Integrative Nutritional Therapies

www.integrativenutritionaltherapies.com Grand Rapids, MI 49505 616-365-9176 Office 616-719-3422 fax

COMPREHENSIVE HEALTH HISTORY

All applicable information must be filled out to see the practitioner Thank you for choosing Integrative Nutritional Therapies to assist you with your wellness journey. My ability to draw effective conclusions about your state of health and how to optimize improvements depends largely on the accuracy of the information in which you provide, including symptoms that you may consider minor or symptoms that have become normal to you. Health issues may be influenced by many factors; therefore, it is important that you carefully consider the questions asked in this form as well as those posed by the practitioner during your consultation. This will assist our goal to provide you with an optimal plan of wellness care, enhance our efficiency, and will provide effective use of your scheduled time. Be sure to save the form data to your desktop after each section.

Date

First Name

Last Name

Street Address

City, State and Zip Code

SSN Please do not use dashes

Required for confidential client file. Notice of Privacy Practices Apply Cell Phone Home Phone

Please note which number to best reach you and/or leave messages E-mail

Age

DOB

Referred by. Please be specific so I can thank them!

Name, address and phone of Primary Physician

Marital Status Single Widowed Emergency Contact Married Long Term Partnership Divorced

Name Occupation

Relationship

Phone

Nature of Business

Current Health Status and Concerns Health, Nutrition and Diet Goals: Short Term Health, Nutrition and Diet Goals: Long Term

5 Top Physical/Emotional complaints in order of importance. Please number them 1-5.

List all medical conditions for which you are being treated

When was the last time you felt well?

What seems to trigger your symptoms?

What seems to make you feel better?

What physician or other health care practitioner have you seen for your condition?

Medications List all medications and OTC non-prescription drugs you are taking Medication/Date Started//Purpose/Dose. LIST ALL INFO PLEASE

Any known reactions to medications? Y N

If Yes, what medications

Vitamins, Supplements, Minerals and Homeopathics List all vitamins, supplements, minerals and homeopathics you are currently taking Supplement, Date started, Food Based or Synthetic, Purpose for taking. LIST ALL INFO PLEASE

Are you allergic to any vitamin, mineral, homepathic or nutritional supplement? Y N If Yes, which ones?

Any known reactions to Iodine or flowers/herbs in the daisy family?

Any known allergies or sensitivities: environmental or food. Please list

What does your total cholesterol run? High Average Low

What does your blood pressure typically run? High Average Low

Are you currently working with another practitioner (Chiro, Naturopath, Nutritionist, etc...) with diet and supplements? Y N If Yes, please name

Are you working with a Chiropractor? Y N If Yes, please name

Have you ever used Standard Process or MediHerb products? Y N Medical and Surgical History

List any surgeries or organs removed. Please list surgery, the purpose and date

Gallbladder removed? Y N How often have you taken anti-biotics as an infant or child? Less than 5 times More than 5 times How often have you taken anti-biotics as a teenager? Less than 5 times More than 5 times How often have you taken anti-biotics as an adult? Less than 5 times More than 5 times Were you Immunized as a child? Y N Were you Immunized as an adult? Y N Do you receive the flu vaccine? Y N Womb History Were you a full term baby? Y N Were you breast fed? Y N Were you bottle fed? Y N If Yes, what age? If Yes, until what age? If Yes, how often?

Do you currently in the last 3 months experience these? Yes ADD/ADHD Asthma Bronchitis Ear Infections Headaches Pneumonia Seasonal Allergies Food Allergies Skin Issues/Acne/Eczema Strep Infections Tonsilitis Upset stomach/digestive issues Anger/hostility Depression/sadness Feeling Overwhelmed Exposed to 2nd hand smoke Have alcoholic parents No

Pain Assessment Are you currently in pain? Y N Is the source of your pain from an injury or accident? Y N

Dental History Do you currently in the last 3 months experience these? Y Problems with gums and soreness Ringing in the ears TMJ problems Clenching your jaw Grinding your teeth Tight muscles in head/neck and jaw White, yellow or grey color on tongue Bad breath Silver fillings ever put into teeth (even baby) Silver fillings in teeth currently Root canals Bridges Other dental procedures N Sometimes

Nutrition

Please list and describe your typical breakfast, lunch, dinner, snacks and beverages. Be specific please. Breakfast Be specific please.

Snack (am) Be specific please.

Lunch Be specific please.

Snack (mid day) Be specific please.

Dinner Be specific please.

Snack (pm) Be specific please.

