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Hawaii Gerson Therapy Program
 - Hawai'i Naturopathic Retreat Center - Mind Your Body - HAWAI'I NATUROPATHIC RETREAT CENTER phone Hawaii Gerson Therpy Center


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Application & Registration for Gerson Therapy

Registration
To register, you will probably be asked to take the following steps:
    
1.  Write an essay relating the chronological story of your illness. Include all events  preceeding the onset of the disease that may have played a role in its development. Include toxic exposure, radiation, mental and emotional issues, relationships, losses- financial or human or animal- unfinished business, grieving process, unfulfilled expectations, set of values, conditioning, or other mental emotional issues.  Also include treatments you undertook and the rate of their success.  Write about your state of health during these last 20 years, and your projection for the future.  Write about the appreciation of your illness as a teacher, what you have learned and what you still have to learn.  Write about your will to live and what you would like to accomplish in the future.  This essay is a very important step in gathering your strength for healing.
    
2.  Complete the Gerson Therapy Patient Information and History questionnaire (below).
    
3.  Send a copy of your diagnosis, most recent laboratory results and imaging studies reports .  We need a CBC, a metabolic pannel and a urinalysis.  If you did not have any blood work done, let us know and we will you a requisition.

4.  Mail, email or fax your essay and questionnaire, and pay the reservation fee of $300.
Mailing address: Hawaii Gerson Therapy Program , attn. Dr. Baylac, 885 Kilauea Ave, Hilo, HI 96720. Fax: 808 982 8202, Email: click here.

Payment
You can pre-pay online, via personal credit card over the phone, wire money, or send a US check or international money order.
Checks should be made to Hawaii Naturopathic Retreat Center Inc. and sent to Hawaii Gerson Therapy Program , attn. Dr. Baylac, 885 Kilauea Ave, Hilo, HI 96720. Money order must be made to Dr. Baylac and sent to the same address.  To pay by credit card click here.
You will be billed for the full amount of your therapy within 24 hours of your arrival and payment in full will be due within 3 days of arrival.  Patients who terminate their therapy due to a medical emergency will be reimbursed for the remaining unused portion of the program.  For the reservation fee there is no refund in case of cancellation, unless there is a medical emergency.



INSTRUCTION
To be able to better help you, we ask that you print this application webpage and fill in the requested information below - or click here (without instruction text). You can fax or mail (or scan and email) it to us. Or copy the text and paste in a wordfile, where you can type your answers.

Alternatively download a wordfile with the same content - like this: right-click here, and choose "save (link) target as". This word-file (applicationform.rtf) you can type your answers in and then attach in an email to us. (Or copy the text from and paste in an email.)




GERSON THERAPY - APPLICATION FORM & QUESTIONNAIRE


GENERAL INFORMATION


Today's date ___________

Name _______________________________________________

Age _____ Sex (M,F) ______

Place of birth ____________________________ Birth date ____________

Marital status ________________________ Number of children _____

Living situation (alone, family, friends) ____________________________

Occupation _________________________________________

Address _____________________________________________________________

City _______________________________________ State/Zip/Country __________________

E-mail address _____________________________________ Fax_____________________

Phone (home) _____________________ Phone (work/cell) ______________________


OPTIONAL
(sometimes it can help explain your health problem)

Religion _________________________ Race ______________



COMPREHENSIVE HEALTH HISTORY
Please describe your current symptoms and problem areas.  If you have received a diagnosis, please include the diagnosis and date received.

Personal Medical History
                                                        Date Diagnosed      Treatment Taken
High Blood Pressure    __Yes __No    ____________    ______________
Heart Disease        __Yes __No    ____________    ______________
Stroke/Thrombosis        __Yes __No    ____________    ______________
Diabetes            __Yes __No    ____________    ______________
Arthritis            __Yes __No    ____________    ______________
Liver/Gall Bladder Disease__Yes __No    ____________    ______________
Kidney Disease        __Yes __No    ____________    ______________
Seizure Disorder        __Yes __No    ____________    ______________
Lung Disease        __Yes __No    ____________    ______________
Asthma        __Yes __No    ____________    ______________
Emphysema        __Yes __No    ____________    ______________
Other:  
____________________________________________________________
____________________________________________________________
____________________________________________________________
Cancer:    Type:_________________   ____________    ______________
        Type:_________________   ____________    ______________
        Type:_________________   ____________    ______________
Have you had any chemotherapy?    __Yes __No
If yes, how many treatments? _____________________________________
For how long did you receive radiation? _____________________________
Was the radiation __successful __not successful __no effect

