Counseling by
David Klein, Ph.D., Hygienic Doctor
Director, Colitis & Crohn's Health Recovery Center

Over 2,000 clients healed and healthy

COPY & PASTE INTO YOUR WORD PROCESSING DOCUMENT
E-MAIL COMPLETED FORMS TO: dave(AT)colitis-crohns.com

Colitis & Crohn's Health Recovery Center
Health Questionnaire & Agreement

Colitis & Crohn’s Health Recovery Center
David Klein, Ph.D., H.D., Director
P.O. Box 256
Sebastopol, CA 95473 USA
www.colitis-crohns.com • www.colitiscurebook.com
Phone: 707- 829-0462 • Fax: 240-414-5341
Skype: davadurian • My schedule on Twitter: DavidKleinPhD

Dear Client,

Below is the Health Questionnaire and Statements of Understanding and Agreement, plus the Health Diary. Please fill them out completely, sign or type your name, then return it to me for my review and evaluation by e-mail, fax or postal mail. Prior to the first consultation, clients must have read Self Healing Colitis & Crohn's. Clients are required to study and apply the healing plan detailed in the book on an ongoing basis. All consultations must be conducted in person, by phone of Skype. You can order the book online at http://www.colitis-crohns.com.

Please note that I am a Hygienic Doctor, offering health education and guidance for Clients and their families. I do not give medical advice or pharmaceutical use advice, or provide treatments. I can only work with Clients who are fully committed to implementing the Natural Hygiene self-healing plan I teach. Your comfort, confidence, efficient healing and lasting health and happiness are my goals. I thank you for working with me and look forward to assisting you on your way to new wellness and happiness!

Healthfully yours,
David Klein, Ph.D., H.D.
Director, Colitis & Crohn’s Health Recovery Center

SERVICES
* Review of Health Questionnaire, Health Diaries and other reports.
* Diet, self-healing and healthful lifestyle education/counseling/coaching by phone and/or in-person.
* Ongoing e-mail and phone guidance and support. E-mail guidance is limited to brief questions and answers and Dr. Klein’s time is billable. Clients must submit their most recent Health Diary containing the questions. Consultations and discussions cannot be conducted by e-mail.

REGULAR CONSULTATION FEE
* $150 for initial consultation.This includes review of Client’s Health Questionnaire, Health Diaries and other reports, and covers up to 50 minutes of assistance, which may be divided into more than one session. Unused time is nonrefundable.
* Additional consultation services beyond the first 50 minutes is billed at $2.50 per minute.
* Payment is due before or on the date of consultations. Checks payable to Dr. David David Klein in U.S. funds, and Visa, Mastercard, Discover, American Express and PayPal are accepted. PayPal I.D: dave@colitis-crohns.com

OFF-HOUR CONSULTATION FEE
*Dr. Klein normally does not work during evenings, on Fridays or on weekends, and cannot guarantee his availability at those times. If Client urgently needs help during those times, and if Dr. Klein is available, the billing rate for each session is $4.00 per minute.

CONSULTING PACKAGE FEE
3 HOURS OF COUNSELING OVER A CONTRACTUAL PERIOD NOT TO EXCEED 3 MONTHS:
PREPAID LUMP SUM = USD $350

SERVICES:
* All basic services listed above.
* Up to 3 hours of assistance.
* After 3 months the full $350 fee is nonrefundable
* Prior to 3 months $175 is nonrefundable. Refund portions are prorated based on the accrued time billed at $2.50 per minute
* Full payment is due before or on the date of the first consultation. Checks payable to Dr. David David Klein in U.S. funds, and Visa, Mastercard, Discover, American Express and PayPal are accepted. PayPal I.D: dave@colitis-crohns.com

RESIDENTIAL CARE (OPTIONAL)
Residential care for Dr. Klein’s clients is available at TrueNorth Health Education and Fasting Center, located at 1551 Pacific Avenue, Santa Rosa, California, approximately 1.5 hours north of San Francisco. TrueNorth is 14 miles northeast of Dr. Klein’s Sebastopol Office. Under the direction of Dr. Alan Goldhamer, TrueNorth offers medically-supervised rest and (optionally) water fasting (if desired and recommended), health diagnostics, organic, vegan cuisine tailored for individual’s needs per Dr. Klein’s recommendations, plus Natural Hygiene education lectures.

