New Patient Form

Permission and Authorization Form
I specifically authorize the natural health practitioner at Infinity Wellness Center to perform a neurological spinal exam and a Nutrition Response Testing health analysis and to develop a natural, complementary health improvement program for me which may include spinal adjustments, acupuncture, dietary guidelines, and nutritional supplements in order to assist me in improving my health and not for the treatment or 'cure' of any diseases.
I understand the Nutritional Response Testing is a safe, non-invasive, natural method of analyzing the body's physical and nutritional needs, and that deficiencies or imbalances in these areas could cause or contribute to various health problems.
I understand that the practitioner is not using a method for 'diagnosing' or 'treating' any disease and that no promise or guarantee has been made regarding the result of Nutritional Response Testing or any natural health, nutritional, or dietary programs recommended.
Cancellation Policy: No fee is charged if more than 48 hour notice is given for a cancellation or reschedule. We require a $50 fee for schedule changes made within 48 hours, but no more than 24 hours prior to the appointment. The patient will be charged full price for missed visits that are no-showed or cancelled within 24 hours of appointment time.
I also understand that Infinity Wellness Center does NOT bill insurance companies directly nor do they accept Medicare. Infinity Wellness Center does provide a Super Bill with diagnostic codes to submit for reimbursement.
This permission form applies to subsequent visits and consultations. I understand that entering my name on the signature line constitutes a legal signature confirming that I acknowledge and agree to the terms above.
Date*
MM slash DD slash YYYY
Name*
First Last
Signature*
Signature of parent or guardian required for minors. Please type your name again here to indicate that you accept the use of electronic signatures, and that you are signing this document here electronically.

What to Expect on Your First Few Visits
Visit #1 The initial visit will take 40 minutes to an hour; thorough history and exam is taken and may include a neurological and kinesiology exam using nutrition response testing. We will take this information and determine if your case is a good fit for us. If it is, we will order any necessary lab testing and formulate a program designed on your exam findings.
Visit #2 This is my favorite day; it will ideally be a week or two after your initial visit. This is when you will receive a Report of Findings (ROF), lab results and treatment plan that is specific to you. We will map out the meridian points, organ systems, and spinal levels that need to be addressed and corrected.
If you agree with the treatment plan and choose to accept care, we will start your treatment this day.
Treatments will include one or a combination of the following techniques:
- Nutritional Response Testing (determining which supplements are best for you)
- Acupuncture or Acupressure
- Chiropractic
- Neuro-Emotional Technique (NET)
- Webster Technique/Prenatal Care
- Cold Laser
- Myofascial Release
- Cranial Sacral Therapy
- Flex.ion Distraction
Subsequent Visits may include a combination of the above treatments. Treatments are determined by what your body needs to keep moving forward in the healing process.

HIPAA Privacy Disclosure Consent
Privacy of your personal information is an important part of our office providing you with quality care. We understand the importance of protecting your personal infonnation. We are committed to collecting, using and disclosing your personal information responsibly.
All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
Uses and Disclosures
1. Your doctor or a staff member may have to disclose your health information up to and including all of your clinical records to another health care provider if it is necessary to refer you to them for treatment of your health condition.
2. It may be necessary for the doctor and members of the staff to use your health information, examination, and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
3. Your doctor and members of the practice staff may need to use your information (ex. name, address, email, phone number, and your clinical records) to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. Appointment reminders will be sent by email to the email address you provided to us or by calling the phone number provided and leaving a message on your voicemail if there is no answer.
4. As our patient, you possess the right to refuse to give us the authority to contact you regarding the above-mentioned circumstances.
Your Right to Limit Uses or Disclosures
1. You have the right to request that this office restricts how your personal information is used and/or disclosed.
2. If there are health care providers, hospitals, or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information.
3. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restrictions would have to be in writing and the restrictions will be binding on this office.
Your Right to Revoke Your Authorization
1. You have the right to revoke your consent at any time as long as we have a written statement. This revocation will not apply to any action already taken by the office before receiving the formal written notice.
I have read and understand the above notice. I understand that entering my name on the signature line constitutes a legal signature confirming that I acknowledge and agree to the terms above.
Date*
MM slash DD slash YYYY
Name*
First Last
Signature*
Signature of parent or guardian required for minors. Please type your name again here to indicate that you accept the use of electronic signatures, and that you are signing this document here electronically.

