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Page 1 of 19 - Trinity Intake Forms

Section 1
MM-DD-YYYY
MM-DD-YYYY
Names and ages of Biological Children

Names and ages of Adopted Children

Names and ages of Step-Children











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Section 2
















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Emotional Well-Being | Heart

Childhood History

Childhood Diseases and/or Accidents


Page 4 of 19 - Trinity Intake Forms

Emotional Well-Being | Heart
Please provide their full name, including maiden name, and describe your relationships with the following people (as applicable):





Page 5 of 19 - Trinity Intake Forms

Physical Health | Body
INSTRUCTIONS
Select only the circles which apply to you.
● O O MILD Symptoms (occurred once or twice last 6 months)
O ● O MODERATE symptoms (occurred once or twice in last month)
O O ● SEVERE symptoms (chronic, occurred once or twice in last week)
Group 1
Group 2

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Physical Health | Body
Group 3
Group 4

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Physical Health | Body
Group 5

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Physical Health | Body
Group 6

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Physical Health | Body
Group 7A
Group 7B

Page 10 of 19 - Trinity Intake Forms

Physical Health | Body

VITALITY

Sleep & Energy










Page 11 of 19 - Trinity Intake Forms

Physical Health | Body

Exercise Programs


Bowel Movements


Sexual Activity




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Physical Health | Body

Daily Beverages & Food Cravings


Female Only

Female Only

Menstrual History
MM-DD-YYYY

Please Explain
Reproductive History












Page  13 of 19 - Trinity Intake Forms

Physical Health | Body
Fun Fact:
Your mind experiences about 70,000 thoughts a day. Sadly, for the average person, 80% are negative. However; 95% are repetitive – meaning they make up most of your 70,000 thoughts! You are running a continuous loop over and over in your head, a loop based on your life experiences up until this point in time. For optimal well-being of body, heart, and soul, you must begin to reprogram your subconscious mind so those repetitive thoughts become congruent with health, happiness, and wholeness!
Female Only
Fun Fact:
Your mind experiences about 70,000 thoughts a day. Sadly, for the average person, 80% are negative. However; 95% are repetitive – meaning they make up most of your 70,000 thoughts! You are running a continuous loop over and over in your head, a loop based on your life experiences up until this point in time. For optimal well-being of body, heart, and soul, you must begin to reprogram your subconscious mind so those repetitive thoughts become congruent with health, happiness, and wholeness!
Pre/Peri/Post Menopausal












Urogenital

Page 14 of 19 - Trinity Intake Forms

Physical Health | Body

Pregnancies


Microbial Issues

Page 15 of 19 - Trinity Intake Forms

Physical Health | Body

Goals:
What do you want to accomplish while working with Carolyn?


Page 16 of 19 - Trinity Intake Forms

Mom with her daughter
I understand that Naturopathic Care is a process and my decision to embark on this journey with Dr. Carolyn will require a commitment on my end. I also accept and acknowledge the commitment Dr. Carolyn has extended to me where she has offered to be my guide, coach and support person on this journey. I am determined to stay the course and finish the race I have entered into to the fullest of my abilities. Additionally, I also acknowledge that I am free to follow this journey as long as I feel is best to me.

ND Informed Consent

According to The Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1) the term drug is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.” A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb or, or Homeopathic Remedy.

Although, a Vitamin, Mineral, Trace Element, Amino Acid, or Herb may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested material or dietary advice is not intended as any primary treatment and or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patients, diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body.

I hereby understand, agree and acknowledge by my signature below that I fully understand that, Carolyn Berghuis, is not a medical doctor, or attempting to perform duties of the medical profession whatsoever. I further understand, agree and acknowledge that anything she says or does is strictly informational use and such information shall not be construed as medical advice. I understand, agree and acknowledge that the information shared with me is for me and me alone regarding my choice whether to use in whole, in part or not at all for my own personal self-healing. I hereby agree to indemnify and hold Carolyn Berghuis, Trinity Holistic Wellness and its associates harmless for any information she shares with me and that it is my understanding that it is my personal choice if I decide to use a process of self-healing. I give Carolyn Berghuis permission to test me with the Bio-Meridian EAV machine. I certify that I am here on this, or any subsequent visit, or contact, whether by mail, phone, or in person on my behalf. I am not an agent or representative of any federal, state, county, local government, or private agency on a mission of investigation.
MM-DD-YYYY

Page 17 of 19 - Trinity Intake Forms


Sign-up For Carolyn’s Trinity Tuesday e-Newsletter
Delivered every Tuesday to your Inbox. Carolyn offers up to date wellness information every Tuesday to keep you “In the know!”


We also use Twitter and Facebook to share great information, so if you are a part of those networks give us a like or a follow!

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I am looking forward to walking with you on this journey!

Blessings,
Carolyn Berghuis, MS, ND, CTN

Page 18 of 19 - Trinity Intake Forms

SunsetCongratulations!

You are taking charge of your life and you have decided to move towards optimal health, happiness and wholeness! This is an exciting time for you!

Becoming well and reaching your highest potential will, no doubt be one of the highlights of your life! Just as all serious athletes invest time, resources, sweat and heart to prepare for upcoming events, you have embarked on a path that requires an investment on your end, an investment of time, resources, perseverance, patience and heart. 

Just like the serious athlete has a general sense of what she has entered into when she takes that first step towards her goal, it is important that you have a general understanding of your first step. In order to help facilitate such an understanding we have created a FAQ Page that answers many important questions for first time patients. Please take a moment and review this page before initialing below.

A Lot Happens in 12 Months

First Three Months - Here we will begin laying a solid foundation and identifying core issues that need to be resolved for you to reach your highest best.
Next Five Months
The fun continues! Here we will begin creating a healthy and vibrant new you. At this point you should already be feeling a little stronger, healthier and happier. 
Next Four Months - Here the continued support and manifestation of a new you begins to reveal itself in greater health, vitality, vibrancy and happiness!

Testimonials

I attended with a friend, who had made a long distance connection with Dr. Carolyn. The whole experience not only took me by surprise, it left me a bit dumbfounded! Although I had taken many steps towards healing previously, LIVE allowed further release…

Korinne, Retreat Attendee

This transformational retreat literally left me speechless and it took many days to process the incredible healing that took place during this 2 day retreat. Optimal physical health can never be reached if you are emotionally unhealthy. This retreat helps you honor second …

Anne, Retreat Attendee

READ MORE TRANSFORMATIONAL STORIES

Carmel, IN 46032 USA

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