Preparing for Your Nutrition Optimization Consultation
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- Solomon Ellis
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1 Preparing for Your Nutrition Optimization Consultation Thanks for your interest in our practice. Please complete these steps to prepare for your Nutrition Optimization Consultation: Step 1: Complete and Return Forms Print and complete the following forms: Client Profile Consent for Medical Services Medical History Nutrition Identify Your Triggers for Eating Nutrition Log Return your forms to Wellness ReSolutions: Fax to: - or - Scan and to: - or - Mail to: wellness-resolutions@myupdox.com Wellness ReSolutions 6740 Perimeter Dr Ste 300 Dublin OH When we have received all of your information, we will contact you to schedule your appointment. Please contact us with any questions at info@wellness-resolutions.com or We look forward to seeing you soon.
2 Client Profile (Please Print) Name: Preferred Name: Date: Date of Birth: Address: Sex: M F City: State: ZIP: Phone: Cell: How do you prefer to be reached? Home Phone Cell Phone Who do you wish us to contact in an emergency? Name: Relationship: Phone: Healthcare Contacts Primary Care Physician: Pharmacy: Phone: Pharmacy Address: City: Zip: Compounding Pharmacy: Phone: Compounding Pharmacy Address: City: Zip: Client Profile 11/13
3 Consent for Medical Services I, the undersigned, hereby request and consent to the services provided within the scope of practice afforded by licensed health care professionals and clinical staff members of Wellness ReSolutions, LLC ( Wellness ReSolutions ). I understand any recommendations and care received at Wellness ReSolutions are supportive only, and do not substitute for regular medical care. I understand I must continue to see my regular treating health care providers as directed by them and take my regular medications as prescribed. I hereby acknowledge and agree as follows: 1. I acknowledge and agree this agreement has been entered into before Wellness ReSolutions has provided the services specified herein to me. 2. I acknowledge and agree this agreement has not been entered into at a time when I am facing an emergency or an urgent health care situation. 3. The services provided to me may include: a. Evaluation of my medical history, lifestyle, laboratory and other test results; b. Physical examination and diagnostic tests; c. Medical recommendations and management for disease prevention and healthy aging, which may include: nutrition, nutritional supplementation, exercise, lifestyle behaviors, stress management, hormone replacement therapy, and other interventions as indicated by medical history, physical examination and laboratory parameters. 4. I understand I have the right to question any therapy proposed and/or provided by Wellness ReSolutions, and that all my questions will be answered prior to receiving such treatment. I understand I have not been and will not be given a guarantee of beneficial or specific results. I affirm I have and will always, to the best of my ability, disclose my complete current and past medical history to Wellness ReSolutions. I understand this history is essential for Wellness ReSolutions to assess and provide competent care to me. I understand the treatment I receive from Wellness ReSolutions and its health care professionals is in large part based upon my disclosures to them. 5. I have the right to revoke this Consent in writing, at any time, except to the extent Wellness ReSolutions has taken action in reliance on this Consent. 6. I understand I am responsible for full payment of services when they are rendered. 7. I understand health care professionals of Wellness ReSolutions are not participating in any health insurance plans and that Wellness ReSolutions cannot assure me that my insurance company or tax-deductible health plan will reimburse for services provided. 8. I understand that if I am eligible or will become eligible for Medicare Part B Benefits within the next two years, I will need to enter into a Medicare Opt-Out Private Contract before receiving services. 9. By voluntarily signing below, I affirm I have read or have had read to me, and fully understand the information contained in this agreement. I have been advised of the risks and benefits of the services provided to me, and I have had the opportunity to ask questions regarding services. I understand this Consent covers the entire course of treatment provided by Wellness ReSolutions. Client Signature: Date: Client Name (print): Consent Medical Services 7/15
4 Medical History - Nutrition Date Name D.O.B My Primary Health Goals My Current Medical Problems Medication Allergies / Reactions Allergies (e.g. food, environmental) Current Medications - Prescription & Non-prescription (name/dose/reason for use) Current Supplements (name/dose/reason for use) Hospital Admissions / Surgeries (Not including pregnancies) Year Illness/Operation Year Illness/Operation Medical History Nutrition 7/14
5 2 Screening Tests Test Date Results? Cholesterol/Lipids Normal Abnormal Blood Sugar Normal Abnormal Bone Density Normal Abnormal Personal and Family History Check boxes if you or a blood relative has suffered any of the following indicate which relative(s), and give details below. Alzheimer s Diabetes Hypertension Osteoporosis Bleeds easily Heart disease Lipid disorder Stroke Cancer (type) HIV / AIDS Mental illness Thyroid disease Family History Details (indicate which disease and which relative affected and explain): Review of Systems Check boxes for any symptom you currently experience and give details. General Excess fatigue Weight loss/gain If checked, list doctor seen, describe condition and duration Weight gained/lost lbs. over months/years (circle one) Easy bruising If yes, do you take blood-thinning medications? Yes No Depression/Anxiety Irritability Constipation Diarrhea Bloating/gas Acidity/reflux Stress Food cravings Feeling hungry often Memory/concentration issues Sleep problems Medical History Nutrition 7/14
