Nutritional Therapy Health History
** All of your personal information will remain strictly confidential! **
What are your top 6 health concerns?
What would you like to accomplish/gain from this consultation?
Do you crave sugar? YES NO
Do you crave salt? YES NO
Do you feel tired, bloated and/or gassy after meals?
Do you experience constipation, gas or diarrhea often?
When and how often?
Do you feel excessively hungry?
Do you have a poor appetite?
What is your food like these days?
What are the 3 healthiest and worst foods you eat each week?
What were your eating habits like as a child?
How much water do you drink per day?
Do you drink alcohol? Yes No
How much and how often?
Do you drink soda (diet or regular)? Yes No
How much and how often?
Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?
Are you currently taking any vitamins/minerals/herbs/homeopathic remedies, prescriptions/non-prescription medications, aspirin, laxatives, diet pills, or any other supplements?
Do you have any known ALLERGIES to Medications or Herbs? Or other FOOD ALLERGIES?
Are you currently under a practitioner’s care for a specific health issue? Yes No
If so, what treatments are you undergoing?
Please list any surgeries, accidents, injuries or childhood diseases you have had along with the type and date:
Family Health History
Age of your first period:
Are your periods regular? Yes No How frequent?
How many days is your flow?
Do you experience PMS? Yes No Is it mild or severe?
# of pregnancies
How many children have you delivered and how were they born (vaginally or by cesarean)?
Were there complications associated with these births?
Did you receive antibiotics during labor? Yes No
Have you ever had a miscarriage or an abortion? Yes No How many?
Are you peri-menopausal? Yes No
When did this change first occur?
Are you menopausal? Yes No
When was your last period?
List your symptoms of peri/menopause:
Additional Comments (All Answer)
Anything else you would like to share?
NUTRITIONAL THERAPY INFORMED CONSENT & DISCLAIMER
GOAL: Our basic goal is to encourage people to become knowledgeable about and responsible for their own health, and to bring it to a personal optimum level. Nutritional therapy is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimum health, absent other non-nutritional complicating factors, requires a sincere commitment from you, possible lifestyle changes, and a positive attitude. A Nutritional Therapist is trained to evaluate your nutritional needs and make recommendations of dietary change and nutritional supplements. A Nutritional Therapist is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. Since every human being is unique, we cannot guarantee any specific result from our programs.
HEALTH CONCERNS: If you suffer from a medical or pathological condition, you need to consult with an appropriate healthcare provider. A Nutritional Therapist is not a substitute for your family physician or other appropriate healthcare provider. A Nutritional Therapist is not trained nor licensed to diagnose or treat pathological conditions, illnesses, injuries, or diseases.
If you are under the care of another healthcare provider, it is important that you contact your other health care providers and alert them to your use of nutritional supplements. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program.
If you are using medications of any kind, you are required to alert the Nutritional Therapist to such use, as well as to discuss any potential interactions between medications and nutritional products with your pharmacist.
If you have any physical or emotional reaction to nutritional therapy, discontinue their use immediately, and contact your Nutritional Therapist to ascertain if the reaction is adverse or an indication of the natural course of the body's adjustment to the therapy.
COMMUNICATION: Every client is an individual, and it is not possible to determine in advance how your system will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance. It is your responsibility to do your part by using your nutrition guidelines, exercise your body and mind sufficiently to bring your emotions into a positive balance, eat a proper diet, get plenty of rest, and learn about nutrition. You must stay in contact with the Nutritional Therapist so we can let you know what is happening and the best course of action. You should request your other healthcare provider, if any, to feel free to contact the Nutritional Therapist for answers to any questions they may have regarding nutritional therapy.
LICENSURE: A Nutritional Therapist is not licensed or certified by any state. However, a Nutritional Therapy Practitioner™ is trained by the Nutritional Therapy Association, Inc.® which provides a certificate of completion to students who have successfully met all course requirements, including a written and practical exam. A license to practice Nutritional Therapy is not required in some states. Laws and regulations regarding certification and licensure requirements differ from state to state.
PERMISSION & AUTHORIZATION FORM
Regarding the use of Lingual-Neural testing
I specifically authorize the natural health practitioners at to perform Lingual-Neural testing (LNT) 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 LNT 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 this analysis 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 LNT or any natural health, nutritional or dietary programs recommended, but rather I understand that LNT 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.
By my/our signature(s) below, I/we confirm that I/we have read and fully understand the above disclaimer, are in complete agreement thereto and do freely and without duress sign and consent to all terms contained herein.
NUTRITIONAL THERAPY MAY NOT BE COVERED BY INSURANCE AND ALL COSTS
ARE THE SOLE RESPONSIBILITY OF THE CLIENT