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CLT Course Order Form (For Registered Dietitians Only)
by
Piotr Zielinski
|
Dec 14, 2015
|
Blog
CLT Course Order Form (For Registered Dietitians Only)
How did you first hear about MRT?
Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Canada
United States
Country
Daytime Phone
*
Evening Phone
Fax Number
Email
*
Male/Female
*
Male
Female
Age
Height (Inches)
Weight (lbs)
Is There A History of Allergies in your Family?
Yes
No
What are your main complaints (In Order of Importance):
Duration of Problem:
List All Medications (Prescription & OTC) Currently Taken on Regular or as Needed Basis:
Drug
Dosage
#Times/Day
Start Date
SCALE OF SYMPTOMS SUFFERED DURING THE LAST SIX (6) MONTHS
Select option
0
If You Do Not Suffer From This
AT ALL
Select option
1
If You Suffer
Occasionally
(less than twice a week) and It Is
Not Severe
Select option
2
If You Suffer
Frequently
(2 or more times per week) and It Is
Not Severe
Select option
3
If You Suffer
Occasionally
(less than twice a week) and When You Do It Is
Severe
Select option
4
If You Suffer
Frequently
(2 or more times per week) and When You Do It Is
Severe
CONSTITUTIONAL SYMPTOMS
Fatigue (tired, sluggish)
0
1
2
3
4
Hyperactive (nervous energy)
0
1
2
3
4
Restless (can’t relax/sit still)
0
1
2
3
4
Sleepiness during day
0
1
2
3
4
Insomnia at night
0
1
2
3
4
Malaise (feel lousy)
0
1
2
3
4
Lungs
“Wheezing” (Asthma/ Asthma-Like Symptoms)
0
1
2
3
4
Chest Congestion
0
1
2
3
4
“Non-Productive” Coughing
0
1
2
3
4
“Productive” Coughing
0
1
2
3
4
EMOTIONAL/MENTAL SYMPTOMS
Depression (feelings of hopelessness)
0
1
2
3
4
Anxiety (vague fears, uneasiness)
0
1
2
3
4
Mood Swings (rapid, distinct changes)
0
1
2
3
4
Irritability (anger, hostility)
0
1
2
3
4
Forgetfulness
0
1
2
3
4
Lack of Concentration/Focus
0
1
2
3
4
EYES
Red or Swollen Eyes
0
1
2
3
4
Watery Eyes
0
1
2
3
4
Itchy Eyes
0
1
2
3
4
“Dark Circles” or “Baggy”
0
1
2
3
4
GENITOURINARY
Increased Urinary Frequency
0
1
2
3
4
Painful Urination
0
1
2
3
4
HEAD/EARS
Headache (any kind)
0
1
2
3
4
Earache
0
1
2
3
4
Ear Infection
0
1
2
3
4
Ringing in Ear
0
1
2
3
4
Itchy Ears
0
1
2
3
4
Discharge from Ear
0
1
2
3
4
MUSCULOSKELETAL
Joint Pains/Aching
0
1
2
3
4
Stiff Joints
0
1
2
3
4
Muscle Aches
0
1
2
3
4
Stiff Muscles
0
1
2
3
4
Arthritis (Diagnosed)
0
1
2
3
4
SKIN
Blemishes, Acne
0
1
2
3
4
Rashes, Hives
0
1
2
3
4
Eczema
0
1
2
3
4
“Rosy” Cheeks
0
1
2
3
4
CARDIOVASCULAR
Irregular Heartbeat
0
1
2
3
4
High Blood Pressure (Diagnosed)
0
1
2
3
4
NASAL/SINUS
Post Nasal Drip
0
1
2
3
4
Sinus Pain
0
1
2
3
4
Runny Nose
0
1
2
3
4
Stuffy Nose
0
1
2
3
4
Sneezing
0
1
2
3
4
DIGESTIVE
Heartburn/Esoph. Reflux
0
1
2
3
4
Stomach Pains/Cramps
0
1
2
3
4
Intestinal Pains/Cramps
0
1
2
3
4
Constipation
0
1
2
3
4
Diarrhea
0
1
2
3
4
Bloating Sensation
0
1
2
3
4
Gas (of Any Kind)
0
1
2
3
4
Nausea, Vomiting
0
1
2
3
4
Painful Elimination
0
1
2
3
4
MOUTH/THROAT
Sore Throat
0
1
2
3
4
Swollen Throat
0
1
2
3
4
Swelling of Lips/Tongue
0
1
2
3
4
Gagging or Throat “Clearing”
0
1
2
3
4
Lesions (“Canker Sores”)
0
1
2
3
4
WEIGHT MANAGEMENT
Overweight
0
1
2
3
4
Fluctuating Weight
0
1
2
3
4
Food Cravings
0
1
2
3
4
Water Retention
0
1
2
3
4
Binge Eating or Drinking
0
1
2
3
4
Purging (all methods)
0
1
2
3
4
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.
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