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(Note: if you arrived here via a search engine -- all symptoms listed below respond positively to a strict regime of detoxification and nutrition. Click here.) 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.) |
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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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