New Patient Nutritional Forms Packet
Name
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First Name
Last Name
Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Sex
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Female
Male
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
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Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
Cell Carrier
For Mobile Text Alerts
Place of Employment
Occupation
Emergency Info
In Case of Emergency, Contact:
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Phone Number
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Area Code
Phone Number
Relationship
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Symptoms Survey Form
Group 1
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Acid foods upset
Get chilled often
“Lump” in throat
Dry mouth, eyes, nose
Pulse speeds after meal
Keyed up, fail to calm
Gag occasionally
Unable to relax, startle easily
Extremities cold, clammy
Strong light irritates
Occasionally weak urine flow
Heart pounds after retiring
“Nervous” stomach
Appetite reduced occasionally
Cold sweats often
Get heated easily
Nerve discomfort
Staring, blink little
Sour stomach frequent
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Group 2
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Joint stiffness after arising
Muscle, leg, toe cramps at night
“Butterfly” stomach, cramps
Eyes or nose watery
Eyes blink often
Indigestion soon after meals
Always seem hungry, “lightheaded” often
Digestion rapid
Vomit occasionally
Hoarseness frequent
Uneven breathing
Pulse slow
Gagging reflex slow
Difficulty swallowing
Temporary constipation or diarrhea
“Slow starter”
Get “chilled”
Perspire easily
Sensitive to cold
Upper respiratory challenges
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Group 3
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get “shaky” if hungry
Fatigue, eating relieves
“Lightheaded” if meals delayed
Heart palpitates if meals missed or delayed
Fatigue in afternoon
Overeating sweets upsets
Awaken after few hours sleep
Crave candy or coffee in afternoon
Moods of “blues” or melancholy
Craving for sweets or snacks
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Group 4
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Hands and feet go to sleep easily/numbness
Sigh frequently, “air hunger”
Hungry between meals
Aware of “breathing heavily”
High-altitude discomfort
Open windows in closed room
Immune system challenges
Afternoon “yawner”
Get “drowsy” often
Swollen ankles worse at night
Muscle cramps, worse during exercise
Difficulty catching breath, especially during exercising
Tightness or pressure in chest, worse on exertion
Skin discolors easily after impact
Tendency to anemia
Noises in head or “ringing in ears”
Fatigue upon exertion
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Group 5
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Dizziness
Dry skin
Burning feet
Blurred vision
Itching skin and feet
Hair loss
Occasional skin rashes
Afternoon “yawner”
Bitter, metallic taste in mouth in morning
Occasional constipation
Worrier, feels insecure
Difficulty catching breath, especially during exercising
Nausea occasionally after eating
Greasy foods upset
Stools light-colored
Skin peels on foot soles
Discomfort between between shoulder blade
Occasional laxative use
Stools alternate from soft to watery
Sneezing attacks
Dreaming, nightmare-type
bad dreams
Bad breath (halitosis)
Milk products cause upset
Sensitive to hot weather
Burning or itching anus
Crave sweets
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Group 6
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Loss of taste for meat
Lower bowel gas several hours after eating
Burning stomach sensations,
eating relieves
Coated tongue
Pass large amounts of foul-smelling gas
Indigestion ⅟2 -1 hour after eating;
Watery or loose stool
Gas shortly after eating
Stomach “bloating”
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Group 7 (A)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Insomnia
Nervousness
Can't Gain Weight
Intolerance to heat
Highly Emotional
Occasional skin rashes
Flush Easily
Night Sweats
Thin, moist skin
Inward trembling
Heart palpitates
Increase appetite w/o weight gain
Pulse fast at rest
Eyelids and face twitch
Irritable and restless
Can't work under pressure
Group 7 (B)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Increase in weight
Decrease in appetite
Fatigue easily
Ringing in ears
Sleepy during day
Sensitive to cold
Dry or scaly skin
Constipation
Mental Sluggishness
Hair coarse/falls out
Headaches upon rising, subsides during day
Slow pulse, below 65
Frequency of urination
Impaired hearing
Reduces initiative
Group 7 (C)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Failing memory
Low blood pressure
Increased sex drive
Headaches "splitting/rendering" type
Decreased sugar tolerance
Group 7 (D)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Abnormal Thirst
Bloating of abdomen
Weight gain hips/waist
Sex drive reduced/lacking
Tendency to ulcers/colitis
Increased sugar tolerance
Women: menstrual disorders
Young girls: lack of menstrual function
Group 7 (E)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Dizziness
Headaches
Hot flashes
Increased blood pressure
Hair growth on face/body (female)
Sugar in urine (not diabetes)
Masculine tendencies (female)
Group 7 (F)
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Weakness/dizziness
Chronic fatigue
Low blood sugar
Nails weak/ridged
Tendency to hive
Arthritic tendencies
Perspiration increase
Bowel disorders
Poor circulation
Swollen ankles
Crave salt
Brown spots or bronzing of skin
Allergies - tendency to asthma
Weakness after colds,influenza
Exhaustion - muscular and nervous
Respiratory disorders
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Group 8
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No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Muscle weakness
Lack of Stamina
Drowsiness after eating
Muscular soreness
Rapid heart beat
Hyper-irritable
Feeling of a band around your head
Melancholia (feeling of sadness)
Swelling of ankles
Diminished urination
Tendency to consume sweets or carbohydrates
Muscle spasms
Blurred vision
Loss of muscular control
Numbness
Night sweats
Rapid digestion
Sensitivity to noise
Redness of palms of hands/bottom of feet
Visit veins on chest/abdomen
Hemorrhoids
Apprehension (feeling as though something bad is going to happen
Nervousness, causing lack of appetite
Nervousness with indigestion
Gastritis
Forgetfulness
Thinning hair
FEMALE ONLY
No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Very easily fatigued
Premenstrual tension
Painful menses
Depressed feeling before menstruation
Menstruation excessive and prolonged
Painful breasts
Menstruate too often
Vaginal discharge
Hysterectomy/ovaries removed
Menopausal hot flashes
Menses scanty or missed
Acne worse at menses
Depression of long standing
MALE ONLY
No Symptoms
Mild Symptoms
Moderate Symptoms
Severe Symptoms
Prostrate problem
Urination difficult or dribbling
Night urination frequently
Depression
Pain on side of legs or heels
Feeling of incomplete bowel evacuation
Lack of energy
Migrating aches and pains
Tire too easily
Avoids activity
Menses scanty or missed
Leg nervousness at night
Diminished sex drive
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TO THE PATIENT: Please list below the 5 main physical complaints you have in order of their important (ex. #1 most important complaint - #5 least important complaint)
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NUTRITIONAL INFORMED CONSENT - According to the Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1), the term "DRUG" is defined to mean: "Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease." A vitamin is not a drug, neither is a Mineral,Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented,or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments and treatments. By typing your name below you indicate that you have read and understand the above information.
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