REMNANT INSTITUTE INC.
Center for Lifestyle Medicine and Education
26 Huervana Street, Lapaz, Iloilo City, Philippines, 5000
+63 33 3291916 / +63 9052661656 [email protected] www.remnant-institute.com
REGISTRATION DATA
Name: ___________________________________________ Age: _________________ Gender: _______________
Birth date: ________________________ Marital status: ______________ # of Children: ____________________
Permanent address: _____________________________________________________________________________
Contact #: _____________________________________ Email address: __________________________________
Language spoken: ______________________________Occupation: _____________________________
Religion faith: ___________________________________ Passport #/National ID: _________________________
Notify in case of emergency Name: _______________________________ Relation: ___________________
Contact numbers: _________________________________________________
PROGRAM REGISTRATION:
_______ Medical Consult _____ 10 Day Intensive Lifestyle ______ 4 Day Detox and
_______ Shared Medical Medicine Program Cleansing Program
Appointment
Session Date: ___________________________ Is this your first time with us? YES ______ NO ______
MEDICAL HISTORY
Check (/) if you have ever been told by a physician that you have any of the following:
____ Angina (yr?) ____ Stroke (yr?) ____ Osteoarthritis
____ Gallbladder disease ____ High blood pressure ____ Gout
____ Hearth attack (yr?) ____ High cholesterol ____ Kidney disease
____ Angioplasty (yr?) ____ High triglycerides ____ Overweight
____ Bypass (yr?) ____ Diabetes ____ Bronchitis/Emphysema
____ Heart failure (yr?) ____ Ulcer ____ Constipation
____ Blood clotting problem ____ Thyroid problem ____ Diverticulosis/Bowel pockets
____ Abnormal ECG (yr?) ____ Osteoporosis ____ Irritable bowel syndrome
____ Irregular heart beats ____ Rheumatoid arthritis ____ Cancer (type?)
____ Other condition (Please specify)__________________________
List of Medications, Herbs and Supplements you are taking: I take None _______
Generic/Brand Name Dose Purpose
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(Please use the space if needed for listing)
Kindly fill in this form diligently as this will serve as basis of our Lifestyle Evaluation
Any history of trauma/accident/surgery (please specify): ________________________________________________________
Any Allergy to food/medicine/herbs (please specify): ________________________________________________________
Family History of Heart disease, Diabetes, Hypertension ________________________________________________________
(Please email medical report, investigations or blood works available)
LIFESTYLE BACKGROUND
Rest and Stress Please Fill in the number of servings you consume weekly (Pls don’t leave blank)
____ Evening is biggest meal ____ Meat of shellfish ____ Salad dressings
____ Eat little or no breakfast ____ Chicken/Turkey ____ Mayonnaise
____ 6 hours or less sleep/night ____ Meat ____ Margarine
____ Sleep restlessly ____ Whole milk or 2% ____ Gravies
____ Suffer insomnia ____ Cheese ____ Soymeat/Gluten
____ Hrs/Week of work ____ Butter or cream ____ Soymilk
____ Very few vacations ____ Sour cream ____ Water
____ Feel under pressure ____ Ice cream/Ice milk ____ Alcohol
____ Eat too fast ____ Yogurt ____ Coffee/Tea/Chocolates
____ Easily emotionally upset ____ Liver/Organ meats ____ Soft drinks/Bottled juices
____ Feel muscular tension ____ Sausage/Hotdogs ____ Candy or sugar
____ Eat between meals ____ Eggs ____ Sugary desserts
____ Feel fearful and depressed ____ Fried foods ____ Honey/Syrups/Jelly
____ Anxiety, worry and tension ____ Salty Snacks ____ Crackers/Cookies/Biscuits
Exercise (beyond everyday occupation) Breathing
____ None ____ Non-smoker
____ Mild (2-3 days/week ____ Ex-smoker (yr?___)
____ Moderate 3-5 days/week ____ Smoker (yr? ____ / # of sticks/day? ____ / How often tried to quit? ____
____ Vigorous 4-6 days/week ____ Live with smoker
Food Diary
____ Breakfast time Usual Menu: _____________________________________________________
____ Lunch time Usual Menu: _____________________________________________________
____ Snack frequency Type: ___________________________________________________________
____ Sweets frequency Type: ___________________________________________________________
VITAL SIGNS/ANTHROPOMETRICS
Blood Pressure: _________________ Weight: _________________
Pulse Rate: _________________ Height: _________________
Respiratory Rate: _________________ BMI: _________________
Temperature: _________________ Waist line: _________________
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Signature over printed name
I voluntarily subjected myself for evaluation and treatment at Remnant Institute Inc. and understood the process I have to take. With
this, I hereby hold the center free of any legal liabilities as I am duly informed of what to expect with regards to possible outcome.
DATE PROBLEM LIST RECOMMENDATION TREATMENT
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