Personal Health History Intake Form

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What type of appointment will you have with Dr. Ellen?

Phone

Zoom

In Person

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Date of Appointment:

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Time of Appointment:

Appointment time

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Address

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State

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Cell Phone Number

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Work Phone Number

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E-mail Address

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What is the color of your iris?

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Sex

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Date of Birth

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What is your blood type?

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What is your weight?

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What is your height?

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What is your age?

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Surgeries: List type, date, and approximate age

Tonsils

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D & C

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Hysterectomy

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Appendix

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Breast Lumps

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Other

Other Surgeries?

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Present Complaints or Problems

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What is your main complaint physically?

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Childhood History

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Habits: How much each day?

Alcohol

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Bread

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Coffee

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Drugs

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Meat

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Fried Foods

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Pasteurized Milk

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Sugar

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Junk Foods

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Salt

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Sleep: Hours per day

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Hours Worked per day

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Exercise

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Woman Only

Have you ever been on the Pill?

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If yes, for how long?

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Are you on them now?

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Ovarian problems

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Uterine problems

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Menopause

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PMS

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Ciclo menstrual

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Are you taking hormone replacements?

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If yes, which ones?

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Men Only

Average Urinary frequency per day

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Any dribbling?

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Do you have leg pains?

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Insomnia?

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Prostrate Gland trouble?

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If yes, explain.

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Genealogical Traits

Are you more similar to your mother or your father? Explain why.

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Please list all medications currently being taken:

Name of Medication, Dosage, Times per Day

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Please list all vitamins, minerals, herbs, and/or supplements currently being taken:

Name of Product and Manufacturer, Dosage, Times per Day

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Daily Food Intake

Your health depends a great deal on the foods you eat daily. Please give two examples of meals and snacks that you consume during a week.

Example 1:

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

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List the liquids you consume during the day. When do you consume them? How much do you consume?

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What do you feel are the healthiest foods you consume? What do you feel are the unhealthiest foods you consume?

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Example 2:

Breakfast:

Snack:

Lunch:

Snack:

Dinner:

Snack:

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List the liquids you consume during the day. When do you consume them? How much do you consume?

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What do you feel are the healthiest foods you consume? What do you feel are the unhealthiest foods you consume?

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Do you feel fuller and more satisfied when you eat a meal with grains and vegetables or when you eat proteins and vegetables? Give an example of a meal that makes you feel best.

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Do you crave sweets? If yes, which do you eat and when do you eat?

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How much sugar, brown sugar, maple syrup or honey do you consume each day?

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Daily or Weekly Exercise

Do you do dry skin brushing before a shower?

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Tell the type or types of exercise that you do daily or weekly. How long do you exercise each time?

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Sleep Patterns

Do you feel tired or have plenty of energy?

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Do you sleep on cotton or silk sheets?

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What time do you go to sleep at night?

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Do you wake up during the night? If so, how many times, and when? Do you urinate during these times? Do you fall back to sleep right away, or do you stay awake for a while?

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What time do you get up in the morning?

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Do you nap during the day? If yes, how long and how many naps?

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Lifestyle and Daily Activities

At what time do you eat breakfast, lunch, and dinner?

Breakfast:

Lunch:

Dinner:

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Do you eat while sitting down and in a peaceful environment?

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Do you drink liquids with your meals? If yes, what do you drink?

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Do you use natural toothpaste? If yes, what brand?

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Do you brush your teeth after each meal and snack?

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Do you have any silver mercury fillings in your teeth?

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Have you been exposed to any heavy chemicals in your life – either at work or elsewhere? If yes, what chemicals?

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Do you wear clothing made from natural fibers?

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Do you use any chemicals when cleaning your home? If yes, which ones?

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If you work, what is your job? Are you happy with your job, the people there, and the environment?

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If you are in a relationship or married, are you happy in your relationship?

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Do you have any pets? If so, what are they? Do you love your pets?

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Do you belong to a support group or participate in activities with friends? If yes, what are they?

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What do you do for fun?

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What brings you the most joy in life?

