New Nutrition Patient Form-Adult Initial Nutrition Visit Form Step 1 of 3 33% HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Personal InformationYour Name(Required) First Last Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Phone(Required)Your Email Address(Required) Email Address Confirm Email Address Date of Birth(Required) Month Day Year Preferred Method of ContactEmailPhoneBest Time to Contact YouSelect A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmAppointment TypeHow would you prefer your appointment?(Required) In Person Appointment Virtual Appointment Please select your preferred type of appointment. For virtual appointments, you will receive instructions on how to connect with us online.Special Dietary NeedsDietary Needs Vegetarian/Vegan Celiac Disease Referral InformationWho Can We Thank for Referring You? Health HistoryPlease list any major illnesses, injuries, surgeries (with approx. dates): Please list any major scars, tattoos, and body piercings (please list): Please list any medications/drugs you are currently taking + current dosage(s) + date you started: Please list any herbs/supplements you are currently taking + current dosage(s) + date you started: Are you currently under the care of a physician or other health care professional? If yes, please give name: Have you had any root canals in the past? Yes No Do you have mercury fillings in your teeth? Yes No Do you get chiropractic adjustments regularly? Yes No Personal and Family HealthMartial Status: Single Engaged Married Divorced Widowed Female Only: Are you pregnant? If so, how far along are you? Do you have any children? If so, how many?Any family history of serious illnesses? Please check all that apply: Cancer Diabetes Heart Disease Stroke Autoimmunity Other If Other, please list and explain any other serious illnesses in your family history: Do you come in close contact with household pets or other animals? If yes, please explain: Personal Habits: Do you use or consume any of the following? Cigarettes/Vaping Coffee Alcohol Vegetable Oils Sugar Soda/Diet Soda Non-Prescription Drugs Sleeping Aids Gluten Foods (wheat) Dairy (cow's milk, yogurt, cheese) Please list any known allergies (ex: foods, medications, spices, environment, etc.) Dairy Eggs Garlic Gluten Mold Peanut Ragweed Shellfish Soy Sulfa Drugs Fragrances Tree Nuts Wheat Other Explain, if Other Top Health ConcernsWhat are your top health concerns? Nutritional Informed ConsentNutritional Informed Consent(Required) I agreeAccording 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. Although a vitamin, mineral, trace element, amino acid, herb, or homeopathic remedy may have an effect on a disease process or symptom, 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 dietary advice is not intended as a primary treatment or therapy for a disease or 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 biomechanical processes of the human body. Nutritional advice and nutritional intake may also enhance the stabilization of the spine following chiropractic adjustments. Our Practice utilizes whole food supplements and herbs to supply nutrients that support cell function and a healthy physiology. The supplements recommended are based on your unique evaluation. The cost of the supplements is not included in your evaluation fee. By my signature below, I understand that the nutritional evaluation is a non-invasive method of analyzing the nutritional needs of my body. Nutritional deficiencies may cause or contribute to various health issues. I understand that the methods used at East Cobb Spine & Sport Chiropractic are not to diagnose or treat any disease or other specific medical condition(s). There is no testing being performed for any specific medical condition. Further, I understand that the nutritional and/or dietary program being recommended is not guaranteed, and no assurances have been made. By my signature below, I understand that the Nutritionist I am seeing is not a medical physician, and I am not consulting for medical, diagnostic, or treatment procedures. The services performed by the Nutritionist are restricted to helping me gain better understanding of my degree of health, so I will have greater self-awareness and be able to use a self-care program for daily living. By my signature below, I authorize East Cobb Spine & Sport Chiropractic to perform a nutritional evaluation on me for the purpose of developing a program to improve my health and not for treatment or cure of any specific disease. My evaluation will not involve the diagnosing of disease or prescribing of drugs, or any act for which a medical license is required. I have read and understand the above:Minor Consent (If Applicable)Parent/Legal Guardian Full Name First Last Date Month Day Year System Survey Form INSTRUCTIONS: LEAVE CIRCLES BLANK IF THEY DON'T APPLY TO YOU! 1 = MILD Symptoms (Occurs Rarely) 2 = MODERATE Symptoms (Occurs Several Times A Month) 3 = SEVERE Symptoms (Occurs Almost Constantly) Gender(Required) Male Female Specialty Diet Vegan Celiac Group 11. Acid foods upset 1 2 3 2. Get chilled often 1 2 3 3. Lump in throat 1 2 3 4. Dry mouth-eyes-nose 1 2 3 5. Pulse speeds after meal 1 2 3 6. Keyed up - fail to calm 1 2 3 7. Gag occasionally 1 2 3 8. Unable to relax; startles easily 1 2 3 9. Extremities cold, clammy 1 2 3 10. Strong light irritates 1 2 3 11. Occasionally weak urine flow 1 2 3 12. Heart pounds after retiring 1 2 3 13. "Nervous" stomch 1 2 3 14. Appetite reduced occasionally 1 2 3 15. Cold sweats often 1 2 3 16. Get heated easily 1 2 3 17. Nerve discomfort 1 2 3 18. Staring, blinks little 1 2 3 19. Sour stomach frequent 1 2 3 Group 220. Joint stiffness on arising 1 2 3 21. Muscle -leg-toe cramp at night 1 2 3 22. "Butterfly" stomach, cramps 1 2 3 23. Eyes or Nose Watery 1 2 3 24. Eyes Blink Often 1 2 3 25. Eyelids swollen, puffy 1 2 3 26. Indigestion soon after Meals 1 2 3 27. Always Seem Hungry; Feels "Lightheaded" Often 1 2 3 28. Digestion Rapid 1 2 3 29. Vomiting occasionally 1 2 3 30. Hoarseness Frequent 1 2 3 31. Uneven Breathing 1 2 3 32. Pulse Slow 1 2 3 33. Gagging Reflex Slow 1 2 3 34. Difficulty Swallowing 1 2 3 35. Temporary Constipation or Diarrhea 1 2 3 36. "Slow Starter" 1 2 3 37. Get "Chilled" 1 2 3 38. Perspire Easily 1 2 3 39. Sensitive to Cold 1 2 3 40. Upper Respiratory Challenges 1 2 3 Group 341. Eat When Nervous 1 2 3 42. Excessive Appetite 1 2 3 43. Hungry Between Meals 1 2 3 44. Irritable Before Meals 1 2 3 45. Get "Shaky" if Hungry 1 2 3 46. Fatigue, Eating Relieves 1 2 3 47. "Lightheaded" if Meals Delayed 1 2 3 48. Heart Palpitates if Meals Missed or Delayed 1 2 3 49. Fatigue in Afternoons 1 2 3 50. Overeating Sweets Upsets 1 2 3 51. Awaken After Few Hours of sleep- Hard to Get Back to Sleep 1 2 3 52. Crave Candy or Coffee in Afternoons 1 2 3 53. Moods of "Blues" or Melancholy 1 2 3 54. Craving for Sweets or Snacks 1 2 3 Group 455. Hands and Feet Go to Sleep Easily, Numbness 1 2 3 56. Sigh Frequently, "Air Hunger" 1 2 3 57. Aware of "Breathing Heavily" 1 2 3 58. High Altitude Discomfort 1 2 3 59. Opens Windows in Closed Rooms 1 2 3 60. Immune System Challenges 1 2 3 61. Afternoon "Yawner" 1 2 3 62. Get "Drowsy" Often 1 2 3 63. Swollen Ankles, Worse at Night 1 2 3 64. Muscle Cramps, Worse During Exercise, Get "Charley Horses" 1 2 3 65. Difficulty Catching Breath, Especially During Exercise 1 2 3 66. Tightness or Pressure in Chest, Worse on Exertion 1 2 3 67. Skin Discolors Easily After Impact 1 2 3 68. Tendency to Anemia 1 2 3 69. Noises in Head, or "Ringing in Ears" 1 2 3 70. Fatigue Upon Exertion 1 2 3 Group 571. Dizziness 1 2 3 72. Dry Skin 1 2 3 73. Burning Feet 1 2 3 74. Blurred Vision 1 2 3 75. Itching Skin and Feet 1 2 3 76. Hair Loss 1 2 3 77. Occasional Skin Rashes 1 2 3 78. Bitter, Metallic Taste in Mouth in Mornings 1 2 3 79. Occasional Constipation 1 2 3 80. Worrier, Feels Insecure 1 2 3 81. Nausea occasionally after eating 1 2 3 82. Greasy Foods Upset 1 2 3 83. Stools light in color 1 2 3 84. Skin Peels on Foot Soles 1 2 3 85. Discomfort between shoulder blades 1 2 3 86. Occasional laxative use 1 2 3 87. Stools alternate from soft to watery 1 2 3 88. Sneezing attacks 1 2 3 89. Dreaming, nightmare type bad dreams 1 2 3 90. Bad breath (halitosis) 1 2 3 91. Milk products cause upset 1 2 3 92. Sensitive to hot weather 1 2 3 93. Burning or itching anus 1 2 3 94. Crave Sweets 1 2 3 Group 695. Loss of taste for meat 1 2 3 96. Lower bowel gas several hours after eating 1 2 3 97. Lowe bowel gas several hour after eating 1 2 3 98. Coated tongue 1 2 3 99. Pass large amount of foul-smelling gas 1 2 3 100. Indigestion 1/2-1 hour after eating; may be up to 3-4 hrs 1 2 3 101. Watery or loose stool 1 2 3 102. GAs shortly after eating 1 2 3 103. Stomach ''bloating'' 1 2 3 Group 7A104. Difficulty Sleeping 1 2 3 105. On edge 1 2 3 106. Can't Gain weight 1 2 3 107. Intolerance to heat 1 2 3 108. Highly emotional 1 2 3 109. Flush easily 1 2 3 110. Night sweats 1 2 3 111. Thin, moist skin 1 2 3 112. Inward trembling 1 2 3 113. Heart races 1 2 3 114. Increased appetite without weight gain 1 2 3 115. Pulse fast and rest 1 2 3 116. Eyelids and face twitch 1 2 3 117. Irritable and restless 1 2 3 118. Can't work under pressure 1 2 3 Group 7B119. Increase in weight 1 2 3 120. Decrease in appetite 1 2 3 121. Fatigue easily 1 2 3 122. Ringing in ears 1 2 3 123. Sleepy during day 1 2 3 124. Sensitive to skin 1 2 3 125. Dry or scaly skin 1 2 3 126. Temporary constipation 1 2 3 127. Mental sluggishness 1 2 3 128. Hair coarse, falls out 1 2 3 129. Tension n head upon arising wears off during day 1 2 3 130. Slow pulse, below 65 1 2 3 131. Changing urinary function 1 2 3 132. Sounds appear diminished 1 2 3 133. Reduced initiative 1 2 3 Group 7C134. Failing memory with age 1 2 3 135. Increased sex drive 1 2 3 136. Episodes of tension in head 1 2 3 137. Decreased sugar tolerance 1 2 3 Group 7D138. Abnormal thirst 1 2 3 139. Bloating of abdomen 1 2 3 140. Weight gain around hips or waist 1 2 3 141. Sex drive reduced or lacking 1 2 3 142. Tendency for stomach issues 1 2 3 143. Increased sugar tolerance 1 2 3 144. Menstrual disorders 1 2 3 Group 7E145. Dizziness 1 2 3 146. Headaches 1 2 3 147. Hot flashes 1 2 3 148. Hair growth on face or body (female) 1 2 3 149. Sugar in urine (not diabetes) 1 2 3 150. Masculine tendencies (female) 1 2 3 Group 7F151. Weakness, dizziness 1 2 3 152. Tired throughout day 1 2 3 153. Nails weak, ridged 1 2 3 154. Sensitive skin 1 2 3 155. Stiff joints 1 2 3 156. Perspiration increase 1 2 3 157. Bowel discomfort 1 2 3 158. Poor circulation 1 2 3 159. Swollen ankles 1 2 3 160. Crave salt 1 2 3 161. Areas of skin darkening 1 2 3 162. Upper respiratory sensitivity 1 2 3 163. Tiredness 1 2 3 164. Breathing challenges 1 2 3 Group 8165. Muscle weakness 1 2 3 166. Lack of stamina 1 2 3 167. Drowsiness after eating 1 2 3 168. Muscular soreness 1 2 3 169. Heart races 1 2 3 170. Hyper-irritable 1 2 3 171. Feeling of a band around your head 1 2 3 172. Melancholia (feeling of sadness) 1 2 3 173. Swelling of ankles 1 2 3 174. Change in urinary function 1 2 3 175. Tendency to consume sweets or carbohydrates 1 2 3 176. Muscle spasms 1 2 3 177. Blurred vision 1 2 3 178. Involuntary muscle action 1 2 3 179. Numbness 1 2 3 180. Night sweats 1 2 3 181. Rapid digestion 1 2 3 182. Sensitivity to noise 1 2 3 183. Redness of palms of hands and bottom of feet 1 2 3 184. Visible veins on chest and abdomen 1 2 3 185. Hemorrhoids 1 2 3 186. Apprehension (feeling that something bad will happen) 1 2 3 187. Nervousness causing loss of appetite 1 2 3 188. Nervousness with indigestion 1 2 3 189. Gastritis 1 2 3 190. Forgetfulness 1 2 3 191. Thinning hair 1 2 3 Female Only192. Very easily fatigued 1 2 3 193. Premenstrual tension 1 2 3 194. Menses more painful than usual 1 2 3 195. Depressed feelings before menstruation 1 2 3 196. Painful breasts during menses 1 2 3 197. Menstruate too frequently 1 2 3 198. Hysterectomy / ovaries removed 3 199. Menopausal hot flashes 1 2 3 200. Menses scanty or missed 1 2 3 201. Acne, worse at menses 1 2 3 Male Only202. Less involved in exercise/social activities 1 2 3 203. Difficult to postpone urination 1 2 3 204. Weak urinary stream 1 2 3 205. Feeling of "blues" or melancholy 1 2 3 206. Feeling of incomplete bowel evacuation 1 2 3 207. Lack of energy 1 2 3 208. Muscles in arms and legs seem softer/smaller 1 2 3 209. Tire too easily 1 2 3 210. Avoids activity 1 2 3 211. Leg nervousness at night 1 2 3 212. Diminished sex drive 1 2 3 Please List Your Top 5 ComplaintsComplaint 1 Complaint 2 Complaint 3 Complaint 4 Complaint 5
