Instructions for Completing Paperwork

Instructions for Completing Paperwork

Make sure you fill all forms out completely including: Permission & Authorization Form (1 page),Confidential Patient Information (2 pages), System Survey Form (2 pages. The doctor will take thepulse and blood pressure) and the Daily Record of Food Intake (1 page or at least two days record). Ifthe forms are not completed, the doctor will not be able to see you and your appointment may need tobe rescheduled.

Daily Food Log Guidelines

InstructionsWrite down the type of food you eat at each meal. Record ANYTHING and EVERYTHING thatpasses your lips.

This includes snacks and the pass-thru-the-kitchen-to-get-to-the-other-room nibbles. Be as specific aspossible. Include sauces, gravies or any condiments.

Write down every morselKeep your form with you all day and write down everything you eat and/or drink, no matter how smallor large the serving. A piece of candy, package of Oreos (count them), handful of nuts or soft drink orjuice... .ANYTHING that crosses your lips.

Do It NOW!Write it down immediately. Don't depend on your memory at the end of the day... .Record as you go.

Be SpecificIf you eat a BLT, write it down. Include WHAT you eat with it (bread, mayo cheese, onion rings,fries, cappuccino, chips, etc.) If you use oil to cook with write down the exact oil used (olive, sesame,coconut, butter, etc).

Tell the truthThere's nothing to be gained by trying to look good or please us when you are filling out the food log.We can help you more if we know exactly what you're eating so help us!

ExampleBreakfast Lunch Dinner2 eggs, fried in butter Corned Beef on Rye w/ Caesar Salad1 pkt Brown Sugar Sour kraut, onions, mayo. Lasagne @ Olive GrdnOatmeal w/Raisins Choc Chip Cookie 3 Bread Sticks

Half & Half Water Xtra cheese & sauceBlack Coffee Sweet Tea

No snacks today... includes supplements and 2 quarts of water.

Mt. Juliet Chiropractic, PC2345N. Mt. Juliet Road, Mt. Juliet, TN 37122

Phone: 615-758-8978 - www.mtjulietchiropractic.com

PERMISSION & AUTHORIZATION FORMREGARDING THE USE OF NUTRITIONAL TESTING

PLEASE READ BEFORE SIGNING:

I specifically authorize the natural health practitioners at the Mt. Juliet Chiropractic toperform a Biomeridian Computer - MSA 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 thetreatment, or "cure" of any disease.

I understand that Biomeridian Computer - MSA Testing is a safe, non-invasive,natural method of analyzing the body's physical and nutritional needs, and that deficiencies orimbalance in these areas could cause or contribute to various health problems.

I understand that Biomeridian Computer - MSA is not a method for "diagnosing" or"treating" of any disease including conditions of cancer, AIDS, infections, or other medicalconditions, and that these are not being tested for or treated.

No promise or guarantee has been made regarding the results of Biomeridian computer -MSA and/or natural health, nutritional or dietary programs recommended, but rather I understandthat Biomeridian Computer - MSA testing is a means by which the body's natural acupuncturepoints can be used as an aid to determining possible nutritional imbalances, so that safe naturalprograms 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.

Date:

Print Name:

Address:

City State Zip

Phone: (_ _)

Signed:

(If minor, signature of parent or guardian required)

Witness:

Confidential Patient Information

Please Print

Name Today's Date_

Address City,State,Zip

Home Phone Cell Phone Work Phone

Age Birthdate Sex: M F Height: Weight_

Marital Status: M S W D Email Address

Your Employer Occupation_

Overall Health (circle one) Excellent Good Fair Poor Other_

Chief Complaint (reason you are here):

Previous Treatments for this Complaint_

Other Complaints or Problems:_

Current Medications / Drugs being taken (use separate sheet if needed)_

Are you currently under the care of a physician or other health care professional? (if yes, please give name and date of last visit)

No Yes

List Nutritional Supplements you are taking (use separate sheet if needed)

Do you smoke, Drink coffee, or use alcohol? No Yes If yes indicate how much below)

Tobacco Coffee Alcohol

History

List any major illnesses (with approximate dates they started)_

List any surgeries or operations with approximate dates:

Name: Date

Past Accidents of Injuries_

List any allergies you have:_

Name of Spouse Describe Health of Spouse

Number of Children if any:

Name of Child Age Sex Any physical conditions or concerns?

M F

M F

M F

Any family history of serious illness (circle those which apply): Cancer / Diabetes / Heart Disease / Other :

Any household pets or other animals you or your family are in close contact with? Dog / Cat / Other_

How were you referred to our office? Friend/Family Name_

Newspaper Yellow Pages Sign Other

I (we) hereby agree to pay for services rendered to the above mentioned patient as the charge is incurred. I understand and agreethat health & accident insurance policies do not cover any of these charges, and that I am wholly responsible for any chargesincurred. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered will beimmediately due and payable.

Method of Payment you plan to use to take care of todays charges:

Check Cash Visa/MC American Express Discover

Patient's Signature Date_

Spouse or Guardian's Signature Date_

Name Date

SYSTEMS SURVEY FORMPatient

Birth Date ' '

Pulse: Recumbent

Blood pressure: Recumbent

Doctor Date

Approx Weight

Standing

Standing

Sex: Male Q Female

Vegetarian: Yes Q] No

Ragland's Test is Positive

INSTRUCTIONS: Fill in only the circles which apply to you.• O O MILD symptoms (occurs rarely).O • O MODERATE symptoms (occurs several times a month).O O • SEVERE symptoms (occurs almost constantly)O O O Leave circles BLANK if they don't apply to you!

1 2 3 GROUP 11 O O O Acid foods upset2 O O O Get chilled often3 O O O "Lump" in throat4 O O O Dry mouth-eyes-nose5 O O O Pulse speeds after meal6 O O O Keyed up - fail to calm7 O O O Cut heals slowly8 O O O Gag easily9 O O O Unable to relax; startles easily

10 O O O Extremities cold, clammy11 O O O Strong light irritates12 O O O Urine amount reduced13 O O O Heart pounds after retiring14 O O O "Nervous" stomach15 OOO Appetite reduced16 O O O Cold sweats often17 O O O Fever easily raised18 O O O Neuralgia-like pains19 OOO Staring, blinks little20 O O O Sour stomach often

GROUP 221 O O O Joint stiffness on arising22 O O O Muscle-leg-toe cramps at night23 O O O "Butterfly" stomach, cramps24 O O O Eyes or nose watery25 O O O Eyes blink often26 O O O Eyelids swollen, puffy27 O O O Indigestion soon after meals28 O O O Always seems hungry; feels "lightheaded" often29 O O O Digestion rapid30 O O O Vomiting frequent31 O O O Hoarseness frequent32 O O O Breathing irregular33 O O O Pulse slow; feels "irregular"34 O O O Gagging reflex slow35 O O O Difficulty swallowing36 O O O Constipation, diarrhea alternating37 O O O "Slow starter"38 O O O Get "chilled" infrequently39 O O O Perspire easily40 O O O Circulation poor, sensitive to cold41 O O O Subject to colds, asthma, bronchitis

GROUP 342 O O O Eat when nervous43 O O O Excessive appetite44 O O O Hungry between meals45 O O O Irritable before meals46 O O O Get "shaky" if hungry47 O O O Fatigue, eating relieves48 O O O "Lightheaded" if meals delayed49 0 O O Heart palpitates if meals missed or delayed50 O O O Afternoon headaches51 O O O Overeating sweets upsets

