Dr. Jim Handzel Mind Body and Flow

A Creating Wellness Center 290 S. Alma School Rd. Suite #11

Chandler, AZ 85224 (480) 883-9494 !!

Dear New Patient,!I would like to take this unique opportunity to welcome you to the office of Mind Body & Flow, A Creating Wellness Center. Weather you are taking your first step towards making you life purposeful, healthy, strong and symptom free or you are looking to step up and take to next step with Powerful Nutrition Response Testing or Chiropractic, Massage or Colon Hydrotherapy, WE WELCOME YOU! We are excited for you, and need to bring a few items to light before we get you started.!1. There is hope. We encourage you to really open up, please express your concerns,

challenges, and success with us while we are working with you.!2. Please take your time, be thorough and complete with all the forms that we have you fill

out. This will help us be more attentive to your concerns and truly reveal any underlying health challenges.!

3. Simply follow your suggested clinical outlines for the most impactful and quickest results.!!Again, I personally thank you for giving us the opportunity to help you and your family. Please share this with others, your referral of other people to health care that is done safely and naturally is how we can impact our community for generations!Sincerely in Your Health,!!!James M Handzel, DC

Dr. Jim Handzel!Mind Body and Flow!

290 S. Alma School Rd., Suite #11 Chandler, AZ 85224

(480) 883-9494

NEW PATIENT INTRODUCTION FORM !!!Patient Name: Date: !1. Main Concern(s): !!!!!!!!!!2. Medications and/or Nutritional Supplements currently on: !!!!!!!!!!3. Dietary Intake for 2 days before appointment: !!

Breakfast: Breakfast: !!!Snacks: Snacks: !!!Lunch: Lunch: !!!Snacks: Snacks: !!!Dinner: Dinner: !!!Snacks: Snacks:

Dr. Jim Handzel 290 S. Alma School Rd. P: (480) 883-9494 Mind Body and Flow Suite #11 www.MindBodyandFlow.comA Creating Wellness Center Chandler, AZ. 85224

Form

: New

Pat

ient

Intro

For

m

Mind Body and Flow - Dr. Handzel NEW PATIENT INFORMATION FORM

Page ! of !1 2✭ Please fill out completely & print clearly: !Name Date _______________________________________________ ______________Address Apt.# _____________________________________________ _____________City State ZIP _______________________________ ____________ ______________Shipping Address _________________________________________________________ _______________________________________________________________________Home Phone (____) ____-_________ Work Phone (____) ____-_________ e-mail address: __________________________ _____________ ___________________REFERRED BY: _________________________________________________________Occupation Employer ________________________ ___________________________Date of Birth Age ____ Sex: M/F Height _____ Weight _____ _________________Overall health (circle one): Excellent / Good / Fair / Poor / Other: ___________________Chief complaint (reason you are here): (use separate sheet if more room needed) _______________________________________________________________________ _______________________________________________________________________Previous treatments for this complaint _________________________________________ _______________________________________________________________________Other complaints or problems: (use separate sheet if needed) _______________________ _______________________________________________________________________ _______________________________________________________________________Current medications/drugs being taken: (use separate sheet if needed) _______________ _______________________________________________________________________Are you currently under the care of a physician or other health care professionals? (If yes, please give name and date of last visit): _______________________________________________________________________Nutritional supplements you are taking: ________________________________________Do you smoke, drink coffee or alcohol? (if yes indicate how much) Cigarettes Coffee Alcohol ______________ _________________ _______________!Office Use Only: !!!!!

!Dr. Jim Handzel 290 S. Alma School Rd. P: (480) 883-9494 Mind Body and Flow Suite #11 www.MindBodyandFlow.comA Creating Wellness Center Chandler, AZ. 85224

Mind Body and Flow - Dr. Handzel NEW PATIENT INFORMATION FORM

Page ! of !2 2!Name: Date _______________________________________________ ______________!HISTORY: List any major illnesses (with approx. dates): ___________________________________ _______________________________________________________________________ _______________________________________________________________________List any surgery or operations (with approx. dates): ______________________________ _______________________________________________________________________Past Accidents or injuries (with approx. dates): __________________________________ _______________________________________________________________________!Marital Status: S M D W Name of Spouse ____________________________Describe health of spouse: Number of children if any _______________________ ___Name of Child Age Sex Any physical conditions or concerns? M/F _________________________ ____ ________________________________ M/F _________________________ ____ ________________________________ M/F _________________________ ____ ________________________________Any family history of serious illnesses (circle those which apply): Cancer / Diabetes / Heart / Other _____________________________________________________________Any household pets or other animals you or family members are in close contact with: _______________________________________________________________________What can we do to make you happier? _________________________________________ _______________________________________________________________________!!SIGNED: DATE ____________________________________________ ____________

