Health Consultant Status Form

Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*

mm/dd/yyyy
Weight in Lbs.*
Height*
SS#
No dashes in SS number please.
Place of Employment*
Married?*
- Yes
- No
Email*
Agreement*
- I agree
Updated Health Consultant Status Form “I hereby agree and acknowledge that I have read and consent to the terms and conditions of this Health Consultant Status form and that by my submission of this form via the About Your Body website I shall abide by its terms and agreements as if I had signed this document and delivered it in person, prior to my first consultation. I further agree that I shall either mail or hand deliver the original signature page to About Your Body indicating my true and accurate signature.” I fully understand that the attending health consultant is not a medical doctor and is not a psychologist. I also understand that diagnosis or treatment for any disease or health condition is beyond the scope of any health consultant. If I have such health problems, disease or health condition, I am now being advised to seek qualified medical advice from a licensed physician. I am here as a client on this or any subsequent visit, solely on my own behalf and not as an agent for federal, state, local or medical agencies for any investigative purposes, and I accept legal responsibility for any cost to the corporation of AYB Inc. or personal financial loss to Daniel Phend, due to lost wages, legal fees, damage to the office equipment and restoration of client files and data. I affirm the above statement and accept responsibility by signing this legally binding form. I understand that ABOUT YOUR BODY INC. consultants teach clients how to build their health through training in the effective use of life-style modification pollution avoidance, clean air, pure water, proper foods, rest, exercise, goal orientation, positive mental attitudes, stress reduction, affecting overall health. I realize that services provided mayor may not include examination of saliva, hair samples, urine, usual dietary practices, computerized analysis, for the purpose of stamina and stress evaluations. Any evaluation test is not medical in nature and such tests are not procedures for the purpose of diagnosis or treatment of any disease or health condition. I fully understand that the attending health consultants do not offer allopatric drugs, surgery or chemical stimulants or chemo radiation therapy. I understand that illness is not being diagnosed or treated. Wellness is being measured and increased. If I desire any services not provided by the attending health consultant, which is my prerogative, I fully understand that I should seek them elsewhere. I have solicited the attending health consultant services in good faith exercising my free will and following the dictates of my own conscience, which allows me to select what I understand is most beneficial to my health. Recommendations, suggestions, and references to meals, menus and nutritional supplements, herbal or homeopathic products are for body building, increased stamina and energy and general health maintenance and do not involve diagnosing, prognosticating or prescribing for the treatment of any disease or health condition. I fully understand that the attending health consultant is encouraging me to maintain my current relationship with my attending physician and what he or she has directed. If I am accompanied by a minor or incompetent, I give full faith that I am legally and totally responsible for the client. I presently seek counsel, advice, opinions, points of view and programs within the scope of practice of the attending health consultants wellness clinic. I am aware and release the health consultant to do analysis on me or the person referred to in the statement above. I understand that the consultants named above are dedicated to educating clients to help themselves to better health, and I agree to accept the responsibility for my own health. I realize that natural health is not an exact science and has many variables. Results from lifestyle changes are not consistently predictable. I fully understand that it is my responsibility to arrange for alternate traditional procedures if I suspect any disease or health problem prior to or after any analysis, and by signing this form, I agree to accept this responsibility. I give full affirmation that I have read and understand this document entirely and that I have received a verbal explanation of any portion that I have had any questions about by the attending health consultant, and he/she has adequately answered my questions and concerns. I understand that the consultation or analysis is not covered by insurance. I also understand that there are no refunds for returned products. I affirm I am legally and financially responsible and if I am divorced, I am the custodial parent of this client. 1 am willing and prepared to declare, affirm or repeat under oath all of the above statements at the attending health consultants request. Do not hit next on this form unless you completely understand the contents If for any reason you do not wish to submit this form, consultation will not be rendered.

Client Information: Authorization for Release of Medical/Health Information
Authorization for Release of Medical/Health Information
I authorize DLS to release health information electronically (e-mail or fax) or by paper.
Patient Name*
First Last
Date of birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Information to be released:
Lab Report(s) date of report
Requisition Number
Billing Statements
Authorized Signature**
First Last

(Signature of Patient or Patient’s legal representative)

*I hereby agree and acknowledge that I have read and consent to the terms and conditions of this Health Consultant Status form and that by my submission of this form via the About Your Body website I shall abide by its terms and agreements as if I had signed this document and delivered it in person, prior to my first consultation. I further agree that I shall either mail or hand deliver the original signature page to About Your Body indicating my true and accurate signature.

