Welcome to Powell Chiropractic Clinic s Health and Wellness program

Transcription

1 Welcome to Powell Chiropractic Clinic s Health and Wellness program We are honored that you have chosen us to help you in the overall Improvement of your health! Dr. Robert Powell is a Board Certified Naturopath and the Director of the Health and Wellness Department. The purpose of consultationevaluation appointment is to determine your primary nutritional needs and your personal goals. Additional testing may be recommended to help determine any underlying dysfunction you may be experiencing. It is important that you are punctual for your appointments, and that any and all paperwork is completed before your scheduled appointment time to prevent unnecessary waiting for you and others. Typically, you will be here for one hour on the initial visit which includes a pre-screening appointment and consultation. As a courtesy to other scheduled patients, we make every effort not to exceed the scheduled time. Interim office visits are an average of minutes. In the event additional time is needed you will be scheduled for another visit. If you need to cancel an appointment please do so within 24- hours. If you have any questions or concerns, please ask for our Health and Wellness Department specifically, and you will have an answer with in a timely manner. You can fill out the Toxicity Questionnaire and the Systems Survey either online or download it and bring it with you to your first appointment. This will give us an idea of your needs and how we may be able to help. Again, welcome and thank you for having confidence in us, we will do our very best to see that your health care goals are met. The Doctors and Staff of Powell Chiropractic Clinic, Inc.

2 Powell Chiropractic Clinic, Inc. Dr. James P. Powell Dr. James D. Powell Dr. Robert Powell Dr. Walter B. Null IV Dr. Abbey M. Crouse REGISTRATION Date: / / / Home Phone:( ) Work:( ) Cell:( ) Patient: Last Name First Name M.I. Maiden Name Street Address: City: State: Zip: Sex M F Age: Date of Birth: / / Single Married Divorced Widowed Chief complaints and/or health goals: Current Care Under: M.D./D.O. D.C. Who were you referred by? Powell Chiropractic Clinic, Inc. Phone: (330) Munson Street, NW Fax: (330) Canton, OH

3 PRACTICE S REQUIREMENTS The Practice: (a) Is required by federal law to maintain the privacy of your Personal Health Information and to provide you with this Privacy Notice detailing the Practice s legal duties and privacy practices with respect to your Personal Health Information. (b) Powell Chiropractic Clinic, Inc. adheres to Ohio law in those instances where Ohio law does not conflict with federal law. (c) Is required to abide by the terms of this Privacy Notice. (d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your Personal Health Information that it maintains. (e) Will distribute any revised Privacy Notice to you prior to implementation. (f) Will not retaliate against you for filing a complaint. EFFECTIVE DATE This Notice is in effect as of 04/15/03. If you would like to review our HIPPA agreement, please advise our staff and we will supply you with detailed information. PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge that I have read this Notice, and that I understand and agree to its terms. Patient Name Patient Signature Date Powell Chiropractic Clinic, Inc. Phone: (330) Munson Street, NW Fax: (330) Canton, OH

4 Explanation of Financial Policy and Care Natural Healthcare that includes whole food supplementation, exercise and other remedies are not generally covered by third party payers (insurance companies). In certain cases, there may be the opportunity for reimbursement according to special circumstances. Our financial policy is that fees are paid at the time of service and when products are provided they can be paid for by cash, check, or credit card. However, if applicable, we will provide you with the proper documentation for your reimbursement needs. Our primary supplement brand is Standard Process. They are devoted to improving the quality of life by providing the safest, most effective, highest quality dietary supplements only through health care professionals. While seeking the nutritional guidance from our Health and Wellness Department, it is suggested that the recommended supplements are purchased from our facility to ensure efficacy of the product. In addition, this office makes every effort to provide the highest quality of products and state of the art methods of assessing patient needs for nutritional support and lifestyle instruction. We make no claims to treat, cure or diagnose disease, but rely solely on the body s ability to heal itself through natural methods. Our staff will provide you with a receipt with every transaction. We will only accept returns that are unopened, unexpired and accompanied by a receipt. Any credits will be applied to your account for further purchases. *I have read and understand the policy of Powell Chiropractic Clinic, Inc. Health and Wellness Department and agree to its method of support and financial policy. Patient Signature Date Witness Signature Date Powell Chiropractic Clinic, Inc. Phone: (330) Munson Street, NW Fax: (330) Canton, OH

