benderchiro.com - New Patient Female Form

HISTORY
List any major illnesses (with approx. dates):
List any surgery or operations with approx. date:
Past Accidents or injuries:
Marital Status:

SMDW
Name of Spouse
Describe health of spouse:
Number of children if any

	Name of Child	Age	Sex	Any physical conditions or concerns?
1.
2.
3.
4.
5.

Any family history of serious illnesses (check which apply):

CancerDiabetesHeartOther
Any household pets or other animals you or family members are in close contact with:
What can we do to make you happier?
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Please put a mark anywhere on your body that you have a scar. That includes piercings, tattoos, surgery scars, stretch marks, and child bearing scars of any kind.
Notes:

PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF NUTRITION RESPONSE TESTING™
PLEASE READ BEFORE SIGNING:

I specifically authorize the natural health practitioners at Bender Chiropractic Health and Vitality Center to perform a 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 Nutrition 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 form applies to subsequent visits and consultations.
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Date:

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Address:

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Signed: (If minor, signature of parent or guardian required)

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Notice of Privacy Practices Acknowledgement

Initial Uses Authorization Form
Effective: 4-15-2003

By signing this form, you acknowledge that you were presented with a copy of the Notice of Privacy Practices of Bender Chiropractic Health and Vitality Center. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices will be placed on display in the office at all times. You may obtain additional copies of our most current notice by requesting it from our privacy official, Dr. William L. Bender

Bender Chiropractic Health and Vitality Center also uses protected health information for the following reasons: (you may opt out of this authorization). Marketing; internal referral board, testimonials, pictures on bulletin board, or information unrelated to healthcare and other marketing materials. (please initial to give us authorization)
(Please initial to give us authorization)
If you have any questions regarding this notice or our health information privacy policies, please contact:
Dr. William L. Bender

You can reach the Privacy Official at: Bender Chiropractic Health and Vitality Center, 33580 Harper Avenue, Clinton Township, MI, 1-586-738-6833
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.
Your Email address: (you may receive PHI through email)
example@example.com
Patient Name:
Signature Patient/Personal Representative:

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Date of Signature:

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Should be Empty:

	None	Mild	Moderate	Severe
1. Acid foods upset
2. Get chilled often
3. “Lump” in throat
4. Dry mouth, eyes, nose'
5. Pulse speeds after meal
6. Keyed up, fail to calm
7. Gag occasionally
8. Unable to relax, startle easily
9. Extremities cold, clammy
10. Strong light irritates
11. Occasionally weak urine flow
12. Heart pounds after retiring
13. “Nervous” stomach
14. Appetite reduced occasionally
15. Cold sweats often
16. Get heated easily
17. Nerve discomfort
18. Staring, blink little
19. Sour stomach frequent

	None	Mild	Moderate	Severe
20. Joint stiffness after arising
21. Muscle, leg, toe cramps at night
22. “Butterfly” stomach, cramps
23. Eyes or nose watery
24. Eyes blink often
25. Eyelids swollen, puffy
26. Indigestion soon after meals
27. Always seem hungry, feel “lightheaded” often
28. Digestion rapid
29. Vomit occasionally
30. Hoarseness frequent
31. Uneven breathing
32. Pulse slow
33. Gagging reflex slow
34. Difficulty swallowing
35. Temporary constipation or diarrhea
36. “Slow starter”
37. Get “chilled”
38. Perspire easily
39. Sensitive to cold
40. Upper respiratory challenges

	None	Mild	Moderate	Severe
41. Eat when nervous
42. Excessive appetite
43. Hungry between meals
44. Irritable before meals
45. Get “shaky” if hungry
46. Fatigue, eating relieves
47. “Lightheaded” if meals delayed
48. Heart palpitates if meals missed or delayed
49. Fatigue in afternoon
50. Overeating sweets upsets
51. Awaken after few hours sleep, hard to get back to sleep
52. Crave candy or coffee in afternoon
53. Moods of “blues” or melancholy
54. Craving for sweets or snacks

	None	Mild	Moderate	Severe
55. Hands and feet go to sleep easily, numbness
56. Sigh frequently, “air hunger”
57. Aware of “breathing heavily”
58. High-altitude discomfort
59. Open windows in closed room
60. Immune system challenges
61. Afternoon “yawner”
62. Get “drowsy” often
63. Swollen ankles worse at night
64. Muscle cramps, worse during exercise; get “charley horse”
65. Difficulty catching breath, especially during exercise
66. Tightness or pressure in chest, worse on exertion
67. Skin discolors easily after impact
68. Tendency to anemia
69. Noises in head or “ringing in ears”
70. Fatigue upon exertion