New Client Evaluation
How did you hear about us?
Name
First Last
Sex
- Male
- Female
Birthdate
Month
Day
Year
Age
Mailing Address
Street Address Address Line 2 City State ZIP Code
Occupation
Marital Status
- Single
- Married
- Divorced
- Widow
Weight
Height
Number of Children
Primary Phone
Secondary Phone
Email
Blood Type
Complaints
Please tell us the main reason why you are here.
Secondary Complaints
Please let us know any other health concerns.
Previous Treatment for these Complaints

Major Illnesses

Surgeries

Injuries

Metabolic Assessment Form
Part I Are there any other major health concerns?
Other Major Health Concerns
Part II Please rate each of the following on a scale from 0-3, with 0 as the least/never to 3 as the most/always.

Category I

	Never	Sometimes	Always
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or "fuzzy" debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
use laxatives frequently

Category II

	Never	Sometimes	Always
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating

Category III
Never Sometimes Always
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc
Multiple smell and chemical sensitivities
Constant skin outbreaks

Category IV

	Never	Sometimes	Always
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting proteins and meats; undigested food found in stools

Category V

	Never	Sometimes	Always
Stomach pain, burning, or aching 1-4 hours after eating
Use of antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids food, milk, or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI

	Never	Sometimes	Always
Difficulty digesting roughage and fiber
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucus like, greasy, or poorly formed
Frequent loss of appetite

Category VII

	Never	Sometimes	Always
Abdominal distention after consumption of fiber, starches, and sugar
Abdominal distention after certain probiotic or natural supplements
Decreased gastrointestinal motility constipation
Increased gastrointestinal motility, diarrhea
Alternating constipation and diarrhea
Suspicion of nutritional malabsorption
Frequent use of antacid medication

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?
- Yes
- No

Category VIII

	Never	Sometimes	Always
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair

Do you have a history of gallbladder attacks or stones?
Do you have a history of gallbladder attacks or stones?
- Yes
- No
Have you had your gallbladder removed?
Have you had your gallbladder removed?
- Yes
- No
Category IX
Never Sometimes Always
Acne and unhealthy skin
Excessive hair loss
Overall sense or bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat

Category X

	Never	Sometimes	Always
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory, forgetful between meals
Blurred vision

Category XI

	Never	Sometimes	Always
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight

Metabolic Assessment Form Continued
Category XII
Never Sometimes Always
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails

Category XIII

	Never	Sometimes	Always
Cannot fall asleep
Perspire easily
Under a high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity

Category XIV

	Never	Sometimes	Always
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing

Category XV

	Never	Sometimes	Always
Tired/sluggish
Feel cold — hands, feet, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness

Category XVI
Never Sometimes Always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
Category XVII
Never Sometimes Always
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night

Category XVIII

	Never	Sometimes	Always
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past

Category XIX (Menstruating Females Only)