5 Name: Toxicity Questionnaire Date: The Toxicity Questionnaire is designed to aid the practitioner in assessing a patient s or client s potential need for a purification program. Section I: Symptoms Rate each of the following based upon your health profile for the past 90 days. Circle the corresponding number. 0 Rarely or Never Experience the Symptom 1 Occasionally Experience the Symptom, Effect is Not Severe 2 Occasionally Experience the Symptom, Effect is Severe 3 Frequently Experience the Symptom, Effect is Not Severe 4 Frequently Experience the Symptom, Effect is Severe 1. DIGESTIVE a. Nausea and/or vomiting b. Diarrhea c. Constipation d. Bloated feeling e. Belching and/or passing gas f. Heartburn EARS a. Itchy ears b. Earaches or ear infections c. Drainage from ear d. Ringing in ears or hearing loss 3. EMOTIONS a. Mood swings b. Anxiety, fear, or nervousness c. Anger, irritability d. Depression e. Sense of despair f. Uncaring or disinterested ENERGY / ACTIVITY a. Fatigue or sluggishness b. Hyperactivity c. Restlessness d. Insomnia e. Startled awake at night EYES a. Watery or itchy eyes b. Swollen, reddened, or sticky eyelids c. Dark circles under eyes d. Blurred or tunnel vision HEAD a. Headaches b. Faintness c. Dizziness d. Pressure LUNGS a. Chest congestion b. Asthma or bronchitis c. Shortness of breath d. Difficulty breathing MIND a. Poor memory b. Confusion c. Poor concentration d. Poor coordination e. Difficulty making decisions f. Stuttering, stammering g. Slurred speech h. Learning disabilities MOUTH/THROAT a. Chronic coughing b. Gagging or frequent need to clear throat c. Swollen or discolored tongue, gums, lips d. Canker sores NOSE a. Stuffy nose b. Sinus problems c. Hay fever d. Sneezing attacks e. Excessive mucous SKIN a. Acne b. Hives, rashes, or dry skin c. Hair loss d. Flushing e. Excessive sweating HEART a. Skipped heartbeats b. Rapid heartbeats c. Chest pain JOINTS / MUSCLES a. Pain or aches in joints b. Rheumatoid arthritis c. Osteoarthritis d. Stiffness or limited movement e. Pain or aches in muscles f. Recurrent back aches g. Feeling of weakness or tiredness 14. WEIGHT a. Binge eating or drinking b. Craving certain foods c. Excessive weight d. Compulsive eating e. Water retention f. Underweight OTHER: a. Frequent illness b. Frequent or urgent urination c. Leaky bladder d. Genital itch, discharge Section I

6 Section II: Risk of Exposure Rate each of the following situations based upon your environmental profile for the past 120 days. 16. Circle the corresponding number for questions 16a-16f below. 0 Never 1 Rarely 2 Monthly 3 Weekly 4 Daily a. How often are strong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.) b. How often are pesticides used in your home? c. How often do you have your home treated for insects? d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office? e. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics? f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes? Circle the corresponding number for questions 17a-17b below. 0 No 1 Mild Change 2 Moderate Change 3 Drastic Change a. Have you noticed any negative change in your health since you moved into your home or apartment? b. Have you noticed any change in your health since you started your new job? Answer yes or no and circle the corresponding number for questions 18a-18d below. No Yes a. Do you have a water purification system in your home? 2 0 b. Do you have any indoor pets? 0 2 c. Do you have an air purification system in your home? 2 0 d. Are you a dentist, painter, farm worker, or construction worker? 0 2 Section II Grand Total (Section I & Section II) Add up the numbers to arrive at a total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a purification program. Adapted with permission from the author of Clinical Purification : A Complete Treatment and Reference Manual, Dr. Gina L. Nick. 02/08 L7125

