Intake Form 

  • English (Canada)
  • English (Canada)
  • Español de México
- select your language -
Field is required!
Field is required!

Personal Health History Intake Form

Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Paid By
Field is required!
Field is required!
What type of appointment will you have with Dr. Ellen?
Field is required!
Field is required!
Adress
Field is required!
Field is required!
State
  • - select a state -
  • Alabama
  • Alaska
  • Arizona
  • Arkansas
  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • North Dakota
  • Ohio
  • Oklahoma
  • Oregon
  • Pennsylvania
  • Rhode Island
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington
  • West Virginia
  • Wisconsin
  • Wyoming
- select a state -
Field is required!
Field is required!
City
Field is required!
Field is required!
Zipcode
Field is required!
Field is required!
  • - select your country -
  • Åland Islands
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa (US)
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda (UK)
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burma (Myanmar)
  • Burundi
  • Cambodia
  • Cameroon
  • Canada
  • Cape Verde
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo, Democratic Republic of the
  • Congo, Republic of the
  • Cook Islands (NZ)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • East Timor (Timor-Leste)
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • Falkland Islands (UK)
  • Faroe Islands (Denmark)
  • Fiji
  • Finland
  • France
  • French Guiana
  • French Polynesia (France)
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Gibraltar (UK)
  • Greece
  • Greenland (Denmark)
  • Grenada
  • Guam (US)
  • Guatemala
  • Guernsey (UK)
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hong Kong (China)
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Isle of Man (UK)
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jersey (UK)
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Macau (China)
  • Macedonia
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mayotte (France)
  • Mexico
  • Micronesia, Federated States of
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Caledonia (France)
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • Niue (NZ)
  • Norfolk Island (Australia)
  • Northern Mariana Islands (US)
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestinian territories
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Pitcairn Islands (UK)
  • Poland
  • Portugal
  • Qatar
  • Réunion (France)
  • Romania
  • Russian Federation
  • Rwanda
  • São Tomé and Príncipe
  • Saint Helena, Ascension and Tristan da Cunha (UK)
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Pierre and Miquelon (France)
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Svalbard and Jan Mayen (Norway)
  • Swaziland
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Togo
  • Tokelau (NZ)
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Wallis and Futuna (France)
  • Western Sahara
  • Yemen
  • Zambia
  • Zimbabwe
- select your country -
Field is required!
Field is required!
Cell Phone Number
Invalid phonenumber!
Invalid phonenumber!
Work Phone Number
Invalid phonenumber!
Invalid phonenumber!
E-mail Address
Field is required!
Field is required!
What is the color of your iris?
  • - select a option -
  • Blue
  • Brown
  • Mixed
- select a option -
Field is required!
Field is required!
Sex
  • - select a option -
  • Male
  • Female
- select a option -
Field is required!
Field is required!
Date of Birth
Select a date
Field is required!
Field is required!
What is your blood type?
Field is required!
Field is required!
What is your weight?
Field is required!
Field is required!
What is your height?
Field is required!
Field is required!
What is your age?
Field is required!
Field is required!

Surgeries: List type, date, and approximate age

Tonsils
Field is required!
Field is required!
D & C
Field is required!
Field is required!
Hysterectomy
Field is required!
Field is required!
Appendix
Field is required!
Field is required!
Breast Lumps
Field is required!
Field is required!
Other
Other Surgeries?
Field is required!
Field is required!
Present Complaints or Problems
Field is required!
Field is required!
What is your main complaint physically?
Field is required!
Field is required!
Childhood History
Field is required!
Field is required!

Habits: How much each day?

Alcohol
Field is required!
Field is required!
Bread
Field is required!
Field is required!
Coffee
Field is required!
Field is required!
Drugs
Field is required!
Field is required!
Meat
Field is required!
Field is required!
Fried Foods
Field is required!
Field is required!
Pasteurized Milk
Field is required!
Field is required!
Sugar
Field is required!
Field is required!
Junk Foods
Field is required!
Field is required!
Salt
Field is required!
Field is required!
Sleep: Hours per day
Field is required!
Field is required!
Hours Worked per day
Field is required!
Field is required!
Exercise
Field is required!
Field is required!

Woman Only

Have you ever been on the Pill?
Field is required!
Field is required!
If yes, for how long?
Field is required!
Field is required!
Are you on them now?
Field is required!
Field is required!
Ovarian problems
Field is required!
Field is required!
Uterine problems
Field is required!
Field is required!
Menopause
Field is required!
Field is required!
PMS
Field is required!
Field is required!
Ciclo menstrual
Field is required!
Field is required!
Are you taking hormone replacements?
Field is required!
Field is required!
If yes, which ones?
Field is required!
Field is required!
Other problems?
Field is required!
Field is required!

Men Only

Average Urinary frequency per day
Field is required!
Field is required!
Any dribbling?
Field is required!
Field is required!
Do you have leg pains?
Field is required!
Field is required!
Insomnia?
Field is required!
Field is required!
Prostrate Gland trouble?
Field is required!
Field is required!
If yes, explain.
Field is required!
Field is required!
Other problems?
Field is required!
Field is required!

Genealogical Traits

Are you more similar to your mother or your father? Explain why.
Field is required!
Field is required!

Please list all medications currently being taken:

Name of Medication, Dosage, Times per Day
Field is required!
Field is required!

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

Name of Product and Manufacturer, Dosage, Times per Day
Field is required!
Field is required!

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:
Field is required!
Field is required!
List the liquids you consume during the day. When do you consume them? How much do you consume?
Field is required!
Field is required!
What do you feel are the healthiest foods you consume? What do you feel are the unhealthiest foods you consume?
Field is required!
Field is required!
Example 2:
Field is required!
Field is required!
List the liquids you consume during the day. When do you consume them? How much do you consume?
Field is required!
Field is required!
What do you feel are the healthiest foods you consume? What do you feel are the unhealthiest foods you consume?
Field is required!
Field is required!
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.
Field is required!
Field is required!
Do you crave sweets? If yes, which do you eat and when do you eat?
Field is required!
Field is required!
How much sugar, brown sugar, maple syrup or honey do you consume each day?
Field is required!
Field is required!

Daily or Weekly Exercise

Do you do dry skin brushing before a shower?
  • - select a option -
  • Yes
  • No
  • Sometimes
- select a option -
Field is required!
Field is required!
Tell the type or types of exercise that you do daily or weekly. How long do you exercise each time?
Field is required!
Field is required!

Sleep Patterns

Do you feel tired or have plenty of energy?
Field is required!
Field is required!
Do you sleep on cotton or silk sheets?
Field is required!
Field is required!
What time do you go to sleep at night?
Field is required!
Field is required!
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?
Field is required!
Field is required!
What time do you get up in the morning?
Field is required!
Field is required!
Do you nap during the day? If yes, how long and how many naps?
Field is required!
Field is required!

Lifestyle and Daily Activities

At what time do you eat breakfast, lunch, and dinner?
Field is required!
Field is required!
Do you eat while sitting down and in a peaceful environment?
Field is required!
Field is required!
Do you drink liquids with your meals? If yes, what do you drink?
Field is required!
Field is required!
Do you use natural toothpaste? If yes, what brand?
Field is required!
Field is required!
Do you brush your teeth after each meal and snack?
Field is required!
Field is required!
Do you have any silver mercury fillings in your teeth?
Field is required!
Field is required!
Have you been exposed to any heavy chemicals in your life – either at work or elsewhere? If yes, what chemicals?
Field is required!
Field is required!
Do you wear clothing made from natural fibers?
Field is required!
Field is required!
Do you use any chemicals when cleaning your home? If yes, which ones?
Field is required!
Field is required!
If you work, what is your job? Are you happy with your job, the people there, and the environment?
Field is required!
Field is required!
If you are in a relationship or married, are you happy in your relationship?
Field is required!
Field is required!
Do you have any pets? If so, what are they? Do you love your pets?
Field is required!
Field is required!
Do you belong to a support group or participate in activities with friends? If yes, what are they?
Field is required!
Field is required!
What do you do for fun?
Field is required!
Field is required!
What brings you the most joy in life?
Field is required!
Field is required!

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. 11 6) 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.
Today's Date
Select a date
Field is required!
Field is required!
Referred by:
Field is required!
Field is required!
Client Signature
Field is required!
Field is required!

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.
cURL error 28: Resolving timed out after 10000 milliseconds

.

.

 

Infinite Iris, Inc.

Services

By Appointment Only
In Person or Phone Consult
FAQ
Contact Us
Or email – admin@ellenjensen.com

Contact

Office Main (760) 471-9977
Office Text (760) 750-0552
Appointment Only (760) 736-0291