CONSULTATION CHECKLIST

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CONSULTATION CHECKLIST

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CONSULTATION CHECKLIST

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CLIENT FOLDER CHECKLIST

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®

Please make sure to include all of the correct documents in each of your Client-Practitioner

Folders, arranged in the following order from top to bottom on the left side and right side of the

folder as shown below. For example, on the left side, the Consultation Plan should be on the very

top, followed by the Clinical Presentation Form underneath, and then the Recommendations

Form underneath that.

Note: Some of the documents listed below (e.g. the Functional Evaluation Form, Re-Evaluation

Form, and Nutri-Q Reports) are not required for all four folder assignments. Please refer to the

specific directions for each folder assignment in the Assignment Guidelines document.

Left Side

o

Consultation Plan*

o

Clinical Presentation Form*

o

Recommendations Form*

Right Side

o

Re-Evaluation Form*

o

Functional Evaluation Form*

o

Nutri-Q Reports*

o

Symptom Burden Analysis Graph*

o

NAQ*

o

Food & Mood Journal*

o

Initial Interview Form

o

Disclaimer

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DISCLAIMER

© Nutritional Therapy Association, Inc.

®

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Your NTP’s Name:

Before beginning Nutritional Therapy with your Nutritional Therapy Practitioner (“NTP”), please

read the following information carefully

and then sign and date page 4.

N U T R I T I O N A L T H E R A P Y G O A L S

The fundamental goal of Nutritional Therapy is to encourage people to become knowledgeable

about—and responsible for—their own health. An NTP helps individuals reach their optimal level

of overall health by supporting and bringing balance to the five foundations listed below. All five

are built upon a single, solid base: a properly prepared, nutrient-dense diet.

• Digestion

• Blood Sugar Regulation

• Fatty Acid Balance

• Mineral Balance

• Hydration

By supporting each of these foundations and helping clients adopt a more nutrient-dense diet,

the body's chemistry can be brought back into natural balance, setting the stage for optimal

health.

Nutritional Therapy is not designed, however, to treat any specific disease or medical condition.

A Nutritional Therapy Practitioner is trained to evaluate your nutritional needs and make

recommendations of dietary change and nutritional supplements, not medical diagnoses or

prescriptions. No comment or recommendation from your NTP should be construed as a medical

diagnosis or prescription.

Reaching optimal health requires sincere commitment, possible lifestyle changes, and a positive

attitude. If you are not willing to change how you eat and live, Nutritional Therapy is not the right

approach for you. Since every human being is unique on a biochemical level, we cannot

guarantee any specific result from our programs.

H E A L T H C O N C E R N S

If you suffer from a medical or pathological condition, you need to consult with an appropriate

healthcare provider. An NTP is not a substitute for your family physician or other appropriate

healthcare provider. A Nutritional Therapy Practitioner is not trained nor licensed to diagnose or

treat pathological conditions, illnesses, injuries, or diseases or prescribe medications.

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DISCLAIMER

© Nutritional Therapy Association, Inc.

®

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Therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for

medication, so it is important you always keep your physician informed of changes in your

nutritional program.

If you are using medications of any kind, you are required to alert the NTP to such use, as well as

to discuss any potential interactions between medications and nutritional products with your

pharmacist. If you have any physical or emotional reaction to Nutritional Therapy, discontinue

their use immediately, and contact your NTP to ascertain if the reaction is adverse or an

indication of the natural course of the body's adjustment to the therapy.

C O M M U N I C A T I O N

Every client is a biochemical individual, and it is not possible to determine in advance how your

body will react to the nutrients or supplements you need. It is sometimes necessary to adjust

your program as we proceed until your body can begin to properly accept targeted nutrients

geared to correct imbalances or deficiencies. It is your responsibility to do your part by:

• Following the nutrition guidelines provided by your NTP.

• Eating a properly prepared, nutrient-dense diet.

• Avoiding harmful foods, substances, and behaviors.

• Moving your body daily.