Beverages (any and all including on the weekends)

How much do you consume daily? 1x Candy Chocolate Pasta Bread Crackers and/or Chips Cookies Caffeine (pop, tea or coffee) Decaf (pop or coffee) Diet pop Fast food Restaurant food Artificial sweeteners Lean cuisine, weight watchers, healthy choices, etc... Low fat or sugar free items 2x 3x More than 3x Never

Do you use a microwave? Y N

What type of nutritional lifestyle do you follow? None specific Paleo/primal Low carb Dairy restricted Fat restricted Vegetarian Vegan Blood type Mediterranean Other Do you have a loss of taste for meat? Y N Does skipping meals affect how you feel? Y N Do you have any cravings? Y N Do you have an aversion to a certain food? Y N If Yes, what food(s)? If Yes, what do you crave? And what do you do when you crave that food? If Yes, explain how

Do you experience? Y Gas with out pain Gas with pain Gas with odor Bloating Heartburn/GERD Burping N Sometimes

Female Medical History

Number of Pregnancies

Number of Miscarriages

Number of Caesarean sections

Number of vaginal deliveries

Number of Living Children

If any abortions, how many

Post Partum Depression

Toxemia

Gestational Diabetes

Age at first menses

Are you in menopause Y N Date of last menstrual period

What type of contraception do you use (Non-hormonal) None Diaphram IUD Condom Partner vasectomy Other

What type of contraception do you use (hormonal) Birth control pills Patch Nuva Ring Other

Have you ever experienced Y Breast tenderness Abnormal pap test Yeast infection Bacterial Infection Ovarian cysts Uterine fibroids Fibrocystic breasts Endometriosis Polycystic Ovarian Syndrome (PCOS) A Hysterctomy N Sometimes

If Yes, to hysterectomy, check all that where removed Uterus Both Ovaries One Ovary Fallopian Tubes

Lifestyle Have you ever used tobacco in the past? Y N If you currently use tobacco, what type? Cigarettes Chew Cigar Pipe Patch/gum Electronic cigarette How often do you drink alcohol? Never Couple drinks per year 1-3 drinks per week 4-6 drinks per week 7-10 drinks per week More than 10 drinks per week Have you ever had a problem with alcohol? Y N If Yes, what types and what methods (IV, smoked, etc..) If you do drink, what type(s) do you drink, list all. If Yes, what types, how much and number of years used

Do you currently or have previously used recreational drugs? Y N

Average number of hours of sleep per night Less than 6 6-7 8-9 9-10 10+ Regarding sleep, do you Y Have trouble falling asleep Have trouble getting back to sleep if awaken Waking up at night Feel rested upon waking up Feel tired upon waking up Have nightmares Have night sweats Mind doesn't seem to calm down at night Insomnia Use sleep aids N Sometimes

Do you exercise daily? Y N

If No, what limits your activity ( injury, fatigue, not making times, etc...)

If Yes, what type and how often?

Stress, Emotions and Social aspects Which of the following provide you with emotional support Spouse/partner Friends Co-workers Which applies to your emotional state Y Overall happy Able to handle stress Able to separate work and pleasure Able see the positive in each situation Tend to be skeptical and negative Typically in a good mood Feel irritable and impatient Feel patient and calm Ever contemplated suicide Sought counseling Ever been in an abusive relationship (parents, family, friends or partner) Was alcohol or other substance abuse present in your childhood home N Sometimes Immediate family Pets Extended family Spiritual/religious

How important is spirituality to you? Spirituality: To be awaken Extremely important Somewhat important Not important at all

Readiness! Please rate on a scale from 0-3 your willingness to change your life to get the results you want. 0: Not Willing and 3: Very Willing 0 Not Willing Be open minded to new suggestions & information Real food grocery shopping weekly Plan and prepare to make real food meals Make meals with love for you & your family daily Eat nutrient dense foods Take rebuilding/repairing supplements daily Modify your lifestyle to get the results you want Keep a wellness and food log Report all your improvements and changes to Melissa before each follow-up appointment (this will be required) Listen to your body and honor what it is asking for Be conscious and aware Let go of old beliefs & myths about fat, counting calories, cholesterol, the "standard american diet" etc... 1 2 3 Very Willing

Policies and Procedures for Integrative Nutritional Therapies and Melissa Malinowski, ND, CNC It is the clients responsibility to make a copy of this page for their records to review throughout the course of working with Melissa Be sure to save the form data to your computer at this point We are required by law to maintain the privacy of the protected health information in your records and to provide you with this notice of our legal duties and privacy practices with respect to that information. This privacy notice is located on the practices website or by opening up a new window and going to: http://www.integrativenutritionaltherapies.com/wp-content/ uploads/2013/09/Notice-of-Privacy-Practices-Form.pdf for your review of the HIPPA law. I acknowledge that I have read this privacy notice. By checking this box and hitting submit you agree to this policy. Yes I agree I acknowledge that all information that is provided for me through this office is not intended to diagnose, treat or cure any illness or disease and is for my education only and I understand this when discussing any of this information to my medical doctors. I understand that I will not hold Integrative Nutritional Therapies, LLC and/or Melissa Malinowski, ND, CNC legally responsible for any information, services provided or supplements recommended. All information, results of Biomeridian assessment, wellness plan or supplements discussed or recommended is to educate me and any decision that I make is my full responsibility. By checking this box and hitting submit you agree to this policy. Yes I agree I acknowledge that any information exchanged during, inside or outside of our appointments cannot be used as health or medical records of any sorts in regards to any type of court of law or litigation. This information is for my education only and cannot be used in any situation other than for education for the client. I acknowledge that my records at this office are not to be subpoenaed and all records from this office will be exempt from being subpoenaed. By checking this box and hitting submit you agree to this policy. Yes I agree I understand and agree that nutrition care at this office is not covered by insurance and that I am financially responsible for services and supplements rendered at the time of each consultation. By checking this box and hitting submit you agree to this policy. Yes I agree

Consultation Charges: The initial consultation will be a flat fee of $160 and runs about 60-90 minutes. Follow-ups will be $70/ per hour (prorated) and typically run between 60-90 minutes. If the appointment runs past the one hour mark the $70/per hour (prorated) will apply. Each appointment will be blocked off for a 2 hour time slot, if we need the time. The preferred method of payment is cash or check. I also accept debit or credit cards too. By checking this box and hitting submit you agree to this policy. Yes I agree Short notice and no call-no show appointments will be charged a $70 short notice/missed appointment fee. By checking this box and hitting submit you agree to this policy. Yes I agree Services and supplements are non-refundable unless arrangements are made with the practitioner and must be paid in full at the time of service. By checking this box and hitting submit you agree to this policy. Yes I agree While results will reflect clients efforts, consistency and compliance, individual results are not guaranteed. Yes I agree All decision made regarding clients medications is the sole decision and responsibility of the client and the prescribing doctor and not the decision or suggestion of Integrative Nutritional Therapies, LLC and/or Melissa Malinowski. If there are any changes in my prescribed medication, it is my responsibility to inform Melissa Malinowski immediately. By checking this box and hitting submit you agree to this policy.

Yes I agree Continuous re-scheduling of scheduled appointments is strongly discouraged. Melissa blocks off this important time for clients. Please plan to make the appointments your priority. By checking this box and hitting submit you agree to this policy. Yes I agree

Only plan to bring children to your appointments if they are being tested. By checking this box and hitting submit you agree to this policy. Yes I agree Because the office does not have a waiting room, arriving early or late for any appointment is discouraged out of respect for the practitioner and other appointments. If you happen to arrive early, please walk in the home office no sooner than 5 minutes to your scheduled appointment time. By checking this box and hitting submit you agree to this policy. Yes I agree Based on the strength of this partnership, the practitioner reserves the right to discontinue care at any time if it is determined that dedication is not continuous or for any other professional basis. If Melissa feels the goals of the client are no longer in alignment with her philosophies, she can end the relationship with no explanation or legal recourse. By checking this box and hitting submit you agree to this policy. Yes I agree Full commitment to your designed nutritional program is crucial for optimal results. Follow-up appointments are a very significant part of your success. Diet modification and nutritional support may be a fundamental part of your wellness program, therefore it is very important to attend all follow-up appointments at their scheduled time. If you are not able to make your follow-up appointment, please call to reschedule or cancel asap to avoid charge. By checking this box and hitting submit you agree to this policy. Yes I agree I acknowledge that this office is in Melissa's home and I will be conscious of the energy that I bring there at each and every appointment. By checking this box and hitting submit you agree to this policy. Yes I agree I acknowledge that I have filled out all applicable pieces of information on this form and that the above information is my total health picture and that it is true to the best of my knowledge. If any information regarding my health changes at any time, I will inform Melissa Malinowski as soon as possible. By checking this box and hitting submit you agree to this policy. Yes I agree This completed form along with any other completed health profile forms must arrive to this office at least 24 hours prior to the scheduled initial appointment. This gives the practitioner time to thoroughly review your health history. By checking this box and hitting submit you agree to this policy. Yes I agree

Date of acknowledgement of these policies

Signature that I agree to all these policies ___________________________________ Printed name that I agree to all these policies _________________________________ Thank you and I look forward to helping you reach your wellness and nutritional goals! Namaste' Melissa Be sure to "like" Integrative Nutritional Therapies on facebook for daily interactive wellness information.

Please be sure to SAVE this form to your computer (desktop is easiest) BEFORE hitting the submit button as the data may be lost. Your computer may ask you to submit from your desktop. Use this saved form to attach in your e-mail to me. E-mail to: [email protected]

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