Clients who are not fasting can visit Dr. Klein’s office for counseling and support. For services, rates and application form see TrueNorth’s website: http://www.healthpromoting.com. Phone: (707) 586-5555.

uMMA VITAMIN B12 TEST (HIGHLY RECOMMENDED)
* The urinary methylmalonic acid (uMMA) test indicates your cellular vitamin B12 level. This is the only known effective test for vitamin B12.
* Procedure: Request a test kit from Dr. Klein. Fill the tiny vial with urine. Send to the testing lab in the pre-addressed envelope.
* Fee for U.S. address: $139.

GENERAL BLOOD TESTS (HIGHLY RECOMMENDED)
I recommend basic blood tests indicating:
* General hematology
* Electrolytes
* Minerals including calcium and iron
* Liver enzymes

It is also very helpful, especially in cases of chronic fatigue and illness, to obtain the more specialized and expensive trace mineral and toxic metals tests for elements including chromium and mercury.

Contact your physician to arrange these tests.

PROTOCOL FOR CONSULTATIONS BY PHONE OR SKYPE
* Client must book the appointments at agreeable times and makes the calls. Please be proactive and diligent to reach me as soon as your need. I am always eager to serve.
* Consultations are held Monday - Thursday from 10:00 AM - 3:00 PM Pacific Time. I am not normally available Friday through Sunday. For Dr. Klein’s availability, follow his current schedule at Twitter: DavidKleinPhD
* Please confirm appointments and call on time.
* If you must cancel an appointment, please phone and e-mail Dr. Klein immediately, giving at least three hours minimum notice.
* Please always call Dr. Klein on time at 707-829-0462, or via Skype at: davadurian
* Dr. Klein is not able to return non-U.S. calls except to Canada & Mexico. Please email dave@colitis-crohns.com to book phone or Skype consultations.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

HEALTH QUESTIONNAIRE & STATEMENTS OF UNDERSTANDING & AGREEMENT

Notes:

PLEASE FILL OUT THIS FORM IN ITS ENTIRETY

Name:

Today’s date:

Consultation is scheduled for: (Client must set this up, confirm and call on time):
__ Monday
__ Tuesday
__ Wednesday
__ Thursday

Time:
__ 10 am Pacific Time
__ 11 am Pacific Time
__ 12 noon Pacific Time
__ 1 pm Pacific Time
__ 2 pm Pacific Time

E-mail address:

Postal mail address:

Phone number:

Where or how did you find Colitis & Crohn’s Health Recovery Services?

How will you be paying for the consultation? I accept Visa, Mastercard, Discover, Amex and PayPal.

Credit card holder’s name as it appears on the card:
Address for which the card is registered:Card number:
Security code:
Expiration date:

Age:
Birth date:
Height in feet and inches:
Weight in pounds:
Describe any recent weight loss or gain:

Please e-mail me a photo of yourself—that will help me know you better.

Occupation:

Are you now working?

How many hours per day?

Do you have plans to decrease or increase your work hours?

Are you on disability or considering it?

Are you able to stop working and take a complete rest for a several weeks?

Are you or your family dependent on your income?

Are you under any financial stress?

Medical diagnosis and health condition:

How long have you been sick with a bowel problem?

Are you currently bleeding heavily?

How many bowel movements have you had in the last 24 hours?

Describe your bowel movement form, difficulties and frequency
(e.g., diarrhea/stools/straining/bleeding/mucus/pains):

Describe your digestion (gas/stomach distress/etc.) and when problems occur:

Are you now under medical care?

