WELCOME TO NEUROFIT NUTRITION!neurofitnutrition.com/wp-content/uploads/2012/05/nfn-new... · 2012-05-10 · WELCOME TO NEUROFIT NUTRITION! You’ve taken a giant step toward an improved

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3939 Bee Cave Road • Su i te B -3 • Aust in , Texas 78746 • 512.699.8764 • in fo@neuro f i tnut r i t ion .com

WELCOME TO NEUROFIT NUTRITION!

You’ve taken a giant step toward an improved lifestyle, and I look forward to becoming your partner in assessing and improving your health. In preparation for your first appointment, let’s quickly go over the process at NeuroFit. During your initial consultation I will conduct a nutritional exam. This exam includes measuring height and weight, taking your blood pressure, and measuring nutritional deficiencies. As a clinical nutritionist, I take a functional medicine approach to promote health and vitality, beyond the absence of symptoms. The key to neurological fitness is to identify the upstream causes of downstream symptoms and disease. That generally entails a detailed conversation about your current state of health, your health history, family history, diet, lifestyle habits, etc. At that point, I will discuss with you potential approaches and recommended laboratory workups. This visit will last approximately 60 minutes and is primarily an information gathering and sharing session. I may make some simple recommendations at this time, but most advice will be deferred until after lab and/or blood work results are in and there has been time to thoughtfully consider your case. The second visit is generally scheduled one to two weeks later, depending on what labs are ordered during the initial consultation. During this visit we will discuss any nutritional deficiencies and lab findings. At that time I will design a customized protocol, which may include supplements, diet recommendations, stress relaxation techniques, and exercise guidelines. Follow-up visits are generally scheduled every two to four weeks after the second visit to evaluate progress and make any adjustments in your program. Follow-up frequency varies with each case. Many clients who have multiple symptoms are seen more often based on the severity of their condition. Before your initial consultation, please take some time to review your New Client Packet and complete all necessary paperwork. Because your health history is such an important part of your assessment, please be sure to complete as much of the form as possible. Please complete and email or mail the following prior to your first appointment:

• Client-Nutritionist Agreement • Health History Form • 3-Day Food Diary

If you have any further questions after reading the enclosed information, please call or email my office. I will be happy to assist you. I look forward to working with you! Nikki Drummond, CCN

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3939 Bee Caves Road • Su i te B -3 • Aust in , Texas 78746 • 512.699.8764 • in fo@neuro f i tnut r i t ion .com

CLIENT-NUTRITIONIST AGREEMENT As a Clinical Nutritionist I am committed to providing my clients with expert recommendations regarding their health and nutritional wellbeing. In order to achieve this goal, I request new clients to review and acknowledge understanding of the following policies and payment procedures by providing the date and your initials at the bottom of each page. FEE SCHEDULE

20-minute Complementary Consultation No Charge

Initial Consultation (60 minutes) $140

Follow-up Consultation (30 minutes) $75

Phone/Email Consultation (15 minutes) $35

CONSULTATION During the Initial Consultation the Nutritionist will review health history information, lab work, and chief complaints with each client and then discuss a recommended plan. NOTE: After the Initial Consultation, the client may call or email once with follow-up questions. Each additional phone call and email will be billed as a Phone/Email Consultation. Follow-Up Consultations are advised every 2-4 weeks. This is necessary because diet and supplement protocols should be adjusted periodically as neurotransmitter levels begin to change. For example: The amount of supplements taken on a daily basis typically decreases over time as values improve. Therefore you will get the most out of your program by:

1. Taking your supplements on a regular basis, and 2. Scheduling regular Follow-up Consultations so protocol adjustments can be made as symptoms

begin to shift. NOTE: After each Follow-up Consultation, the client may call or email once with follow-up questions. Each additional phone call and email will be billed as a Phone/Email Consultation. MISSED APPOINTMENTS The client agrees that if he/she is unable to keep an appointment, he/she will provide a minimum of 24 hours prior notice to the nutritionist by leaving a message or speaking with the nutritionist directly. If an appointment is canceled or missed without 24-hour notice, the client understands that he/she will be billed for the entire session. Exceptions may be made for emergencies.