	Never	Sometimes	Always
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning

Perimenopausal
Perimenopausal
- Yes
- No
Alternating menstrual cycle lengths
Alternating menstrual cycle lengths
- Yes
- No
Extended menstrual cycle (greater than 32 days)
Extended menstrual cycle (greater than 32 days)
- Yes
- No
Shortened menstrual cycle (less than 24 days)
Shortened menstrual cycle (less than 24 days)
- Yes
- No
Category XX (Menopausal Females Only)
Never Sometimes Always
Hot flashes
Mental fogginess
Disintrest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching
How many years have you been menopausal?
How many years have you been menopausal?
Since menopause, do you ever have uterine bleeding?
Since menopause, do you ever have uterine bleeding?
- Yes
- No
Part III
How many alcoholic beverages do you consume per week?
How many alcoholic beverages do you consume per week?
How many caffeinated beverages do you consume per day?
How many caffeinated beverages do you consume per day?
How many times do you eat out per week?
How many times do you eat out per week?
How many times do you eat raw nuts or seeds per week?
How many times do you eat raw nuts or seeds per week?
Rate your stress level on a scale of 1-10 during the average week:
Rate your stress level on a scale of 1-10 during the average week:
Please enter a number from 1 to 10.
How many times do you eat fish per week?
How many times do you eat fish per week?
How many times do you work out per week?
How many times do you work out per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Part IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Trauma History
Please note on the form below:
1. Areas where you have scars, even if they are very old or difficult to see. Don't forget C-sections, episiotomies, vaccination scars, surgeries, body piercings, tattoos, cosmetic surgeries, vasectomies, stretch marks, etc. Please note the approximate age you were when you got each scar.
2. Please note the location of any surgeries, including exploratory surgeries, laparoscopies etc. Please note the year of the surgery.
3. Please note areas where there are any internal metal objects, such as surgical pins, metal plates, hip replacements etc.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

Dental History
Directions: On the form below, please describe what kind of dental work/procedure has been done on each tooth and the approximate age you were at the time. Please include if you have undergone any of the following procedures:
- Silver fillings
- Composite or porcelain fillings
- Gold fillings or crowns
- Root canals
- Veneers
- Bridge
- Dentures
- Extracted teeth
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Body Type Assessment
Please select the body type which most closely resembles you.
- Tend to have a small chest relative to the rest of the body; a forward head carriage; rounded shoulders and "baby fat" all over the body.
- Tend to have a sturdy body with a straight flat back and extra weight carried in the front.
- Tend to have extra weight on the thighs and upper hips, a curvy waist and tapering lower arms and legs. Also tends to carry fat on the stomach, mainly below the belly button.
- Tend to have a small upper body compared to the lower body, with a small waist and "saddlebags" on the outer thighs. Extra weight tends to be carried behind (especially on the rear end) with a relatively flat stomach.

Body Type Assessment
Please select the body type which most closely resembles you.
- Tend to have a small chest relatively to the midsection of the body and weight gain all over, including on the back. Also tend to have a forward head carriage, a "double-chin" and less defined muscles.
- Tend to have a strong, sturdy appearance with a broad chest and thick arms and legs. Carries weight out in front with a rounded rear end and a thick neck.
- Tend to have long arms and legs, with accumulation of fat on the thighs and "love handles" —a roll of fat around the middle. From the side, a flat rear-end. Neck tends not to accumulate weight.
- Tend to have a pot belly but without significant weight gain on the arms and legs; weight gain is primarily on the belly. Usually have a fullness or pressure in the upper abdomen, just under the rib cage.

Neurotransmitter Assessment Form™ (NTAF)
Please rate the following on a scale from 0-3, 0 as the least/never to 3 as the most/always.
Section A

Never Sometimes Always
Is your memory noticeably declining?
Are you having a hard time remembering names and phone numbers?
ls your ability to focus noticeably declining?
Has it become harder for you to learn new things?
How often do you have a hard time remembering your appointments?
Is your temperament generally getting worse?
Is your attention span decreasing?
How often do you find yourself down or sad?
How often do you become fatigued when driving compared to in the past?
How often do you become fatigued when reading compared to in the past?
How often do you walk into rooms and forget why?
How often do you pick up your cell phone and forget why?

Section B

Never Sometimes Always
Do you have a high stress level?
How often do you feel you have something that must be done?
Do you feel you never have time for yourself?
How often do you feel you are not getting enough sleep or rest?
Do you find it difficult to get regular exercise?
Do you feel uncared for by the people in your life?
Do you feel you are not accomplishing your life's purpose?
Is sharing your problems with someone difficult for you?

Section C

Section C1
Never Sometimes Always
How often do you get irritable, shaky, or have light-headedness between meals?
How often do you feel energized after eating?
How often do you have difficulty eating large meals in the morning?
How often does your energy level drop in the afternoon?
How often do you crave sugar and sweet in the afternoon?
How often do you wake up in the middle of the night?
How often do you have difficulty concentrating before eating?
How often do you depend on coffee to keep yourself going?
How often do you feel agitated, easily upset, and nervous between meals?

Section C2
Never Sometimes Always
How often do you get fatigued after meals?
How often do you crave sugar and sweets after meals?
How often do you feel you need stimulants, such as coffee, after meals?
How often do you have difficulty losing weight?
Is your waist girth larger than your hip girth?
How often do you urinate?
Have your thirst and appetite increased?
How often do you gain weight when under stress?
How often do you have difficulty falling asleep?

Section D

Never Sometimes Always
Are you losing interest in hobbies?
How often do you feel overwhelmed?
How often do you have feelings of inner rage?
How often do you have feelings of paranoia?
How often do you feel sad or down for no reason?
How often do you feel like you are not enjoying life?
How often do you feel you lack artistic appreciation?
How often do you feel depressed in overcast weather?
How much are you losing your enthusiasm for your favorite activities?
How much are you losing your enjoyment for your favorite foods?
How much are you losing your enjoyment of friendships and relationships?
How often do you have difficulty falling into deep, restful sleep?
How often do you have feelings of dependency on others?
How often do you feel more susceptible to pain?
How often do you have feelings of unprovoked anger?
Do you feel you are losing interest in life?

Section E

Never Sometimes Always
How often do you have feelings of hopelessness?
How often do you have self-destructive thoughts?
How often do you have an inability to handle stress?
How often do you have anger and aggression while under stress?
How often do you feel you are not rested, even after long hours of sleep?
How often do you prefer to isolate yourself from others?
How often do you have unexplained lack of concern for family and friends?
How easily are you distracted from your tasks?
How often do you have an inability to finish tasks?
How often do you feel the need to consume caffeine to stay alert?
How often do you feel your libido has been decreased?
How often do you lose your temper for minor reasons?
How often do you have feelings of worthlessness?

Section F

Never Sometimes Always
How often do you feel anxious or panicked for no reason?
How often do you have feelings of dread or impending doom?
How often do you feel knots in your stomach?
How often do you have feelings of being overwhelmed for no reason?
How often do you have feelings of guilt about everyday decisions?
How often does your mind feel restless?
How difficult is it to turn your mind off when you want to relax?
How often do you have disorganized attention?
How often do you worry about things you were not worried about before?
How often do you have feelings of inner tension and inner excitability?

Section G

Never Sometimes Always
Do you feel your visual memory (shapes & images) has decreased?
Do you feel your verbal memory has decreased?
Do you have memory lapses?
Has your creativity decreased?
Has your comprehension diminished?
Do you have difficulty calculating numbers?
Do you have difficulty recognizing objects & faces?
Do you feel like your opinion about yourself has changed?
Are you experiencing excessive urination?
Are you experiencing a slower mental response?

Child Neurotransmitter & Nutrition Questionnaire (CNNQ)
Section General

Food Allergies
Does your child have any food sensitivities or allergies? (please list)

Healthy Foods
List your child's 4 healthiest foods eaten regularly.

Unhealthy Foods
List your child's 4 unhealthiest foods eaten regularly.

Candy
How many times a week does your child eat candy?
Soda
How many times a week does your child drink soda?

Craves
List the top 4 foods your child craves regularly.

Medications
List the medication(s) your child is currently prescribed and over the counter.

