NUTRITIONAL NEW PATIENT INFORMATION

PLEASE PRINT CLEARLY

DATE:

NAME:

E-MAIL ADDRESS:

ADDRESS:

CITY:

STATE:

ZIP:

CELL#:

HOME #:

WORK #:

DATE OF BIRTH:

REFERRED BY:

OCCUPATION:

EMPLOYER:

OVERALL HEALTH:

EXCELLENT GOOD FAIR POOR

PLEASE LIST ANY PROBLEMS YOU ARE EXPERIENCING:

LIST ANYTHING RELATED TO YOUR HEALTH YOU FEEL IS NOT NORMAL – EVEN THINGS YOU HAVE GOTTEN USED TO:

WHAT DO YOU CONSIDER YOUR MAJOR HEALTH PROBLEM?

HAVE YOU EVER BEEN TREATED FOR ANY OF THESE ELSEWHERE?

YES NO

IF YES, WHERE?

DR.’S NAME:

CURRENT MEDICATION/DRUGS BEING TAKEN:

NUTRITIONAL SUPPLEMENTS YOU ARE TAKING:

DO YOU (IF YES, HOW MUCH):

SMOKE:

COFFEE:

ALCOHOL:

EXERCISE:

HISTORY

LIST ANY MAJOR ILLNESSES (WITH DATES):

LIST ANY SURGERIES (WITH DATES):

PAST ACCIDENTS OR INJURIES:

MARITAL STATUS:

SINGLE MARRIED DIVORCED WIDOWED

NAME OF SPOUSE

DESCRIBE HEALTH OF SPOUSE:

NUMBER OF CHILDREN (IF ANY):

ADD CHILD

SIGNATURE:

DATE:

Family Health History

Please review the diseases and conditions listed below and indicate those that are current health problems of a family member by using the designation C under his or her column. Use the designation P to indicate a past problem. Leave blank those spaces that do not apply. Use the reverse side if you need more space.

FATHER Age

MOTHER Age

SPOUSE Age

BROTHER(S)

SISTER(S) Age

CHILDREN Age

Condition

If any of the above family members are deceased, please list their age at death and cause

Toxicity Questionnaire

Mark the corresponding number for each symptom using the following scale and your health profile for the last 90 days

0 Rarely or Never experience the symptom

1 Occasionally experience the symptom; Effect is not severe

2 Occasionally experience the symptom; Effect is severe

3 Frequently experience the symptom, Effect is not severe

4 Frequently experience the symptom, Effect is severe

1. DIGESTION

TOTAL

2. EARS

TOTAL

3. EMOTIONS

TOTAL

4. ENERGY/ACTIVITY

TOTAL

5. EYES

TOTAL

6.HEAD

TOTAL

7. LUNGS

TOTAL

8. MIND

TOTAL

9. NOSE

TOTAL

10. MOUTH/THROAT

TOTAL

11. SKIN

TOTAL

12. HEART

TOTAL

13. JOINTS/MUSCLES

TOTAL

14. WEIGHT

TOTAL

15. OTHER

TOTAL

SECTION I TOTAL

SECTION II: RISK OF EXPOSURE

Rate each of the following situations based on your environmental profile for the last 120 days.

Use the scale defined below for the following questions

0 - Never 1 - Rarely 2 - Monthly 3 - Weekly 4 - Daily

A. How often are strong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc)

0 1 2 3 4

B. How often are pesticides used in your home?

0 1 2 3 4

C. How often do you have your home treated for insects?

0 1 2 3 4

D. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?

0 1 2 3 4

E. How often are you exposed to nail polish, perfume, hair spray, and other cosmetics?

0 1 2 3 4

F. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?

0 1 2 3 4

TOTAL

Use the scale defined below for the following questions

0 - No 1 - Mild change 2 - Moderate change 3 - Drastic change

A. Have you noticed any negative change since you moved into your home or apartment?

0 1 2 3

B. Have you noticed any negative change in your health since you started your new job?

0 1 2 3

TOTAL

For the following questions, answer yes or no by selecting the number that corresponds to yes or no

A. Do you have a water purification system in your home?

No Yes

B. Do you have any indoor pets?

No Yes

C. Do you have an air purification system in your house?

No Yes

D. Are you a dentist, painter, farm worker, or construction worker?

No Yes

TOTAL

SECTION II TOTAL

GRAND TOTAL (Section I and Section II)

Add up the numbers to arrive at a total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a Clinical Purification TM program.

Allergy Questionnaire

This questionnaire is designed to help us understand the extent to which allergens may be affecting you.

For each question, check the box corresponding to yes or no based on your health profile for the last year.

Do you sneeze a lot?

No Yes

Do you experience bloating after eating?

No Yes

Is your “stomach” always churning?

No Yes

Do you have trouble with your sense of smell?

No Yes

Do You have trouble with your sense of taste?

No Yes

Do you feel nauseous after you eat much of the time?

No Yes

Do you experience headaches, which seem to be caused by sinus pressure?

No Yes

Do you have an aversion to "good food"?

No Yes

Does your mouth seem too dry frequently?

No Yes

Do you have cravings for certain foods?

No Yes

Do you have a place on your body, which always itches?

No Yes

Do you have any rashes on your skin?

No Yes

Do you have unexplained joint pains?

No Yes

Do certain places always make you sick?

No Yes

Do you notice that you feel more congested after resting?

No Yes

Are you tired too much of the time?

No Yes

If yes, which time of the day

Morning

Afternoon

Evening

TOTAL (Number of checks in the column labeled “Yes”)

PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF NUTRITION RESPONSE TESTING

PLEASE READ BEFORE SIGNING:

I specifically authorize the natural health practitioners at the Alternative Health Care Center to perform Nutrition Response Testing health analysis and to develop a natural, complementary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or “cure” of any disease.

I understand that Nutrition Response testing is a safe, non-invasive, natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems.

I understand that Nutritional Response Testing is not a method for “diagnosing” or “treating” of any disease including conditions of cancer, AIDS, Infections, or other medical conditions, and that these are not being tested for or treated.

No promise or guarantee has been made regarding the results of Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand that Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe, natural programs can be developed for the purpose of bringing about a more optimum state of health.

I have read and understand the foregoing.

This permission slip form applies to subsequent visits and consultations

Date

Print Name:

Address:

City:

State:

Zip:

Phone:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signed:

(If minor, signature of parent or guardian required)

Witness:

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