GETTING STARTED INTRODUCTORY FORM

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Transcription:

GETTING STARTED INTRODUCTORY FORM I am interested in: In office consultation Questions regarding my appointment: Phone consultation Skype consultation I am interested in the: Getting Started Program Getting To Know You Program Keeping You On Track Program Commitment To Succeed Program Day of the week that works best for me: Time of the day that works best for me: Questions regarding appointment:

NUTRITION QUESTIONNAIRE Name: Date: Address: City/State/Zip: Phone (Home): (work): (cell): Email Address: Date of Birth: Height: Weight: Reason for consultation: Goals: How many times do you usually eat per day? Describe 3 full typical day s meals, snacks and drinks, and time of each (please be specific and very complete): Day 1:

Day 2: Day 3: Do you smoke? Drink alcohol? How much/when? Do you drink caffeine? What kind? How much/when? Do you overeat? If so, which foods and how often? Do you have any food allergies, restrictions or sensitivities? If yes, please describe. Describe your daily energy levels: Do you get noticeably irritable, lightheaded or weak if you haven t eaten in awhile? If yes, please describe. Do you crave any of the following? (Please X off) Sugar Meat Bread Chocolate Fish Fat Desserts Milk Alcohol Fried Foods Pasta Other

Which oils do you use/consume? (Please check off) Butter Peanut oil Canola oil Margarine Corn oil Sun/Safflower oil Olive oil Crisco Mayonnaise Coconut oil Vegetable oil Grape seed oil Hemp oil Soybean oil Flax oil Walnut oil Sesame oil Other How is your dental health? Do you have problems chewing or swallowing? Do you eat fast? Is your eating environment peaceful or stressful? How much time do you have for meals? How is your digestion? How often do you have a bowel movement? How often do you urinate? EXERCISE Do you exercise? If so, what kind? How often? Since when?

Daily Energy Level Daily Energy Level After Exercise Daily Stress Level General Enjoyment of Life Excellent Excellent Very High Excellent Good Good High Good Fair Fair Moderate Fair Poor Poor Low Poor None How many hours of sleep do you get on average each night? Any problems sleeping? Do you take any nutritional supplements or vitamins? If so, which ones? Be specific. Attach sheet if necessary. Please list any prescription or over the counter medications you take on a regular basis. Be specific and list dosages. Attach sheet if necessary. Family History: Please list any disease, illness, or ailments in your immediate family (i.e. parents,grandparents,siblings).

Rank your skin without lotion: (please circle) Very dry Dry Normal Oily Combination Symptoms Please circle any of the following that pertain to you (past or present) Acne Cold Sores Hair Loss Hypothyroid Ringing In Ears Addiction (alcohol & drugs) Chronic Fatigue Headaches (frequent) Hyperthyroid Seizures Anemia Constipation Headaches (migraine) Indigestion Severe Mood Swings Anorexia Dandruff Heart Disease Insomnia Skin Conditions Anxiety Depression Heart Burn Intestinal Problems Stroke Arthritis (Osteo) Diabetes (Type 1) Hemorrhoids Kidney Stones Thyroid Conditions Arthritis (Rheumatoid) Diabetes (Type 2) Herpes Simplex Liver Problems Ulcer Bladder Infections Diarrhea High Blood Pressure Memory Loss or Confusion Weight (Gain) Bloating Emphysema High Cholesterol Panic Attacks Weight (Loss) Bronchitis Fainting HIV Parasites Yeast Infections Cancer Gall Bladder Problems Hot Flashes Pregnant/Nursing Other: Colds (frequent) Gout Hypoglycemia Respiratory Problems Other:

Women: Please circle any that pertain: Men: Please circle any that pertain: PMS Irregular Periods Painful Periods Loss of Periods Birth Control Pills Peri-menopause Loss of Libido Frequent Urination Difficulty Urinating Erectile Dysfunction Loss of Libido Prostate Enlargement Menopause Hysterectomy Children Please feel free to expand on any concerns you think are important/relevant to your health.

JACQUELINE JUSTICE, M.S., C.N.S. Functional Nutritionist (914) 297-SLIM (7546) Welcome to my practice. I look forward to working with you in the days ahead. At this time, I would like to acquaint you with the policies that I feel will support the most beneficial use of our time together. 1. A 75 minute appointment is scheduled for your initial visit. During that hour we will spend time going over the enclosed questionnaire, as well as, discussing your lifestyle issues and health goals. You will leave with a preliminary eating plan based on your needs. At your first follow-up appt. (usually scheduled one to two weeks later), you will receive a customized eating plan. 2. A 24-hour notice of cancellation is requested. If for any reason you are unable to provide that, please remember that it is your reserved time and you are responsible for full payment. 3. Should a problem arise and I need to cancel our appointment, you will be given a minimum of 24 hours notice. 4. Please be prompt, as appointments do not extend past the reserved time. 5. Please see Weight Loss and Wellness Programs for fee information. Thank you. I look forward to our work together! I have read the above guidelines and agree to abide by all policies. Please print: Name Signature Date

CREDIT CARD AUTHORIZATION FORM FOR PHONE AND SKYPE CONSULTATIONS I hereby authorize my signature to be on file with Jacqui Justice for the purpose of charging my consultations and product services on my credit card. I authorize the respective credit card company designated below to accept this form in lieu of my signature appearing on the individual credit card receipt for consultations and product services rendered. I am aware that I will receive the receipt, and that this slip will act as my record of this transaction. I authorize Jacqui Justice to run my credit card the day my appointment has taken place and or when an order has been placed or picked up. (Order example: supplements) Cancellation and No-Show Policy: No refunds will be issued for not showing up for a previously scheduled appointment or any cancellation made less than 24 hours prior to appointment date. Family and personal emergencies may be exceptions to this rule. Client Name: Card Type:! VISA! MASTERCARD! AmEx Credit Card Number: Expiration Date: / Security Code: Card Holder Billing Address: City: State: Zip: Phone: Cell: Card Holder Name (Print) Card Holder Signature! Date Please print out, sign and fax completed form to: (914) 961-5016

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