All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.
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- Elfrieda Warren
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1 Nutritional Counseling Food Sensitivity Testing Neurotransmitter Testing Hormone Testing Wellness & Prevention 111 O Fallon Commons Drive O Fallon, MO Phone: Fax: Dr. Olivia Joseph Certified Clinical Nutritionist Board Certified Acupuncturist drolivia@connectwithwellness.com All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge. BEFORE SEEING DR. OLIVIA APPOINTMENT: 1st Appointment DATE: TIME: 30 minute evaluation Fill out Nutrition Questionnaire Fill out 3 day Food Log Watch the Basic Nutrition video at on the video page DURING YOUR FIRST APPOINTMENT A DISCUSSION OF THE FOLLOWING WILL OCCUR: [Cost $150] Comprehensive Review of Nutritional & Health History. Supplement protocol to immediately relieve your symptoms and current health problem(s). Possible benefits and timing of a cleansing/detoxification program. Possible benefits and timing of laboratory testing used to evaluate: Food Allergies/Sensitivities---Hormone Imbalances---Stress Hormone Issues Lifestyle changes that you need and are willing to make. Follow Up Appointments (30 minutes): 2nd APPOINTMENT DATE: Before appointment watch the Detoxification Video at - Bio-Impedence Analysis will be done on this visit to determine toxicity levels, hydration, mineral & essential fatty acid deficiency. 3rd APPOINTMENT DATE: Before appointment watch the Do I need Vitamins? video at 4th APPOINTMENT DATE: Please fill out a new nutritional questionnaire and 3 day food log and turn in 24 hours prior to your final evaluation of the year. Please bring to all appointments: This Folder A copy of any recent diagnostic or laboratory testing Any vitamins or supplements not recommended by Dr. Olivia or purchased at this office DURING YOUR FOLLOW UP APPOINTMENTS THE FOLLOWING WILL OCCUR: [COST $150] Discussion of results from changing lifestyles, taking recommended supplements and cleansing [if done]. Review results of any additional testing. Repeat bio-impedence analysis to objectively measure any changes. Any additional lifestyle goals will be discussed. Please be writing down your goals. BETWEEN APPOINTMENTS: Take recommended supplements. Eat glycemically balanced every 2-4 hours. Drink at least ½ your body weight in ounces of water daily. Dr. Olivia with any questions, changes, improvements and Read the nutrition tips of the Blog page of Keep a list of any questions for Dr. Olivia on your next visit. Note: More information about the supplements can be found at: All Natural and Glycemically Balanced Recipes can be found at:
2 111 o fallon commons drive ~ o fallon ~ Nutritional Assessment Questionnaire for Ages 10 & Up Please Use Blue or Black Ink Only Personal History Date: Name: Address: City: State /Prov: Zip/Postal Code: Birth Date: Age: Home Phone: Cell Phone : Sex: [ ] Male [ ] Female Social Security # Circle One: Married Single Divorced Widowed Address: How were you referred to our office?
3 Nutritional Assessment Questionnaire for Ages 10 & Up Please list your top five main health concerns or health goals in order of importance: 1) 2) 3) 4) 5) Please circle any medications you are currently taking: Antacids Asthma Inhalers Anti-Histamines Antibiotics Antidepressants Sleeping Pills Thyroid medication Progesterone Estrogen Birth Control Steroids Diuretics Blood Pressure Cholesterol Diabetic ADD/ADHD Fill in the number that applies: 1=monthly 2=weekly 3=daily Artificial Sweeteners Coffee Fast Food Fried Foods Margarine High Fructose Corn Syrup Nicotine Carbonated Beverage Lunch Meat Please list how many times you exercise per week: Please list any additional vitamins or herbs that you take: How many ounces of water are you drinking daily? oz/cups
4 Please fill in the number that applies: 0 (or leave blank) never 1 = Minor of mild symptoms, rarely occurs (once a month or less) 2 = It is a moderate symptom or occurs weekly 3= It is a severe symptoms and frequently occurs (almost daily) Gastrointestinal Health Belching or gas within an hour of eating Heartburn/GERD Bloating or cramping after eating Bad Breath Excess fullness after meals Feel better if don t eat Feel like skipping breakfast Sleepy after meals Diarrhea Constipation Undigested food in stools Nausea Stomach upset by greasy foods Greasy stools Headache over the eye Gallbladder attacks Fibromyalgia Wheat sensitivity Dairy sensitivity Crohn s disease Allergies Airborne allergies Sinus congestion Asthma, frequent respiratory illness Dark circles under the eyes Feel worse in moldy or musty places Eating sugar or alcohol increases symptoms Hives Ear infections Eczema Coated tongue (white) Anus itches Chronic antibiotic use A HIGH SCORE IN THE ABOVE CATEGORIES MAY REQUIRE ADDITIONAL FOOD SENSITIVITY TESTING Vitamin/Mineral Deficiencies History of Carpal Tunnel Reduced bone density White spots on fingernails Crave Chocolate Tendency to Anemia Lump in throat Bursitis or tendonitis Joints pop or click Muscles easily fatigue Poor Memory Restless leg syndrome Ringing in ears Depression Anxiety Small bumps on the back of arms Water retention Polycystic ovarian syndrome PMS Breast tenderness Severe cramping Heavy bleeding with cycles Hot Flashes Irregular menstrual cycles Insomnia Excess facial or body hair Vaginal Dryness
5 Please fill in the number that applies: 0 (or leave blank) never 1 = Minor of mild symptoms, rarely occurs (once a month or less) 2 = It is a moderate symptom or occurs weekly 3= It is a severe symptoms and frequently occurs (almost daily) Blood Sugar/Adrenal Eat desserts or sugary snacks Fatigue all day Headaches if meals skipped or delayed Become dizzy when standing up suddenly Store fat in abdomen Perspire easily, even if not hot Excessive appetite Crave caffeine or sugar in the afternoon Sleepy in afternoon Crave Sweets Crave Salty Foods Low blood pressure Sensitive to light Keyed up, jittery Binge eating Irritable before meals Hormone/Thyroid (a high score in this category may require additional testing) Wake up with headaches Coarse hair/hair loss Mentally sluggish Difficulty losing weight Difficulty conceiving Polycystic ovarian syndrome Breast tenderness Heavy bleeding with cycles Irregular menstrual cycles Excess facial or body hair Low Libido Loss of eyebrows Flush easily Seasonal sadness Endometriosis PMS Severe cramping Hot Flashes Insomnia Vaginal Dryness
6 Daily Food Log Please Fill Out Completely With Your Typical Food Choices Day 1 Day 2 Day 3 Time Breakfast: Time Breakfast: Time Breakfast: Time Mid-Morning: Time Mid-Morning: Time Mid-Morning: Time Lunch: Time Lunch: Time Lunch: Time Mid-Afternoon: Time Mid-Afternoon: Time Mid-Afternoon: Time Dinner: Time Dinner: Time Dinner: Time Evening: Time Evening: Time Evening: Ounces Water Intake: Ounces Water Intake: Ounces Water Intake: Other Drinks: Other Drinks: Other Drinks: Energy: Energy: Energy: Sleep Quality: Sleep Quality: Sleep Quality:
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Name: Address: Date: Gender: Telephone: Emergency Contact Name / Number: / Please list your top major health concerns in order of importance: 1. 2. 3. Please circle if you have the following: Organ Transplant
Chief Concerns When did this problem begin and what if anything caused the onset?
Nature Cure Family Health Patient Information Today s date Name Age Date of Birth Address Zip: Phone (H) (C) (W) Is it okay to leave a message? (H) Y N (C) Y N (W) Y N Email (This will be used for us to
Metabolic Assessment Form
Nancey C. Savinelli, PhDc, Naturopath, CNC, LMT, MA Couns. Psychology 0100 Crown Valley Parkway, Suite 5D, Laguna Niguel, CA 92677 949 218 8788 / www.naturalhealthctr.net / nancey@naturalhealthctr.net
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
Hormone Consultation for Women
Healthway Compounding Pharmacy 2544 McLeod Dr. N., Ste. 2 Saginaw, MI 48604 989-791-1691 Toll Free: 866-883-8868 Fax: 989-791-4603 Hormone Consultation for Women Today s Date: / / Patient Name: Birth date:
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Naturopathic New Patient Form
611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!