Please list all surgeries (i.e., include cosmetic, implants, biopsies):

Name of surgical procedure:                      Year:
1.  ________________________________________    ______________
2.  ________________________________________    ______________
3.  ________________________________________    ______________
4.  ________________________________________    ______________
5.  ________________________________________    ______________
6.  ________________________________________    ______________
7.  ________________________________________    ______________
8.  ________________________________________    ______________
9.  ________________________________________    ______________
10.________________________________________    ______________

Any tattoos or piercings?  __Yes __No.  If yes, when and where? __________
_____________________________________________________________
To your knowledge, are you HIV positive?  __Yes __No
To your knowledge, do you have AIDS?  __Yes __No
Have you had any blood transfusions?  __Yes __No  Blood type, if known: ____
If yes, when? ___________________________________________________
What is your current stress level (5 high)? __1 __2 __3 __4 __5
Past Occupations:  ______________________________________________
_____________________________________________________________
Have you been exposed to any of the following?
Agricultural chemicals        __Yes __No
Industrial/Workplace chemicals    __Yes __No
Cigarette smoking            __Yes __No
    If yes, how much?    _______________ For how long?  _____________
    Date of last cigarette smoked? ________________________________
    Second hand smoke/how much/how long? ______________________
Alcohol use?                __Yes __No  How much? _______________
Recreational drugs?        __Yes __No  How much? _______________
                    How long? ___________________________
“Street drugs”            __Yes __No  If yes, which ones? __________

Dental History

Do you have silver mercury fillings? __Yes __No  If yes, how many? _________
Do you have root canals?        __Yes __No  If yes, how many? ___________
Have you been tested for having metal toxicity?

Food Issues / Sensitivities

Do you have any food allergies?  __Yes __No
if yes, please list ________________________________________________
Do any foods give you significant gas, pain, or bloating?  __Yes __No
If yes, please list ________________________________________________
Please describe your diet (e.g., fresh organic vegetables and fruit, restaurants 3 times per week):
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Stomach Disorders or General Digestion Problems

Acid Indigestion        __No    __Yes, in the past    __Yes, currently
Acid Reflux            __No    __Yes, in the past    __Yes, currently
Bloating/Flatulence     __No    __Yes, in the past    __Yes, currently
Colitis                __No    __Yes, in the past    __Yes, currently
Constipation            __No    __Yes, in the past    __Yes, currently
Diarrhea            __No    __Yes, in the past    __Yes, currently
Diverticulitis            __No    __Yes, in the past    __Yes, currently
Hiatal Hernia        __No    __Yes, in the past    __Yes, currently
Irritable Bowel Syndrome    __No    __Yes, in the past    __Yes, currently
Ulcers            __No    __Yes, in the past    __Yes, currently

Current Medications

Please list, including    Dosage        When you started taking it
1. ________________________________    _____________________
2. ________________________________    _____________________
3. ________________________________    _____________________
4. ________________________________    _____________________
5. ________________________________    _____________________
6. ________________________________    _____________________
7. ________________________________    _____________________
8. ________________________________    _____________________
9. ________________________________    _____________________
10. ________________________________    _____________________

Note:  Please do not discontinue any medications until advised by your Gerson practitioner or private medical doctor.

Please list any supplements, vitamins, or herbs you are taking, including    :
                Dosage        When you started taking it
1. ________________________________    _____________________
2. ________________________________    _____________________
3. ________________________________    _____________________
4. ________________________________    _____________________
5. ________________________________    _____________________
6. ________________________________    _____________________
7. ________________________________    _____________________
8. ________________________________    _____________________
9. ________________________________    _____________________
10. ________________________________    _____________________

Have you contracted any of the following disease/infections?
Sexually Transmitted Diseases
Syphilis            __Yes __No
Gonorrhea            __Yes __No
Genital Herpes        __Yes __No
Genital Warts        __Yes __No
Chlamydia trachomatis    __Yes __No

Miscellaneous:
Candida albicans        __Yes __No
Trichomonas vaginalis    __Yes __No
Other, please list:  _________________________________________
_____________________________________________________________