Initials Date

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C l ien t -Nutr i t ion is t Agreement – Page 2 o f 3

PAYMENT METHOD Payment for services is expected prior to or at the time of the appointment and can be made by check, cash, money order, or PayPal for credit card processing. Should the client’s account remain unpaid for 30 days, the nutritionist reserves the right to suspend services until charges are paid in full or a suitable payment arrangement is agreed to in writing by both the client and the nutritionist. If legal means are required to secure payment, legal costs will be charged to the client. Making a PayPal Payment:

1. Go to PayPal.com 2. Click on ‘Send Money’ 3. Input the email address [email protected]

RETURNED CHECKS A processing fee of $30.00 will be charged for all returned checks. INSURANCE The client acknowledges and understands that NeuroFit Nutrition and Nikki Drummond, CCN, do not accept insurance or government funded assistance programs as payment. All charges are the client’s responsibility from the date services are rendered. A receipt will be provided and the client may choose to submit to their insurance company directly. TELEPHONE CALLS/ SCHEDULING The standard fee rate will be charged as listed above for telephone consultations. Brief phone contacts with the clients that are related to scheduling of less than ten minutes duration will not be billed. The client must approve phone contacts with family or friends in advance by signing a release of information form. CLIENT MANAGEMENT SYSTEM Nikki Drummond, CCN and NeuroFit Nutrition use the client management program MINDBODY to manage client information and to function as an online store. All information is password protected and only accessible by the client, NeuroFit Nutrition employees, and MINDBODY. By signing this Nutritionist-Client Agreement, you agree and authorize your information be added into the MINDBODY system.

Initials Date CONFIDENTIALITY All communications between the client and nutritionist are confidential. Information will only be released to a third party under the following conditions:

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C l ien t -Nutr i t ion is t Agreement – Page 3 o f 3

1. The client authorizes the nutritionist to release information with written permission; 2. The client is threatening serious bodily harm to self or another;

REFERELS & MEDICAL TREATMENT The Nutritionist will evaluate the nature of the client’s concerns to determine whether a referral to another practitioner is necessary. RELEASE The client understands that all services provided to the client from the Nutritionist are consultative in nature. The testing used to make recommendations made by the Nutritionist is not used or intended to diagnose or treat any disease, symptom, or medical condition and should not substitute seeing a physician. Clients are notified to call 911 if they experience a medical emergency. AGREEMENT The client, by signing below, indicates that he/she fully understands and agrees to the above stated policies.

Client’s Printed Name

Client’s Signature Date

Signature of Nutritionist – Nikki Drummond, CCN Date

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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact:

Nikki Drummond, CCN 3939 Bee Cave Road, Suite B-3 Austin, Texas 78746 512.699.8764 [email protected]

WHO WILL FOLLOW THIS NOTICE

1. Nikki Drummond, CCN (“ Nutritionist”)

2. All Nutritionist’s employees

We understand that medical information about you and your health is personal, and we are committed to protecting this information. Each time you visit the Nutritionist, a record of the recommendations and services you receive is made. Typically, this record contains your symptoms, examinations, diagnoses, nutritionist notes, past treatments, plan for future care or treatment, and billing record. This record serves as:

1. A basis for planning nutritional recommendations;

2. A means of communication among the many health care professionals who contribute to your care;

3. A means by which you or a third-party payor can verify that services billed were actually provided;

4. A tool for educating health professionals;

5. A source for information for public health officials; and

6. A tool for assessing and continually working to improve the service rendered.

This Notice applies to all of the records of your care generated by the Nutritionist. This Notice will tell you about the ways we may use and disclose medical information about you. It also describes your rights and our obligations regarding the use and disclosure of medical information.

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Not ice o f Pr i vacy Pract ices – Page 2 o f 2

OUR RESPONSIBILITIES The Nutritionist shall:

1. Make every effort to maintain the privacy of your health information;

2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;

3. Abide by the terms of this notice;

4. Notify you if we are unable to agree to a requested restriction; and accommodate reasonable

requests you may have to communicate health information by alternative means or at alternative locations.

