or refund for this book. I have read and understand the above statements. 

 

Print Name:   Date:

 

 

Food Medicine for Your Health and Wellness!

 


 Food Consultation on a schedule time we agree

$250

This amount includes the digital tongue diagnosis and

ALL of the following books - 5 books total!

 

 1. FOODS OF FOOD MEDICINE TM

It is a unique food encyclopedia with knowledge of food biology, chemistry, and physics.
This book also provides food effects for health.

 

2. SEASONAL FOOD MEDICINE TM
 Specific foods required by the body and vital organ systems during the changing seasons.
This is your guide through spring, summer, autumn and winter foods and related systems.

 

3. BALANCED FOOD MEDICINE TM

It takes an in-depth look at the importance of food, the major determinants of health,
the balance of chemistry, physics and biology, and special care for specific illnesses.

It is a comprehensive guide for your health and wellness.

 

4. NATURAL MEDICINE WORKS
 It is the complete collection of inspirational recoveries and patient testimonials
that will touch your heart, mind and soul.
This book also includes history, theory and use of natural medicine.

 

5. TAI CHI EXERCISES
 Classical Tai Chi exercises from China to benefit the mind and body.
Tai Chi is good for the nervous, cardiovascular, digestive, metabolic,
respiratory systems as well as skeletal, muscle and joint activities.
This book illustrates and explains 24 forms and 174 movements carefully and precisely.