** If for some reason you have to cancel or postpone your appointment, you must give the office a 24 hour notice to fill your slot or you will be charged the full amount of the appointment.
Name
First Last

Who Referred you?
First Last

Name of the person who referred you to Daniel Phend or About Your Body, Inc.
Number of organs removed
Number of synthetic drugs (Currently using)
Number of times you smoke in a day
Number of steroid type drugs (Used in the past year)
Number of amalgam (silver) Fillings in you mouth
Personal stress (1-10)
Please enter a value between 1 and 10.
No. of sugar type products in a day
Number of exercise sessions in a week
Number of alcoholic drinks a day (avg.)
Number of caffeine products per day (coffee, tea, soda)
Number of street drugs used each month
Number of toxic exposures (Radiation, chemicals, insecticides, etc…)
Number of all known allergies
Number of major injuries in the past
Number of unresolved emotional factors (Anger, depression, anxiety, etc… )
Number of major infections in the past
I am responsible for my body (1-10)
Please enter a value between 1 and 10.
Number of glasses of water per day
Amount of fat in diet (1-10)
Please enter a value between 1 and 10.
How many pounds overweight
Amount of Negativity (1-10)
Please enter a value between 1 and 10.

Number the weaknesses which apply to you. If it doesn't apply, leave it blank
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.

GROUP ONE
“Nervous” stomach
Please enter a value between 1 and 3.
Dry Mouth-eyes-nose
Please enter a value between 1 and 3.
Pulse speeds after meal
Please enter a value between 1 and 3.
Keyed up – fail to calm
Please enter a value between 1 and 3.
Mentally alert, quick
Please enter a value between 1 and 3.
Extremities cold, clammy
Please enter a value between 1 and 3.
Heart pounds after retiring
Please enter a value between 1 and 3.
Acid foods upset
Please enter a value between 1 and 3.
Cold sweats often
Please enter a value between 1 and 3.
Fever easily raised
Please enter a value between 1 and 3.
Neuralgia-like pains
Please enter a value between 1 and 3.
Are your weaknesses made worse by emotional stress?
Please enter a value between 1 and 3.
Group Two
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Perspire easily
Please enter a value between 1 and 3.
Muscle-leg-toe cramps at night
Please enter a value between 1 and 3.
Eyelids swollen, puffy
Please enter a value between 1 and 3.
Indigestion soon after meals
Please enter a value between 1 and 3.
Digestion rapid
Please enter a value between 1 and 3.
Vomiting frequent
Please enter a value between 1 and 3.
Difficulty swallowing
Please enter a value between 1 and 3.
Constipation, Diarrhea alternating
Please enter a value between 1 and 3.
Joint stiffness after rising
Please enter a value between 1 and 3.
Circulation poor, sensitive to cold
Please enter a value between 1 and 3.
Subject to colds, asthma, bronchitis
Please enter a value between 1 and 3.
Are your weaknesses made worse by physical stress?
Please enter a value between 1 and 3.
GROUP THREE
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Afternoon headaches
Please enter a value between 1 and 3.
Get “shaky” if hungry in afternoons
Please enter a value between 1 and 3.
Faintness if meals delayed
Please enter a value between 1 and 3.
Awaken after few hours sleep hard to get back to sleep
Please enter a value between 1 and 3.
Heart palpitates if meals missed or delayed
Please enter a value between 1 and 3.
Eat when nervous
Please enter a value between 1 and 3.
Crave candy or coffee
Please enter a value between 1 and 3.
Abnormal craving for sweets or snacks
Please enter a value between 1 and 3.

GROUP FOUR
INSTRUCTIONS
Number the weaknesses which apply to you. If it doesn’t apply, leave it blank.

Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Bruise easily, "black and blue”
Please enter a value between 1 and 3.
Sigh frequently, “air hunger”
Please enter a value between 1 and 3.
Aware of “Breathing heavily”
Please enter a value between 1 and 3.
Opens window in closed rooms
Please enter a value between 1 and 3.
Susceptible to colds and fevers
Please enter a value between 1 and 3.
Swollen ankles, worse at night
Please enter a value between 1 and 3.
Muscle cramps, worse during exercise
Please enter a value between 1 and 3.
Shortness of breath on exertion
Please enter a value between 1 and 3.
Dull pain in chest or radiating into left arm, worse on exertion
Please enter a value between 1 and 3.
Hands and feet go to sleep easily, numbness
Please enter a value between 1 and 3.
Tendency to anemia
Please enter a value between 1 and 3.
Tension under the breastbone, or feeling of “tightness” worse on exertion
Please enter a value between 1 and 3.
GROUP FIVE
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Dry skin
Please enter a value between 1 and 3.
Skin rashes frequent
Please enter a value between 1 and 3.
Bitter metallic taste in mouth in mornings
Please enter a value between 1 and 3.
Bowel movements painful, or difficult
Please enter a value between 1 and 3.
Biliousness
Please enter a value between 1 and 3.
Greasy foods upset
Please enter a value between 1 and 3.
Stools light colored
Please enter a value between 1 and 3.
Pain between shoulder blades
Please enter a value between 1 and 3.
Laxatives used often
Please enter a value between 1 and 3.
History of gallbladder attacks or gallstones
Please enter a value between 1 and 3.
Sneezing attacks
Please enter a value between 1 and 3.
GROUP SIX
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Lower bowel gas several hours after eating
Please enter a value between 1 and 3.
Burning stomach sensations after eating relieves
Please enter a value between 1 and 3.
Coated tongue
Please enter a value between 1 and 3.
Indigestion 1/2 – 1 hour after eating; may be up to 3 – 4 hours
Please enter a value between 1 and 3.
Gas shortly after eating
Please enter a value between 1 and 3.
Stomach “bloating” after eating
Please enter a value between 1 and 3.

GROUP SEVEN
INSTRUCTIONS
Number the weaknesses which apply to you. If it doesn’t apply, leave it blank.

Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
A
Pulse fast at rest
Please enter a value between 1 and 3.
Nervousness
Please enter a value between 1 and 3.
Can’t gain weight
Please enter a value between 1 and 3.
Intolerance to heat
Please enter a value between 1 and 3.
Highly emotional
Please enter a value between 1 and 3.
Rush easily
Please enter a value between 1 and 3.
Night sweats
Please enter a value between 1 and 3.
Inward trembling
Please enter a value between 1 and 3.
Heart palpitates
Please enter a value between 1 and 3.
Insomnia
Please enter a value between 1 and 3.
B
Impaired hearing
Please enter a value between 1 and 3.
Decrease in appetite
Please enter a value between 1 and 3.
Ringing in ears
Please enter a value between 1 and 3.
Constipation
Please enter a value between 1 and 3.
Mental sluggishness
Please enter a value between 1 and 3.
Headaches upon arising wear off during day
Please enter a value between 1 and 3.
Slow Pulse, below 65
Please enter a value between 1 and 3.
Increase in weight
Please enter a value between 1 and 3.
C
Low blood pressure
Please enter a value between 1 and 3.
Failing memory
Please enter a value between 1 and 3.
Increased sex desire
Please enter a value between 1 and 3.
Headaches, “splitting or rending type”
Please enter a value between 1 and 3.
Decreased sugar tolerance
Please enter a value between 1 and 3.
D
Bloating of intestines
Please enter a value between 1 and 3.
Abnormal thirst
Please enter a value between 1 and 3.
Weight gain around hips or waist
Please enter a value between 1 and 3.
Sex desire reduced or lacking
Please enter a value between 1 and 3.
Tendency to ulcers or colitis
Please enter a value between 1 and 3.
Increased sugar tolerance
Please enter a value between 1 and 3.
Women: menstrual disorders
Please enter a value between 1 and 3.
Young girls: lack of menstrual function
Please enter a value between 1 and 3.
E
Hot flashes
Please enter a value between 1 and 3.
Headaches
Please enter a value between 1 and 3.
Dizziness
Please enter a value between 1 and 3.
Increased blood pressure
Please enter a value between 1 and 3.
Sugar in urine (not diabetes)
Please enter a value between 1 and 3.
Masculine tendenosis (female)
Please enter a value between 1 and 3.
F
Low blood pressure
Please enter a value between 1 and 3.
Chronic fatigue
Please enter a value between 1 and 3.
Weakness, dizziness
Please enter a value between 1 and 3.
Tendency to hives
Please enter a value between 1 and 3.
Arthritic tendencies
Please enter a value between 1 and 3.
Perspiration increase
Please enter a value between 1 and 3.
Crave salt
Please enter a value between 1 and 3.
Brown spots or bronzing of skin
Please enter a value between 1 and 3.
Allergies – tendency to asthma
Please enter a value between 1 and 3.
Exhaustion – muscular and nervousness
Please enter a value between 1 and 3.
Respiratory disorder
Please enter a value between 1 and 3.
Are you Male or Female?*
- Male
- Female