THE METHODS WHICH WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe different ways we may use and disclose your Protected Health Information. The examples provided serve only as guidance and do not include every possible use o disclosure.

1. As Required by Law: We will disclose medical information about you when required to do so by federal or Texas laws or regulations.

2. To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you to medical or law enforcement personnel when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

3. For Treatment: We will use and disclose your Personal Health Information to provide, coordinate,

or manage your health care and any related service. For example, we may share your information with your primary care physician or other specialists to whom you are referred for treatment purposes.

4. For Health Care Operations: We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the Nutritionist’s office in an efficient manner and ensure that all clients receive quality services.

5. Appointment Reminders: We may use and disclose medical information in order to remind you of an appointment. For example, Nutritionist or any of her employees may provide a written or telephone reminder that your next appointment with Nutritionist is coming up.

CLIENT MANAGEMENT SYSTEM Nikki Drummond, CCN and NeuroFit Nutrition use the client management program MINDBODY to manage client information and to function as an online store. All information is password protected and only accessible by the client, NeuroFit Nutrition employees, and MINDBODY. All information added into MINDBODY software is owned by MINDBODY but is secure and password protected information.

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NEW CLIENT HEALTH HISTORY FORM Please take some time to complete this Health History Form prior to your initial consultation. It is very important that you answer the questions with careful thought so that I can develop a roadmap for our time together. As a functional medicine nutritionist, my job is to search for the upstream causes of downstream symptoms and disease, and this form is designed to identify these areas. If you have any questions, please feel free to contact me at 512.699.8764 or [email protected]. DELIVERY INSTRUCTIONS Please complete this form and return it to us at least 48 hours before your first appointment. This allows us time to review your answers and develop a structure for our first meeting. When completed, please email this form to [email protected] or mail to: NeuroFit Nutrition 3939 Bee Cave Road, Suite B-3 Austin, Texas 78746 CLIENT CONTACT INFORMATION

First Name Middle Initial Last Name

Date of Birth Gender Height Weight

Street Address Suite/Apt.

City State Zip Code

Home Phone Work Phone Cell Phone

May confidential messages be left at these numbers? ! Yes ! No Which one(s)?

Email Address

Occupation Employer

Emergency Contact Name Relationship

Emergency Contact Phone Number(s)

Parent/Guardian Name(s) (minors only)

Do you have any special needs (e.g., are you visually or hearing impaired)? ! Yes ! No

If you have special needs, please explain any accommodations you may require.

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PERSONAL AND FAMILY MEDICAL HISTORY Have you or anyone in your family been diagnosed with any of the following?

Self

Fam

ily

Condition Whom? Self

Fam

ily

Condition Whom?

! ! Anemia ! ! Glaucoma

! ! Arthritis ! ! Heart Disease

! ! Anxiety ! ! High Blood Pressure

! ! Asthma ! ! Kidney Disease

! ! Cancer ! ! Psoriasis

! ! Diabetes ! ! Schizophrenia

! ! Depression ! ! Stroke

! ! Eczema ! ! Thyroid Disorder

! ! Epilepsy ! ! Tuberculosis

! ! Other, please explain: Please list all medical conditions for which you have been diagnosed, going back to childhood.

Condition Date of Diagnosis*

* Please list as much information as possible. Even an approximate month or time of year (spring, fall, etc.) can be helpful.

Please list any surgeries you have had including the year and outcome.

Type of Surgery Outcome Date of Surgery*


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Please list any allergies to foods, medications, pollens, etc. of which you are aware.

Allergen Reaction

Please list all prescription medications you take including strength and times per day.

Medication Strength Times per Day

Please list all supplements, vitamins, herbs, etc. that you take including strength and times per day.

Supplement Strength Times per Day

NOTE: Please bring all medication and supplement bottles with you to your appointment. Please list all of the healthcare providers that you are currently seeing including their specialties.

Provider’s Name Specialty

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GENERAL HEALTH INFORMATION Please list all current health problems for which you are being treated.

