client health history

8/13/2019 Client Health History

1/22

Integrative Nutritional Therapieswww.integrativenutritionaltherapies.com

Grand Rapids, MI 49505616-365-9176 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, includingsymptoms 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 thequestions 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 efficiencyand 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


2/22

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

Name, address and phone of Primary Physician

Marital Status

Single Married Divorced

Widowed Long Term Partnership

Emergency Contact

Name Relationship Phone

Occupation

Nature of Business

Current Health Status and Concerns

Health, Nutrition and Diet Goals: ShortTerm

Health, Nutrition and Diet Goals: LongTerm

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


3/22

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


4/22

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 INFOPLEASE

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


5/22

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...) withdiet and supplements?

Y

N

If Yes, please name

Are you working with a Chiropractor?

YN

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


6/22

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

If Yes, how often?

Womb History

Were you a full term baby?

Y

N

Were you breast fed?

Y

N

If Yes, until what age?

Were you bottle fed?

Y

N

If Yes, what age?


7/22

Do you currently in the last 3 monthsexperience these?

Yes No

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

Pain Assessment

Are you currently in pain?

Y

N

Is the source of your pain from an injury or accident?

Y

N


8/22

Dental History

Do youcurrently in the last 3 monthsexperience these?

Y N Sometimes

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

Nutrition

Please list and describe your typical breakfast, lunch, dinner, snacks and beverages. Be specificplease.

Breakfast Be specific please.


9/22

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)


10/22

How much do you consume daily?

1x 2x 3x More than3x

Never

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

Do you use a microwave?

Y

N


11/22

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

If Yes, explain how

Do you have any cravings?

Y

N

If Yes, what do you crave? And what do you do when youcrave that food?

Do you have an aversion to a certain food?

Y

N

If Yes, what food(s)?


12/22

Do you experience?

Y N Sometimes

Gas with out pain

Gas with pain

Gas with odor

Bloating

Heartburn/GERD

Burping


13/22

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 Condom

Diaphram Partner vasectomy

IUD Other

What type of contraception do you use (hormonal)

Birth control pills Patch Nuva Ring Other


14/22

Have you ever experienced

Y N Sometimes

Breast tenderness

Abnormal pap test

Yeast infection

Bacterial Infection

Ovarian cysts

Uterine fibroids

Fibrocystic breasts

Endometriosis

Polycystic Ovarian Syndrome(PCOS)

A Hysterctomy

If Yes, to hysterectomy, check all that where removed

Uterus Both Ovaries One Ovary Fallopian Tubes


15/22

Lifestyle

Have you ever used tobaccoin the past?

Y

N

If Yes, what types, how much and number ofyears used

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

If you do drink, what type(s) do you drink, list all.

Have you ever had a problem with alcohol?

Y

N

Do you currently or have previously used recreational drugs?

Y

N

If Yes, what types andwhat methods (IV,smoked, etc..)


16/22

Average number of hours of sleep per night

Less than 6

6-7

8-9

9-10

10+

Regarding sleep, do you

Y N Sometimes

Have trouble falling asleep

Have trouble getting back to sleep ifawaken

Waking up at nightFeel rested upon waking up

Feel tired upon waking up

Have nightmares

Have night sweats

Mind doesn't seem to calm down atnight

Insomnia

Use sleep aids

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?


17/22

Stress, Emotions and Social aspects

Which of the following provide you with emotional support

Spouse/partner Immediate family Extended family

Friends Pets Spiritual/religious

Co-workers

Which applies to your emotional state

Y N Sometimes

Overall happy

Able to handle stress

Able to separate work and pleasure

Able see the positive in each situationTend 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 abusepresent in your childhood home

How important is spirituality to you? Spirituality: To be awaken

Extremely important

Somewhat important

Not important at all


18/22


19/22

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 respectto that information. This privacy notice is located on the practices website or by opening up anew window and going to: http://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdffor 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 todiagnose, treat or cure any illness or disease and is for my education onlyand I understandthis when discussing any of this information to my medical doctors. I understand that I will nothold Integrative Nutritional Therapies, LLC and/or Melissa Malinowski, ND, CNC legallyresponsible for any information, services provided or supplements recommended. Allinformation, results of Biomeridian assessment, wellness plan or supplements discussed orrecommended 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 appointmentscannot be used as health or medical records of any sorts in regards to any type of court of lawor litigation. This information is for my education only and cannot be used in any situation otherthan for education for the client. I acknowledge that my records at this office are not to besubpoenaed 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 amfinancially 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
http://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdfhttp://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdfhttp://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdfhttp://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdfhttp://www.integrativenutritionaltherapies.com/wp-content/uploads/2013/09/Notice-of-Privacy-Practices-Form.pdf


20/22

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. Eachappointment 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/missedappointment 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 thepractitioner and must be paid in full at the time of service. By checking this box and hittingsubmit you agree to this policy.

Yes I agree

While results will reflect clients efforts, consistency and compliance, individual results are notguaranteed.

Yes I agree

All decision made regarding clients medications is the sole decision and responsibility of theclient and the prescribing doctor and not the decision or suggestion of Integrative NutritionalTherapies, LLC and/or Melissa Malinowski. If there are any changes in my prescribedmedication, 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 offthis 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


21/22

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 isdiscouraged out of respect for the practitioner and other appointments. If you happen to arriveearly, 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 careat any time if it is determined that dedication is not continuous or for any other professionalbasis. 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-upappointments are a very significant part of your success. Diet modification and nutritionalsupport may be a fundamental part of your wellness program, therefore it is very important toattend all follow-up appointments at their scheduled time. If you are not able to make yourfollow-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 Ibring 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 theabove information is my total health picture and that it is true to the best of my knowledge. If anyinformation regarding my health changes at any time, I will inform Melissa Malinowski as soonas 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 thisoffice at least 24 hours prior to the scheduled initial appointment. This gives the practitioner timeto thoroughly review your health history.By checking this box and hitting submit you agree to this policy.

Yes I agree


22/22

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

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