7 SYSTEMS SURVEY FORM (Restricted to Professional Use) PATIENT AGE DOCTOR DATE INSTRUCTIONS: Circle the number that applies to you. If a symptom does not apply, leave it blank. Circle either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occurs several times a month), or (3) for SEVERE symptoms (occurs almost constantly). GROUP ONE Acid foods upset Gag Easily Appetite reduced Get chilled, often Unable to relax, startles easily Cold sweats often Lump in throat Extremities cold, clammy Fever easily raised Dry mouth-eyes-nose Strong light irritates Neuralgia-like pains Pulse speeds after meal Urine amount reduced Staring, blinks little Keyed up - fail to calm Heart pounds after retiring Sour stomach frequent Cuts heal slowly Nervous stomach GROUP TWO Joint stiffness after arising Digestion rapid Slow starter Muscle-leg-toe cramps at night Vomiting frequent Get chilled infrequently Butterfly stomach, cramps Hoarseness frequent Perspire easily Eyes or nose watery Breathing irregular Circulation poor, Eyes blink often Pulse slow; feels irregular sensitive to cold Eyelids swollen, puffy Gagging reflex slow Subject to colds, Indigestion soon after meals Difficulty swallowing asthma, bronchitis Always seem hungry; Constipation, feels lightheaded often diarrhea alternating GROUP THREE Eat when nervous Heart palpitates if meals Crave candy or coffee Excessive appetite missed or delayed in afternoons Hungry between meals Afternoon headaches Moods of depression Irritable before meals Overeating sweets upsets blues or melancholy Get shaky if hungry Awaken after few hours sleep Abnormal craving for Fatigue, eating relieves - hard to get back to sleep sweets or snacks Lightheaded if meals delayed GROUP FOUR Hands and feet go to sleep Get drowsy often Bruise easily, black easily, numbness Swollen ankles and blue spots Sigh frequently, air worse at night Tendency to anemia hunger Muscle cramps, worse Nose bleeds frequent Aware of breathing during exercise; get Noises in head, or heavily charley horses ringing in ears High altitude discomfort Shortness of breath Tension under the Opens windows in on exertion breastbone, or feeling closed room Dull pain in chest or of tightness, Susceptible to colds radiating into left arm, worse on exertion and fevers worse on exertion Afternoon yawner

8 SYSTEMS SURVEY FORM - Page 2 GROUP FIVE Dizziness Feeling queasy; headache Sneezing attacks Dry skin over eyes Dreaming, nightmare type Burning feet Greasy foods upset bad dreams Blurred vision Stools light-colored Bad breath (halitosis) Itching skin and feet Skin peels on foot soles Milk products cause Excessive falling hair Pain between shoulder distress Frequent skin rashes blades Sensitive to hot weather Bitter, metallic taste Use laxatives Burning or itching anus in mouth in mornings Stools alternate from Crave sweets Bowel movements soft to watery painful or difficult History of gallbladder Worrier, feels insecure attacks or gallstones GROUP SIX Loss of taste for meat Coated tongue Mucous colitis or Lower bowel gas several Pass large amounts of irritable bowel hours after eating foul-smelling gas Gas shortly after eating Burning stomach Indigestion 1/2-1 hour after Stomach bloating sensations, eating relieves eating; may be up to 3-4 hours after GROUP SEVEN (A) Insomnia (E) Nervousness Dizziness Canʼt gain weight (C) Headaches Intolerance to heat Failing memory Hot flashes Highly emotional Low blood pressure Increased blood Flush easily Increased sex drive pressure Night sweats Headaches, splitting Hair growth on face Thin, moist skin or rendering type or body (female) Inward trembling Decreased sugar Sugar in urine Heart palpitates tolerance (not diabetes) Increased appetite without Masculine tendencies weight gain (female) Pulse fast at rest (D) Eyelids and face twitch Abnormal thirst (F) Irritable and restless Bloating of abdomen Weakness, dizziness Canʼt work under pressure Weight gain around Chronic fatigue hips or waist Low blood pressure (B) Sex drive reduced Nails, weak, ridged Increase in weight or lacking Tendency to hives Decrease in appetite Tendency to ulcers, Arthritic tendencies Fatigue easily colitis Perspiration increase Ringing in ears Increased sugar Bowel disorders Sleepy during day tolerance Poor circulation Sensitive to cold Women: menstrual Swollen ankles Dry or scaly skin disorders Crave salt Constipation Young girls: Brown spots or Mental sluggishness lack of menstrual bronzing of skin Hair coarse, falls out function Allergies - tendency Headaches upon arising to asthma wear off during day Weakness after colds, Slow pulse, below 65 influenza Frequency of urination Exhaustion - muscular Impaired hearing and nervous Reduced initiative Respiratory disorders

