Microsoft word - nutritional counseling intake forms 070808.doc

Please fill out the following information for our records: Patient Information Name: _____________________________________________________________________________ Address: ____________________________________________________________________________ City: _______________________ State: __________________ Zip: _____________________ Daytime phone: ____________________________ Home phone: ______________________________ Cell phone: _______________________________ E-mail address: ____________________________ Profession: ________________________________ How many hours/wk do you work? _____________ Place of Birth: ________________________ Emergency Contact Information Name: ______________________________ Cell phone: ___________________________ Have you ever seen a Nutritional Counselor before? □ Yes □ No How were you referred to The Berkley Center for Reproductive Wellness? Friend ________ Relative ________ Seminar ________ Internet ________ Other __________ acupuncture herbs nutrition fertility massage pregnancy Weight (6 months ago) _________ Weight (1 yr ago) _________ Would you like your weight to be different? _________ Please indicate any significant illness you or blood relatives have had: Illness Disease Have you ever had a Sexually Transmitted Diseases? Date _________ Date _________ Date _________ Date _________ List any medications and vitamin supplements you are currently taking: (Continue on back of this page if necessary) Check the Box if any of the following statements is true: □ I am taking Lithium (Eskalith, Lithobid, Lithonate, Lithotabs) acupuncture herbs nutrition fertility massage pregnancy What are the main Health problems for which you are seeking treatment? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What other forms of treatment have you sought? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any Health problems you now have. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ List any accidents, surgeries, or hospitalizations (include date). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Lab results (please include copies). ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How do you FEEL about the following areas of your life? __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ acupuncture herbs nutrition fertility massage pregnancy Are you pregnant? □ Yes □ No # of pregnancies _______ # of live births ____ # of abortions ____ # of miscarriages ____ Date of Last GYN exam ________ Date of last Pap smear ________ Mammogram ________ Bone Density Scan ________ Results___________________________________________________ _________________________________________________________ Average number of pads you use per day: 1st day _____ 2nd day _____ 3rd day _____ 4th day _____ 5th day _____ Please indicate the nature of pain and when experienced: (N) = Never experienced; (PM) = Pre Menses; (M) = During Menses; (AM) = After Menses Please indicate if any apply to you and when you experience each symptom: (N) = Never experience; (G) = General y experience; (PM) = Pre Menses; (M) = During Menses ___ Discharge
___ Vaginal Dryness
___ Headache
___ Dizziness
___ Swollen/Tender breasts ___ Water retention ___ Diarrhea
___ Constipation ___ Gas
___ Mood swings ___ Depression
___ Poor appetite ___ Heavy appetite
___ Increased Libido ___ Decreased Libido

___ Hot Flashes ___ Night Sweats
___ Insomnia
□ Endometriosis □ Ovarian cysts □ PCOS Other _______________________ Please indicate your Birth Control History: (Please use the back if need be.) acupuncture herbs nutrition fertility massage pregnancy Date of last prostate check-up __________ Lab results ________________________________________________________________________________________ Frequency of urination: Daytime ___ Nighttime ___ Color of urine: □ clear □ murky □ odor ______ □ other _____________________________________________________________________________________________ ____________________________________________________________________________________________________ The following list of symptoms you may or may not experience. Please indicate as follows: No mark ( ) = Never experience; Check Mark (√ ) = Sometimes experience; Plus sign (+) = Frequently experience ==============
acupuncture herbs nutrition fertility massage pregnancy Please briefly describe your fertility history. You may include diagnosis for you and your partner, treatments, past and upcoming procedures with relative dates. Please add any other information you deem relevant. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please indicate the use and frequency of the following: Please indicate when you experienced any of the following past or present: acupuncture herbs nutrition fertility massage pregnancy What role does exercise play in your life? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you follow a regular awareness practice? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What percentage of your food is home-cooked? _______% Where do you get the rest from? __________________________________________________________________________________________ Please list foods you regularly eat: As a CHILD… BREAKFAST As an Adult… (One year ago) BREAKFAST acupuncture herbs nutrition fertility massage pregnancy Is your diet mostly cooked, raw or a combination? _______________________________________________________ Please indicate which of the following you eat and the frequency: Please list the veggies you eat: Please list the fruit that you eat: FOR OFFICE USE ONLY acupuncture herbs nutrition fertility massage pregnancy We understand that there are times when you will need to cancel and/or reschedule your appointment. We are pleased to accommodate your needs. It is our policy, however, that all cancellations and/or rescheduling must be done at least 24 hours prior to the date/time of your appointment. A fee of $50.00 will be charged if your cancellation/re-scheduling is not done 24 hours prior to the date/time of your appointment or for any check that has been returned. Thank you for your understanding. Please sign here indicating that you understand and accept this policy: Patient Signature ____________________ Date acupuncture herbs nutrition fertility massage pregnancy I am attending this nutritional consultation and working with Kathie Alli, CHHC of my own volition. Kathie Alli recommends that you inform your medical doctor of any and all dietary changes which you make as a result of Kathie Alli’s recommendations. I understand that Kathie Alli, the person leading and teaching this program, is not a doctor or registered dietician. I take full responsibility for my health and for the decisions regarding my diet that I make as a result of Kathie Alli’s recommendations. I understand that Kathie Alli is a Certified Holistic Health Counselor, trained to help guide clients regarding the improvement of their health through dietary and lifestyle changes. She is not an herbalist or legal administrator of specialized supplements. Any dietary supplements that are recommended are suggestions and whether or not I partake of these suggestions is as a result of my own volition. I hereby release and discharge Kathie Alli from any and all claims that I or anyone in association with me, have or may have, now or in the future. I have read and understand all of the above, and agree to proceed under these conditions. I understand that the above is meant to have legal significance and be legally binding. _________________________________________________ Print your full name _________________________________________________ Sign your full name _____________________ Today’s date acupuncture herbs nutrition fertility massage pregnancy We, the undersigned, do affirm that __________________________________ has been advised by Kathie Alli, Holistic Health & Nutrition Counselor to consult a physician regarding the condition or conditions for which such patient seeks Nutritional Counseling. I, ___________________________ have received a copy of this document. Please print your name __________________________________________ Patient Signature ________________________________________________________________ Kathie Alli, HHC; AADP _______________ Date acupuncture herbs nutrition fertility massage pregnancy


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