G
INSTRUCTIONS
Number the weaknesses which apply to you. If it doesn’t apply, leave it blank.
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Painful menses
Please enter a value between 1 and 3.
Premenstrual tension
Please enter a value between 1 and 3.
Very easily fatigued.
Please enter a value between 1 and 3.
Depressed feeling before menstruation
Please enter a value between 1 and 3.
Menstruation excessive and prolonged
Please enter a value between 1 and 3.
Painful breasts
Please enter a value between 1 and 3.
Menstruate too frequently
Please enter a value between 1 and 3.
Vaginal discharge
Please enter a value between 1 and 3.
Menopause hot flashes, etc.
Please enter a value between 1 and 3.
Menses scanty
Please enter a value between 1 and 3.
Acne, worse at menses
Please enter a value between 1 and 3.

G
INSTRUCTIONS
Number the weaknesses which apply to you. If it doesn’t apply, leave it blank.
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Tire too easily
Please enter a value between 1 and 3.
Urination difficult
Please enter a value between 1 and 3.
Night urination frequent
Please enter a value between 1 and 3.
Pain on inside of legs or heel
Please enter a value between 1 and 3.
Feeling of incomplete bowel evacuation
Please enter a value between 1 and 3.
Prostate trouble
Please enter a value between 1 and 3.
Leg nervousness at night
Please enter a value between 1 and 3.
Diminished sex desire
Please enter a value between 1 and 3.

H
INSTRUCTIONS
Number the weaknesses which apply to you. If it doesn’t apply, leave it blank.
Use: (1) – for Mild symptoms / (2) • for Moderate symptoms / (3) – for Severe Symptoms.
Chronic cough
Please enter a value between 1 and 3.
Pain around ribs
Please enter a value between 1 and 3.
Shortness of breath
Please enter a value between 1 and 3.
Chest pain
Please enter a value between 1 and 3.
Difficulty breathing
Please enter a value between 1 and 3.
Coughing up phlegm
Please enter a value between 1 and 3.
Coughing up blood
Please enter a value between 1 and 3.
Bronchitis (frequent)
Please enter a value between 1 and 3.
Infections settle in lungs
Please enter a value between 1 and 3.
Sensitive to smog
Please enter a value between 1 and 3.

I
Frequent urination
Please enter a value between 1 and 3.
Rose colored (bloody) urine
Please enter a value between 1 and 3.
Dripping after urination
Please enter a value between 1 and 3.
Difficulty passing urine
Please enter a value between 1 and 3.
Cloudy urine
Please enter a value between 1 and 3.
Rarely need to urinate
Please enter a value between 1 and 3.
Frequent bladder infections
Please enter a value between 1 and 3.
Painful/burning when passing urine
Please enter a value between 1 and 3.
Urination when you cough or sneeze
Please enter a value between 1 and 3.
Strong smelling urine
Please enter a value between 1 and 3.
J
Throat infections
Please enter a value between 1 and 3.
Poor wound healing
Please enter a value between 1 and 3.
Slow to recover from cold or flu
Please enter a value between 1 and 3.
Gets boils or styes
Please enter a value between 1 and 3.
Swollen lymph glands
Please enter a value between 1 and 3.
Catch colds or flu too easily
Please enter a value between 1 and 3.
Bumpy skin on back of arms
Please enter a value between 1 and 3.
Inflamed or bleeding gums
Please enter a value between 1 and 3.
Chronic lung congestion
Please enter a value between 1 and 3.
Post nasal drip
Please enter a value between 1 and 3.
Breathe through mouth
Please enter a value between 1 and 3.
Swollen tongue
Please enter a value between 1 and 3.
Hyperactivity
Please enter a value between 1 and 3.
Food sensitivity or allergy
Please enter a value between 1 and 3.

To The Client:
Please list below the five main physical complaints you have in order of their importance:
History of illness and treatment:
What was the last medical physician’s diagnosis:
When?
List current medications being taken:
Operations, accidents or injuries:
How many bowel movements per day do you have?
List foods most often craved:
How much red meat do you consume weekly?
What is your weekly carbonated beverage intake?
What is your daily water intake?
What does your exercise routine consist of?
List Current nutrition now being taken:

Health Consultant Status Form

Health Consultant Status Form

Step 1 of 11

Client Information: Authorization for Release of Medical/Health Information

Number the weaknesses which apply to you. If it doesn't apply, leave it blank

Group Two

GROUP THREE

GROUP FOUR

GROUP FIVE

GROUP SIX

GROUP SEVEN

A

B

C

D

E

F

G

G

H

I

J

To The Client: