Nutrition Patient Questionnaire

  • This is a confidential patient symptom survey. Please check each condition which is true for you. Take your time. If you are not sure the condition applies to you or do not understand a term, do not check the box. Use common sense. For example. insomnia once last month probably isn't that important and would not be marked. However, Insomnia 1-2 times per week is notable and would be marked. Please take your time...
  • What DrugPrescribed ForFor How Long 
  • What DrugPrescribed ForFor How Long 
  • What VitaminBrandDosage 
  • Please list any known allergies (ex. foods, medications, spices, environmental, etc.)
  • Informed Consent
  • By documenting your email address on this page, you are agreeing that health information for yourself can be freely shared via email between yourself and Dr. David B Tuchinsky D.C. PLLC. While usually considered safe, email is not the most secure method of sharing personal information.

    According to the Federal Food, Drug. and Cosmetic Act, as amended. Section 201 (g) (1), the term 'DRUG" is defined to mean:

    "Articles intended for use in the Diagnosis. Cure, Mitigation, Treatment or Prevention of disease

    A Vitamin is not a drug, NEITHER is a Mineral. Trace Element, Amino Acid, Herb, or Homeopathic Remedy.

    Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented or be classified as a drug by anyone.

    Therefore. please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

    Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body.

    Medical insurance is not accepted in our office for functional medicine and our office cannot assist you with a claim resolution. In addition, Dr. Tuchinsky does not submit notes or records to insurance companies.
  • Notice of Privacy Practices
  • 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.

    We are required by law to maintain the privacy of protected health information and must inform you of our privacy practices and legal duties. You have the right to obtain a paper copy of this notice upon request. We reserve the right to change the terms of the Notice at any time. Any changes will be effective for all protected health information that we maintain.

    We have designated a privacy Officer to answer your questions about our privacy practices and to ensure that we comply with applicable laws and regulations. The Privacy Officer also will take your complaints and can give you information about how to file a complaint. Our Privacy Officer for the practice is David B. Tuchinsky, D.C., PLLC. You can contact the Privacy Officer at 800-371-0902.

    Use and disclosure of your protected health information that we may make to carry out treatment, payment and healthcare operations.

    We may use information in your records to provide treatment to you. We may disclose information from your record to help you get health care services from another provider, a hospital, etc. For example, if you want an opinion about your condition from a specialist, we may disclose information to that specialist to obtain that consultation. We may use or disclose information from your record to obtain payment for services that you receive. For example, we may submit a diagnosis with a health insurance claim in order to demonstrate to the insurer that the service should be covered. We may use or disclose information from your record to allow "health care operations". These operations include activities like reviewing records to see how care can be improved, contacting you with information about treatment alternatives and coordinating care with providers. For example, we may use information in your record to train staff about your condition or treatment.

    Your Rights You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be allowed for treatment, payment or health care operations. However, we do not have to agree to these restrictions. You have the right to receive confidential communications from us. For example if you want to receive bills and other information at an alternate address please notify us. You have the right to inspect the information in your record, and may obtain a copy of it. This may be subject to certain limitations and fees. Your request must be in writing. If you believe information in your record is inaccurate or incomplete, you may request amendment of the information. You must submit sufficient information to support your request for amendment. Your request must be in writing.

    You have the right to request an accounting of certain disclosures made by us.

    You have the right to complain to us about our privacy practices. (Including the actions of our staff with respect to the privacy of your health information.) You have the right to complain to the Secretary of the Department of Health and Human Services about our privacy practices. You will not face retaliation from us for making complaints.

    Except as described in this Notice, we may not make any use or disclosure information from your record unless you give your written authorization. You may revoke an authorization in writing at any time, but this will not affect any disclosure made by us before the revocation. In addition, if the authorization was obtained as a condition for obtaining insurance coverage the insurer may have the right to contact the policy or a claim under the policy even if you evoke the authorization.

    Use of disclosure of your protected health information that we are required to make without your permission. In certain circumstances, we are required by law to make disclosure of your health information. For example, state law requires us to report suspected child abuse or neglect. Also, we must disclose information to the Department of Human Services, if requested, to prove that we are complying with regulations that safeguard your health information.

    We may use or disclose information from your record if we believe it is necessary to prevent or lessen a serious and imminent threat to safety of a person or the public. We may report suspected cases of abuse neglect, or domestic violence involving adult or disabled victims.

    Use of disclosure of your protected health information that we are allowed to make without your permission. There are certain situations where we are allowed to disclose information from your record without your permission. In these situations, we must use our professional judgment before disclosing information about you. Usually, we must determine that the disclosure is in your best interest and may have to meet certain guidelines and limitations.

    We may assist in health oversight activities, such as investigations of possible health care fraud.

    We may disclose information from your record as authorized by worker's compensation laws.

    We may disclose information from your record if ordered to do so by a court, grand jury, or administrative tribunal. Under certain conditions, we may disclose information in response to a subpoena or other legal process, even if this is not ordered by a court.Your provider or office staff may contact you to provide appointment reminders as a courtesy. However, you are responsible for remembering your appointment.

    We may contact you with information about treatment alternatives or health related benefits or services that may be of interest to you.INFORMED CONSENT REGARDING E-MAIL OR THE INTERNET USE OF PROTECTED PERSONAL INFORMATIONDr. David B. Tuchinsky D.C., PLLC provides patients the opportunity to communicate with them by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail.

    1. Risks:
    a. General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail to other recipients without the original sender(s) permission, or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten, or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history.

    b. Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send, or receive e-mail from their place of employment risk having their employer read their e-mail.

    2. It is the policy of Dr. David B. Tuchinsky D.C., PLLC that all e-mail messages sent or received, which concern the diagnosis, or treatment, of the patient will be a part of that patient's protected personal health information and we will treat such e-mail messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. Dr. David B. Tuchinsky D.C., PLLC will use reasonable means to protect the security and confidentiality of e-mail, or Internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail, or internet communications.

    3. Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail included agreement with the conditions:

    a. All e-mail to, or from, patients concerning diagnosis and/or treatment will be made a pert of the protected personal health information. As a part of the protected personal health information, other individuals and upon written authorization other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.

    b. Dr. David B. Tuchinsky D.C., PLLC and his assistants may forward e-mail messages within the practice as necessary for diagnosis and treatment. We will not, however, forward the e-mail outside the practice without the consent of the patient, as required by law.

    c. We will endeavor to read e-mail promptly, but can provide no assurance that the recipient of the particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency.

    d. It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.

    e. Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning diagnosis, or treatment of AIDS/HIV infection; other sexually transmissible, or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health, or developmental disability; or alcohol and drug abuse.

    f. Dr. David B. Tuchinsky D.C., PLLC cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail, or internet communication. However, Dr. David B. Tuchinsky D.C., PLLC and his assistants are not liable for improper disclosure of confidential information not caused by it employee's gross negligence, or wanton misconduct.

    g. If consent is given for the use of e-mail, it is the responsibility of the patient to inform Dr. David B. Tuchinsky D.C., PLLC staff of any type of information you do not want to be sent by e-mail.

    h. It is the responsibility of the patient to protect their password or other means of access to e-mail sent, or received, from Dr. David B. Tuchinsky D.C., PLLC to protect confidentiality. Dr. David B. Tuchinsky D.C., PLLC is not liable for breaches of confidentiality caused by the patient.


    Any further use of e-mail initiated by the patient that discusses diagnosis, or treatment, constitutes informed consent to the foregoing.

    I understand that my consent to the use of e-mail may be withdrawn at any time by written communication to Dr. David B. Tuchinsky D.C., PLLC, [email protected]

    I have read this form carefully and understand the risks and responsibilities associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail.
  • Date Format: MM slash DD slash YYYY
    I have read and understand the above.