Date of Birth
* Date of Birth
Weight one year ago
List Skype name/ID, FaceTime phone number if applicable.
Do you have any medical diagnoses? Please list them if yes.
What medications do you take (prescription and over the counter)? Please list them.
What supplements (vitamins, minerals, herbs, etc.) do you take?
What kind of lab testing have you had done? Please list tests.
Please list a typical day's diet for you, including breakfast, lunch, dinner, snacks, and beverages consumed.
Do you currently follow a specific diet? Please explain.
Do you have any food allergies or sensitivities? Please describe.
Are there certain foods you avoid because of the way they make you feel? Please explain.
Do you have any problems chewing or swallowing? If yes, please explain.
Do you experience any of the following symptoms? Please check all that apply.
Watery or itchy eyes
Bags or dark circles under eyes
Blurred or tunnel vision
Earaches, ear infections
Ringing in ears
Excessive mucus formation
Sore throat, hoarseness, loss of voice
Gagging, frequent need to clear throat
Swollen or discolored tongue, gums, lips
Cracks, sores at sides of mouth
Flushing, hot flashes
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Shortness of breath
Pains or aches in joints
Pain or aches in muscles
Feelings of weakness, tiredness, fatigue
Stiffness or limitation of movement
Cravings for certain foods
Confusion, poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Frequent or urgent urination
Genital itch or discharge
If you selected other, please describe.
Do you have cravings for certain foods? Please explain.
How often do you cook at home?
How often do you eat out or eat takeout?
What are your favorite foods?
What are your least favorite foods?
What do you think needs to change most about your diet? Please explain.
What has been stopping you from making this change on your own? Please explain.
On a scale of 1-5 with 5 being 100% confident, how confident are you that you can follow a diet plan that we customize for your needs? If you did not select 5, please explain what your hesitation is.
Please list your top 3 health goals.
Please state your primary dietary goal.
What do you hope to get most out of working with Jennifer?
How did you hear about Jennifer and, if from a referral, whom may we thank?
HIPAA NOTICE OF PRIVACY PRACTICES This notice outlines your protected health information, how it may be used, and what your rights are. Please review carefully and ask any questions prior to signing. Questions about this notice can be directed to Jennifer Caryn Brand Nutrition. OUR PLEDGE REGARDING PROTECTED HEALTH INFORMATION: We, Jennifer Caryn Brand Nutrition understand that protected health information about you and your health is personal. We are committed to protecting health information about you. This Notice applies to all of the records of your care generated by Jennifer Caryn Brand Nutrition, whether made by Jennifer Caryn Brand Nutrition personnel or your personal doctor or other health care provider. This Notice will tell you about the ways in which we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The law requires us to: • make sure that protected health information that identifies you is kept private • notify you about how we protect protected health information about you • explain how, when and why we use and disclose protected health information • follow the terms of the Notice that is currently in effect. We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all protected health information that we maintain by: • posting the revised Notice in our office • making copies of the revised Notice available upon request • posting the revised Notice on our website. HOW WE MAY USE AND DISCLOSE PROTECTED HEALTH INFORMATION ABOUT YOU The following categories describe different ways that we use and disclose protected health information without your written authorization. For Treatment: We may use protected health information about you to provide you with, coordinate or manage your medical treatment or services. We may disclose protected health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. Jennifer Caryn Brand Nutrition staff may also share protected health information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose protected health information about you to people outside Jennifer Caryn Brand Nutrition’s office who may be involved in your medical care. We may use and disclose protected health information to contact you as a reminder that you have an appointment for treatment or medical care at Jennifer Caryn Brand Nutrition. We may use and disclose protected health information to tell you about or recommend possible treatment options or alternatives or health-related benefits or services. For Payment for Services: We may use and disclose protected health information about you so that the treatment and services you receive at Jennifer Caryn Brand Nutrition may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about nutrition services you received at Jennifer Caryn Brand Nutrition so your health plan will pay us or reimburse you for the service. We may also tell your health plan about the nutrition services you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations: We may use and disclose protected health information about you for Jennifer Caryn Brand Nutrition health care operations, such as our quality assessment and improvement activities, case management, coordination of care, business planning, customer services and other activities. These uses and disclosures are necessary to run the facility, reduce health care costs, and make sure that all of our patients receive quality care. We may also combine protected health information about many Jennifer Caryn Brand Nutrition patients to decide what additional services Jennifer Caryn Brand Nutrition should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other Jennifer Caryn Brand Nutrition personnel for review and learning purposes. We may also combine the protected health information we have with protected health information from other health care facilities to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of protected health information so others may use it to study healthcare and health care delivery without learning who the specific patients are. We may also contact you as part of a fundraising effort. Subject to applicable state law, in some limited situations the law allows or requires us to use or disclose your health information for purposes beyond treatment, payment, and operations. However, some of the disclosures set forth below may never occur at our facilities. As Required By Law: We will disclose protected health information about you when required to do so by federal, state or local law. Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. Health Risks: We may disclose protected health information about you to a government authority if we reasonably believe you are a victim of abuse, neglect, or domestic violence. We will only disclose this type of information to the extent required by law, if you agree to the disclosure, or if the disclosure is allowed by law and we believe it is necessary to prevent or lessen a serious and imminent threat to you or another person. Judicial and Administrative Proceedings: If you are involved in a lawsuit or dispute, we may disclose your information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made, either by us or the requesting party, to tell you about the request or to obtain an order protecting the information requested. Business Associates: We may disclose information to business associates who perform services on our behalf (such as billing companies); however, we require them to appropriately safeguard your information. Public Health. As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. To Avert a Serious Threat to Health or Safety: We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These activities include audits, investigations, and inspections, which may be necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws. Law Enforcement: We may release protected health information as required by law, or in response to an order or warrant of a court, a subpoena, or an administrative request. We may also disclose protected health information in response to a request related to identification or location of an individual, victims of crime, decedents, or a crime on the premises. Organ and Tissue Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank to facilitate organ or tissue donation and transplantation. Special Government Functions: If you are a member of the armed forces, we may release protected health information about you if it relates to military and veterans’ activities. We may also release your protected health information for national security and intelligence purposes, protective services for the President, and medical suitability or determinations of the Department of State. Coroners, Medical Examiners, and Funeral Directors: We may release protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose protected health information to funeral directors consistent with applicable law to enable them to carry out their duties. Correctional Institutions and Other Law Enforcement Custodial Situations: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release protected health information about you to the correctional institution or law enforcement official as necessary for your or another person’s health and safety. Worker’s Compensation: We may disclose information as necessary to comply with laws relating to worker’s compensation or other similar programs established by law. Food and Drug Administration: We may disclose to the FDA, or persons under the jurisdiction of the FDA, protected health information relative to adverse events with respect to drugs, foods, supplements, products and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. YOU CAN OBJECT TO CERTAIN USES AND DISCLOSURES. Unless you object, or request that only a limited amount or type of information be shared, we may use or disclose protected health information about you in the following circumstances: • We may share with a family member, relative, friend, or other person identified by you protected health information directly relevant to that person’s involvement in your care or payment for your care. We may also share information to notify these individuals of your location, general condition or death. • We may share information with a public or private agency (such as the American Red Cross) for disaster relief purposes. Even if you object, we may still share this information if necessary for the emergency circumstances. If you would like to object to use and disclosure of protected health information in these circumstances, please call or write to our contact person listed on page 1 of this Notice. YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION ABOUT YOU. You have the following rights regarding protected health information we maintain about you: Right to Inspect and Copy: You have the right to inspect and copy protected health information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing to Jennifer Caryn Brand Nutrition. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request, and we will respond to your request no later than 30 days after receiving it. There are certain situations in which we are not required to comply with your request. In these circumstances, we will respond to you in writing, stating why we will not grant your request and describe any rights you may have to request a review of our denial. Right to Amend: If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend or supplement the information. To request an amendment, your request must be made in writing and submitted to Jennifer Caryn Brand Nutrition. In addition, you must provide a reason that supports your request. We will act on the/ your request for an amendment no later than 60 days after receiving the request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, and will provide a written denial to you. In addition, we may deny your request if you ask us to amend information that: • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment • Is not part of the protected health information kept by Jennifer Caryn Brand Nutrition • Is not part of the information which you would be permitted to inspect and copy, or • We believe is accurate and complete. Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Jennifer Caryn Brand Nutrition. You may ask for disclosures made up to six years before your request (not including disclosures made before June 25, 2014). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We are required to provide a listing of all disclosures except the following: • For your treatment • For billing and collection of payment for your treatment • For health care operations • Made to or request by you, or that you authorized • Occurring as a byproduct of permitted use and disclosures • For national security or intelligence purposes or to correctional institutions or law enforcement regarding inmates • As part of a limited data set of information that does not contain information identifying you Right to Request Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, the disclosure is to the Secretary of the Department of Health and Human Services, or the disclosure is for one of the purposes described on pages 4-5. To request restrictions, you must make your request in writing to Jennifer Caryn Brand Nutrition. Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to Jennifer Caryn Brand Nutrition. We will accommodate all reasonable requests. Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time by contacting Jennifer Caryn Brand Nutrition. OTHER USES AND DISCLOSURES We will obtain your written authorization before using or disclosing your protected health information for purposes other than those provide for above (or as otherwise permitted or required by law). You may revoke this authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your information, except to the extent that we have already taken action in reliance on the authorization. YOU MAY FILE A COMPLAINT ABOUT OUR PRIVACY PRACTICES If you believe your privacy rights have been violated, you may file a complaint with Jennifer Caryn Brand Nutrition, or file a written complaint with the Secretary of the Department of Health and Human Services. A complaint to the Secretary should be filed within 180 days of the occurrence of the complaint or violation. If you file a complaint, we will not take any action against you or change our treatment of you in any way. Acknowledgement Confirming Receipt of HIPAA Privacy Notice, I acknowledge I have received a copy of the HIPAA Privacy Notice. Typing your name below serves as your electronic signature, that you have read and agree to the HIPAA notice of privacy practices.