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Informed Consent Statement: Ellen Tart-Jensen, Ph.D., D.Sc., CCII-3, Naturopath, Iridologist

1) I fully understand that Ellen Tart-Jensen is a lay natural health advisor who deals strictly in helping people to improve their general health and fitness through better nutrition, improved lifestyle, health habits, and positive mental attitudes. 2) I fully understand that Ellen Tart-Jensen is not a licensed physician and cannot diagnose diseases, prescribe drugs, or recommend treatments for specific disease conditions. 3) I understand that all evaluation/analysis performed by Ellen Tart-Jensen, or her representatives are deigned to evaluate my inherent constitution and temperament for the sole purpose of helping me to improve my general health through nutrition, habits, and attitudes. I further understand that said evaluations cannot determine specific disease conditions I may have and do not replace the diagnostic services offered by licensed physicians. 4) I understand that Ellen Tart-Jensen neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services or products she or her representative provide, whether in person or by mail or by telephone, will cure, treat, prevent or mitigate any disease condition; but are provided solely for the purpose of increasing energy, supporting the natural function of body systems and otherwise improving general health and fitness. 5) I certify that Ellen Tart-Jensen or her representative have not suggested that I cease any medical care I may be undertaking. I understand that the decisions I make regarding my health care and the health care of those under my guardianship are my responsibility and certify that I will not hold Ellen Tart-Jensen or her representative responsible for the consequences of my decisions.  6) I affirm that I am not attending this session, now or in the future, as part of any investigation, entrapment, or undercover operation on behalf of any government agency, regulatory body, media outlet, or private investigative entity. I further affirm that I am not participating for the purpose of collecting information for reporting, litigation, licensing review, or any adversarial action without full disclosure and consent.  7) I certify that I am here on this and on any subsequent visit or contact, whether by mail, telephone, or in person, solely on my own behalf and not as an agent or representative of any federal, state, county, or local government or private agency on a mission of investigation.  I have read and understand the foregoing and agree to the terms and conditions set therein.

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Today's Date

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Referred by:

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Client Signature

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What to Expect from an Iridology and Nutrition Consultation: Ellen Tart-Jensen, Ph.D., D.Sc., CCII-3, Naturopath, Iridologist

Iridology is the study of the iris or colored part of the eye as well as the pupil border and sclera and how they relate to each of the body systems. Each iris contains 28,000 nerve endings that go to all parts of the body. The border of the pupil connects directly through the optic nerve which is a bundle of over a million nerves that go to the brain and spinal cord and out to all the organs and glands of the body. Through specific signs in the eye, the iridologist can uncover an incredible amount of information concerning genetics as well as the health of the body. During your iris analysis, Ellen Jensen takes photographs of the client’s eyes and projects them onto a large computer monitor. She will then examine and point out to you the details of your iris structure and pigmentation, sclera signs, and pupillary border shape and strength. She will explain the areas of the iris that reveal specific strengths and deficiencies within the body. The iris analysis will help you to better understand what your inherited strengths and weaknesses are, what chronic disease may be more likely to impact your health, and how your lifestyle can influence this. The iris acts as the body’s blueprint. By understanding it, you have an empowering road map towards optimal health and well-being. Have you ever asked yourself why some people live longer than others? Why can some people abuse their bodies more than others? Why do some people get sick when others don’t? Physicians seek answers to these questions daily, yet many reasons continue to elude them. Wouldn’t you like to understand your health picture better? Let iridology help you.  12  If you have current health challenges, iris analysis can target contributors to these problems. Once identified, corrective measures can be employed, providing you with an opportunity to get better faster. Because the iris can also reveal potential for future health risks, preventive measures can be effectively applied to reduce these risks. During your session, Ellen Jensen will look at your eyes as well as your health history record and point out areas of concern. She then will make a list of goals to work on. She will provide a plan that includes specific nutrition, exercise, drinks, and remedies that will help you to meet those goals and bring your body back into balance. She firmly believes the statement that her father-in-law, Dr. Bernard Jensen taught, “Nature will help to heal when given the opportunity.” If you cannot come in person for iris photography and analysis, you may have a zoom consultation. For this, you may have someone take high quality pictures of your eyes with a good cell phone camera. For more clarity, you may hold a magnifying lens over the eye and have the person take the pictures through the lens. You may send the pictures ahead of time to Jennifer at admin@ellenjensen.com to ensure the pictures are of good quality for a proper analysis.

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Personal Health History

Intake Form

Personal Health History Intake Form

Surgeries: List type, date, and approximate age

Habits: How much each day?

Woman Only

Men Only

Genealogical Traits

Please list all medications currently being taken:

Please list all vitamins, minerals, herbs, and/or supplements currently being taken:

Daily Food Intake

Daily or Weekly Exercise

Sleep Patterns

Lifestyle and Daily Activities

Contact

760-471-9977

760-750-0552