Dr. Jim Handzel 290 S. Alma School Rd. P: (480) 883-9494 Mind Body and Flow Suite #11 www.MindBodyandFlow.comA Creating Wellness Center Chandler, AZ. 85224

Form

: New

Pat

ient

Info

rmat

ion

Form

//

SYMPTOM SURVEY FORMPatient Doctor Date

INSTRUCTIONS: Fill in only the circles which apply to you.MILD symptoms (occurred once or twice last 6 months).MODERATE symptoms (occurred once or twice last month).SEVERE symptoms (chronic, occurred once or twice last week).Leave circles BLANK if they don't apply to you!

GROUP 11 Acid foods upset

8 Gag easily

15 Appetite reduced

2 Get chilled often3 "Lump" in throat4 Dry mouth-eyes-nose5 Pulse speeds after meal6 Keyed up - fail to calm7 Cut heals slowly

9 Unable to relax; startles easily10 Extremities cold, clammy11 Strong light irritates12 Urine amount reduced13 Heart pounds after retiring14 "Nervous" stomach

16 Cold sweats often17 Fever easily raised18 Neuralgia-like pains19 Staring, blinks little20 Sour stomach often

21 Joint stiffness on arising

29 Digestion rapid

37 "Slow starter"

22 Muscle-leg-toe cramps at night23 "Butterfly" stomach, cramps24 Eyes or nose watery25 Eyes blink often26 Eyelids swollen, puffy27 Indigestion soon after meals

30 Vomiting frequent31 Hoarseness frequent32 Breathing irregular33 Pulse slow; feels "irregular"34 Gagging reflex slow35 Difficulty swallowing

38 Get "chilled" infrequently39 Perspire easily40 Circulation poor, sensitive to cold41 Subject to colds, asthma, bronchitis

28 Always seems hungry; feels "lightheaded" often

36 Constipation, diarrhea alternating

1 2 3

Vegetarian: Yes No Birth Date / / Approx Weight

GROUP 2

Pulse: Recumbent StandingBlood pressure: Recumbent Standing

Sex: Male Female

Ragland's Test is Positive

Eat when nervous

49 Heart palpitates if meals missed or delayed

53 Crave candy or coffee in afternoons

Excessive appetiteHungry between mealsIrritable before mealsGet "shaky" if hungryFatigue, eating relieves"Lightheaded" if meals delayed

50 Afternoon headaches51 Overeating sweets upsets

52 Awaken after few hours sleep - hard to get back to sleep

54 Moods of depression - "blues" or melancholy55 Abnormal craving for sweets or snacks

42434445464748

GROUP 3

56 Hands and feet go to sleep easily, numbness57 Sigh frequently, "air hunger"58 Aware of "breathing heavily"59 High altitude discomfort60 Opens windows in closed rooms61 Susceptible to colds and fevers62 Afternoon "yawner"63 Get "drowsy" often64 Swollen ankles, worse at night65 Muscle cramps, worse during exercise; get "charley horses"66 Shortness of breath on exertion67 Dull pain in chest or radiating into left arm, worse on exertion68 Bruise easily, "black and blue" spots69 Tendency to anemia70 "Nose bleeds" frequent71 Noises in head, or "ringing in ears"72 Tension under the breastbone, or feeling of "tightness",

worse on exertion

GROUP 4

1 2 3

GROUP 573 Dizziness74 Dry skin75 Burning feet76 Blurred vision77 Itching skin and feet78 Excessive falling hair79 Frequent skin rashes80 Bitter, metallic taste in mouth in mornings81 Bowel movements painful or difficult82 Worrier, feels insecure83 Feeling queasy; headache over eyes84 Greasy foods upset85 Stools light colored86 Skin peels on foot soles87 Pain between shoulder blades88 Use laxatives89 Stools alternate from soft to watery90 History of gallbladder attacks or gallstones91 Sneezing attacks92 Dreaming, nightmare type bad dreams93 Bad breath (halitosis)94 Milk products cause distress95 Sensitive to hot weather96 Burning or itching anus97 Crave sweets

GROUP 698 Loss of taste for meat99 Lower bowel gas several hours after eating

100 Burning stomach sensations, eating relieves101 Coated tongue102 Pass large amounts of foul-smelling gas103 Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs.104 Mucous colitis or "irritable bowel"105 Gas shortly after eating106 Stomach "bloating" after eating