Please describe current medical care:

Have you recently taken or are you currently taking any of the following medications?
___ anti-inflammatories
dosages:

___ immunosuppressants
dosages:

___ antibiotics
dosages:

Please list all current medications and dosages, other drug use, therapies, alcohol and tobacco use:

Please summarize past health problems:

Please describe past medications, alcohol, tobacco and recreational drug use:

___ anti-inflammatories
dosages:

___ immunosuppressants
dosages:

___ antibiotics
dosages:

___ others:

Have you thoroughly read and studied Self Healing Colitis & Crohn's?

When did you begin implementing its dietary recommendations?

Are you under any family stress?

Will your family and advising medical doctor support you in making diet and lifestyle changes per Self Healing Colitis & Crohn's?

Do you have inflammation now?

Do you have a fever now, or have you had a fever recently?

Please describe your energy levels during the day and evening:

How many hours of sleep do you get?

Do you take rests and naps during the day?

Please list questions you have about the information and plan in Self Healing Colitis& Crohn’s:

Please describe your eating habits, how much you eat, frequency, and any recent changes in you diet:

What approximate percentages of your entire diet did these foods make up 1 month ago /   1 week ago /   now:

Meat:     /   /  

Dairy:     /   /  

Cereals/pastas/bread/grains/pastries:     /   /  

Fresh/raw fruit::     /   /  

Cooked vegetables & potatoes:     /   /  

Fresh/raw vegetables:     /   /  

Raw nuts and seeds:     /   /  

Beans/legumes:     /   /  

Snacks (e.g., crackers, cookies, chocolate, ice-cream, candies, etc.):     /   /  

Carbonated soft drinks:     /   /  

Coffee:     /   /  

Teas::     /   /  

What is the approximate percentage of your diet that is raw/uncooked food?

Do you use table salt?

Do you use spices or seasonings?

Do you use bottled salad dressings or mayonnaise?

Please list any supplements/vitamins/remedies you take:

If you eat meat, do you believe you can or cannot give it up?

Do you have any food allergies?

What kind of water do you drink, and how much?

Do you ever drink chlorinated city water (not recommended)?

Is your household water chlorinated, and if yes, do you have a shower filter?

Do you have a juicer (what kind)?

Do you have a steamer?

Do you cook with any aluminum pots and pans (not recommended)?

Do you monitor your blood pressure and saliva pH?

If you are a female are you pregnant?

How is your appetite?

Do you wake up hungry?

Are you able to exercise? Describe:

What are your favorite leisure time activities/hobbies?

Do you have a spiritual and/or self-improvement practice? Describe:

Are there any parts of your body and life that you do not like? Describe:

What brings the most joy into your life?
1.
2.
3.

Please describe any fears, shame and worries you have and how much you believe

they are affecting your health and happiness:

Please describe any other kind of health support or therapies you are now having:

How fast do you want to go with your diet and healthful lifestyle transition?

What aspect(s) of the Vegan Diet self-healing plan are you unsure about?

What would you like to learn more about?

Would you like ongoing support ?

How can Dr. Klein best support you?

Some new clients who are healing would like to communicate with and receive some encouragement from my successful past clients who are in their age group or general locale. After you have healed, would you like to placed on my private list of client contacts?
___ Yes
___ Maybe
___ No

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

REQUIRED — PLEASE FILL OUT AND SIGN OR INITIAL

Colitis & Crohn's Health Recovery Center
Statements of Understanding and Agreement
I ______________________________ (Client) agree to consult Dr. David Klein (Consultant) for self-healing, health education and counseling services at the following fee: $ _____________.

Please check one:
REGULAR CONSULTATION FEE
* $150 for initial consultation. This includes review of Client’s Health Questionnaire, Health Diaries and other reports, and covers up to 50 minutes of assistance, which may be divided into more than one session. Unused time is nonrefundable.
* Additional consultation services beyond the first 50 minutes is billed at $2.50 per minute.
* Payment is due before or on the date of consultations. Checks payable to Dr. David Klein in U.S. funds, and Visa, Mastercard, Discover, American Express and PayPal are accepted. PayPal I.D: dave@colitis-crohns.com

