EAGLE DIGESTIVE HEALTH FORM

New Patient Nutrition Form
PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF DIGESTIVE HEALTH & NUTRITIONAL RESPONSE TESTING
PLEASE READ BEFORE SIGNING:
I specifically authorize the natural health practitioners at Eagle Sport and Family Chiropractic to perform a Nutritional Response Testing health analysis and to develop a natural, health improvement program for me which may include dietary guidelines, nutritional supplements, etc. This program is designed to assist me in improving my health during the next 4 months with a MINIMUM of 1 follow up appointment per month. This is not for the treatment, or "cure" of any disease!

I understand that Nutritional Response Testing is a safe, non-invasive, natural methodof analyzing the body's physical and nutritional needs. Nutritional Response Testing is donc with physical touch and palpitation on the body.

I understand that Nutritional Response Testing is not a method of "diagnosing" or "treating" ANY disease, conditions, cancer, infections, AIDS. or medical conditions.

No promise or guarantee has been made regarding the results of Nutritional Response Testing or any other nutritional program or dietary program recommended, but rather I understand that Nutritional Response Testing is used to aid in determining possible nutritional imbalances for the purpose of developing a safe natural program to get to a more optimum state of health. I have read and understand the foregoing. In signing I hereby give consent to subsequent visits and consultations.
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(If a minor, signature of parent or guardian required)
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Name
Address

Address

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CityState

Zip
Mobile
Email
example@example.com
Height
Age
Date of Birth

MonthDayYear
Date
Weight: Current
Lowest
Highest
Ideal
Do you have any children?
What are the foods you stay away from?
What are the foods you consume a lot of or often?
Do you use the following ? And if so how much per week? (Note: one serving of alcohol is defined as a 12-ounce beer, 5-ounce glass of wine, or 1.5 ounces of liquor)
Coffee
Sugar
Alcohol
Tabacco
Microbiome & Digestive Health
Do you get heartburn or reflux?
Do you often have gas that has a sulfur or foul smell?
Are you sensitive to supplements?
Have you ever been vegan or vegetarian for any length of time?
Can you tolerate meat?
Do you currently or have you used hormone replacement therapy?
Have you been on antibiotics in the last year? If so, how many rounds?
Do you have a history of antibiotic use as a child or adult?
Does your gut temporarily feel better after a round of antibiotics?
Were you caesarian delivered (aka C-section)?
Were you breast fed? If so, how long?
Do you drink filtered water? If so, what type of filter?
Do you have a water filtration system for your house? If so, what type?
Do you have a water filtration system for your house? If so, what type?
Do you have a history of cold sores, warts or skin tags?
Have you gotten food poisoning before?
Do you have skin issues?
Do you have a history of foot fungus or yeast infections?
How many times a day are you having a bowel movement?
Do your bowel movements have a tendency to be more: Harder (constipated) or Loose Stool (diarrhea)How many times a day are you having a bowel movement?
Medical History: Please list any major illnesses, surgeries.
Medical History
Current Medications: Please list
Current Vitamins, Herbs or Nutritional Supplements:
Current Vitamins, Herbs or Nutritional Supplements: Please
Chief Complaint: (Please List when each symptom began and be as descriptive as possible.)
Client Goals
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New Patient Nutrition Form

PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF DIGESTIVE HEALTH & NUTRITIONAL RESPONSE TESTING

PLEASE READ BEFORE SIGNING: