WELCOME!
We're honored to be part of your team.
Got 30 minutes? Let's get started with your intake.
Please have on hand:
• Diagnosis name & date
• Treatment names & dates
• List of medications
• Photo (optional)
• Credit or debit card for payment via Stripe
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Name

 
First name *

(Psst! The asterisk "*" up there just means this is a required field.)
 
Last name (surname) *

 
CONTACT INFO

 
What's your mailing address? *

We'll ship your program materials here unless you tell us otherwise!

Address | City | State | Zip or Postal Code | Country
 
What phone number(s) should we use to reach you?

List cell, home, and/or work phone in preference order.
Include area code (and country code if outside the U.S.).

EXAMPLE:  1. Cell (XXX) XXX-XXXX. 2. Home (XXX) XXX-XXXX.
 
Is a friend or family member helping with your care?

Enter the name(s) of anyone you'd like to authorize to speak with us on your behalf, and let us know this person's relationship to you (if any).

Name | Relationship | Phone (if different)
 
What's the best way for us to reach you?


 
Who referred you?

Please let us know who to thank!
 
Demographics

Let us know a bit more about you
 
Date of birth?

 
Current weight?

Tell us which units you're using!

EXAMPLE:  177 lbs or 61 kg.
 
What's your usual weight, if different?

If your weight has changed recently, let us know your previous, typical weight.
No change? Hit TAB or ENTER to skip this.
 
Height?


How tall are you? Tell us which units you're using!

EXAMPLE: 5'8" or 172 kg.
 
What's your ABO blood type?


 
Tell us about your DIAGNOSIS...

 
What date were you diagnosed?

 
Tell us about your TREATMENTS so far...

 
SURGERIES

Did you have an initial surgery to remove the tumor(s)? If you have had additional surgeries (for tumor recurrence, cyst drainage, shunt placement or necrosis), please list those as well.

Date(s)  |  Reason  |  Amount Removed  |  Complications
 
RADIATION TREATMENTS

Have you had radiation therapy? Gamma knife, Cyber knife, brachytherapy, Boron or Proton, or stereotactic radiosurgery?

Start Date  |  Duration of Radiation
 
CHEMOTHERAPY & all other treatments...

Have you been treated with chemotherapy, immunotherapy or biological agents (e.g., Avastin)? Please include any clinical trials you have participated in.
 
Dates  | Name of Drug(s)
 
When was your last MRI, CT or PET scan?

 
What did the results of your last MRI, CT or PET scan show (compared to your previous scan(s)?

 
What are your plans (or your doctor's recommendations) for your next treatments? When are you scheduled to begin receiving these treatments?

 
Please indicate any of the following symptoms you are CURRENTLY EXPERIENCING


 
PRESENT Health Conditions

Indicate conditions you CURRENTLY HAVE but not those you've only had in the past.
If you select autoimmune, please specify which condition under OTHER.

 
PAST Health History

Indicate conditions you've had IN THE PAST but do not currently have.
If you select autoimmune, please specify which condition under OTHER.

 
DIET & LIFESTYLE

 
What kind of diet do you follow?

Check all that apply

 
Alcohol consumption (beer, wine, and

How often do you consume beer, wine and/or other alcoholic beverages?

 
Food ALLERGIES or sensitivities


 
Have you been diagnosed with any GI condition?


 
Digestive difficulties or symptoms?


 
Are there any particular foods (or food groups) that upset your digestion?


 
How often have you taken antibiotics? How many courses per year? Have you had a history of repeated antibiotic use?

 
Tell us about any chemical sensitivities—perfumes, exhaust fumes, cleaning agents, strong odors?

 
What do you do for exercise?

List exercise activities, frequency (e.g., 2x/wk) and intensity.

Activity  | Frequency  |  Mild, Moderate or Strenuous?
 
Sleep habits

 
On average, how many hours of sleep to you get each night?


 
What time to you typically go to bed?


 
Trouble sleeping?


 
What are your goals for your health?


 
List your current MEDICATIONS (prescription and over-the-counter). No need to add doses.

If you would prefer to upload a file with your list, you can do that next.
 
Prefer to attach a list of your medications and supplements?

If you didn't enter your list above, you can upload it here. Click the cloud arrow to select your file, or drag-and-drop.

Nothing to upload? Hit TAB or SCROLL down to the next question.
 
DRUG ALLERGIES

List all drugs, herbs, vitamins or supplements that have caused any adverse reaction or allergic response.
 
Is there any additional information you'd like to share with us?

 
Send us a photo (pre- or post-diagnosis)! We won't share your picture, it just helps us get to know you better!

A silly mug shot, an image of you enjoying your favorite sport or activity, a selfie from a trip or vacation, a pic of you and your favorite pet.
 
Please read the Consent Form and sign by selecting *

I am enrolling in the educational and consulting services of Nutritional Solutions so I can learn about health factors within my control: my diet, nutrition, and lifestyle choices. By optimizing these factors, I believe I can nourish my health and well-being. I understand that the consultants at Nutritional Solutions [Jeanne M. Wallace, PhD, CNC and Michelle Gerencser, MS] are not medical physicians or health care practitioners. They do not dispense medical advice nor prescribe treatment. I understand these services are not a substitute for medical care and are not intended to diagnose, treat, alleviate, or care for disease.

Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessments serve as a guide to help me develop an appropriate nutrition program tailored to my individual needs, and also help me monitor my progress in achieving my health goals.

Personal information supplied to Nutritional Solutions will be kept strictly confidential (unless I consent to sharing it). Furthermore, I agree that all of the information I receive from Nutritional Solutions is for the sole use of me, my immediate family and my healthcare team; and that no part of this information may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of Nutritional Solutions. I also agree that I will not participate in or encourage electronic piracy of copyrightable materials.

This form is a release of potential liability. I agree to hold Nutritional Solutions and its employees harmless for claims or damages in connection with our work together.

By selecting "I Agree" below, I, {{answer_p6ZtwUXkc1bN}} {{answer_zYtwbLSaUAI7}} confirm I have read, fully understand, and agree to all the above statements and agreements.
I am enrolling in the educational and consulting services of Nutritional Solutions so I can learn about health factors within my control: my diet, nutrition, and lifestyle choices. By optimizing these factors, I believe I can nourish my health and well-being. I understand that the consultants at Nutritional Solutions [Jeanne M. Wallace, PhD, CNC and Michelle Gerencser, MS] are not medical physicians or health care practitioners. They do not dispense medical advice nor prescribe treatment. I understand these services are not a substitute for medical care and are not intended to diagnose, treat, alleviate, or care for disease.

Methods of nutritional evaluation or testing made available to me are not intended to diagnose disease. Rather, these assessments serve as a guide to help me develop an appropriate nutrition program tailored to my individual needs, and also help me monitor my progress in achieving my health goals.

Personal information supplied to Nutritional Solutions will be kept strictly confidential (unless I consent to sharing it). Furthermore, I agree that all of the information I receive from Nutritional Solutions is for the sole use of me, my immediate family and my healthcare team; and that no part of this information may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of Nutritional Solutions. I also agree that I will not participate in or encourage electronic piracy of copyrightable materials.

This form is a release of potential liability. I agree to hold Nutritional Solutions and its employees harmless for claims or damages in connection with our work together.

By selecting "I Agree" below, I, {{answer_p6ZtwUXkc1bN}} {{answer_zYtwbLSaUAI7}} confirm I have read, fully understand, and agree to all the above statements and agreements.
     
 
Which program best serves your needs? *

Each program includes 90 minutes of prepaid consulting time with Michelle Gerencser, MS, a comprehensive packet of program materials—Dr. Wallace's research report & references, worksheets, handouts—and access to our Side Effects Hotline.

Not sure which program fits your needs? See program descriptions online www.Nutritional-Solutions.net or call (435) 563-0053.




 
Shipping? *

Within 1-2 business days, we'll mail your program materials so you can begin to prepare for your appointment! Choose the appropriate shipping option:

 
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