	None	Mild	Moderate	Severe
71. Dizziness
72. Dry skin
73. Burning feet
74. Blurred vision
75. Itching skin and feet
76. Hair loss
77. Occasional skin rashes
78. Bitter, metallic taste in mouth in morning
79. Occasional constipation
80. Worrier, feels insecure
81. Nausea occasionally after eating
82. Greasy foods upset
83. Stools light-colored
84. Skin peels on foot soles
85. Discomfort between shoulder blades
86. Occasional laxative use
87. Stools alternate from soft to watery
88. Sneezing attacks
89. Dreaming, nightmare-type bad dreams
90. Bad breath (halitosis)
91. Milk products cause upset
92. Sensitive to hot weather
93. Burning or itching anus
94. Crave sweets

NEW PATIENT INFORMATION FORM

HISTORY

PERMISSION & AUTHORIZATION FORM REGARDING THE USE OF NUTRITION RESPONSE TESTING™

Systems Survey Form

Notice of Privacy Practices Acknowledgement

	None	Mild	Moderate	Severe
95. Loss of taste for meat
96. Lower bowel gas several hours after eating
97. Burning stomach sensations, eating relieves
98. Coated tongue
99. Pass large amounts of foul-smelling gas
100. Indigestion ⅟2-1 hour after eating; may be up to 3-4 hours after
101. Watery or loose stool
102. Gas shortly after eating
103. Stomach “bloating

	None	Mild	Moderate	Severe
104. Difficulty sleeping
105. On edge
106. Can’t gain weight
107. Intolerance to heat
108. Highly emotional
109. Flush easily
110. Night sweats
111. Thin, moist skin
112. Inward trembling
113. Heart races
114. Increased appetite without weight gain
115. Pulse fast at rest
116. Eyelids and face twitch
117. Irritable and restless
118. Can’t work under pressure

	None	Mild	Moderate	Severe
119. Increase in weight
120. Decrease in appetite
121. Fatigue easily
122. Ringing in ears
123. Sleepy during day
124. Sensitive to cold
125. Dry or scaly skin
126. Temporary constipation
127. Mental sluggishness
128. Hair coarse, falls out
129. Tension in head upon arising wears off during day
130. Slow pulse below 65
131. Changing urinary function
132. Sounds appear diminished
133. Reduced initiative

	None	Mild	Moderate	Severe
134. Failing memory with age
135. Increased sex drive
136. Episodes of tension in head
137. Decreased sugar tolerance

	None	Mild	Moderate	Severe
138. Abnormal thirst
139. Bloating of abdomen
140. Weight gain around hips or waist
141. Sex drive reduced or lacking
142. Tendency for stomach issues
143. Immune system challenges
144. Menstrual disorders

	None	Mild	Moderate	Severe
145. Dizziness
146. Headaches
147. Hot flashes
148. Hair growth on face or body (female)'
149. Sugar in urine (not diabetes)
150. Masculine tendencies (female)

	None	Mild	Moderate	Severe
151. Weakness, dizziness
152. Tired throughout day
153. Nails weak, ridged
154. Sensitive skin
155. Stiff joints
156. Perspiration increase
157. Bowel discomfort
158. Poor circulation
159. Swollen ankles
160. Crave salt
161. Areas of skin darkening
162. Upper respiratory sensitivity
163. Tiredness
164. Breathing challenges

	None	Mild	Moderate	Severe
165. Muscle weakness
166. Lack of stamina
167. Drowsiness after eating
168. Muscular soreness
169. Heart races
170. Hyperirritable
171. Feeling of a band around head
172. Melancholia (feeling of sadness)
173. Swelling of ankles
174. Change in urinary function
175. Tendency to consume sweets/carbohydrates
176. Muscle spasms
177. Blurred vision
178. Involuntary muscle action
179. Numbness
180. Night sweats
181. Rapid digestion
182. Sensitivity to noise
183. Redness of palms of hands and bottom of feet
184. Visible veins on chest and abdomen
185. Hemorrhoids
186. Apprehension (feeling that something bad is going to happen)

	None	Mild	Moderate	Severe
192. Very easily fatigued
193. Premenstrual tension
194. Menses more painful than usual
195. Depressed feelings before menstruation
196. Painful breasts during menses
197. Menstruate too frequently
198. Hysterectomy/ovaries removed
199. Menopausal hot flashes
200. Menses scanty or missed
201. Acne, worse at menses

	None	Mild	Moderate	Severe
202. Less involved in exercise/social activities
203. Difficult to postpone urination
204. Weak urinary stream
205. Feeling of “blues” or melancholy
206. Feeling of incomplete bowel evacuation
207. Lack of energy
208. Muscles in arms and legs seem softer/smaller
209. Tire too easily
210. Avoid activity
211. Leg nervousness at night
212. Diminished sex drive