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1 Name Age Date Street Address City State Zip Code Cell phone Other phone Sex Blood type Height Weight Date of Birth Marital Status No. of Children address: Occupation Who may we thank for referring you? Opt: Faith/Religion Circle reason(s) for office visit: Allergy Assessment Bio Energetic Assessment Colon Hydrotherapy Dental Assessment Ionic Foot Cleanse Infrared Sauna Nutritional Assessment Weight Loss Purification/Detox Program Light Therapy Encouragement List current health problems for which you are being treated: Current medications, prescriptions or over-the-counter drugs: Drug Name Reason for taking Drug Name Reason for taking Major hospitalizations, surgeries, injuries: Please list all procedures, complications (if any) and dates: Year Surgery, illness or injury Outcome Circle the level of stress you are experiencing on a scale of 1-10 (1 being the lowest) Identify the major causes of stress (e.g. changes in job, work, residence or finances, legal problems) Do you consider yourself Underweight Overweight Just right My goal weight is Is your job associated with potentially harmful chemicals (e.g. pesticides, radioactivity, solvents) or health and/or life threatening activities (e.g. fireman, etc.)? What are your current health goals:
2 Name: Date: Rate each of the following areas based on your symptoms in past month on a scale of 0-4: 0: Never or almost never --- 4: Frequently and severely Head Headaches Faintness Dizziness Nose Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus Lungs Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Energy/Activity Fatigue, sluggish Apathy, lethargy Hyperactivity Restlessness Insomnia Emotions Mood swings Anxiety, fear Anger, irritability, aggressiveness Depression Tearful Eyes Watery or itchy eyes Swollen, reddened or sticky eyelid Bags or dark circles under eyes Blurred vision Reason for visit today: Mouth/Throat Chronic coughing Gagging, frequent need to clear throat Sore throat, loss of voice, hoarseness Canker sores Heart Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain Joint/Muscle Pain in joints Arthritis Stiffness Aches in muscles Bone loss Weakness or tiredness Mind Poor memory Confusion, poor concentration Poor physical coordination Difficulty with making decisions/foggy thinking Stuttering or stammering Slurred speech Learning disabilities Ears Itchy ears Earaches, ear infections Drainage from ear Ringing in ears Loss of hearing Skin Acne Hives or rashes Dry skin Hair loss Flushing or hot flashes Excessive sweating Easy bruising Increased facial/body hair Digestive Tract Nausea, vomiting Diarrhea Constipation Bloating, belching Passing gas Heartburn Intestinal/stomach pain Poor appetite Bloody stools Liver or gallbladder trouble Genito-Urinary Frequent urination Painful urination Blood in urine Inability to control urine Kidney stones Prostate trouble Weight Craving certain foods Compulsive eating Cold body temperature Water retention Recent weight gain Recent weight loss Other Numbness in Swelling of ankles Frequent illness Sensitive to chemicals GRAND TOTAL: Curing disease or any other illnesses is between you and your health care/medical professional. The Nutrition and Wellness Center does not treat any
3 Check all that apply: Medical (Men) Enlarged prostate Prostate cancer Decreased sex drive Infertility Sexually transmitted disease Medical (Women) Menstrual irregularities Breast tenderness Endometriosis Infertility Fibrocystic breasts Ovarian fibroids or cysts Uterine Fibroids Premenstrual Syndrome (PMS) Breast cancer Vaginal infections Vaginal dryness Decreased sex drive Sexually transmitted disease Menopause # of pregnancies Age of first period Date of last menstrual cycle Typical menstrual cycle days Length of flow days Any recent changes in menstrual flow (i.e. heavier, lighter) Exercise 1-2 days per week 3-4 days per week 5-7 days per week Less than 30 minutes 30 minutes 60 minutes Walk Run, jog, other aerobic Weights/strength training Stretching Yoga Additional Therapies Acupuncture Chiropractic Colonics Massage Health Habits Cigarettes/day Cigars/day Wine glasses/day Liquor ounces/day Beer glasses/day Coffee cups/day Tea cups/day Soda/day Diet soda/day Water glasses/day Eating Habits Eat one meal/day Eat two meals/day Eat three meals/day Graze (small, frequent meals) Generally, eat on the run Eat constantly whether hungry or not Skip meals which ones Juice how often Nutrition and Diet Balanced diet (animal and vegetable sources) Vegetarian Vegan Salt restriction High protein/low carb. Dairy free Wheat free Egg free Soy free Gluten free Corn free Other Current Supplements Amino acids Antioxidants (turmeric,etc) Calcium CoQ10 Digestive enzymes EPA/DHA Herbs Homeopathics Magnesium Multivitamin/mineral Probiotics Vitamin C Vitamin D3 Vitamin E Zinc Others Making Lifestyle Changes I am comfortable and willing to make diet and lifestyle changes immediately I am not as comfortable making diet and lifestyle changes and prefer to make small changes initially I have taken supplements before and am comfortable taking a variety of items daily I have not taken supplements before but am open to starting I am willing and able to invest what is needed per month to achieve optimal health I am not ready for supplements I Would Like To(check off): (Energy & Vitality) Have more energy Have more endurance Be less tired Sleep better Be free of pain Get fewer colds and flu Get rid of allergies Not be dependent on medications Stop using laxatives and stool softeners Improve sex drive (Stress) Learn how to reduce stress Think more clearly and be more focused Improve memory Be less depressed Be less moody Be less indecisive Feel more motivated (Life Enrichment) Reduce my risk of degenerative disease Age gracefully Maintain health Change from treating disease to creating a healthy lifestyle _ Curing disease or any other illnesses is between you and your health care/medical professional. The Nutrition and Wellness Center does not treat any
4 TWO DAY ACTIVITY SHEET Please thoroughly complete the diet and activity chart below. Provide as much detail as possible, including quantity/serving sizes and whether food is cooked or raw. Morning Meal Day 1 Day 2 Snack Mid-Day Meal Snack Evening Meal Snack Water (cups) Fats & Oils used Condiments Type of exercise Duration of exercise Sleep (Hours) Time to bed Time for Relaxation
5 INFORMED CONSENT FORM The Nutrition and Wellness Center does not do any of the following things, either implied or intended: 1. We do not diagnose. 2. We make no attempt to cure any condition. 3. We make no claims or imply any claims that suggestions and/or opinions are given to cure any condition. 4. We do not claim that any supplemental material we may speak about will cure any condition, or that its' purpose is to treat any condition. 5. We do not prescribe or treat disease; however, we do attempt to educate you in/on dietary recommendations and exercise if it is not contradictory to the recommendations of your primary physician. I, the undersigned client, understand the above statements. All decisions relative to my well-being and health must be made by me. I further understand that The Nutrition and Wellness Center staff are not medical doctors and are not attempting to portray them self or conduct the activities of medical doctors. Whether I participate in the programs and therapies provided at The Nutrition and Wellness Center is my decision based on my God given inalienable rights and my constitutionally guaranteed rights secured by the Bill of Rights. It is my creator-endowed inalienable right to ask for assistance of my own choosing and I accept full responsibility. (For adults using the RJL Bio-Impedance device for body composition and the BioEnergetic Assessment/Bio Meridian: I am not pregnant. I do not have an implanted electrical device. I understand that I will be using a galvanic skin response measurement device to collect bioelectrical impedance measurements. I understand these devices are not intended to diagnose and are not to be a replacement for seeking medical attention.) Cancellation Policy: We have a 48 hour cancellation and/or rescheduling policy. Cancellations less than 48 hours in advance of the appointment time, will have a 50% fee of appointment cost applied to account. Please call (757) or info@tnawc.com to cancel or reschedule. PRINTED NAME: Signature: Date:
6 Welcome to The Nutrition and Wellness Center. We appreciate the confidence and trust you have placed in our clinical and nutritional expertise. Our utmost commitment is to see that you achieve your health goals in the most efficient manner possible. We are a team that is committed to excellence in serving and supporting you in the process of achieving optimal health. Complete the client forms attached and bring to your appointment. We require that you complete the forms prior to your appointment so that the entire duration of your appointment can be dedicated to health evaluation and consultation. If forms are not completed prior, please arrive 15 min early. Your Initial Consultation may include (any or all of) the following depending on scheduled appointment time: Evaluation of your health o Check weight o Functional testing *Bio-Impedance Analysis A fluid analysis to identify measurements of resistance and reactance to determine cellular health, energy storage capacity due to intact cellular membrane integrity, resting metabolic rate of calories burned in 24 hours, body fat percentage and pounds, lean mass percentage and pounds, and intracellular and extracellular distribution of your total body water. One of the earliest signs of failing health is a shift of fluid from intracellular to extracellular, indicating possible toxicity. Ragland's Test An analysis of your blood pressure when standing and lying down to determine the level of adrenal health and function, which is associated with your ability to handle stress. Applied Kinesiology Assessment This is a kinesiology technique designed to access the energetic anatomy of the body via specific anatomical points (acupuncture points/meridians) using a muscle response. This assessment uses sensory input and motor output giving subjective data. Eye and Tongue Analysis An analysis looking at the physical markers of the eyes & tongue. BioEnergetic Assessment This BioMeridian scan accesses acupuncture meridians of the body and thereby gives a general picture of the energy flow through organs and structures located along those meridians. The assessment provides a means of measuring the energetic profiles of organs, glands, immune system, the musculoskeletal system and allergies. It is not diagnostic and gives objective data. Blood Work Review Not required but if available for initial, it may be reviewed and discussed. Individual consultation o Review Health History and address problem areas. o Discuss assessment results. o Establish health goals and commitment to reach them. Development of individualized plan for optimal health o Individualized Supplement Plan - A nutrition supplement plan may be developed to assist you with your bio-individual chemistry health needs identified during the evaluation of your functional test results and health history. Your supplement plan may include medical foods, vitamins, minerals, herbs, enzymes, amino acids, fatty acids, glandular therapy, homeopathy, essential oils and Bach Flower remedies. o Personalized Menu Plan - A menu plan will be developed based on your basal metabolic rate, blood type, health history, functional test results and/or activity level. o Follow up appointments A follow up appointment and additional functional testing will be scheduled and determined based on your individual health needs and goals. ONLY FOR APPOINTMENTS THAT INCLUDE the*bio-impedance Analysis Do not consume alcohol 24 hours prior to your appointment. Do not exercise 12 hours prior to your appointment. Do not eat for 3 hours before your appointment. Drink at least 2-3 glasses of water before your appointment. If possible, do not drink caffeine the day of your appointment. Cancellation Policy: 48 hour cancellation and/or rescheduling policy. Cancellations less than 48 hours in advance of the appointment time, will have a 50% fee of appointment cost applied to account. Please call (757) or info@tnawc.com to cancel or reschedule.
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