new patient instructions

The Living Proof Institute | ADD MORE LIVE TO YOUR LIFE™9277 Centre Pointe Drive | Suite 350 | West Chester | Ohio | 45069 | O: 513 785 0686 | F: 877 426 0285

New Patient Instructions

Congratulations on your new health journey! We promise to make this transition towards a healthier lifestyle a much easier one for you. In order to help you as effectively as possible please follow the below instructions.

1. Along with this form, please download and fill out the “Nutritional Assessment Questionnaire” form from www.thelivingproofinstitute.com

2. Please fill out the patient demographic and chief complaint forms to help us understand your health related goals and challenges.

3. Please fill out your list of medications and/or supplements where indicated

4. Document your diet for at least 3 days. Do not change how you eat, simply write it down. You will be asked to fill out a similar form daily as a patient moving forward.

5. Have a partner take your body measurements. Follow the instructions closely. Please call if you have any questions.

6. Please call your doctors office and have your most recent lab work and pertinent medical records faxed to our office. Our fax number is 877 426 0285

7. During your first appointment, you will be asked to provide a urine and saliva sample. We have provided detailed instructions on how to prepare for this appointment. Please follow these instructions closely, call if you have questions.

http://www.thelivingproofinstitute.com

http://www.thelivingproofinstitute.com

Name ___________________________________________________________________ Date __________________________________

Phone# _____________________________ Cell# _______________________________ Work# ______________________________

Address __________________________________________ City _______________________ State ______ Zip Code ___________

Date of Birth ____________Social Security# ______________________ Email ______________________@_________________

Status: Single Married Divorced Children? Y N How many?________ Occupation ________________________

Name of Family Doctor __________________________________________________ Phone ___________________________

Name of Specialist ______________________________________________________ Phone ___________________________

Emergency Contact _____________________________________________________ Phone ___________________________

How did you hear about us? TV Radio Friend Lecture Other________________________________

CHIEF COMPLAINT / HISTORY


DEMOGRAPHIC INFORMATION

New Patient Intake Form

WHAT WOULD YOU LIKE TO IMPROVE ABOUT YOUR HEALTH?1. _______________________________________________2. _______________________________________________3. _______________________________________________What treatment have you had for these conditions?1. _______________________________________________2. _______________________________________________3. _______________________________________________

Complete this section even if you have minor aches and pains or any other problem areas (i.e. stomach)

Circle the intensity of your pain (0 = no pain, 10 = worst pain) 0 1 2 3 4 5 6 7 8 9 10 Is this due to: ☐ Poor Lifestyle? ☐ Illness? ☐ Auto Injury? ☐ Work Injury? ☐Unknown? ☐ Other?_____________________________________________________________________________How long have you had this complaint?______________________________________________________Are your symptoms: ☐ Improving? ☐ Getting Worse?! ☐ About the same? ☐ Comes and goes?Does the Pain Radiate? ☐ Yes ☐ No If yes, describe:_______________________________________Have you had these symptoms before? ☐ Yes ☐ No When?_________________________________Have you lost time from work? ☐Yes ☐ No Dates lost______________________________________Date returned to work_______________ Dr Ordered? ☐ Yes ☐ No Self determined? ☐ Yes ☐ NoEffect on Activities: ☐ No Effect ☐ Extra Effort Required ☐ Occasional Limitation ☐ Severe Limitation

MEDICATIONS AND SUPPLEMENTS


TELL US MORE ABOUT YOUR CURRENT HEALTH AND LIFESTYLE

I currently weigh ___________ poundsI would like to lose _________ pounds by _________My Waist size is ___________ inchesMy blood pressure is: ☐ High ☐ Low ☐ Normal ☐ ?My Cholesterol is: ! ☐ High ☐ Low ☐ Normal ☐ ?I eat __________ servings of fruits per dayI eat __________ servings of vegetables per dayI drink ________ ounces of water per dayI exercise _____ hours per weekI exercise _____ days per week

I sleep _________ hours per nightI go to bed at: ________ and wake up at: _______In the morning I feel: ☐ tired ☐ refreshed After work I feel: ☐ tired ☐ energeticSmoking! ☐ Yes ☐ No ______Packs/dayCoffee ! ☐ Yes ☐ No ______Cups/daySoft Drinks ! ☐ Yes ☐ No ______Cans/dayAlcohol ! ☐ Yes ☐ No ______Drinks/weekI eat out __________ times per week