INFORMED CONSENT NOTICE I have been informed of alternatives to receiving the health care services proposed in my treatment plan, including no treatment at all, and have agreed to move forward with the proposed plan of treatment. All of my questions have been answered concerning the proposed plan of treatment to my satisfaction. Our office and its employees make no representations, claims, or guarantees regarding the efficacy of our recommendations. The protocols we recommend are based upon a combination of our clinical experience and knowledge of scientific and medical literature. With this information individualized protocols may be offered and applied as either adjunctive or primary protocols for certain conditions. The undersigned consents to the provision of services by a Master’s degree level clinical nutritionist, and CNS (certified nutrition specialist) candidate. By signing this informed consent you agree to hold harmless Jennifer Caryn Brand Nutrition, its owners, employees and contractors from all professional and personal liability, negligence, or other legal liability. You agree to be responsible for all legal costs and fees that may result from action(s) on your part or on the part of your representative(s) against us. If a legal case is brought against us, you agree that we shall be judged by the standard principles of complementary/holistic/alternative/functional medicine and not the standards and principles of consensus of conventional/allopathic medicine. You have the right to have this consent reviewed by your lawyer before accepting any services from our office and we suggest that you exercise this right. Our office may make available nutritional supplements and other health related products. You are in no way obligated to purchase these products from our office or any other specific location or company. You may freely choose to purchase such products from any source(s) you wish. Jennifer Caryn Brand Nutrition and its employees may profit from the sale of supplements and other products we make available to our clients. Most insurance plans cover services that they consider medically necessary and/or reasonable and customary. Many of our services such as nutritional consults, exercise programs, dietary protocols and testing (blood/urine/saliva) are often not considered by insurance companies to be necessary or a “covered service” and, therefore, reimbursable, based upon their own criteria. Our office does not accept insurance assignment. By signing this form you accept full financial responsibility for all non-covered services; including but not limited to consultations, and blood/saliva/urine and other laboratory tests and procedures. SIGNATURE ON FILE: I request that the provider make either to me or on my behalf payment of authorized benefits to Jennifer Caryn Brand Nutrition for services furnished to me. I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. Your signature verifies and affirms that you have not been told to discontinue treatments with any other medical specialists or other health care providers. Your signature is being given prior to rendering any services, advice, and/or recommendations whatsoever from Jennifer Caryn Brand Nutrition. It is the responsibility of the client to follow-up with our office for results of all testing and laboratory procedures. It should not be assumed on the part of the client that if they are not contacted Jennifer Caryn Brand Nutrition, or its employees, or if the client does not schedule or keep consultation, that test results are normal (or without abnormalities), and may not require further follow ups or advice. Health/medical recommendations and/or possible referral and additional follow-up may be warranted based upon laboratory testing and evaluations. The client is further notified that some tests, or all, may not be covered by their insurance company. The client assumes full responsibility for the costs of non-covered tests. Jennifer Caryn Brand Nutrition does not assume responsibility for costs of non-covered tests. Jennifer Caryn Brand Nutrition does not assume full responsibility for costs incurred regarding non covered and/or potentially-covered services, including but not limited to procedures, lab tests (blood, urine, saliva, etc.), and our consultations. Jennifer Caryn Brand Nutrition also recommends that you get medical clearance from your MD before you partake in any of the exercise modalities we might suggest. Jennifer Caryn Brand Nutrition does not allow their sessions with any client to be recorded on any kind of device, if a client wants to record a session Jennifer Caryn Brand Nutrition has to give its consent. By entering your signature below you are acknowledging that you have read this entire agreement, understand all terms, verbiage (language) and concepts herein, and agree to proceed with care. By signing below you agree that you have weighed the risks and benefits of proceeding with the services and have decided that it is in your best interest to obtain the services proposed. Having been informed of the potential risks, I hereby give my consent or the consent of the minor to which I am legal guardian for said services. I understand this consent agreement and have executed it freely and willingly. JENNIFER CARYN BRAND NUTRITION REQUIRES 48 HOURS NOTICE UPON CANCELLING AN APPOINTMENT. IF AN APPOINTMENT IS SCHEDULED FOR MONDAY, CANCELATION MUST BE RECEIVED BY FRIDAY 12:00PM PACIFIC TIME. IF PRIOR NOTICE IS NOT GIVEN, YOU WILL BE CHARGED THE FEE ASSOCIATED WITH THE SCHEDULED APPOINTMENT. SIGNING THIS AGREEMENT CONFIRMS YOUR CONSENT TO THESE TERMS. I have sought the clinical and health care services of Jennifer Caryn Brand Nutrition – for my personal healthcare or for my child or children who are minors. I understand that this health practice uses some approaches and methods that are known as complementary, alternative, holistic or functional in nature. This may not be covered by my insurance plan or might not be generally accepted by mainstream medicine. The terms complementary, holistic, alternative or functional refer to therapies that may include, but are not limited to, dietary and nutritional supplement advice, yoga, certain dietary/exercise protocols to follow, and certain metabolic tests that are used for informational purposes. Furthermore, the information gained from laboratory and evaluation tests may be interpreted differently from mainstream medical doctors. Approaches for improving general health and nutrition may be based upon the tests/evaluations and philosophies of complementary/functional/holistic/alternative medicine and may or may not be consistent with mainstream medical tests/evaluations and philosophies. Although prescriptions and over-the-counter medications are used when your physician deems it necessary, foods, vitamins, minerals, enzymes, herbs, and other nutritional approaches may also be chosen as therapy or as adjunctive to medical therapies. It is your responsibility to ensure you inform your medical doctor of all supplements/diets you will be partaking in so that he/she can make sure there are no contraindications to your medicine. We will be glad to discuss and confer with your medical doctor concerning these supplements/diets if he or she wishes to do so and with your approval. In addition to recommending oral nutritional supplements it is not uncommon that our office might use products/approaches that are not FDA (Food and Drug Administration) approved or evaluated for any condition though are in compliance and permitted to be used pursuant to the federal Dietary Supplement Health and Education Act of 1994. Our programs are exclusively an office based operation. We are not affiliated with a local hospital. As a result, WE STRONGLY RECOMMEND THAT IN ADDITION TO OUR SERVICE YOU MAINTAIN A RELATIONSHIP WITH ONE OR MORE PHYSICIANS QUALIFIED TO CARE FOR YOUR INDIVIDUAL HEALTH CONDITIONS. For example, in case of children we advise you seek the advice of a pediatrician; if you have cardiovascular disease consult a cardiologist; and if you have cancer consult with a oncologist; if you have any other degenerative conditions like, Diabetes, Lupus, Lou Gehrig’s disease (ALS), Multiple Sclerosis, or any other auto-immune disease seek the advice from the appropriate medical professional. We often refer clients to these and other healthcare professionals when it is deemed necessary. These physicians can provide you and your family with emergency care if hospitalization is needed and ongoing follow-up care. We are happy to communicate and cooperate with your doctor(s) regarding your medical condition(s), options or any other health related issues. As with many health related services, there are certain potential complications which may arise during the receipt of these services. Those complications range from discomfort through serious health concerns requiring emergency medical care. The probability of these complications are rare but you are being made aware of the full range of possibilities that may occur and assume the risk of proceeding with care by signing this agreement. Typing your name below serves as your electronic signature, that you have read and agree to the Informed Consent notice.
All sessions are virtual. Type your initials to acknowledge.
Communication outside of sessions: I respond to email and phone messages typically within the same day, however it may take up to 72 [business] hours for a response depending on my availability (Saturday and Sunday are not included in this timeframe). Depending on the level of communication requested between sessions, additional fees for services provided may be charged. Type your initials to acknowledge.
All pricing is subject to change. Fees paid for sessions, and any services provided are nonrefundable. Type your initials to acknowledge.
Jennifer Caryn Brand Nutrition does not take insurance. Type your initials to acknowledge.
Costs of recommended supplements and laboratory assessments are not included in Jennifer Carny Brand Nutrition’s pricing and services. They are the responsibility of you/the client. Laboratory assessments requested from your doctor may or may not be covered by insurance. It is your/the client's responsibility to work with your doctor and insurance company. Type your initials to acknowledge.
Jennifer Caryn Brand Nutrition has the right to refuse service to anyone who does not abide by the policies and expectations outlined between practitioner and client. Type your initials to acknowledge.
For all appointments, notice of cancelation must be given 48 hours prior to the scheduled appointment. If your appointment is on Monday, notice of cancelation must be received by noon Pacific Time on the preceding Friday. If an appointment is not canceled within these parameters, you will be charged for the cost of an individual session. Type your initials to acknowledge.