1 2 352 OOO53 O OO54 O OO55 O OO

56 O OO57 OOO58 O OO59 O OO

O O OO O OO O OO O OO O OO O OO O OO O OO O OO O OO O OO O O

60616263646566676869707172 O OO

73 O OO74 O OO75 OOO76 OOO77 OOO78 OOO79 O OO80 O OO81 OOO82 O OO83 00084 OOO85 O OO86 O OO87 OOO88 O OO89 OOO90 O OO91 O OO92 O OO93 OOO94 OOO95 O OO96 OOO97 OOO

98 O OO99 OOO

100 O O O101 O O O102 O O O103 O O O104 000105 O O O106 000

Awaken after few hours sleep - hard to get back to sleepCrave candy or coffee in afternoonsMoods of depression - "blues" or melancholyAbnormal craving for sweets or snacks

GROUP 4Hands and feet go to sleep easily, numbnessSigh frequently, "air hunger"Aware of "breathing heavily"High altitude discomfortOpens windows in closed roomsSusceptible to colds and feversAfternoon "yawner"Get "drowsy oftenSwollen ankles, worse at nightMuscle cramps, worse during exercise; get "Charley horses"Shortness of breath on exertionDull pain in chest or radiating into left arm, worse on exertionBruise easily, "black and blue" spotsTendency to anemia"Nose bleeds" frequentNoises in head, or "ringing in ears"Tension under the breastbone, or feeling of "tightness", worseon exertion

GROUP 5DizzinessDry skinBurning feetBlurred visionItching skin and feetExcessive falling hairFrequent skin rashesBitter, metallic taste in mouth in morningsBowel movements painful or difficultWorrier, feels insecureFeeling queasy; headache over eyesGreasy foods upsetStools light coloredSkin peels on foot solesPain between shoulder bladesUse laxativesStools alternate from soft to wateryHistory of gallbladder attacks or gallstonesSneezing attacksDreaming, nightmare type bad dreamsBad breath (halitosis)Milk products cause distressSensitive to hot weatherBurning or itching anusCrave sweets

GROUPSLoss of taste for meatLower bowel gas several hours after eatingBurning stomach sensations, eating relievesCoated tonguePass large amounts of foul-smelling gasIndigestion 1/2-1 hour after eating; may be up to 3-4 hrs.Mucous colitis or "irritable bowel"Gas shortly after eatingStomach "bloating" after eating

1 2 3 GROUP7A107 O O O Insomnia108 O O O Nervousness109 OOO Can't gain weight110 O O O Intolerance to heat111 O O O Highly emotional112 O O O Flush easily113 O O O Night sweats114 O O O Thin, moist skin115 O O O Inward trembling116 OOO Heart palpitates117 O O O Increased appetite without weight gain118 O O O Pulse fast at rest119 O O O Eyelids and face twitch120 O O O Irritable and restless121 OOO Can't work under pressure

GROUP 7B122 O O O Increase in weight123 O O O Decrease in appetite124 O O O Fatigue easily125 O O O Ringing in ears126 O O O Sleepy during day127 OOO Sensitive to cold128 O O O Dry or scaly skin129 O O O Constipation130 O O O Mental sluggishness131 O O O Hair coarse, falls out132 OOO Headaches upon arising, wear off during day133 O O O Slow pulse, below 65134 O O O Frequency of urination135 O O O Impaired hearing136 OOO Reduced initiative

GROUP 7C137 O O O Failing memory138 O O O Low blood pressure139 O O O Increased sex drive140 O O O Headaches, "splitting or rending" type141 O O O Decreased sugar tolerance

GROUP7D142 O O O Abnormal thirst143 O O O Bloating of abdomen144 O O O Weight gain around hips or waist145 O O O Sex drive reduced or lacking146 O O O Tendency to ulcers, colitis147 O O O Increased sugar tolerance148 OOO Women: menstrual disorders149 O O O Young girls: lack of menstrual function

GROUP7E150 O O O Dizziness151 O O O Headaches152 OOO Hot flashes153 O O O Increased blood pressure154 O O O Hair growth on face or body (female)155 OOO Sugar in urine (not diabetes)156 O O O Masculine tendencies (female)

GROUP7F157 O O O Weakness, dizziness158 OOO Chronic fatigue159 O O O Low blood pressure160 O O O Nails weak, ridged161 OOO Tendency to hives162 OOO Arthritic tendencies163 O O O Perspiration increase164 OOO Bowel disorders165 O O O Poor circulation166 O O O Swollen ankles167 OOO Crave salt168 O O O Brown spots or bronzing of skin169 OOO Allergies - tendency to asthma

1 2 3170 OOO171 OOO172 OOO

173 O O O174 O O O175 O O O176 O O O177 000178 O O O179 O O O180 OOO181 OOO

OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

193 O O O194 O O O195 O O O196 O O O197 O O O198 O O O199 O O O

182183184185186187188189190191192

200201202203204

OOOOOOOOOOOOOOO

205 O O O206 O O O207 O O O

OO O O000000O O O

208209210211212

213 OOO214 O O O215 000216 O O O217 O O O218 O O O219 O O O220 O O O221 O O O222 O O O223 O O O224 O O O

Weakness after colds, influenzaExhaustion - muscular and nervousRespiratory disorders

GROUP 8ApprehensionIrritabilityMorbid fearsNever seems to get wellForgetfulnessIndigestionPoor appetiteCraving for sweetsMuscular sorenessDepression; feelings of dreadNoise sensitivityAcoustic hallucinationsTendency to cry without reasonHair is coarse and/or thinningWeaknessFatigueSkin sensitive to touchTendency toward hivesNervousnessHeadacheInsomniaAnxietyAnorexiaInability to concentrate; confusionFrequent stuffy nose; sinus infectionsAllergy to some foodsLoose jointsFEMALE ONLYVery easily fatiguedPremenstrual tensionPainful mensesDepressed feelings before menstruationMenstruation excessive and prolongedPainful breastsMenstruate too frequentlyVaginal dischargeHysterectomy / ovaries removedMenopausal hot flashesMenses scanty or missedAcne, worse at mensesDepression of long standingMALE ONLYProstate troubleUrination difficult or dribblingNight urination frequentDepressionPain on inside of legs or heelsFeeling of incomplete bowel evacuationLack of energyMigrating aches and painsTire too easilyAvoids activityLeg nervousness at nightDiminished sex drive

List the five main complaints you have in the order of their importance:

4..

5..

Dally ReCOrd Of FOOd Intake I Your diet may be the key to better health.

Each day, record all the items you eat and drink. Be sure to include the approximate amount of eachitem. When you have completed this form, return it to your health care professional for evaluation.

Standard

Name:

Day 1-Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables &_Fruits:__

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

Snack:

Bowel MovementS(# and consistency):

LUNCH Time:

MID-DAY SNACK Time:

Hours of Sleep:

DINNER T,r

NIGHTTIME SNACK Time:

Quality of Sleep: (g«xi)1 2 3 4 5 (poor)

Day 2-Date:

BREAKFAST Time:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, S Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Time:

Snack:

Bowel Move fnentS(# and consistency):

LUNCH Time:

MID-DAY SNACK Time.

Hours of Sleepy

DINNER Tn

NIGHTTIME SNACK Time:

Quality of Sleep: (good)1 2 3 4 5 (poor)

Day 3-Date:

BREAKFAST T,me:

Meat & Dairy:

Vegetables & Fruits:

Breads, Cereals, & Grains:

Fats (butter, margarine, oils, etc.):

Candy, Sweets, & Junk Food:

Water Intake (fl. oz.):

Other Drinks:

MID-MORNING SNACK Tin

Snack:

Bowel Movements^ and consistency):

LUNCH Time:

MID-DAY SNACK Tir

Hours of Sleep:

DINNER Time:

NIGHTTIME SNACK Time:

Quality of Sleep: (good)1 2 3 4 5 (poor)

Notes:

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