Health Problem Date of Diagnosis*


Please list the healthcare providers that you are currently seeing for treatment of these health problems.

Provider’s Name Specialty

What was the date of your last blood work*? * Please bring a copy of your blood work to your first appointment.

Please rate your stress level on a scale of 1 to 10 (1 being the lowest).

1 2 3 4 5 6 7 8 9 10 Please identify the major causes of stress in your life currently (e.g., changes in job, difficulties at home, relationship issues, legal problems, etc.).

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Please check any conditions that you currently have or have experienced in the past.

Cur

rent

Pas

t

Condition Cur

rent

Pas

t

Condition Cur

rent

Pas

t

Condition

! ! Alcoholism ! ! Emphysema ! ! Liver Disease

! ! Anemia ! ! Epilepsy ! ! Migraines

! ! Anorexia ! ! Fibromyalgia ! ! Miscarriages

! ! Arthritis ! ! Food Intolerance ! ! Mononucleosis

! ! Asthma ! ! Gallbladder Disease ! ! Mumps

! ! Atrial Fibrillation ! ! GERD ! ! Neurological Disorders

! ! Bleeding Disorders ! ! Glaucoma ! ! Obesity

! ! Bulimia ! ! Gout ! ! Organ Transplant

! ! Cancer ! ! Headaches ! ! Osteoporosis

! ! Chemical Sensitivities ! ! Heartburn/Indigestion ! ! Pace Maker

! ! Chronic Fatigue ! ! Heart Disease ! ! Psoriasis

! ! Chicken Pox ! ! Hepatitis ! ! Prostate Problems

! ! Colitis ! ! Herpes ! ! Psychiatric Problems

! ! Constipation ! ! High Blood Pressure ! ! STDs

! ! Depression ! ! High Cholesterol ! ! Stroke

! ! Diabetes ! ! High Triglycerides ! ! Thyroid Disorder

! ! Diarrhea ! ! HIV/AIDS ! ! Tuberculosis

! ! Diverticular Disease ! ! Infection, Chronic ! ! Ulcers

! ! Drug Addiction ! ! Irritable Bowel ! ! Urinary Tract Infections

! ! Eating Disorder ! ! Kidney/Bladder Disease ! ! Vaginal Infections

! ! Eczema ! ! Learning Disabilities ! ! Varicose Veins

! ! Other, please explain:

What is your blood type? ! O ! A ! B ! AB ! Don’t know

Do you feel rested when you wake up in the morning? ! Yes ! No

Do you exercise? ! Yes ! No

If so: Days per Week Duration Type of Exercise

! 5 – 7 days/week ! 45 min or more ! Walking ! Swimming

! 3 – 4 days/week ! 30 – 45 min ! Running / Jogging ! Yoga / Pilates

! 1 – 2 days/week ! Less than 30 min ! Weight lifting ! Aerobics class

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Please check any symptoms that you currently have or have experienced in the past year.

Cur

rent

Pas

t Yea

r

Symptom Cur

rent

Pas

t Yea

r

Symptom Cur

rent

Pas

t Yea

r

Symptom

General: Cardiovascular: Neurological:

! ! Bruise easily ! ! Chest pain ! ! Anxiety

! ! Chills ! ! High blood pressure ! ! Depression

! ! Cold hands/feet ! ! Irregular heart beat ! ! Dizziness

! ! Fainting ! ! Poor circulation ! ! Easily agitated

! ! Fever ! ! Swollen ankles ! ! Forgetfulness

! ! Headaches/Migraines ! ! Headaches

! ! Irregular periods Eyes, Ears, Nose, Throat: ! ! Hopelessness

! ! Itching/Hives/Rash ! ! Bleeding gums ! ! Migraines

! ! Muscle cramps ! ! Difficulty swallowing ! ! Mood swings

! ! Pain in joints ! ! Ear discharge ! ! Nervousness

! ! Sores that won’t heal ! ! Earaches ! ! Overwhelmed easily

! ! Hearing loss ! ! Poor focus

Gastrointestinal: ! ! Nose bleeds ! ! Restlessness

! ! Belching after meals ! ! Persistent cough ! ! Sad/tearful often

! ! Bloating ! ! Ringing in ears ! ! Suicidal thoughts

! ! Bowel change ! ! Runny nose ! ! Sweats

! ! Constipation ! ! Sinus problems ! ! Trouble falling asleep

! ! Diarrhea ! ! Vision changes ! ! Trouble staying asleep

! ! Excessive thirst ! ! Worry often

! ! Floating stools Genito-Urinary: ! ! Yawn often

! ! Indigestion ! ! Blood in urine

! ! Mucus in stools ! ! Frequent urination

! ! Nausea ! ! Genital itching

! ! Rectal bleeding ! ! Hemorrhoids

! ! Stomach pain ! ! Incontinence

! ! Vomiting ! ! Painful urination

! ! Rectal itching

Are you currently pregnant or nursing? ! Yes ! No

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NUTRITION & EATING HABITS

Do you eat out often? ! Yes ! No

Have you lost or gained weight recently? ! Yes ! No

If yes, please explain:

Are you vegan or vegetarian? ! Vegan ! Vegetarian

Food sensitivities: ! Dairy ! Gluten ! Soy ! Corn ! Eggs

Do you restrict fat from your diet? ! Yes ! No Please indicate average servings per day of the following food types.

Food Type Servings per Day

Fruits

Dark green / leafy vegetables

Beans, peas, legumes

Dairy (milk, cheese)

Eggs

Meat, poultry, fish

White flour products (white rice, pasta, bread)

Sweets (cookies, ice cream, etc.)

Do you consume alcohol? ! Yes ! No

If yes: glasses of wine per ! Day ! Week

glasses of beer per ! Day ! Week

mixed drinks per ! Day ! Week

Do you smoke? ! Yes ! No

If yes: cigarettes per day cigars per day

Do you consume caffeine? ! Yes ! No

cups of coffee per day caffeinated sodas per day

glasses of tea per day caffeinated diet sodas per day

How many glasses of water do you drink per day?

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How many meals do you eat per day? ! None ! One ! Two ! Three ! Four or more

What are your eating habits? ! Graze (small frequent meals) ! Skip breakfast

! Eat constantly (whether hungry or not) ! Add salt to food

! Generally eat on the run What long-term expectations do you have for your health overall?

Please rate your commitment to your health on a scale of 1 to 10 (1 being the lowest).

1 2 3 4 5 6 7 8 9 10 What are your main interests and hobbies?

What prompted you to contact us?

Who referred you to us? Is there anything else you would like Nikki to know about you or your health?

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3-DAY FOOD DIARY

It is important to keep an accurate record of your usual food and beverage intake as a part of this study. Please complete this 3-Day Food Diary for three consecutive days with one day being a weekend day.

• Record information as soon as possible after the food has been consumed.

• Do not change your eating behavior during this time. The purpose of this food record is to analyze your present eating habits.

• Describe the food or beverage consumed. For example, if you had a glass of milk, what kind was it? Whole milk? 2%? Skim? Or if you had toast, was it whole wheat, white, or buttered? And if you ate chicken, make sure to record if it was fried, baked, breaded, etc.

• Record the amount of each food consumed using standard measurements as much as possible, such as 8 ounces, ½ cup, 1 teaspoon, etc. But please do not obsess over this point. Your measurements need not be scientifically accurate; I just ask that you estimate using these standard measurements as best you can.

• Please record all beverages, including water.

• Please record all bowel movements and their consistency (regular, loose, firm, watery, etc.).

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FOOD DIARY – DAY 1

Name Date

Time Food/Beverage Amount

BOWEL MOVEMENTS NOTES

Time Consistency

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Name Date



Time Consistency

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Name Date



Time Consistency

Documents

WELCOME TO NEUROFIT NUTRITION!neurofitnutrition.com/wp-content/uploads/2012/05/nfn-new... · 2012-05-10 · WELCOME TO NEUROFIT NUTRITION! You’ve taken a giant step toward an improved