• Getting plenty of sleep, rest, and relaxation.

• Staying in contact with the NTP so they can stay abreast of your progress and provide the

best course of action going forward.

If your other healthcare providers have any questions regarding Nutritional Therapy, they are

free to contact your NTP.

L I C E N S U R E

Upon completion of the program, passing midterm and final examinations (both written and

practical), and completing all required homework, one will be certified as a “Nutritional Therapy

Practitioner”™ (NTP®) by the Nutritional Therapy Association, Inc.®. Note that a Nutritional

Therapy Practitioner does not diagnose or treat disease, but instead makes nutritional

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DISCLAIMER

© Nutritional Therapy Association, Inc.

®

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C L I E N T P R I V A C Y P O L I C Y

During the course of Nutritional Therapy, your NTP will ask that you provide relevant personal

details and information relating to your background, health, lifestyle, etc. (hereafter referred to

as “Information”), including but not limited to:

• Your full name, physical address, email address, phone number, date of birth, etc.

• Your health history, including injuries, surgeries, prescriptions, etc.

This Information will be gathered from you via in-person interviews, questionnaires, evaluations,

intake documents, phone, email, mail, video conferences, etc., and used to:

• Help assess your nutritional needs.

• Make recommendations for dietary changes and nutritional supplements to support your

specific nutritional needs and goals.

• Comply with all legal and NTA training obligations.

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To ensure the maximum benefit of Nutritional Therapy, it is important that your Information is

accurate and up-to-date. If you notice any changes to your health, begin taking new

prescriptions, etc., please notify your NTP as soon as possible. It is also your right as a client to

access, update, or delete your records at any time. To do so, simply notify your NTP in writing.

Your NTP will retain your Information for the length of time you are a client, after which they will

take reasonable steps to dispose of your Information in a secure fashion.

Though NTPs are not HIPAA regulated entities, the NTA is committed to protecting client privacy

and requires students and graduates to uphold the privacy best practices and the policies laid

out in the U.S. Standards for Privacy of Individually Identifiable Health Information. Your NTP will

take all reasonable steps to protect your Information from unauthorized access, use, or

disclosure by using strong passwords, up-to-date software on all devices, and locking file

cabinets for physical documents. However, even the best security practices cannot guarantee

that all stored data will be completely free from third-party interception or corruption.

In accordance with Standards for Privacy of Individually Identifiable Health Information, your

consent is required for your NTP to collect, use, and disclose your personal Information. By

signing below, you acknowledge consent for your NTP to collect your Information.

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DISCLAIMER

© Nutritional Therapy Association, Inc.

®

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F O R M F O R E D U C A T I O N A L P U R P O S E S O N L Y

This disclaimer is a template used for educational purposes. The NTA recommends that NTPs

update this template to reflect local laws regarding client interactions before using in private

practice.

S I G N A T U R E

By signing below, I confirm that I have read and fully understand the above disclaimer, am in

complete agreement thereto, and do freely and without duress sign and consent to all terms

contained herein:

Name:

Date:

Signature:

Guardian Name and Signature for Client Under 18 Years of Age:

Name:

Date:

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SYMPTOM BURDEN ANALYSIS GRAPH

© Nutritional Therapy Association, Inc.

®

_{& Richard C. Weatherby, ND}

Name:

Date:

* Given their interconnectedness, a case can be made for combining Sugar Handling and Adrenals (in which case you would write the same number for both in the Priority row). ** Similarly,

for some clients it may make sense to combine all of Digestion as a single priority (in which case you would write the same number for all of the Digestion columns in the Priority row).

Regardless of which approach you use, always think Foundationally and work North to South.

