All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.

Similar documents
Symptom Review (page 1) Name Date

..Welcome. Personal History. Current Health History. Lifestyle

Digestion Assessment Scorecard

METABOLIC ASSESSMENT FORM

Metabolic Assessment Form

New Patient Medical History Intake Form

Ayurvedic Intake Form

Symptom Questionnaire

What do you believe is causing your most important health concern?

New Client Health & Wellness Paper Work

NEW PATIENT HEALTH HISTORY

WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE

Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:

BALANCING BODY CHEMISTRY HEALTH ASSESSMENT

Hormone. for Women. Dr. Melanie MacIver, ND

Metabolic Assessment Form Please list your five major health concerns in your order of importance.

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Metabolic Assessment Form

Emotional Relationships Social Life Sexually Recreation

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

City: State: Zip: Age: Height: Current weight: Weight 6 months ago: Employer: Work #: Ext:

THE HORMONE HEALTH PROFILE

Have you ever been diagnosed with any of the following? The patient has a history of the following conditions: Glaucoma

Metabolic Assessment Form

Office Use. Stage of. Technique/Plan +/- Change. Establishing Your Health Goals. Date: Name: Age: Referred by:

METABOLIC ASSESSMENT FORM

Medications/Supplements/Vitamins/Herbs currently taking regularly

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Bodily Conditions Rooted in Hormone Imbalance

SYMPTOM SURVEY FORM Name Date

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

Nutrition Questionnaire

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire

Patient Intake Form for Acupuncture Treatment at Infinite Healing

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other

Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership

Pure Health Natural Medicine

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Client Nutrition Intake Form

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

New Patient Intake Form

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

OKANAGAN HEALTH & PERFORMANCE Inc.

HORMONE QUIZ Time to get clear about your symptoms

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX

Name Date of visit. Reasons for coming. Health goals Medical history. Diseases, Surgeries, Traumas. List vitamins and herbs consumed

Nutrition Consultation Intake Form Please write or print clearly

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

NUTRITION CLIENT INTAKE FORM. Address: City: State: ZIP Code: Phone (H): Phone (C): Emergency Contact: Phone: Relationship:

Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form

ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No

PATIENT QUESTIONNAIRE / ASSESSMENT

HEALTH SURVEY. This is a health survey designed to help you assess where you are; recognition is well on the way to healing.

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

Legal Name Preferred Name (if different) Date of Birth. What are your long term personal goals for our work together?

Dr Cara Flamer GSH Medical 801 Eglinton Ave West, Suite 100 Toronto, ON

Oriental Medicine Questionnaire

SYSTEMS SURVEY FORM. Doctor

SHEILA WOLFSON, M.Ed., C.N.S. Nutritionist and Health Counselor. 20 Main Street, Suite 300, Natick, MA Phone/Fax (508)

Medical History Form

Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?

3. Male? 4. Hydrocortisone (or derivates)? 5. Other? Vitamins/minerals/trace elements: How are you doing? very well well average not well very bad

HORMONE QUIZ Time to get clear about your symptoms

New Patient Information

JOHN MICHAEL ROACH, MD

Name: Date of Birth: Age: Address: City State Zip

Lucas D. Brown, L.Ac. (312)

Hormone Evaluation Quiz

Directions to Whole Woman Health - located in the NW Des Moines/Beaverdale area:

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

DR. HEDAYA S PSYCHO-METABOLIC QUESTIONNAIRE

ANTI-AGING HORMONE BALANCING WEIGHT LOSS NUTRITION

Reproductive Health Questionnaire

GETTING STARTED INTRODUCTORY FORM

WOODLANDS FAMILY CHIROPRACTIC

Nutrition Questionnaire

Medical Health Questionnaire

PERSONAL HEALTH HISTORY FORM DEMOGRAPHIC INFORMATION Name (last, first, middle initial) Social Security Number Birth date

Denise E. Bruner, M.D. & Associates, P.C.

NEW PATIENT INTAKE FORM

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac

!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R.

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP

Nutritional Assessment Questionnaire

Chief Concerns When did this problem begin and what if anything caused the onset?

Metabolic Assessment Form

Patient History Form

Inner Balance Acupuncture

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

Hormone Consultation for Women

Adult Health History Summary

VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE

Naturopathic New Patient Form

Transcription:

Nutritional Counseling Food Sensitivity Testing Neurotransmitter Testing Hormone Testing Wellness & Prevention 111 O Fallon Commons Drive O Fallon, MO 63368 Phone: 636-978-0970 Fax: 636-978-7570 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 www.cookingwitholivia.com 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 www.cookingwitholivia.com - 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 www.cookingwitholivia.com 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. Email Dr. Olivia with any questions, changes, improvements and Read the nutrition tips of the Blog page of www.cookingwitholivia.com Keep a list of any questions for Dr. Olivia on your next visit. Note: More information about the supplements can be found at: www.metagenics.com All Natural and Glycemically Balanced Recipes can be found at: www.cookingwitholivia.com

111 o fallon commons drive ~ o fallon 63368 636.978.0970 ~ www.wellnessconnection-ofallon.com..welcome 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 E-mail Address: How were you referred to our office?

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

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

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

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:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback