Functional Diagnostic Nutrition Intake and Terms of Service Agreement Packet

Functional Diagnostic Nutrition® INTAKE FORM
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Date of Birth:*
Height:*
Weight:*
Occupation:*
Marital Status:
How did you hear about us?*

Social Media (Facebook, Instagram, etc)Google SearchYelpNextdoorArlNow/Patch/etcOther
Type a question
Emergency Contact Name:*
Emergency Contact Number:*
Emergency Contact Relation:
Please take your time and complete the following questions to the best of your ability. Your answers will be kept confidential. Don't hesitate to let us know if you have any questions. Should you wish to bring any additional information to our attention, please note it at the end of the form. Thank you.

	Yes	No	Write In Answers
Do you experience problems falling asleep?
Do you experience problems staying asleep?
What time do you normally go to bed?
What time do you normally awaken?
Do you feel rested upon awakening?
Do you awaken regularly between 2-3 A.M.?
Do you recall your dreams?
Do you frequently have nightmares?
Is your energy good all day?
What time is the lowest?
Do you feel tired all the time?
If yes, how long have you felt this way?
Do you suffer from anxiety or depression?
If yes, for how long and is it linked to any event? Please describe.
Do you suffer from pain?
If yes, please explain, location, quality of pain:
Are you mentally and/or emotionally exceptionally stressed?
If yes, how long have you felt this way?
Do you suffer from low blood sugar?
If yes, please explain.
How many meals (including snacks) do you eat a day?
How much time between meals/snacks?
Do you eat within 1 hour of awakening?
If no, how long after awakening until you eat your first meal of the day?
Do you have a bedtime snack?
If no, how many hours between dinner and bedtime?
Please describe a typical day's meals and snacks from awakening until bedtime (ending your day).
Breakfast: (time)
Lunch: (time)
Dinner/Supper: (time)
Snack: (time)
Snack: (time)
Snack: (time)
Do you frequently skip meals?
Do loud (sounds) noises bother you?
Are you startled easily? Easily stressed?
Do you suffer from allergies? If so, please list:
Do you suffer from recurrent/chronic infections?
If yes, please describe.
Do you take any thyroid hormones?
If yes, please list type, dosage, and how long you have been taking them:
Do you suffer mental confusion? Brain fog?
Do you need caffeine (Coffee, tea, etc) to get going in the morning?
Have you ever fainted?
If yes, please explain:
Are you easily upset?
If yes, please explain:
Are you taking sleeping medication?
If yes, please list:
Are you taking any anti-depressants?
If yes, please list type and dosage:
Do you exercise?
If yes, what type, time of day, how long, how often?
If no, is there any reason you cannot exercise?
If yes, please explain:
Do you feel better or worse after exercise?
Do you frequently experience a second wind (high energy) late at night?
What is your daylight light source? (i.e indoor/outdoor, fluorescent, full spectrum, etc.)
How much time do you get outdoor light (direct or indirect) daily?
Do you wear sunglasses when you are outdoors?
Does sunlight bother you?
Do you have high blood pressure?
If yes, please list any medication and dosages:
Do you have low blood pressure?
Do you ever feel nauseous for no reason?
Do you have bloating?
Do you have heartburn?
Do you have constipation?
Do you have gas?
Do you belch following meals?
Do your bowel movements alternate between constipation and diarrhea?
Do you have abdominal/intestinal pain?
Do you get bloated after meals?
Do you get diarrhea often?
Have you travelled outside of the U.S.?
If yes, please list countries:
Are your stools compact/hard to pass?
Do you have any known food allergies?
Have you had root canals?
If yes, how many and when?
Have you had any teeth extracted, including wisdom teeth?
If yes, when?
Do you have a dental bridge in your mouth?
If yes, what is the material used?
Do you have metal fillings in your mouth?
If yes, how many and what materials were used?
Do you use birth control?
If so, what kind and for how long?
Do you have braces?
If yes, what is the material used?
Do you have TMJ (jaw problems)?
If yes, please describe:

Describe any believed exposure(s) to environmental and/or chemical toxins:*
Describe your hobbies and forms of recreation:*
Are you currently taking nutrtional supplements?*

YesNo
If yes, please list all products and daily dosages:*
Have you ever had any head, neck, or back injuries?*

YesNo
If yes, please describe:*
How long has it been since you felt your best? When did you start feeling badly? Can you link it to a specific incident? Please explain.*
Please list your main health complaints, the one(s) you would most like to get rid of:*
What therapies have you already done to heal or reduce your health complaints?*
What do you most love that your health complaint prevents you from doing?*
From of a scale of 1-10, how committed are you to getting well?*

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Most
Please explain:*
Any additional notes:*

Teal Center FDN -Terms of Service Agreement
What we do and do not do
We obtain a set of laboratory test results from certified laboratories in the United States and provide you with a nutritional interpretation of those test results that you can use exclusively as an educational tool for personal health purposes.

Your doctor may use the same test results to diagnose and treat disease, but we do not do this. The information we provide is not intended to, cannot, and should not be expected to be a substitute for a personal consultation with your own qualified doctor. We do not accept any liability for any failure to identify any medical condition or disease; this is not the purpose of our services.

We may provide you with information relating to products that we believe might benefit you, but such information is not to be taken as an endorsement or recommendation. Some such products may not be available without a prescription, but we do not dispense or prescribe any prescription products. The information provided is intended for educational purposes only and should not be taken as professional medical advice or used as a substitute for medical care. We are not responsible for any adverse affects or consequences that may result, either directly or indirectly, from that information.
Consult your doctor
We are not qualified medical advisors and make no claims to be so. The information we provide should not be taken to be, and is not a substitute for, personal medical advice and instruction. You should not take any action based solely on our advice.

You should consult your doctor:

for any medical interpretation of your test results;
on any matter relating to your health and well-being;
before making any changes to your exercise or diet;
before taking any nutritional, herbal, homeopathic or hormonal supplementation;
before beginning any therapy.
Exclusion of warranties
We will provide our services to you with reasonable care and skill. But we make no other warranty, express or implied, with respect to those services. All other warranties are excluded to the maximum extent permitted by law.

We make no warranty as to the accuracy of the laboratory test results we receive.

We make no warranty, expressed or implied, as to the quality or effectiveness of any diagnosis, apparatus, treatment or product. In no event will we be liable for any physical or mental injury, or any negative side effects, that may arise from the use of any such diagnosis, apparatus, treatment or product.

We believe that the information we provide, including that on our web sites, brochures, flyers and information packets, is accurate, but we cannot guarantee such accuracy. We therefore make no warranty as to the accuracy of that information, and it should not be relied upon as being correct, complete or accurate. It is your responsibility to verify such matters independently from primary sources of information and by taking specific professional advice.
Exclusion of liability
If you rely on, buy or use a product or therapy, you do so at your own risk. Each person is different, and the way someone reacts to a product or therapy may be significantly different from another. We cannot predict how you may react to any particular product or therapy.

To the maximum extent permitted by law, we exclude:

• any and all liability in contract, tort (including negligence), breach of statutory duty or otherwise for any direct, indirect, special, incidental, or consequential costs, losses, claims, damages, expenses or proceedings (including but not limited to loss of profits and wasted management time) incurred or suffered by you arising directly or indirectly out of or in connection with our services, including but not
limited to any loss, damage or expense arising from any defect, error, imperfection, fault, mistake or inaccuracy with the information or advice we provide; pg. 2 © 2015 Functional Diagnostic Nutrition® Rev. 08/2015

• any and all liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions we may provide;

• any and all liability for injury or loss arising from any product or treatment you may choose to take;

• any and all liability for any failure to identify any medical condition or disease. You understand and agree that this is not the purpose of our services.

This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation)
compensatory, direct, indirect or consequential damages, loss of data, income or profit, loss of or damage to
property and claims of third parties.
No recommendation
All material and information we may provide about products and therapies is provided solely for educational purposes and for use when discussing your health with your doctor. By providing you with such material and information, we do not necessarily endorse, recommend or promote any such product or therapy.
In Summary
It is common practice for naturopaths, nutritionists and other non-licensed practitioners to collect your signature on a form such as this. By doing so you acknowledge and accept that we:

• are not medically qualified;
• are not a substitute for advice from a qualified doctor;
• recommend that you consult your doctor before making any changes to your diet or exercise regime or taking any dietary supplement;
• do not warrant the accuracy of any information provided;
• are not liable for any losses you may suffer by relying on our advice;
• do not recommend any particular product;

By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.
2015 Functional Diagnostic Nutrition®

By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.

I have read and understood the above and I agree to it.
Signature*

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Date*

MonthDayYear
Date
Name*

First NameLast Name
Entering/typing name in the signature field above constitutes signing the document, confirming the signer agrees to the terms and conditions stated.
(If sending via mail or scanning and emailing document)
example@example.com
Entering/typing name in the signature field above constitutes signing the document, confirming the signer agrees to the terms and conditions stated.

2015 Functional Diagnostic Nutrition®

The Teal Center for Therapeutic Bodywork, Ltd.

CLIENT AGREEMENT
I, First and Last name*, give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk.
I also understand that

1. That massage therapy and/or acupuncture
- is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow;
- is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have
2. That the massage therapists and/or acupuncturists
- do not diagnose illness, disease or any other physical or mental disorder; do not prescribe medical treatment or pharmaceuticals; and
- do not perform any spinal manipulations
3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

If I need to reschedule due to illness, inclement weather, family emergencies, or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date

POLICIES
Welcome!

And thank you for choosing The Teal Center Please READ and INITIAL each of the following:
First and Last name* Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged in full. The only excusable reasons for late cancellation is for illness, inclement weather, family emergencies, and/or exposure to COVID. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are made 48 hours prior to the scheduled appointment.
First and Last name* The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to the Teal Center.
First and Last name* If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.
First and Last name* In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.
First and Last name* Tips are appreciated but never expected. If you wish to leave a gratuity for therapist we ask that you do so in cash or by check made directly to the therapist.
First and Last name* If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.
First and Last name* The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.
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Functional Diagnostic Nutrition® INTAKE FORM

Teal Center FDN -Terms of Service Agreement

What we do and do not do

Consult your doctor

Exclusion of warranties

Exclusion of liability

No recommendation

In Summary

The Teal Center for Therapeutic Bodywork, Ltd.

POLICIES