ADVANCED NUTRITIONAL CONSULTING

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ADVANCED NUTRITIONAL CONSULTING Steven Salyers DC MS CNS DACBN Certified Nutrition Specialist, Diplomat American Clinical Board for Nutrition Last Name: First Name: Street Address: City: State: Zip: Phone: Work: Cell: Would you like text reminders for your appointments? Y N If yes, please provide cell carrier: Email: Would you like email reminders? Y N Date of Birth: Age: Height: Weight: SS#: Employer: Occupation: Who may we thank for referring you to us? Present Complaint: Other health care providers you are seeing, with their specialty: What diagnosis were you given? Women Only: Age of onset of menopause (if applicable): How was your health as a child? Excellent Good Fair Poor Serious Illness/Injuries/Surgeries Date Outcome 1

Test History Year Test Year Chest X-Ray Pap Smear Kidney X-Ray Mammogram GI Series Sigmoidoscopy Colon X-Ray Rectal Exam Spine X-Ray PSA Blood Tests Complete Physical Exam Other: Other: Please circle any medications you are currently taking or have taken in the last 3 months: Allergy Medication Chemotherapy Oral Contraceptives Other: Antacids Cortisone Pain Medication Anti-Inflammatory Heart Medication Radiation Antibiotic/Antifungal High Blood Pressure Relaxants Antidepressants Hormones Sleeping Pills Anti-diabetic/Insulin Laxatives Thyroid Asprin/ Tylenol/ Advil Lithium Ulcer Medication Do you (circle day or week as appropriate): Use Tobacco packs per day / week Drink Soda cups per day / week Drink Coffee cups per day / week Use Artificial Sweeteners packs per day / week Drink Black Tea cups per day / week Use Margarine pats per day / week Drink Alcohol drinks per day / week How many times a week do you eat in restaurants? Breakfast: Lunch: Dinner: What types of restaurants? Health & Lifestyle Overview 1. Please tell me what is bothering you. If this involves a specific health condition or illness, please tell me about it in as much detail as possible. List the very first time that you noticed the condition and describe carefully any factors that you think may have played a role in it s onset and progression: 2

2. Is your health currently getting better, worse or staying the same. Why do you think so? 3. What have you tried to do to improve your state of health (e.g. doctors, treatments, etc.)? 4. Have you had stressful occurrences that you believe have negatively affected your health? Are any of these situations continuing to impact your life? 5. Please list any other health concerns, even if you think they may not be important: 6. Why did you choose our office? 3

7. For our time together to be a true win for you, what do you want to take place over the course of your health care here? 8. How long do you feel this will take? 9. Do you think the pain/symptoms that you are experiencing could be your body s way of saying I need some help Let s change things here. Please explain: 10. What areas of your lifestyle are likely involved with your condition and you would like to improve? (Prioritize #1, 2, 3, etc) My level of anxiety Not enough quiet time & rest My exercise program Me pace of living My diet & nutrition My relationships My spiritual life My lifestyle choices 11. Please list any self-destructive lifestyle habits (e.g. smoking, lack of exercise, alcohol, excessive sweets, fast food, overeating, etc.) 13. What is your present level of commitment to change the underlying cause of problem(s) which relate to your lifestyle? (rate from 1 to 10, with 10 being 100% committed). 14. What obstacles could prevent you from changing those lifestyle factors that are undermining your health? 4

15. What might stop you from following the therapeutic protocols that I may prescribe for you? 16. Who will be your greatest support for you in your health goals? Family Health History Age State of Health Age at Death Cause of Death Father: Mother: 5

Diet Survey Please list everything you eat & drink for 2 3 Days Time Breakfast Snack Lunch Snack Dinner Snack Day 1 Day 2 Day 3 I clearly understand and agree that all services rendered to me are charged directly to me, and that I am personally responsible for payment. Patient Signature: Date: 6

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