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FUNCTIONAL EVALUATION

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Name:

Date:

Visit #:

Gender:

Age:

Height:

Weight:

Pulse:

T O P 5 H E A L T H C O N C E R N S

N A Q F I N D I N G S

1:

2:

3:

4:

5:

Digestion

STOM ACH

HCl Point

X ↓ 1” (L)

Chapman Reflex:

Stomach

6th_(L)_LNT Baseline 1: 2: 3:

PANC RE A S

Enzyme Point

X ↓ 1” (R)

GAL LB LA DD E R

Murphy’s Sign

Acute - Under Ribs (R) Knees Bent

Chapman Reflex:

Liver/GB

6th_(R)_LNT Baseline 1: 2: 3:

Right Thumb Web

Chronic - On edge of skin web & muscle next to bone at base of thumb

None Mild Severe

SM AL L INTE STIN E

Chapman Reflex:

Small Intestine

8th_{, 9}th_{& 10}th_{(R & L)} Baseline 1: 2: 3:

Right Left Right Left Right Left Right Left

LNT 8th 9th 10th

Bennett Reflexes:

Small Intestine

Palpate 2-3” diameter Baseline 1: 2: 3:

around umbilicus ↑

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FUNCTIONAL EVALUATION

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LA RG E INTE STIN E

Ileocecal Valve

½ between right ASIS & umbilicus. A→P with slight circular motion (clockwise). LNT

Baseline 1: 2: 3:

Large Intestine

Roll gently side to side over the large intestine, starting just lateral of the ileocecal valve and medial of the ASIS (1), up the ascending colon (2), turning just below the right rib cage (3), along the transverse colon (4), turning again just before the left rib cage (5), down the descending colon (6 & 7), and on the sigmoid colon (8). LNT

Baseline 1: 2: 3: B B B B 4 4 4 4 A 3 5 C A 3 5 C A 3 5 C A 3 5 C 2 6 2 6 2 6 2 6 1 7 1 7 1 7 1 7 8 8 8 8

Iliotibial Band (Chapman Reflex – Colon)

L→M (R & L) along IT band at 3-5 points. A, B & C below correlate with A, B & C above in Large Intestine. LNT

Baseline 1: 2: 3:

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FUNCTIONAL EVALUATION

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Sugar Handling

AD R EN AL S

Ragland’s Postural Hypotension

Always ask client if they ever get dizzy when standing quickly.

Supine: Systolic: Diastolic:

Standing: Systolic:

Excellent: +6 to +10 Fair: 0 to +5 Poor: -1 to -10 Fail: -11 to -20 Exhaustion: > -21

Paradoxical Pupillary Reflex

Contraindications: Recent eye surgeries, recent head injuries, susceptibility to seizures, and colored contact lenses. Excellent: Constricts

and holds for 20 seconds

Fair: Constricts and

holds for at least 10 seconds then pulses

Poor: Constricts and

pulses, then enlarges at 5-10 seconds

Fail: Constricts and

pulses, then gets larger almost immediately

Exhaustion: Becomes

larger Immediately or fails to constrict

Chapman Reflex:

Adrenal

Right Baseline Left 1: Right Left 2: Right Left 3: Right Left

1-2” → & 2”↑ from

umbilicus (R & L) LNT

Posterior Ilium

(Short Leg)

Baseline 1: 2: 3:

Right Left Right Left Right Left Right Left Record shorter leg in

either “Right” or “Left” column (e.g. ¼”) LNT

Contraindications: Back, hip, knee, or ankle injuries.

Inguinal Ligament Tenderness

A→P (R & L) along the inguinal ligament, which runs between the ASIS and the lateral edge of the pubic bone. Palpate the entire ligament by drawing your fingers back and forth across it like a bow on a violin at a 90-degree angle. LNT

Baseline 1: 2: 3:

PANC RE A S

Right Thenar Pad

Palpate in center of pad

Chapman Reflex:

Pancreas/Spleen

7th_(L)_LNT

Baseline 1: 2: 3:

LIV E R

Dr. DeJarnette’s Sign (3

rd

_Rib)

A→P on right rib slightly lateral of chondracostal junction. Compare with left rib. LNT

Baseline 1: 2: 3:

Murphy’s Sign

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FUNCTIONAL EVALUATION

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Fatty Acids

Oral pH

Optimal = 7.2 – 7.4

Repeated Muscle Challenge

Contraindications: Local joint or muscle injuries. LNT

Postural Muscle: Muscle Side Baseline 1: 2: 3:

e.g. Quadriceps

>20 reps:

No deficiency 15-19 reps: Mild deficiency 9-14 reps: Moderate deficiency 0-8 reps: Severe deficiency

Non-Postural Muscle: Muscle Side Baseline 1: 2: 3:

e.g. Deltoids

>20 reps:

No deficiency 15-19 reps: Mild deficiency 9-14 reps: Moderate deficiency 0-8 reps: Severe deficiency

LIV E R

Murphy’s Sign

Copy from Liver

Chapman Reflex:

Liver/GB

Copy from Liver

Dr. DeJarnette’s Sign

(3

rd

_Rib)

Copy from Liver

Mineral Balance

Lowenburg’s Test

Contraindications: Phlebitis, edema, thrombosis, or any vascular or circulation problems in the legs. LNT

Baseline 1: 2: 3:

Iodine Status Test

Apply 2” x 2” patch & instruct client to monitor for next 24 hours, noting when patch has completely disappeared. Contraindications: Iodine or shellfish allergy. Hashimoto’s.

Time Applied: Time Faded: Hours:

Zinc Status Test

Contraindications: Eating or drinking anything (other than water), smoking, or chewing gum less than 30 minutes before the taste test.

Excellent: Strong,

unpleasant taste noted immediately

Fair: Definite (but not

strongly unpleasant) taste noted immediately that intensifies with time

Poor: No taste noted

immediately, with dry, mineral, or furry taste developing after 10-15 seconds

Deficient: Tastes like

water (no specific taste is noted when held in mouth for up to 30 seconds)

Extremely Deficient:

Tastes sweet when held in the mouth for up to 30 seconds

Iron Status Test

Sufficient: Lines

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FUNCTIONAL EVALUATION

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Hydration

Vascular Hydration Indicator

Water

Diuretics

Excellent: Veins stay

the same Fair: Veins are still visible but reduced Poor: Veins are no longer visible fl. oz. or ml / day

of pure water fl. oz. or ml / day of diuretics

KIDN E Y S

Chapman Reflex:

Kidneys

Right Baseline Left 1: Right Left 2: Right Left 3: Right Left

1” →↑ from

umbilicus (R & L) LNT

Endocrine

PITUITAR Y

Pituitary / Hypothalamus Point

Palpate for tenderness, A→P LNT Baseline 1:

2:

3:

THY ROID

Costal Margins: Thyroid

General tenderness to palpations LNT Baseline 1:

2:

3:

Chapman Reflex:

Thyroid/Heart

2 (R & L) LNT

Baseline 1: 2: 3:

Pretibial Edema: Thyroid

¼ - ⅓ up tibia from ankle

None: Disappears

immediately Mild: Disappears within 10 seconds Severe: Remains longer than 10 seconds

RE PR ODU CTIV E

Medial Heel: Uterus/Prostate

½ between ankle bone & heel bone (R & L)

Contraindications: Pregnancy

Right Left

Inside Arch: Ovaries/Testes

Apex of arch (R & L)

Contraindications: Pregnancy Right Left

Iliotibial Band

(Chapman Reflex:

Uterus/Prostate)

Baseline 1: 2: 3:

Where client’s fingers end when held by side of legs (R & L). Overlaps with Chapman Reflex for the Colon. LNT

Chapman Reflex:

Ovaries/Testes

Pubic Symphysis (inner)

Baseline 1: 2: 3:

Always ask permission to palpate this area first or have the client use their own hands. LNT

Chapman Reflex:

Uterus/Prostate

Pubic Symphysis (outer)

Baseline 1: 2: 3:

Always ask permission to palpate this area first or have the client use their own hands. LNT

Breast Tenderness

Have client palpate around the circumference of the breast/pectoral tissue

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FUNCTIONAL EVALUATION

®

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Immune & Allergy

Chapman Reflex: Sinuses

1st_{Intercostal Space}

(R & L) LNT

Baseline 1: 2: 3:

Chapman Reflex: Lungs

3rd_{& 4}th_Intercostal

Spaces (R & L) LNT Right Baseline Left 1: Right Left 2: Right Left 3: Right Left

3rd

4th

Chapman Reflex: Thymus

5th_{Intercostal Space (R)}

LNT Baseline 1: 2: 3:

Histamine Point

½ between xiphoid and mid-mammary (R). Locate the 6th_{intercostal space on the right side only and move up one rib and over}

lateral from the sternum. Sits on the edge of the pectoralis muscle at a 5:00 position.

Sanchez-Cuenca Test (Allergic Tension)

Take pulse for 60 sec. sitting. Have client stand, wait 15-30 sec. and take 2nd_{60-second pulse. Rise of 6+ beats/minute indicates allergic tension.}

Pulse Sitting: Pulse Standing: Difference: Allergic Tension?

Toe Touch

Contraindications: Lower back problems.

Measure inches / cm from end of fingers to floor. LNT

Baseline 1: 2: 3:

Internal Hip Rotation

Contraindications: Ankle, knee, or hip problems

.

Measure rotation in

degrees. (R & L) LNT

Baseline 1: 2: 3:

Cardiovascular

Blood Pressure

Copy forward from Adrenals

Pulse

Copy from Immune & Allergy

Left Thenar Pad

Palpate in center of pad Systolic: Diastolic:

Chapman Reflex:

Thyroid/Heart

2 (R & L) LNT

Baseline 1: 2: 3:

Detoxification

Balance Test:

Complete test first with eyes open. If the client can remain steady for 20 seconds, repeat the test with eyes closed. LNT

Eyes Open 20+ sec.:

Excellent 11-19 sec.: Satisfactory 6-10 sec.: Poor 0-5 sec.: Fail 1: 2: 3:

Eyes Closed 20+ sec.:

Excellent 11-19 sec.: Satisfactory 6-10 sec.: Poor 0-5 sec.: Fail 1: 2: 3:

Point Test:

Lightly touch 2+ points on client’s upper & lower arms (2 spots inner & 2 outer arm) & ask the client to touch the same spot.

Upper Arm <1”:

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CLINICAL PRESENTATION FORM

®

Name:

Date:

CLIENT CONCERNS INITIAL INTERVIEW

FOOD JOURNAL

NAQ PRIORITIES

FE POINT

#

NUTRIENT

NEW #

NUTRIENT

NEW #

NUTRIENT

NEW #

SHORT-TERM GOALS (ACTION STEPS)

LONG-TERM GOALS (BIG PICTURE)

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RECOMMENDATIONS

®

Client:

Date:

Visit #:

E A T I N G T I P S :

¨ Eat foods in their whole, unprocessed forms as much as

possible, with a good mixture of cooked and raw dishes.

¨ Eat a good balance of fats, proteins, and carbohydrates (e.g.

baked chicken thighs with salt, pepper, and fresh herbs, roasted Brussels sprouts with bacon & one small sweet potato.)

¨ Include nutrient-dense superfoods as often as possible,

including organ meats, fermented foods, and homemade bone broth.

¨ Eat as much fatty meat, fish, and vegetables as you like until

you feel satiated. Those with blood sugar issues should limit carbohydrates.

¨ Eat only when you are actually hungry. Ask yourself, “Would I

eat meat and vegetables right now?” If yes, you are hungry. If no, you are having sugar cravings.

¨ While the body shifts from burning primarily sugar to using

mostly fat for fuel, you may need to eat more often. But after a couple of weeks, your energy will become more stable and you won’t need to eat as often. If you still feel the urge to eat frequently after a few weeks, increase the quantity of fats and proteins in your meals.

¨ Eat only when you are in a calm and relaxed state. If necessary,

meditate before eating (visit Calm.com or HeadSpace.com for guided meditations).