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Welcome to Dr. Dan’s Natural Healing Center !Nutrition Response Testing/Morphogenic Field Testing Initial Evaluation includes two visits. The first visit includes Initial Evaluation by Dr. Dan, Heart Rate Variability test and tissue pH measurement. For those patients over 50 we will also perform a Max Pulse test. For those looking to lose weight we may perform a Bioelectrical Impedance Analysis.

The second visit includes the Review of Findings by Dr. Dan, a review of your food log by our Patient Advocate/Nutrition Counselor, and explanation & handouts of your individualized plan.

!What to Bring With You to Your First Appointment:!Nutrition Patients: * Please complete the Medical History Form (attached, print pages 2 to 7).* Please bring results of any recent blood work.* Please bring a Summary of past dental history (tooth extractions, amalgam or other filings, crowns, root canals, partial plates, etc.)!Acupuncture Patients: * Please complete Acupuncture Symptom Survey Form (attached, print pages 6 to 13).* Please wear loose fitting clothes and refrain from alcohol and heavy meals 24 hours before your appointment.

!!To your great health! !!!Dan Eyink, MD

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Dental History Questionnaire

1. Any teeth pulled? If so, which one(s)? _________________________________ ______________________________________________________________________

• Any Implants? _________________________________________________ • Titanium post?_________________________________________________ • Zirconium post?________________________________________________

2. History of braces? Circle: YES NO◽ P️ermanent retainer ? ◽ ️Removable retainer?

3. History of dental trauma? ____________________________________________

4. History of bridge(s)?________________________________________________________

5. History of cavities? __________________________________________________

6. Composite fillings? Circle: YES NO

7. Metal Amalgam fillings? Circle: YES NO • Amalgam fillings pulled?

8. History of crown? Circle: Gold Porcelain

9. History of Root Canal ___________________________________________________________________________________________________________________________________________

10. History of Gum Disease, Gum Recession or Gum Surgery/Graft? ____________________________________________________________________________________________________________________________________________________________

11. History of Wisdom Teeth removed? Circle: YES NO

12. History of TMJ? Headgear? Circle: YES NO

13. History of Dental Sealants? Circle: YES NO

14. History of Fluoride Treatments? Circle: YES NO

15. Any other dental history? ____________________________________________________________________________________________________________________________________________________________________

! ! !Scar History Chart

!Please mark in a colored marker all of your past scars. Number each and give a short explanation to its cause (ie. appendectomy, hysterectomy, circumcision, episiotomy, burns, tattoos, and piercings) !

1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ 4. ______________________________________________________________________________ 5. ______________________________________________________________________________ 6. ______________________________________________________________________________ 7. ______________________________________________________________________________ 8. ______________________________________________________________________________ 9. ______________________________________________________________________________ 10. ______________________________________________________________________________ !

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