NutritionalEvaluation Form

Confidential Patient Record

Name* Sex* Age* DOB* Date*
 
Address* City* State* Zip*
 
Home Business Fax Mobile
 
Email* Occupation* Employer
 
Names/Ages of Children Marital Status (select one )*MARRIED SINGLE WIDOWED DIVORCED
 
Name of spouse Spouse's employer
 
Name and phone of emergency contact* Relationship*
 
How did you hear about our office?*

Nutritional & Metabolic Evaluation

Please complete the following information as completely as possible. This helps us to address your concerns and needs, and to b uild a healthp rogram pe rsonally d esig ned for you.

Complaints | Please rank your health complaints and rate their severity (on a scale from 1-10, 10 being the worst).*
 
Other Information | Please tell us any additional information or concerns about your health.
 
 
Goals | What are your goals for seeing Dr. Barsten?*
 
Limitations | What limitations do you have, if any, in working with Dr. Barsten? (e.g. unwilling to take nutritional supplements, working in excess of 60 hours a week, won't give up smoking or alcohol, etc).
 
Stress Level | Rate your stress level currently on a scale from 1-10 (10 being the most stress). Note that stress can come in forms such as overwork, relationships, health concerns, tiresome family or work responsibilities, excessive fear, worry, anxiety, insomnia, roa d rag e, not happy with life, depression, etc.
 
Overall stress*  Main reasons for stress
 
 
If over a level 5, what steps are you currently taking to reduce your stress?
 
Energy Level | List on a scale from 1-10 (1 is lowest, 10 is highest) what is your energy level during the following times:
 
AM* Afternoon* Evening* Late PM* After meals*   Overall*
 
Sleep Quality | How is your sleep? (check all that apply)* Restful Restless Hard to get sleep Wake up often Nightmares
 
What time do you usually go to sleep?* Hours of sleep/night?*
 
Type of mattress? How old is it? Type of pillows, sheets, and blankets?
 
Exercise | Do you exercise?* How often?* For how long per session?
 
What type of exercise do you do?
 
Medical History | Please describe any conditions which are under the care of a physician.
 
Diagnosis
 
Date of onset Duration of current symptoms
 
Doctor(s) involved, their specialty
 
How diagnosed (what tests)?
 
Current treatment (medication, etc.)
 
Treatment received in past, if any, and how it worked
Medications | Please list any medications you are taking, or have taken in the past, and for how long. State the reason for taking it.
 
Antacids Anti-in.ammatories Diuretics Muscle Relaxors Steroids (prednisone, anabolics, cortisone)
Antibiotics Birth Control Pills Hormones(estrogen, progesterone, DHEA,testosterone, thyroid) Pain Killers
Antidepressants Blood Pressure Medication Parasite Medication Yeast/Fungal Medications
Antihistamines Cardiac/Heart Medication
 
 
Drugs | This is strictly con.dential. Please list any recreational drugs used now or in the past:
 
How often? How long?
 
Surgeries/Hospitalizations | What surgeries, operations, traumas, fractures, car accidents, etc. have you had?
 
Appendectomy Breast Implants C-Sections Eye Surgery Laparoscopy
Arthroscopy Biopsies D&Cs Implants/Prostheses Tonsils/Adenoids
Cosmetic Surgery Body piercings Plastic or metal inside your body
 
Other (please list all with brief details such as date, outcome, etc.)
 
 
Scars | Describe any scars on your body (major and minor ones)
 
Smoking | Do you currently smoke?* How much? How long?
 
Dental Work | Indicate how many of the following you have:
 
Silver .llings Composites Veneers Dentures Porcelain crowns
Root canals Grinded/worn teeth Posts Sensitive teeth Gold crowns
Extractions BioCalex root canals Extractions Temporaries Steel crowns
Implants Bleeding gums New cavities infections/pockets
 
Do you need further dental work?* If so, what?
 
Sunlight | Amount of natural sunlight you receive daily outside?*
 
Hours spent daily under flourescent light?* Hours of sunlight daily through windows?*
 
Clothing | How often do you wear 100% natural clothing (cotton, ramie, wool, slik, linen)?*
 
How often to you wear 100% synthetic clothing (polyester, acrylic, nylon, rayon, etc.)?* Blends?*
 
Family History | Check those that apply and indicate the outcome and age of onset.
 
  Maternal
Grandma Grandpa
Paternal
Grandma Grandpa
Mother Father Brother Sister Onset Outcome
                     
Allergies
Arthritis (type)
Asthma
Cancer (type)
Diabetes
Heart Disease
Mental Disease
Thyroid Imbalance
 
Other
 
Review of Systems | Please check the " NOW " box for all conditions that you are now experiencing and mark theP "AST" box for any condition or symptoms experienced at any time in your life.
 
 Now Past Now Past Now Past Now Past Now Past
General Nose G-I System Neurologic Conditions
Weight loss Nosebleeds Gas Seizures/Epilepsy Hypertension
Weight gain Sinus problems Heartburn Strokes Diabetes
Head Lungs Indigestion Tingling sensation Thyroid condition
Headache Difficulty breathing Ulcers Numbness Heart condition
Dizziness Asthma Vomiting/Nausea Weakness Rheumatic arthritis
Head trauma Pneumonia Abdominal Pain Difficulty walking Rheumatic fever
Fainting Wheezing Diarrhea Poor coordination Glaucoma
Blacking out Persistent cough Constipation Muscle/Bone Alcoholism
Eyes Coughing phlegm Blood in stool Joint pain Cancer/Tumor
Change in vision Coughing blood Hemorrhoids Stiffness Polio
Cataracts Tuberculosis Gall bladder disease Muscle ache Parkinson
Light sensitivity Vascular Liver disease Arthritis Multiple Sclerosis
Flashes in vision Chest pain G-U System Bone pain Gout
Spots in vision Palpitations Difficulty urinating Fractures Anemia
Mouth Ankle swelling Pain urinating Dislocations Osteoporosis
Bleeding gums Cold feet/hands Blood in urine Skin Osteoarthritis
Cold sores Leg cramps Incontinence Rash High cholesterol
Dentures Calf pain Foul odor of urine Bruising Migraines
Sore throat Varicose veins Increased urination Brittle nails TIAs
Jaw pain Low blood pressure Decreased urination Changes in moles Headache unlike
Changes in taste High blood pressure Urinary infection Itching any previously
Hoarseness Genital infection Peeling experienced
 
Bowel Movements | Please circle those that apply.
How often:*daily | more than once a day | skip days
Consistency:*normal | too hard | too soft | diarrhea alternating with hard
Amount:*normal | too little Color:*brown | black | yellow | whitish Other:* mucus | foul smell | lots of gas
Comments*
Female Specific Issues | Please circle those that apply and fill in the blanks.
Are you pregnant? Y N Going through menopause? Y N Have your periods stopped? Y N
Breast feeding? Y N Are your periods regular? (28 day cycle) Y N Do you have monthly periods? Y N
Date of your last menstural period? Have you had a hysterectomy (indicate date, partial or total)
Emotional Tendency | Please check those emotions that you have a tendency towards.
Anger Anxiety Criticism Fear Insecurity Worry Inability to forgive (self/others) Other
 
Appliances/Cookware | Please check which of the following you use:
Gas stove Microwave oven Aluminum cookware Air purifier (Brand )
Electric stove Water bed Telfon cookware Water purifier (Brand )
Electric blanket Iron cookware Stainless steel cookware Shower filter (Brand )
Date filter was last changed
 
Toxic Inventory / Personal Care Products | Please list any toxins, chemicals, or solvents you have had exposure to or use of. These can
include products for the yard, work, furniture, art, building/carpentry, etc. (list the brand names in the space provided):
 
Shampoo Deodorant Toothpaste
Body Soap Hand/Body Lotion Laundry Soap
Dish Soap Household Cleaner Hairspray/Gel
Nail Polish Hair Coloring Air Freshener
Ant/Roach Spray Pesticides Other
Electromagnetic Exposure | How many hours do you spend daily:
Watching TV Talking on a cell phone Near electrical equipment
Wearing a pager Working on a computer Sleeping near an electric clock?
 
Water/Hydration | How many glasses (8-10oz) of plain water do you drink in an average day?*
Do you drink tap water? *
 
What brand(s) of drinking water do you use?
 
Do you cook with tap, bottled, or filtered water on a regular basis?*
 
If you have a home water purifier, when was the last time you changed the cartridge?
Diets | Please check any applicable diet that you are currently on.
Allergy rotation/desensitization No dairy Candida diet Yeast-free Low salt Low fat Diabetic*
Atkins/Zone diet Vegetarian Vegan Any other diet
 
Food Habits | How often do you eat out, and at what type of restaraunts?*
 
How often do you prepare meals at home?* Do you avoid food/drinks that list "natural .avors" on the label?*
Please check if you do any of the following:
Eat while working, watching TV, driving, etc. Eat food past 7pm Eat/chew food too fast Skip meals often (which ones)  
 
 
Food Choices | Please check each type of food you eat twice a week or more. (C=commercially grown, O=organically grown)
COCOCOCOCO
Premade Foods Harvest Meat/Fish Dairy Condiments
Canned foods Fresh vegetables Beef, pork, lamb Eggs Table salt
Boxed cereal Fresh fruit Chicken Butter Sea salt
Frozen dinners Whole grains Turkey Milk Ketchup
Frozen juices Whole beans Canned tuna Milk, raw Mustard
Take-out food Fresh fish Cheese Vinegar
Frozen fish Sweeteners
Restaurant fish
Food Stressors | Please check which of the following you have every week, and indicate how many times per week you consume it.
Stimulants     Toxic Oils     Hormone Platters
(non-organic)
    Empty/Processed    
Coffee(inc. decaf)  Fried foods  Beef  White pasta
Black tea, chai tea  Fast foods  Chicken  White bread
Soft drinks (cola, etc.)  Potato or corn  chips  Milk, Ice cream  Instant cereal
Drinks w/NutraSweet  Roasted nuts  Cheese, butter  Cookies
Alcohol  Smoked meats  Yogurt  Store-bought  muffins
Chocolate  Margarine  Hot  dogs/sausage  Minute rice
Candy, pastry, sweets  Shortening  Pork, lunch  meats  Bagels
 
   
  
  
  
  
  
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Metabolic Policies Form:

Greg Barsten, DC, MS, CCN, RH (AHG)

HealthQuest
14107 Winchester Blvd., Ste. J
Los Gatos, CA 95032
(408) 358-2225
www.HealthQuestForMe.com

Welcome! Thank you for selecting HealthQuest for your healthcare needs. Please take a few moments and familiarize yourself with our policies.

Rates and Fees

Initial evaluations and in-office testing are charged at a rate of $300 per hour (30 minute increments). Follow-up visits are the same rate (15 minute increments). Outside lab fees may be extra.

Telephone consultations (15 minute increments) are the same rate as above. Brief questions (less than 5 minutes) are free. However, if the time exceeds 5 minutes and/or calls are frequent, we will suggest a phone consultation so as to better address concerns, and not piece together important information.

Insurance: Upon request, we will provide you with a receipt and, if appropriate for your condition, a claim form that you can submit to your insurance company to seek direct reimbursement. HealthQuest does not accept insurance for payment. In addition, HealthQuest does not provide services within the Medicare or Medicaid contract.

Email communication is available for brief questions or clarification. It is not a substitute for an office visit and is offered as a simple communication option. We will respond at our earliest opportunity.

Preparation Guidelines

Please do not eat 1 hour before the appointment, including coffee.

In consideration for some of our chemical and environmentally-sensitive patients, please do not wear any perfume or cologne the day of your appointment.

Medical Records

Please bring your latest lab (blood, etc.) and imaging studies if applicable (reports only, not the actual films) with you to the appointment. Make copies as the copies we obtain from you will be kept for our records. Please do not fax to our office if more than 5 pages. Be sure to allow enough time to have these in your possession before the appointment. You may need to sign an “authorization to release medical records” form at your doctor’s office.

All records are strictly confidential.

Retail Sales and Product Shipping

Supplements may be ordered by phone or email. We will ship out based on current inventory and may take a day to process. We ship either USPS or UPS and you pay actual charges plus $4 handling fee. Some products are available for direct ordering through our website http://www.HealthQuesForMe.com. Our Virtual Pharmacy can meet most of your supplement needs.

Return Policy

If for any reason you decide to return a product, we are happy to give you a refund or credit if the bottle is unopened, has not expired, and was purchased within 60 days. No returns will be allowed for purchases greater than 60 days or for special items (homeopathics, enzymes, probiotics, custom herbs or tonics).



Copies, Reports and Forms

There is an additional charge of $25 to $100 to complete forms or write reports based on their complexity. There is a $15 charge to make copies of chart contents. We encourage you to keep copies of your lab results to avoid this charge.

No Show and Cancellation Policy

If you need to reschedule your appointment, please give us 48-hour notice so that we have time to offer that time to another patient who may be waiting to get in. We reserve the right to charge $100 for appointments missed or canceled with less than 48-hour notice. Our staff will attempt to remind you of your visit, but it is your responsibility to remember all appointments.

1.Services are payable at the time of service. We accept, cash, check, VISA and MasterCard.

2.Phone consultations can be billed to your credit card. We can send you a statement describing the service/fees.

3.Supplements or products can be shipped and charged to your credit card.

Payment Policy

Credit Card Authorization

This authorizes Dr. Greg Barsten/HealthQuest to maintain my VISA or MasterCard on file. I understand that Dr. Barsten/HealthQuest will keep this number confidential. For my convenience, you will use this number to charge my supplements, mailed supplement orders, telephone consultations, no-shows and late cancellations. I do not need to reauthorize for each order. I will give Dr. Barsten/HealthQuest a verbal or written update when this card expires.

*Name: (print clearly)

  


image max width:200px, height:70px

Informed Consent

I, the undersigned, have voluntarily requested that Dr. Greg Barsten assist me in management of my health concerns. I have understood and agree to all policies and terms provided herein. I also understand that Dr. Barsten is a chiropractor, clinical nutritionist and herbalist and serves as a consultant utilizing natural biological methods. I also realize that his services are not to be construed as the ‘practice of medicine’ or serve as a substitute for standard medical care.

Signed(Please enter your full name) *Date

When all pages are completed and received by the office, we will call to schedule the visit.

 

Chiropractic

Botanical Medicine

Clinical Nutrition

Sports Therapy

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HIPAA Regulation Form

HIPAA

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.

Dr. Greg Barsten dba HealthQuest is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example)

"On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Dr. Greg Barsten dba Health Quest."

"It is our policy to provide a substitute health care provider, authorized by Dr. Greg Barsten dba Health Quest to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider's absence due to vacation, sickness, or other emergency situation."

Please note that one of our treatment rooms is an enclosed space, does not have walls that meet the ceiling. Every effort will be made to protect your privacy. If you are at all uncomfortable, please inform any of our staff.

Our answering machine is not a closed system. When messages are retrieved, there is a chance your message could be overheard. Again every effort is made to take messages off of the machine with your privacy considered.

Our filing area is monitored by staff at all times, as it is separate from the treatment rooms.

Workers' Compensation

We may disclose your health information as necessary to comply with State Workers' Compensation Laws.

Emergencies

We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Public Health

As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Judicial and Administrative Proceedings

We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

Deceased Persons

We may disclose your health information to coroners or medical examiners.

Research

We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Specialized Government Agencies

We may disclose your health information for military, national security, prisoner and government benefits purposes.

Marketing

We may contact you for marketing purposes or fundraising purposes, as described below: (example)

"As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment"

"It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event It is not our policy to disclose any personal health information about your condition for the purpose of Dr. Greg Barsten dba Health Quest sponsored fund-raising events."

Change of Ownership. In the event that Dr. Greg Barsten dba HealthQuest is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Dr. Greg Barsten dba HealthQuest is not required to agree to the restriction that you requested.

You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

You have the right to inspect and copy your health information.

You have a right to request that Dr. Greg Barsten dba HealthQuest amend your protected health information. Please be advised, however, that Dr. Greg Barsten dba HealthQuest is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your protected health information made by Dr. Greg Barsten dba HealthQuest.

You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices

Dr. Greg Barsten dba HealthQuest reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, Dr. Greg Barsten dba HealthQuest is required by law to comply with this Notice.

Dr. Greg Barsten dba HealthQuest is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Dr. Greg Barsten by calling this office at 408-358-2225. If Dr. Greg Barsten is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints

Complaints about your Privacy rights, or how Dr. Greg Barsten dba HealthQuest has handled your health information should be directed to Dr. Greg Barsten by calling this office at 408-358-2225 If Dr. Greg Barsten is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

*This notice is effective as of

I have read the Privacy Notice and understand my rights contained in the notice.

By way of my signature, I provide Dr. Greg Barsten dba HealthQuest with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice

*Patient's Name (print)  
*Patient's Signature max width:200px, height:70px *Date
*Authorized Facility Signature max width:200px, height:70px *Date
OH.J. Ross Company, Inc. 2002, 2003 HIPAA Interactive-All Rights Reserved FORM 03.501
   
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Chiropractic Treatment Form

Greg Barsten, DC, MS, RH (AHG), CCN

HealthQuest

14107 Winchester Blvd., Suite J

Los Gatos, CA 95032 (408) 358-2225 www.HealthQuestforMe.com

Informed Consent For Chiropractic Treatment

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physio therapy, on me (or on the patient named below, for whom I am legally responsible ) or by the doctor of chiropractic named above and/or other licensed doctors of chiropractic who now or in the future work at the clinic listed.

I have had the opportunity to discuss with the doctor of chiropractic named above and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some material risks to proposed care and treatment, “material risks” including but not limited to fractures, disk injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known to him or her, is in my best interest.

I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

To be completed by the patient:

To be completed by the patient’s representative, if necessary, (e.g. if the patient is a minor or is

physically or mentally incapacitated)

Print Patient’s Name

Print Name of Representative

Initial of Patient

Initial of Representative

Date

Date

   
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Schedule an Appointment Today! - (408) 358-2225
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Chiropractic Evaluation Form

Confidential Patient Record

Name Sex Age DOB Date
Address City State Zip
Home Business Fax Mobile
Email Occupation Employer
Names/Ages of Children Marital Status Married Single WidowedDivorced
Name of Spouse Spouse's Employer
Name and Phone of Emergency Contact Relationship
How did you hear about our office?
Have you ever been to a chiropractor before? Yes NoIf yes, which doctor?

Health Evaluation

Using the diagram below, mark the areas of your body where you currently feel pain or other abnormal sensation. Also indicate where your pain travels (if appropriate). You can also write notes next to your markings if a description would be helpful. Then, please answer the ques- tions to the right by selecting the number that best represents your pain, where 1 is no pain and 10 is pain as bad as you can imagine (describe if your pain is sharp, achey, stiff, sore, numb, tingling or a combination).

How long ago did your pain start?
20 Characters Left
Rate your pain by selecting the one number that best describes your pain at its WORST in the past 24 hours.
12345678910
Rate your pain by selecting the one number that best describes your pain at its LEAST in the past 24 hours.
12345678910
Rate your pain by selecting the one number that best describes your pain on AVERAGE for the past WEEK.
12345678910
What makes your pain/discomfort better or worse?
20 Characters Left
Is your pain constant? Yes No
Has it gotten worse? Yes No
Does it wake you from sleep? Yes No
15466 Los Gatos Blvd. #215
Los Gatos, California 95032
408.358.2225
Comments & Additional Information
Cancellation Policy
Please call our office 24 hours in advance, to prevent being charged for no-show appointments. Your initials below indicate that you understand you will be charged for the visit if you miss your appointment without a 24-hour cancellation.

Please enter your Initials in the Box


 
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