FORMS

Application for Nutrition Response Testing

Step 1 of 10

Little Rock Chiropractic Clinic

1100 West 3rd Street Little Rock, Arkansas 72201

PERMISSION & AUTHORIZATION FORM

REGARDING THE USE OF NUTRITION RESPONSE TESTING™

PLEASE READ BEFORE SIGNING:

I specifically authorize the natural health practitioners at Little Rock Chiropractic Clinic to perform a Nutrition Response Testing health analysis and to develop a natural, complementary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or “cure” of any disease.

I understand that Nutrition Response Testing is a safe, non-invasive, natural method of analyzing the body’s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems.

I understand that Nutrition Response Testing is not a method for “diagnosing” or “treating” of any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated.

No promise or guarantee has been made regarding the results of Nutrition Response Testing or any natural health, nutritional or dietary programs recommended, but rather I understand that Nutrition Response Testing is a means by which the body’s natural reflexes can be used as an aid in determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

I have read and understand the foregoing. This permission form applies to subsequent visits and consultations.

Signature of patient*
Signature of parent or guardian only*

Little Rock Chiropractic Clinic

1100 West 3rd Street Little Rock, Arkansas 72201

Patient Consent for Use and Disclosure
Of Protected Health Information

PLEASE READ BEFORE SIGNING:
I hereby give my consent for Little Rock Chiropractic Clinic, P.A. (hereinafter referred to as “LRCC”) to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

LRCC's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. A copy of this Notice is available upon request to Dr. Richard L. Riley or Denise Moix, our Privacy Officers, or any other LRCC staff member.

LRCC reserves the right to revise its Notice of Privacy Practices at any time and agrees to provide me a revised copy upon my request to LRCC.

With this consent, the LRCC may call (or text message) my home or other designated phone number on file and leave a message on voice mail or in person in reference to any items that assist LRCC in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, LRCC may mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as patient statements.

With this consent, LRCC may e-mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as appointment reminders and patient statements.

I have the right to request that LRCC restrict how it uses or discloses my PHI to carry out TPO. However, LRCC is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to LRCC's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that LRCC has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, LRCC may decline to provide treatment to me as permitted by Section 164.506 of the Code of Federal Regulations.
Signature of patient*
Signature of parent or guardian only*
Consent
I have been given and am in receipt of LRCC’s Notice of Privacy Practices.
(please initial)*
Consent
I do not wish to receive a copy of LRCC’s Notice of Privacy Practices.
(please initial)*
Phone
This field is for validation purposes and should be left unchanged.

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	N/A	(1) Mild	(2) Moderate	(3) Severe
1 Acid foods upset
2 Get chilled, often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meal
6 Keyed up - fail to calm
7 Cuts heal slowly
8 Gag easily
9 Unable to relax, startles easily
10 Extremities cold, clammy
11 Strong light irritates
12 Urine amount reduced
13 Heat pounds after retiring
14 "Nervous stomach
15 Appetite reduced
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach frequent

	N/A	(1) Mild	(2) Moderate	(3) Severe
21 Joint stiffness after arising
22 Muscle-leg-toe cramps
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen, puffy
27 Indigestion soon after meals
28 Always seem hungry; feels "lightheaded" often
29 Digestion rapid
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
36 Constipation, diarrhea alternating
37 "Slow starter"
38 Get "chilled" infrequently
39 Perspire easily
40 Circulation poor, sensitive to cold
41 Subject to colds, asthma, bronchitis

	N/A	(1) Mild	(2) Moderate	(3) Severe
42 Eat when nervous
43 Excessive appetite
44 Hungry between meals
45 Irritable before meals
46 Get "shaky" if hungry
47 Fatigue, eating relieves
48 "Lightheaded" if meals delayed
49 Heart palpitates if meals missed or delayed
50 Afternoon headaches
51 Overeating sweets upsets
52 Awaken after few hours sleep - hard to get back to sleep
53 Crave candy or coffee in afternoons
54 Moods of depression - "blues" or melancholy
55 Abnormal craving for sweets or snacks

	N/A	(1) Mild	(2) Moderate	(3) Severe
56 Hands and feet go to sleep easily, numbness
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 High altitude discomfort
60 Opens windows in closed room
61 Susceptible to colds and fevers
62 Afternoon "yawner"
63 Get "drowsy" often
64 Swollen ankles worse at night
65 Muscle cramps, worse during exercise; get "charley horses"
66 Shortness of breath on exertion
67 Dull pain in chest or radiating into left arm, worse on exertion
68 Bruise easily, "black and blue" spots
69 Tendency to anemia
70 "Nose bleeds" frequent
71 Noises in head, or "ringing in ears"
72 Tension under the breastbone, or feeling of "tightness", worse on exertion

	N/A	(1) Mild	(2) Moderate	(3) Severe
73 Dizziness
74 Dry skin
75 Burning feet
76 Blurred vision
77 Itching skin and feet
78 Excessive falling hair
79 Frequent skin rashes
80 Bitter, metallic taste in mouth in mornings
81 Bowel movements painful or difficult
82 Worrier, feels insecure
83 Feeling queasy; headache over eyes
84 Greasy foods upset
85 Stools light-colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks or gallstones
91 Sneezing attacks
92 Dreaming, nightmare type bad dreams
93 Bad breath (halitosis)
94 Milk products cause distress
95 Sensitive to hot weather
96 Burning of itching anus
97 Crave sweets

	N/A	(1) Mild	(2) Moderate	(3) Severe
98 Loss of taste for meat
99 Lower bowel gas several hours after eating
100 Burning stomach sensations, eating relieves
101 Coated tongue
102 Pass large amounts of foul-smelling gas
103 Indigestion ½ - 1 hour after eating; may be up to 3-4 hours
104 Mucous colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating

	N/A	(1) Mild	(2) Moderate	(3) Severe
107 Insomnia
108 Nervousness
109 Can't gain weight
110 Intolerance to heat
111 Highly emotional
112 Flush easily
113 Night sweats
114 Thin, moist skin
115 Inward trembling
116 Heart palpitates
117 Increased appetite without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can't work under pressure

	N/A	(1) Mild	(2) Moderate	(3) Severe
122 Increase in weight
123 Decrease in appetite
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
127 Sensitive to cold
128 Dry or scaly skin
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
132 Headaches upon arising wear off during day
133 Slow pulse, below 65
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative

	N/A	(1) Mild	(2) Moderate	(3) Severe
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches, "splitting or rendering" type
141 Decreased sugar tolerance

FORMS

Application for Nutrition Response Testing

Step 1 of 10

History

Little Rock Chiropractic Clinic

1100 West 3rd Street Little Rock, Arkansas 72201

PERMISSION & AUTHORIZATION FORM

REGARDING THE USE OF NUTRITION RESPONSE TESTING™

Little Rock Chiropractic Clinic

1100 West 3rd Street Little Rock, Arkansas 72201

Patient Consent for Use and Disclosure Of Protected Health Information

Patient Consent for Use and Disclosure
Of Protected Health Information