↓ ↓

GROUP 7A107 Insomnia

114 Thin, moist skin

121 Can't work under pressure

108 Nervousness109 Can't gain weight110 Intolerance to heat111 Highly emotional112 Flush easily113 Night sweats

115 Inward trembling116 Heart palpitates117 Increased appetite without weight gain118 Pulse fast at rest119 Eyelids and face twitch120 Irritable and restless

122 Increase in weight

130 Mental sluggishness

123 Decrease in appetite124 Fatigue easily125 Ringing in ears126 Sleepy during day127 Sensitive to cold128 Dry or scaly skin

131 Hair coarse, falls out132 Headaches upon arising, wear off during day133 Slow pulse, below 65134 Frequency of urination135 Impaired hearing136 Reduced initiative

129 Constipation

1 2 3

GROUP 7B

Failing memory

170 Weakness after colds, influenza

Low blood pressureIncreased sex driveHeadaches, "splitting or rending" typeDecreased sugar tolerance

171 Exhaustion - muscular and nervous172 Respiratory disorders

137138139140141

GROUP 7C

173 Apprehension174 Irritability175 Morbid fears176 Never seems to get well177 Forgetfulness178 Indigestion

GROUP 8

1 2 3

Abnormal thirstBloating of abdomenWeight gain around hips or waistSex drive reduced or lackingTendency to ulcers, colitis

142143144145146

GROUP 7D

Increased sugar toleranceWomen: menstrual disordersYoung girls: lack of menstrual function

147148149

DizzinessHeadachesHot flashesIncreased blood pressureHair growth on face or body (female)

150151152153154

GROUP 7E

Sugar in urine (not diabetes)Masculine tendencies (female)

155156

Weakness, dizzinessChronic fatigueLow blood pressureNails weak, ridgedTendency to hives

157158159160161

GROUP 7F

Arthritic tendenciesPerspiration increase

162163

Bowel disordersPoor circulationSwollen ankles

164165166

Crave saltBrown spots or bronzing of skin

167168

Allergies - tendency to asthma169

179 Poor appetite180 Craving for sweets181 Muscular soreness182 Depression; feelings of dread183 Noise sensitivity184 Acoustic hallucinations185 Tendency to cry without reason186 Hair is coarse and/or thinning187 Weakness188 Fatigue189 Skin sensitive to touch190 Tendency toward hives191 Nervousness192 Headache193 Insomnia194 Anxiety195 Anorexia196 Inability to concentrate; confusion197 Frequent stuffy nose; sinus infections198 Allergy to some foods199 Loose joints

200 Very easily fatigued201 Premenstrual tension202 Painful menses203 Depressed feelings before menstruation204 Menstruation excessive and prolonged205 Painful breasts

FEMALE ONLY

206 Menstruate too frequently207 Vaginal discharge208 Hysterectomy / ovaries removed209 Menopausal hot flashes210 Menses scanty or missed211 Acne, worse at menses212 Depression of long standing

213 Prostate trouble214 Urination difficult or dribbling215 Night urination frequent216 Depression217 Pain on inside of legs or heels218 Feeling of incomplete bowel evacuation

MALE ONLY

219 Lack of energy220 Migrating aches and pains221 Tire too easily222 Avoids activity223 Leg nervousness at night224 Diminished sex drive

List the five main complaints you have in the order of their importance:

1.

2.

3.

4.

5.

PERMISSION, AUTHORIZATION and HIPPA FORM REGARDING THE USE OF

NUTRITION RESPONSE TESTING!PLEASE READ BEFORE SIGNING: !

I specifically authorize the natural health practitioners at the Mind Body and Flow 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 organ responses can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health. !

Please check-off all that: ⬜ I have read and understand the foregoing. !⬜ I acknowledge and agree Mind Body & Flow’s Notice of Privacy Practices

under HIPPA Compliancy are to protect my patient records and security. (You may retain your own copy of the federal HIPPA document upon request) !⬜ This permission form applies to subsequent visits and consultations.

Date:

Patient Print Name:

Address:

City State Zip

Phone: ( ) -

Signed:

(If minor please check, signature of parent or guardian required) → ⬜

!Witness:

Dr. Jim Handzel 290 S. Alma School Rd. P: (480) 883-9494 Mind Body and Flow Suite #11 www.MindBodyandFlow.comA Creating Wellness Center Chandler, AZ. 85224

Form

: Per

mis

sion

and

Aut

horiz

atio

n Fo

rm