CONSULTING PACKAGE FEE:
3 HOURS OF COUNSELING OVER A CONTRACTUAL PERIOD NOT TO EXCEED 3 MONTHS: LUMP SUM USD $350

SERVICES:
* All basic services listed above.
* Up to 3 hours of assistance.
* After 3 months the full $350 fee is nonrefundable
* Prior to 3 months $175 is nonrefundable. Refund portions are prorated based on the accrued time billed at $2.50 per minute.
* Payment is due before or on the date of consultations. Checks payable to Dr. David Klein in U.S. funds, and Visa, Mastercard, Discover, American Express and PayPal are accepted. PayPal I.D: dave@colitis-crohns.com

The Client understands that:
* The Consultant is not a medical doctor or a physician and he cannot determine and make decisions regarding any need the Client may have for medical attention—that is the Client’s full responsibility.
* The Consultant does not diagnose, treat or advise in medical matters, including medication use.
* The Consultant is a Hygienic Doctor with a degree in Natural Health and Healing from the University of Natural Health, concentrating in educating and guiding people with inflammatory bowel disease to recover their health via implementing healthful living practices.
* The Consultant is also a Nutrition Educator, educated, trained and legally certified by the state of California through Bauman College to counsel people in matters of nutrition and health.
* The Consultant welcomes working in concert with medical doctors and registered nurses of the Client’s choice.
* The Consultant’s ability to provide effective healing counseling services is dependent upon the completeness and depth of information provided by the Client and his/her medical doctor.
* The Consultant’s natural healing program is not a quick fix — during the initial stage, healing is often a slow and unsteady process that requires patience, understanding and diligence.
* The Consultant’s natural healing and healthful lifestyle programs are proven to be effective only as long as they are adhered to — there is no permanent “cure” if we continue toxic and enervating lifestyle habits. In other words: health is the result of healthful living, and there are no exceptions to this biological law of life.
* The Consultant requires that the Client promptly notify the Consultant of any great concern related to healing or illness symptoms, pains, or difficulties, if the Client deviates from the Consultant's guidance, if the Client is confused, and if the Client undergoes any kind of new or increased or decreased medical or non-medical treatment.
* The Consultant's goal is to help the Client self-heal his/her illness condition and become healthier in a manner which is safe and comfortable.
* The best healing results are realized via a complete rest of a duration which is dictated by the Client’s physiological needs.
* The Consultant can only work with the Client if his/her involved family and advising medical doctor support the approach advised by the Consultant.
* The Consultant can only work with Client if his/her goal is to make a safe, medicallyapproved transition off all drug therapies for inflammatory bowel disease as well as other non-recommended “healing remedies”
* There is some risk in this and any detoxification program. In all cases of inflammatory bowel disease, the body already is in a heightened detoxification mode due to an overload of disease-causing toxic matter in the body. In the process of completely eliminating this toxic matter under the Consultant’s natural detoxification plan, increased symptoms are temporarily experienced by some Clients. Detoxification causes every client to experience temporary weight loss, as toxic matter is eliminated. The Consultant strives to avoid detoxification problems. If detoxification symptoms including weight loss do begin to become extreme, the Consultant will recommend modifications to the Client’s diet and self-healing program aiming to slow down the detoxification process to a safe and more comfortable pace. If at any time during the self-healing program when detoxification and other health condition concerns cannot be quickly resolved, it is the Client’s responsibility to obtain medical help as needed and to inform Dr. Klein of the situation.
* The Consultant requires that Client take full responsibility for his/her decisions and actions and communicate with the Consultant in a courteous, respectful manner. The Consultant is not able to work with a Client who is angry, blaming, threatening and disrespectful.
* The Consultant puts his heart into his work and does his best to compassionately help the Client.
* The Consultant requires open and honest communication and always strives to give satisfying service.
* Dr. Klein normally does not work during evenings, on Fridays or on weekends, and cannot guarantee his availability at those times. If Client urgently needs help during those times, and if Dr. Klein is available, the billing rate for each session is $4.00 per minute.
* If the Client is dissatisfied with the Consultant's services and would like a refund, the Consultant requires that the Client kindly notify the Consultant of this in a timely manner for a full and final release.