6 3 Weight/Height Current weight: Desired weight: Height: Nutrition What are your greatest challenges to making healthy nutrition choices? Who does your grocery shopping? How often do you eat out - times/week? Do you ever fast? Yes No If Yes, how often and why: Type of foods: Do you use weight gain/loss supplements? Yes No If Yes, what and why: Food allergies: Food(s) you crave: Food dislikes: Do you awaken hungry during the night? Yes No If Yes, what do you do: Favorite snacks/foods/beverages: Meal Frequency Always: Sometimes: Never: Breakfast Usual time you have breakfast: Morning Snack Lunch Who does your cooking? Afternoon Snack Usual time you have evening meal: Dinner Evening Snack How many servings of the following do you have per day? Fruit: Vegetables: Whole grains: Refined grains: Dairy: Water (oz.): Juice (oz.): Caffeinated drinks(oz): Artificially sweetened drinks (oz): How many servings of the following do you have per week? Fish: Red meat: Chicken/Pork: Nuts (oz.): Weight Management Note: Complete Identify Your Triggers for Eating form What are the most important reasons you want to lose weight? When did you begin gaining excess weight? Give reasons, if known: In the past, what has stopped you from losing weight? List any weight-loss diets or weight-loss medications you have been on during the past 12 months, along with the reason(s) for following it, benefits or problems you experienced, and reason(s) for stopping any diet or medication. Medical History Nutrition 7/14
7 4 Exercise/Fitness Activities - Check only one and provide details under Comments. Inactive: no regular physical activity with a sit-down job Light activity: no organized physical activity during leisure time Moderate activity: occasionally involved in activities such as weekend golf, tennis, jogging, swimming, or cycling Heavy activity: consistent lifting, stair climbing, heavy construction, or regular participation in jogging, swimming, cycling or active sports at least three times per week Vigorous activity: participation in extensive physical exercise for at least 60 minutes per session 4 times per week Comments: Sleep Habits Number of hours slept each night: Bedtime: Awaken: Quality of sleep: Excellent Good Poor Number of times you awaken at night: Are you able to return to sleep? Yes No Social Habits Smoking: Never Former year quit: Current cigarettes/day: Alcohol: Yes No If Yes, what kind: How many drinks/week: Recreational drugs: Yes No If Yes, have you ever taken street drugs with a needle: Yes No Miscellaneous Include comments on current sources of stress, additional information you would like to share, or to elaborate on previous questions. Personal Needs/Expectations Check all boxes below that pertain to what you need in order to succeed in achieving your health goals. Assessment of current diet (Average calories, protein, fat, carbohydrates) General meal plan (including total daily calorie needs, macronutrient needs and food servings per meal Individualized 7-day meal plan (based on YOUR food preferences and lifestyle) Recipes ( 3 breakfast, lunch, and dinner ideas) Dining out options Weekly check-ins (5 min phone or , weigh-ins if applicable) Weekly online food diary assessment 7 or 30 day detox program Food allergy/celiac lab testing Micronutrient deficiencies lab testing Nutrient injections Other Client Signature: Date: Client Name (print): Medical History Nutrition 7/14
8 Identify Your Triggers for Eating Indicate the times, places, events, etc. that contribute to your choice to eat. Complete this worksheet over a several day period to improve accuracy. Date Time Where I have the urge to eat Who I am with My mood (anger, depressed, nervous, happy, etc.) How strong is my craving? (1-5) Low = 1, High = 5 Nutrition Eating Triggers 7/14
9 Nutrition Log Record your eating activity over three consecutive days including at least one weekend day. Name: Start weight (lbs.): Day 1 Date: Time Food/Beverage (name/ingredients/brand) End weight (lbs.): Quantity (be precise) Nutrition - Log 2/14
10 2 Nutrition Log Day 2 Date: Time Food/Beverage (name/ingredients/brand) Weight (lbs.): Quantity (be precise) Nutrition - Log 2/14
11 3 Nutrition Log Day 3 Date: Time Food/Beverage (name/ingredients/brand) Weight (lbs.): Quantity (be precise) Nutrition - Log 2/14
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COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
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Health Profile Dietary consultation involves a health profile. The purpose of the health profile is not to establish a diagnosis, but rather to determine a client s health status in order to guide his
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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Apt. /unit: City: State: Zip Code:
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WellSpan Medical Weight Management 2339 South George Street York, PA (717)
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Ayurvedic Intake Forms Please write legibly.
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Nashoba Valley Chiropractic (978)
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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My Weight Loss Contract 2009
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