I WOULD LIKE HELP WITH THE FOLLOWING (CHECK ALL THAT APPLY)

☐ Diet and Nutrition☐ Lifestyle Coaching☐ Grocery Store Tour☐ Chiropractic Care☐ Weight Loss

☐ Condition(s) Listed Above☐ Exercise Program☐ General Health and Wellness☐ Supplements☐ Other ______________________________

☐ Headaches☐ Fatigue☐ Pain/Tension/Numbness! ☐ Neck! ☐ Shoulders! ☐ Low Back! ☐ Legs! ☐ Arms! ☐ Hands! ☐ Feet! ☐ Other____________

☐ Sleep Issues☐ Hormone Imbalances! ☐ Hot Flashes! ☐ Mood Swings! ☐ PMS! ☐ Irritability☐ Digestive Problems! ☐ Constipation ! ☐ Acid Reflux! ☐ IBS/Crohn’s! ☐ Food Sensitivities

☐ Sinus Problems/Allergies☐ Difficult Weight Loss☐ Arthritis☐ Depression/Anxiety☐ High Stress Levels☐ High Blood Pressure☐ Dizziness☐ Fibromyalgia☐ Other _________________☐ Other _________________☐ Other _________________

CHECK OFF ANY SYMPTOMS THAT YOU HAVE EXPERIENCED Circle the condition that bothers you the most and indicate how long you have had this/these condition(s)

DRUG / VITAMIN DOSAGE REASON FOR TAKING

Medical History - Please CHECK MARK current conditions and CIRCLE past conditions

General□ Allergies□ Depression□ Dizziness□ Fainting□ Fatigue□ Fever□ Headaches□ Difficulty / Loss of sleep□ Mental illness□ Nervousness□ Tremors□ Weight loss / gain□ Major Stress

Muscle / Joint □ Arthritis / rheumatism□ Bursitis□ Foot trouble□ Muscle weakness□ Low back pain□ Neck pain□ Mid back pain□ Joint pain

Skin □ Boils□ Bruise easily□ Dryness□ Hives or allergies□ Itching□ Varicose veins

Eye, Ear, Nose & Throat□ Colds□ Deafness□ Ear ache□ Eye pain□ Gum trouble□ Hoarseness□ Nasal obstruction□ Nose bleeds□ Ringing of the ears□ Sinus infection□ Sore throat□ Tonsillitis□ Vision problems

Gastrointestinal□ Abdominal pain□ Bloody or tarry stool□ Colitis / Crohn’s□ Colon trouble□ Constipation□ Diarrhea□ Difficult digestion□ Diverticulosis□ Bloated abdomen□ Excessive hunger□ Gallbladder trouble□ Hernia□ Hemorrhoids□ Intestinal worms□ Jaundice□ Liver trouble□ Nausea□ Painful defecation□ Pain over stomach□ Poor appetite□ Vomiting□ Vomiting of blood

Genitourinary□ Bed-wetting□ Bladder infection□ Blood in urine□ Kidney infection□ Kidney stones□ Prostate trouble□ Pus in urine□ Stress incontinence

Urination□ More than 8x in 24hrs□ Decreased flow/force□ Painful urination□ Urgency to urinate

Respiratory□ Chest pain□ Chronic cough□ Difficulty breathing□ Hay fever□ Shortness of breath□ Spitting up phlegm / blood□ Wheezing

Cardiovascular□ High blood pressure□ Low blood pressure□ Hardening of the arteries□ Irregular pulse□ Pain over heart□ Palpitation□ Poor circulation□ Rapid heart beat□ Slow heart beat□ Swelling of ankles

Women only□ Congested breasts□ Hot flashes□ Lumps in breast□ Menopause□ Vaginal discharge

Menstrual flow□ Reg. □ Irreg □ Pain/crampsDays of flow: ______________Length of cycle: ____________Date - 1st day last period: _________________________Are you pregnant? □ yes, □ noIf yes, how many months?____How many children do you have?_________________________Birth control method: _________________________Date of last PAP test: _________________________□ normal, □ abnormalDate of last mammogram: _________________________□ normal, □ abnormal

Check any of the conditions you have or have had: □ Alcoholism□ Anemia□ Appendicitis□ Arteriosclerosis□ Asthma□ Bronchitis□ Cancer□ Chicken pox□ Cold sores□ Diabetes□ Eczema□ Edema□ Emphysema□ Epilepsy□ Goiter□ Gout□ Heart burn□ Heart disease□ Hepatitis□ Herpes□ High cholesterol□ HIV/AIDS□ Influenza□ Malaria□ Measles□ Miscarriage□ Multiple sclerosis□ Mumps□ Numbness/tingling□ Pace maker□ Osteoporosis□ Pneumonia□ Polio□ Rheumatic fever□ Stroke□ Thyroid disease□ Tuberculosis□ UlcersOther _______________________________________________________________________________________________________


Day 1 - Date:Day 1 - Date:Day 1 - Date:

Breakfast | Time: Lunch | Time: Dinner | Time:

Vegetables and Fruit:

Breads, Cereals and Grains:

Fats (butter, oils etc):

Candy, Sweets & Junk Food:

Fluid Intake:

Supplements / Medications:

Energy Level After Meal: (good) 1 2 3 4 5 (poor) Energy Level After Meal: (good) 1 2 3 4 5 (poor) Energy Level After Meal: (good) 1 2 3 4 5 (poor)

Mid Morning Snack | Time: Mid-Day Snack | Time: Nighttime Snack | Time:

Bowel Movements (# and consistency): Hours of Sleep: Quality of Sleep: (good) 1 2 3 4 5 (poor)

Day 2- Date:Day 2- Date:Day 2- Date:






Fluid Intake:





Day 3- Date:Day 3- Date:Day 3- Date:






Fluid Intake:





Daily Record of Food IntakeEach day, record all the items you eat and drink. Be sure to include the appropriate amount of each item. Also note your digestion and energy.

Name:________________________________________________Date of Birth______________________


Name:__________________________________________________Date of Birth______________________


Where to measureNeck - At the widest part of the neck

Shoulders - With the arms resting at your side

Right Bicep - With the arm resting at the side at the widest part of the arm

Waist - With the core muscles relaxed, measurement taken at the belly button

Hips - Widest part of the hips

Right Thigh - Taken at the widest part of the right upper thigh

Right Calf - Taken at the widest part of the right calf

Note : When taking the measurement, ideally it should be done on the skin (clothing removed) and with a gentle tug.

Body Part Date Date Date Date

Neck

Shoulders

Right Biceps

Chest

Waist (Belly Button)

Hips (Widest Part)

Right Upper Thigh

Right Calf

Total Inches

Weight

Patient Measurement FormPlease have a partner help you with your measurements. Follow the simple guide

Your ideal meal is:1 cup of cooked oatmeal ! ! ! ! ! ! ! 1 bagel or 2 slices of any bread1 banana! ! ! ! ! ! or! ! 1 banana1 egg! ! ! ! ! ! ! ! ! ! 1 tablespoon of peanut/almond butter


Name:__________________________________________________Date of Birth_____________________

Sample Requirements (Please check that you have understood and followed these instructions) Consume a serving of protein and a serving of carbohydrate 2 hours before your test. Water up to 1 hour before. Do not consume anything by mouth 1 hour before your test including water. Do not brush your teeth up to 3 hours before your test. No lipstick or makeup day of test. No coffee, caffeinated beverages, soda or alcohol the day of test. No chewing gum on day of test

ACCEPTABLE forms of Protein:• Handful of Nuts or seeds• 4-6 ounces of unprocessed meat• 1-2 eggs• 1/2 - 1 cup of legumes (tofu, beans etc.)

NON-acceptable forms of protein:• Processed meat or proteins• Lunch meat

ACCEPTABLE forms of Carbohydrates:• 1-2 cups vegetable• 1 cup of fruit• 1 cup Whole Grain/Oat items• 1 cup of rice (brown/wild/white)

NON-acceptable forms of carbohydrates:• Cookies• Candy• Refined/Processed sugars and breads

First Appointment InstructionsThe samples collected during your exam will determine how your body’s bio-chemistry work. Please follow the below instructions closely for the date of your first appointment. This is very important, please call in advance if you have any questions.

Please indicate what you ate before your appointment: __________________________________________________________________________________________________________________________________________________________________________

Time of Meal:_______________________________

Office Use Only

Time of Collection:___________________________ Blood Sugar: _______________________________

new patient instructions

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