Diet Difficulty
Do you find it difficult as a parent to have your child on a special diet?
Please rate the following on a scale from 0-3, 0 as the least/never to 3 as the most/always.
Section A (K52)

Never Sometimes Always
Does your child eat pasta, breads, and breaded foods?
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating wheat foods?
Does your child eat dairy products?
Does your child have symptoms (fatigue, hyperactivity, etc.) after eating dairy products?

Section B (K53)

Never Sometimes Always
Does your child eat fried fish?
Does your child eat roasted nuts or seeds?
Is your child missing essential fatty acid rich foods in his/her diet? (for example: avocados, flax seeds, olives) (mark "never" if present and "always" if missing)
Does your child eat fried foods?

Section C (K34)
Never Sometimes Always
Is your child's mental speed slow?
Does your child have difficulty with learning or memory?
Does your child have difficulty with balance and coordination?
Section D (K16)

Never Sometimes Always
Does your child have stress?
Does your child not have enough sleep and rest? (mark "always" if not enough)
Does your child not have regular exercise? (mark "always" if no exercise)
Does your child feel overly worried and scared?

Section E (K16, K51)

Never Sometimes Always
Does your child have temper tantrums?
Does your child exhibit wild behavior?
Does your child frequently yell or scream for unnecessary reasons?
Does your child have an inability to nap or sleep when physically exhausted? (mark "always" if unable)
Is your child overly talkative?
Does your child fidget and squirm when seated?
Does your child run and climb excessively when it is inappropriate?
Does your child have difficulty playing quietly or engaging in leisure activities?

Section F (K51)

Never Sometimes Always
Does your child get excited easily?
Does your child have anxiousness and panic for minor reasons?
Does your child feel overwhelmed for minor reasons?
Does your child find it difficult to relax when she/he is awake?
Does your child have disorganized attention?

Section G (K50)

Never Sometimes Always
Does your child seem depressed?
Does your child have mood changes with overcast weather?
Does your child have symptoms of inner rage?
Does your child seem uninterested in games or hobbies?
Does your child have difficulty falling into deep restful sleep?
Does your child seem uninterested in friendships?
Does your child have symptoms of unprovoked anger?
Does your child seem uninterested in eating?

Section H (K49)

Never Sometimes Always
Does your child have difficulty handling stress?
Does your child have anger and aggression while being challenged?
Does your child feel tired even after long sleeps?
Does your child tend to isolate from others?
Does your child get distracted easily?
Does your child have constant need and desire for candy and sugar?
Does your child have disorganized attention?

Section I (K48)

Never Sometimes Always
Does your child have difficulty with visual memory?
Does your child have difficulty remembering locations?
Does your child have fatigue or low endurance for learning activities?
Does your child have difficulty with attention or low attention span or endurance?
Does your child have slow or difficult speech?
Does your child have uncoordinated or slow movement?

Step 1 of 16

Permission and Authorization Form

What to Expect on Your First Few Visits

HIPAA Privacy Disclosure Consent

Uses and Disclosures

Your Right to Limit Uses or Disclosures

Your Right to Revoke Your Authorization

New Client Evaluation

New Client Evaluation

Metabolic Assessment Form

Metabolic Assessment Form Continued

Trauma History

Dental History

Toxicity Questionnaire

Section I: Symptoms

Toxicity Questionnaire

Section II: Risk of Exposure

Neurotransmitter Assessment Form™ (NTAF)

Section A

Section B

Section C

Section D

Section E

Section F

Section G

Child Neurotransmitter & Nutrition Questionnaire (CNNQ)

Section General

Section A (K52)

Section B (K53)

Section C (K34)

Section D (K16)

Section E (K16, K51)

Section F (K51)

Section G (K50)

Section H (K49)

Section I (K48)

Medication History

	Never	Sometimes	Always
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc
Multiple smell and chemical sensitivities
Constant skin outbreaks

	Never	Sometimes	Always
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight

	Never	Sometimes	Always
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night

	Never	Sometimes	Always
Hot flashes
Mental fogginess
Disintrest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching