~A Wholistic Way To Life~
Jennifer Echert, Naturopath
Intake and Information Forms
How To Choose A Holistic Practitioner (pdf format)
Whether you hear about a service or practitioner through a personal
referral or a directory, take the time to call for a brief interview. Most
practitioners will be able to spend a few minutes speaking with you and
answering your questions. Think about your questions ahead of time and
be precise about your health concerns and previous treatment in order to
obtain the information you need. Here are some suggested interview

New Client Profile (pdf format)
This provides us with very basic information so that we can understand
your health history and your current concerns and goals. Please complete
as accurately and completely as possible before we begin. The Mutual
Understandings and Consent to Treatment portion is provided to enable
our sharing of a common understanding of our rights and roles in this
professional therapeutic relationship. Please read this agreement and sign
at the end indicating that you have read, understood and agreed to it.  
Please ask any questions if you would like clarification or additional

Health Appraisal Questionnaire (pdf format)
This questionnaire helps us to assess your current overall health. It will
allow us to keep track of how your physical, mental and emotional states
respond to changes you make in your eating habits, priorities,
supplement program, social and family life, level of physical activity and
time spent on personal growth. All information is held in strict confidence.

Candida Questionnaire (pdf format)
An overgrowth of Candida Albicans yeast in the gastrointestinal tract is a
complex syndrome known as chronic Candidiasis. This overgrowth of
Candida is believed to cause a wide variety of symptoms in nearly every
system of the body including the gastrointestinal, endocrine,
genitourinary, nervous and immune systems. Symptoms may include:
fatigue, allergies, immune system malfunction, depression, chemical
sensitivities and digestive disturbances. Small intestinal bacterial
overgrowth and leaky gut syndrome are related to Candidiasis.

Medical Request Form (pdf format)
This form gives your written permission to your doctors to release your
medical records to my office. This allows a review of your complete charts,
lab and imaging reports so that we may discuss them together.

Basal Body Temperature Evaluation (pdf format)
Low basal body temperatures may reflect hypothyroidism. Common signs
and symptoms of hypothyroidism are: depression, difficulty in losing
weight, dry skin, headaches, lethargy or fatigue, menstrual problems,
recurrent infections, sensitivity to cold. High basal body temperatures
above 98.6º may be evidence of hyperthyroidism. Common signs and
symptoms of hyperthyroidism include: bulging eyeballs, fast pulse,
hyperactivity, inability to gain weight, insomnia, irritability, menstrual
problems, nervousness.

Body Ph Evaluation (pdf format)
Disease favors certain pH levels. Symptoms associated with acidosis are:
insomnia, colitis, irritability, racing heart-beat, hard stool, restlessness,
anxiety and nervousness, dry skin and mouth, acid urine, ammonia in
urine, urinary calculi, diarrhea and dehydration, breathlessness, excessive
dietary intake of carbohydrates, protein, and an avoidance of green leafy
vegetables. Symptoms associated with alkalosis are: joint stiffness, night
cramps, slow pulse, allergies, bursitis, high cholesterol and osteo-type
arthritis, alkaline urine, no ammonia in urine, water and fluid retention,
decreased respiratory rate.  

Food Consumption Log (pdf format)
A food consumption log is generally used for an entire week in order to
keep track of what you are consuming and help you make changes in
your diet. The information you record will help us design a program that
will meet your specific needs. By writing things down as you go,
information and habits emerge that we tend to otherwise not see.
Disclaimer: Naturopath's are not required to be licensed in the state of Illinois.  The contents of this website are
intended as a sharing of knowledge and information from the research and experience of Jennifer Echert, and are
based upon her opinions. They are not intended to replace a one-on-one relationship with a qualified health care
professional and they are not intended as medical advice. You are encouraged to make your own health care
decisions based upon your research and in partnership with a qualified health care professional.

Copyright © 1996-2006 BERKANA™, 2007-2016 BerkanaWay. All Rights Reserved. The contents of this website
may be copied in full, with copyright, contact, creation and information intact, without specific permission, when
used only in a not-for-profit format. If any other use is desired, permission is required in writing from Jennifer

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