9 SYSTEMS SURVEY FORM - Page 3 GROUP EIGHT Muscle Apprehension weakness Lack of Stamina Drowsiness Irritability after eating Muscular Morbid fears soreness Rapid Never heart seems beat to get well Hyper-irritable Forgetfulness Feeling Indigestion of a band around 179 your Poor head appetite Melancholia (feeling of 180 sadness) Craving for sweets Swelling Muscular of soreness ankles Diminished Depression; urination feelings of dread Tendency Noise sensitivity to consume sweets Acoustic or hallucinations carbohydrates 185 Tendency to cry Muscle spasms Blurred without reason vision Loss Hair is of coarse muscular and/or control Numbness thinning Night Weakness sweats Rapid Fatiguedigestion Sensitivity to noise 189 Skin sensitive to touch Redness of palms of hands 190 and Tendency bottom toward of feet hives Visible Nervousness veins on chest and abdomen Headache Hemorrhoids Insomnia Apprehension Anxiety (feeling that something bad is going to Anorexia happen) Nervousness Inability to concentrate; causing loss of confusion appetite Nervousness Frequent stuffy with nose; sinus indigestion infections Gastritis Allergy to some foods Forgetfulness 199 Loose joints Thinning hair FEMALE ONLY Very easily fatigued Premenstrual tension Painful menses Depressed feelings before menstruation Menstruation excessive and prolonged Painful breasts Menstruate too frequently Vaginal discharge Hysterectomy/ovaries removed Menopausal hot flashes Menses scanty or missed Acne, worse at menses Depression of long standing (TO BE COMPLETED BY DOCTOR) MALE ONLY Prostate trouble Urination difficult or dribbling Night urination frequent Depression Pain on inside of legs or heels Feeling of incomplete bowel evacuation Lack of energy Migrating aches and pains Tire too easily Avoids activity Leg nervousness at night Diminished sex drive IMPORTANT TO THE PATIENT: Please list below the five main physical complaints you have in order of their importance Postural Blood Pressure: Recumbent Standing Pulse Hema-Combistix Urine readings: ph Albumin per cent Glucose per cent Occult Blood ph of Saliva ph of Stool specimen Weight Hemoglobin Blood Clotting Time BARNES THYROID TEST This test was developed by Dr. Broda Barnes, M.D. and is a measurement of the underarm temperature to determine hypo and hyperthyroid states. The test is conducted by the patient in the a.m. before leaving bed - with the temperature being taken for 10 minutes. The test is invalidated if the patient expends any energy prior to taking the test - getting up for any reason, shaking down the thermometer, etc. It is important that the test be conducted for exactly 10 minutes, making the prior positioning of both the thermometer and a clock important. PRE-MENSES FEMALES AND MENOPAUSAL FEMALES Any two days during the month FEMALES HAVING MENSTRUAL CYCLES The 2 nd and 3 rd day of flow OR any 5 days in a row. MALES Any 2 days during the month. You can do the following test at home to see if you may have a functional low thyroid. Use an oral thermometer or a digital one. When you use a digital one, place the probe under your arm for 5 minutes then turn your machine on; continue on for an additional 5 minutes. When using a regular one, shake down the night before.