Bacterial/viral infections:
Herpes simplex        __Yes __No
Tuberculosis        __Yes __No
Malaria            __Yes __No
Meningitis    
Viral            __Yes __No
Bacterial        __Yes __No
Encephalitis            __Yes __No
Streptococcal        __Yes __No
Staphylococcal        __Yes __No
Septicemia            __Yes __No
Brucellosis            __Yes __No
Candidiasis            __Yes __No
Listeria            __Yes __No
Salmonella            __Yes __No
Camphylobacter        __Yes __No
Heliobacter            __Yes __No
Dysentry            __Yes __No
Hepatitis            
A            __Yes __No  If yes, when infected? __________
B            __Yes __No  If yes, when infected? __________
C            __Yes __No  If yes, when infected? __________
Epstein Barr            __Yes __No
Cytomegalovirus        __Yes __No

Other pertinent history or information: __________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Females Only:

Age at onset of menstruation? _________
How many pregnancies?  ________ Miscarriages _________ Abortions _______
Number of children?  ____________ Alive ________ Deceased ________
How many Cesarean sections?  _________
Age at onset of menopause?  ___________
Have you taken oral contraceptive pills?  __Yes __No  If yes, for how long? _______
Have you taken Hormone Replacement Therapy (HRT)?  __Yes __No
If yes, for how long? _______________________________________________
Have you experienced any other following (please check)?
absence of periods    __            cervical dysplasia __    
endometriosis __                hemorrhage __
infection in reproductive organs __    infertility __
yeast infections __                 ovarian cysts __
premature birth __                still birth __
diabetes during pregnancy __        pelvic inflammatory disease __
tubal pregnancy __                toxemia __
irregular cycle __                placenta previa __
uterine fibroids __

Family History

Mother: __Alive __Deceased        Father: __Alive __Deceased
Sisters:  Number Alive ___     Number Deceased ___
Brothers:  Number Alive ___    Number Deceased ___

Please insert the names of the family members wherever it applies below.  Include mother, father, brothers, sisters, aunts, uncles, grandparents and your children.

High Blood Pressure     __Yes  __No  ____________________________
Heart Disease         __Yes  __No  ____________________________
Stroke-Thrombosis         __Yes  __No  ____________________________
Diabetes             __Yes  __No ____________________________
Arthritis             __Yes  __No  ____________________________
Liver/Gall Bladder Disease__Yes  __No  ____________________________
Lung Disease         __Yes  __No  ____________________________
Asthma         __Yes  __No  ____________________________
Emphysema         __Yes  __No  ____________________________
Kidney Disease         __Yes  __No  ___________________________
Seizure Disorder         __Yes  __No  ____________________________
Auto-immune disease     __Yes  __No  ____________________________
Rheumatoid Arthritis__Yes  __No  ____________________________
SLE (Lupus)        __Yes  __No  ____________________________
Celiac            __Yes  __No  ____________________________
Chrons        __Yes  __No  ____________________________
Hyper-thyroidism    __Yes  __No  ____________________________
Hypo-thyroidism    __Yes  __No  ____________________________
Multiple Sclerosis        __Yes  __No  ____________________________
Mental Disease/Depression__Yes  __No  ___________________________
Cancer        Type___________________Relative_______________
    Type___________________Relative_______________
    Type___________________Relative_______________
    Type___________________Relative_______________
Other: 
______________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Social History

Do you have family/friends for a support system?  __Yes __No

Have you recently experienced any losses (i.e., family / friend / job / pet / divorce / financial / mobility / independence)?  __Yes __No
If yes, please explain:  _____________________________________________
_______________________________________________________________
Do you have a spiritual or religious practice, belief system or faith community?  __Yes __No ___________________________________________________________


Optional Exercise

As an optional self-help exercise, please take a few moments to draw a picture of:

1.  How you see yourself in association with your family (stick figures are fine).
2.  If you have cancer, please draw a picture of how you see or feel the cancer in your body.
        







Note: You can alternatively download a wordfile with the same content - like this: right-click here, and choose "save (link) target as", to download a word-file (applicationform.rtf) that you can type your answers in and then attach in an email to us. (Or copy the text from and paste in an email.)




Mind Your Body
Hawaii Gerson Therapy Program
A center for health, longevity and happiness.
Tel 808 982 8202
Fax 808 443 0313
Email: click here
www.gersonhawaii.us


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