The Client agrees to:
* Make a full commitment to implement the healing and health-building guidelines detailed in Self Healing Colitis & Crohn's and those recommended by Consultant, and to make this natural health approach his/her lifestyle with the goal of realizing a life of disease-free wellness.
* Study Self Healing Colitis & Crohn's on a daily basis until the information is fully understood and implemented on a daily routine basis.
* Set up all consultations, confirm each one and make the phone or Skype calls.
* Pay the Consultant for all of his questionnaire review and evaluation work, education and counseling work prior to or on the day of all rendered services.
* Work no more than four hours per day, and do so only if necessary and physically possible and if the work is low-stress, and take a sabbatical with complete rest as soon as possible.
* Furnish copies of blood chemistry tests made within the last six months. If blood tests have not been conducted within the previous four weeks, have a new full panel of tests made, and submit a copy of the report to the Consultant.
* Furnish a recent photo of him/herself.
* On a daily basis fill out the Health Diary (scroll down for a copy) and provide updated diaries to the Consultant prior to each consultation.
* Take full responsibility for his/her decisions and actions.
* Take full responsibility and the initiative for determining if he/she needs medical attention, as the Consultant cannot make that determination since he is not a physician. The name(s) and phone number(s) of the Client’s advising medical doctor(s) who the Client will contact if medical attention is needed is/are:

______________________________________________________

______________________________________________________

* Continue his/her health education during and after the healing phase. Additional recommended health education materials are available via the Consultant from http://www.colitis-crohns.com.

Client: please sign or type your name indicating your understanding and agreement:

Name: _________________________________
Guardia:________________________________
Date: __________________________________

Confidentiality / Disclosure:

Dr. Klein is authorized to share the enclosed information and any other verbally-communicated or written information regarding the Client’s case with only these individuals:

Name: ___________________________ Relationship: ______________________
Name: ___________________________ Relationship: ______________________
Name: ___________________________ Relationship: ______________________
Name: ___________________________ Relationship: ______________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

HEALTH DIARY
Colitis & Crohn's Health Recovery Center
Copy, paste and send to: dave@colitis-crohns.com
or Fax to: 240-414-5341

1. KEEP A MASTER COPY FOR EVERY DAY USE
2. DR. KLEIN REQUIRES YOUR PREVIOUS DAY’S DIARY BEFORE HE CAN HELP YOU
3. IT iS THE CLIENT’S RESPONSIBILITY TO SET UP CONSULTATIONS AND PHONE DR. KLEIN.
4. CONSULTATIONS ARE HELD MONDAY – THURSDAY
5. CHECK TWITTER FOR DR. KLEIN’S AVAILABILITY AT
   http://twitter.com/DavidKleinPhD

Name:

1. Date:

2. Weight in pounds:

3. How I felt today:

4. Energy leve:l

5. Symptoms:

6. Main concerns/struggles:

7. Questions I have:

8. Healing signs:

9a. No. of bowel movements:

9b. Diarrhea?

9c. Blood?

9d. Mucus?

10a. No. of hours of sleep:

10b. No. of hours of rest:

10c. No. of hours of work/chores:

10d. No. of hours of exercise:

10e. Type of exercise:

11. Total water intake in quarts or 8 oz. glasses:

12. Morning foods/drinks and quantity:

13. Midday foods/drinks and quantity:

14. Afternoon foods/drinks and quantity:

15. Evening foods/drinks and quantity:

16. Supplements:

17. Medications and dosage:

18. Therapies:

19. Medical advice received today:

20a. Time spent reading Self Healing Colitis & Crohn's today:
20b. Time spent studying the Vegan Healing Diet sections today:

21. Other Natural Hygiene literature read today:

22. Tests and health medical exams I am planning:

23. Healing and lifestyle plans I am making:

24 My affirmation of the day:

25a. Need a consultation with Dr. Klein?

25b. When?

25. How can Dr. Klein best support you?

26. Other info: