Application For Nutrition Response Testing

Application for Nutrition Response Testing

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Name

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Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Office Phone

Cell Phone

Referred to our clinic by

Email Address

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Occupation*

Employer Name*

Employer Address

Street Address Address Line 2 City State ZIP Code

Height (in feet)*

Weight*

Weight in pounds

Sex*

Overall Health*

Excellent

Good

Fair

Other

Height (in inches)*

Age*

Date of Birth*

Month

Day

Year

Relationship Status*

Name of Spouse*

Number of children

Is the patient a minor?*

Yes

Name of Parent or Legal Guardian*

First Middle Initial Last

Chief complaint (reason you are here)*

Previous treatments for this complaint

History

List any major illnesses (with approximate dates)

List any surgery or operations (with approximate dates)

Past accidents or injuries

Name of Child(ren), Age, Sex, and any physical conditions or concerns?

Any family history of serious illnesses?*

Cancer

Diabetes

Heart

Other

None of the above

Any family history of serious illnesses - Please Explain*

Any household pets or other animals you or family members are in close contact with

What can we do to make you happier?

PLEASE READ BEFORE SIGNING:

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. Scheduled appointments that are not kept by the patient with no prior notification of cancellation may be subject to a $25 charge. Returned checks for insufficient funds may be charged $30 per incident.

Patient Signature*

INSTRUCTIONS: Mark the number that applies to you. If a symptom does not apply, leave it blank.

Mark either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occurs several times a month), or (3) for SEVERE symptoms (occurs almost constantly).

GROUP ONE - SUPPORT PARASYMPATHETIC

	N/A	(1) Mild	(2) Moderate	(3) Severe
1 Acid foods upset
2 Get chilled, often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meal
6 Keyed up - fail to calm
7 Cuts heal slowly
8 Gag easily
9 Unable to relax, startles easily
10 Extremities cold, clammy
11 Strong light irritates
12 Urine amount reduced
13 Heat pounds after retiring
14 "Nervous stomach
15 Appetite reduced
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach frequent

GROUP TWO - SUPPORT SYMPATHETIC

	N/A	(1) Mild	(2) Moderate	(3) Severe
21 Joint stiffness after arising
22 Muscle-leg-toe cramps
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen, puffy
27 Indigestion soon after meals
28 Always seem hungry; feels "lightheaded" often
29 Digestion rapid
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
36 Constipation, diarrhea alternating
37 "Slow starter"
38 Get "chilled" infrequently
39 Perspire easily
40 Circulation poor, sensitive to cold
41 Subject to colds, asthma, bronchitis

GROUP THREE - HYPOGLYCEMIA

	N/A	(1) Mild	(2) Moderate	(3) Severe
42 Eat when nervous
43 Excessive appetite
44 Hungry between meals
45 Irritable before meals
46 Get "shaky" if hungry
47 Fatigue, eating relieves
48 "Lightheaded" if meals delayed
49 Heart palpitates if meals missed or delayed
50 Afternoon headaches
51 Overeating sweets upsets
52 Awaken after few hours sleep - hard to get back to sleep
53 Crave candy or coffee in afternoons
54 Moods of depression - "blues" or melancholy
55 Abnormal craving for sweets or snacks

GROUP FOUR - CARDIOVASCULAR

	N/A	(1) Mild	(2) Moderate	(3) Severe
56 Hands and feet go to sleep easily, numbness
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 High altitude discomfort
60 Opens windows in closed room
61 Susceptible to colds and fevers
62 Afternoon "yawner"
63 Get "drowsy" often
64 Swollen ankles worse at night
65 Muscle cramps, worse during exercise; get "charley horses"
66 Shortness of breath on exertion
67 Dull pain in chest or radiating into left arm, worse on exertion
68 Bruise easily, "black and blue" spots
69 Tendency to anemia
70 "Nose bleeds" frequent
71 Noises in head, or "ringing in ears"
72 Tension under the breastbone, or feeling of "tightness", worse on exertion

GROUP FIVE - LIVER, GALLBLADDER, INTESTINES

	N/A	(1) Mild	(2) Moderate	(3) Severe
73 Dizziness
74 Dry skin
75 Burning feet
76 Blurred vision
77 Itching skin and feet
78 Excessive falling hair
79 Frequent skin rashes
80 Bitter, metallic taste in mouth in mornings
81 Bowel movements painful or difficult
82 Worrier, feels insecure
83 Feeling queasy; headache over eyes
84 Greasy foods upset
85 Stools light-colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks or gallstones
91 Sneezing attacks
92 Dreaming, nightmare type bad dreams
93 Bad breath (halitosis)
94 Milk products cause distress
95 Sensitive to hot weather
96 Burning of itching anus
97 Crave sweets

GROUP SIX - DIGESTION OF PROTEIN

	N/A	(1) Mild	(2) Moderate	(3) Severe
98 Loss of taste for meat
99 Lower bowel gas several hours after eating
100 Burning stomach sensations, eating relieves
101 Coated tongue
102 Pass large amounts of foul-smelling gas
103 Indigestion ½ - 1 hour after eating; may be up to 3-4 hours
104 Mucous colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (A) Hyperthyroid

	N/A	(1) Mild	(2) Moderate	(3) Severe
107 Insomnia
108 Nervousness
109 Can't gain weight
110 Intolerance to heat
111 Highly emotional
112 Flush easily
113 Night sweats
114 Thin, moist skin
115 Inward trembling
116 Heart palpitates
117 Increased appetite without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can't work under pressure

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (B) Hypothyroid

	N/A	(1) Mild	(2) Moderate	(3) Severe
122 Increase in weight
123 Decrease in appetite
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
127 Sensitive to cold
128 Dry or scaly skin
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
132 Headaches upon arising wear off during day
133 Slow pulse, below 65
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (C) Hyper-Pit

	N/A	(1) Mild	(2) Moderate	(3) Severe
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches, "splitting or rendering" type
141 Decreased sugar tolerance

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (D) Hypo-Pit

	N/A	(1) Mild	(2) Moderate	(3) Severe
142 Abnormal thirst
143 Bloating of abdomen
144 Weight gain around hips or waist
145 Sex drive reduced or lacking
146 Tendency to ulcers, colitis
147 Increased sugar tolerance
148 Women: menstrual disorders
149 Young girls: lack of menstrual function

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (E) Hyper Andrenals

	N/A	(1) Mild	(2) Moderate	(3) Severe
150 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 Hair growth on face of body (female)
155 Sugar in urine (not diabetes)
156 Masculine tendencies (female)

GROUP SEVEN - ENDOCRINE SYSTEM, HPA AXIS: (F) Hypo Andrenals

	N/A	(1) Mild	(2) Moderate	(3) Severe
157 Weakness, dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails, weak, ridged
161 Tendency to hives
162 Arthritic tendencies
163 Perspiration increase
164 Bowel disorders
165 Poor circulation
166 Swollen ankles
167 Crave salt
168 Brown spots or bronzing of skin
169 Allergies - tendency to asthma
170 Weakness after colds, influenza
171 Exhaustion - muscular and nervous
172 Respiratory disorders

GROUP EIGHT

	N/A	(1) Mild	(2) Moderate	(3) Severe
173 Apprehension
174 Irritability
175 Morbid fears
176 Never seems to get well
177 Forgetfulness
178 Indigestion
179 Poor appetite
180 Craving for sweets
181 Muscular soreness
182 Depression; feelings of dread
183 Noise sensitivity
184 Acoustic hallucinations
185 Tendency to cry without reason
186 Hair is coarse and/or thinning
187 Weakness
188 Fatigue
189 Skin sensitive to touch
190 Tendency toward hives
191 Nervousness
192 Headache
193 Insomnia
194 Anxiety
195 Anorexia
196 Inability to concentrate; confusion
197 Frequent stuffy nose; sinus infections
198 Allergy to some foods
199 Loose joints

FEMALE ONLY

	N/A	(1) Mild	(2) Moderate	(3) Severe
200 Very easily fatigued
201 Premenstrual tension
202 Painful menses
203 Depressed feelings before menstruation
204 Menstruation excessive and prolonged
205 Painful breasts
206 Menstruate too frequently
207 Vaginal discharge
208 Hysterectomy/ovaries removed
209 Menopausal hot flashes
210 Menses scanty or missed
211 Acne, worse at menses
212 Depression of long standing

MALE ONLY

	N/A	(1) Mild	(2) Moderate	(3) Severe
213 Prostate trouble
214 Urination difficult or dribbling
215 Night urination frequent
216 Depression
217 Pain on inside of legs or heels
218 Feeling of incomplete bowel evacuation
219 Lack of energy
220 Migrating aches and pains
221 Tire too easily
222 Avoids activity
223 Leg nervousness at night
224 Diminished sex drive

IMPORTANT
Please list below the five main physical complaints you have in order of their importance

Physical complaint 1

Physical complaint 2

Physical complaint 3

Physical complaint 4

Physical complaint 5

Chi Rho Corrective

650 S Shackleford Rd Ste 400-Z, Little Rock, AR 72211

PERMISSION & AUTHORIZATION FORM

REGARDING THE USE OF NUTRITION RESPONSE TESTING™

PLEASE READ BEFORE SIGNING:

I specifically authorize the natural health practitioners at Chi Rho Corrective to perform a Nutrition Response Testing health analysis and 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 Nutrition Response Testing 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 Nutrition Response Testing is 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 Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand that Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid in determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

I have read and understand the foregoing. This permission form applies to subsequent visits and consultations.

Signature of patient*
Signature of parent or guardian only*

Chi Rho Corrective

650 S Shackleford Rd Ste 400-Z, Little Rock, AR 72211

Patient Consent for Use and Disclosure
Of Protected Health Information

PLEASE READ BEFORE SIGNING:
I hereby give my consent for Chi Rho Corrective, P.A. (hereinafter referred to as “CRC”) to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

CRC's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. A copy of this Notice is available upon request to Dr. Joshua Witter, our Privacy Officers, or any other CRC staff member.

CRC reserves the right to revise its Notice of Privacy Practices at any time and agrees to provide me a revised copy upon my request to CRC.

With this consent, the CRC may call (or text message) my home or other designated phone number on file and leave a message on voice mail or in person in reference to any items that assist CRC in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, CRC may mail to my home or other designated location on file any items that assist CRC in carrying out TPO, such as patient statements.

With this consent, CRC may e-mail to my home or other designated location on file any items that assist CRC in carrying out TPO, such as appointment reminders and patient statements.

I have the right to request that CRC restrict how it uses or discloses my PHI to carry out TPO. However, CRC is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to CRC's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that CRC has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, CRC may decline to provide treatment to me as permitted by Section 164.506 of the Code of Federal Regulations.
Signature of patient*
Signature of parent or guardian only*
Consent
I have been given and am in receipt of CRC's Notice of Privacy Practices.
(please initial)
Consent
I do not wish to receive a copy of CRC's Notice of Privacy Practices.
(please initial)

Consent to Treat Form – Chi Rho Corrective
CHI RHO CORRECTIVE – CONSENT TO CHIROPRACTIC TREATMENT

At Chi Rho Corrective, we are committed to providing quality chiropractic care focused on corrective and wellness-based treatment. Please read the following information carefully and sign below to indicate your understanding and consent.

Nature of Chiropractic Treatment
Chiropractic care involves the science, philosophy, and art of detecting and correcting vertebral subluxations and other musculoskeletal dysfunctions. Techniques may include spinal adjustments/manipulations, soft tissue therapy, rehabilitative exercises, and other supportive modalities.

Potential Benefits
Chiropractic treatment can improve mobility, reduce pain, restore function, and promote overall wellness.

Possible Risks
As with any healthcare procedure, there are potential risks, including but not limited to:

Temporary soreness or discomfort

Dizziness or nausea

Aggravation of underlying conditions

Rare but serious complications such as stroke (with cervical spine manipulation)

Voluntary Consent
I understand that:

The doctor will explain the procedures and answer all questions.

I have the right to refuse or discontinue treatment at any time.

I am not being coerced into treatment and consent voluntarily.

Acknowledgment
I acknowledge that no guarantee has been made regarding the outcome of my treatment.
Signature of Patient (or Legal Guardian)*
HIPAA Consent Form – Chi Rho Corrective
CHI RHO CORRECTIVE – HIPAA PRIVACY CONSENT FORM

To comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Chi Rho Corrective must inform you of your rights and our responsibilities regarding your Protected Health Information (PHI).

Your Rights:

You have the right to review our Notice of Privacy Practices before signing this consent.

You have the right to request restrictions on how we use and disclose your PHI.

You may revoke this consent in writing at any time.

Our Responsibilities:

We will use your PHI for treatment, payment, and healthcare operations.

We will maintain the privacy of your records as required by law.

We will provide care whether or not you sign this form, though refusal may limit insurance processing.

Consent:
By signing below, you acknowledge that you:

Have received and/or reviewed Chi Rho Corrective’s Notice of Privacy Practices .

Authorize the use and disclosure of your PHI as described above.

Signature of Patient (or Legal Guardian)*

Application for Nutrition Response Testing

History

Chi Rho Corrective

650 S Shackleford Rd Ste 400-Z, Little Rock, AR 72211

PERMISSION & AUTHORIZATION FORM

REGARDING THE USE OF NUTRITION RESPONSE TESTING™

Chi Rho Corrective

650 S Shackleford Rd Ste 400-Z, Little Rock, AR 72211

Patient Consent for Use and Disclosure Of Protected Health Information

Consent to Treat Form – Chi Rho Corrective

Nature of Chiropractic Treatment

Potential Benefits

Possible Risks

Voluntary Consent

Acknowledgment

HIPAA Consent Form – Chi Rho Corrective

Your Rights:

Our Responsibilities:

Consent:

Patient Consent for Use and Disclosure
Of Protected Health Information