follow-up nutrition appointment reminder & checklist follow up... · 2014-05-23 · ku...

KU Integrative Medicine | 3901 Rainbow Blvd, MS 1017 | Kansas City, KS 66160 | Sudler Bldg #2053 (913) 588-6208 | Fax (913) 588-0012 | http://integrativemed.kumc.edu | E-mail: [email protected] 05222014

Follow-up Nutrition Appointment Reminder & Checklist _________________________ scheduled with ______________________. Appointment Date: Appointment Time:

Forms: (Complete and Return Prior to Your Appointment)

□ Medication/Supplement List (it may be a good idea to enter these into a word processing document to update easily in the future)

□ Medical Symptoms Questionnaire

□ Diet Diary: (For one day. If you track your diet electronically (iPhone app or online tool), please print out a day or two of your records)

□ Fats and Oils Worksheet

□ Challenges, Successes, Questions and Goals

BIA Assessment: (Review Attached Handout for Preparation Instructions) See the enclosed summary to prepare for a re-measure of your body composition using the BIA. Lab Results: If you have received lab orders, test results from your lab work take 3 weeks to get to us. Your follow-up consultation is dependent on us receiving your lab results. Questions: If you have any questions, please contact one of our patient service representatives:

Nancy Lynn or Crystal Lowe Patient Service Representatives 913-588-6208

Failure to cancel your appointment at least 24 hours in advance may result in a fee of $25.

http://integrativemed.kumc.edu/

mailto:[email protected]


Medication/Supplement List How many times and at what ages have you taken

Infancy Childhood Teen Adulthood

Antibiotics _____________ _____________ _____________ _____________

Steroids _____________ _____________ _____________ _____________

Include non-prescription drugs as well as vitamins, minerals, and other nutritional supplements. Indicate the mg or IUs and the form (e.g. calcium vs. calcium lactate) when possible.

Supplements / Medications Dose Units Frequency Start Date Stop Date

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Challenges, Successes, Goals & Questions I look forward to seeing you again! In order to help you best achieve your nutrition and health goals, it’s important to monitor your progress. The following forms will help determine your current nutrition status. Be as honest as possible, so we can effectively meet your goals! Please complete the questions below and enclosed documents for the upcoming nutrition appointment:

List barriers or challenges you faced throughout the last several weeks or months: List changes that you’re pleased with (e.g. symptom changes; weight or inches lost; increasing or decreasing a certain food in your diet; other “successes”): List your goals and/or expectations for this appointment: List any questions you have today:




Services Pricelist Physician Services New Patients Established Patients 60 minutes: $300 25 minutes: $150 90 minutes: $350 40 minutes: $175 120 minutes: $400 60 minutes: $200 90 minutes: $250 120 minutes: $300 Phone Consults 15 minutes: $75 30 minutes: $150 60 minutes: $200

Nurse Practitioner/Physician Assistant Services New Patients Established Patients 60 minutes: $255 25 minutes: $127 90 minutes: $297 40 minutes: $148 120 minutes: $340 60 minutes: $170 90 minutes: $212 120 minutes: $255 Phone Consults 15 minutes: $63 30 minutes: $127 60 minutes: $170

Nutrition Services New Patients/Established Patients/Phone Consults 15 minutes: $25 75 minutes: $105 30 minutes: $45 90 minutes: $125 60 minutes: $85 BIA Testing: $25

Neurofeedback Services – Initial consult or physician referral required prior to treatment Two hour Neuromapping: $400 Neuromap Reading (by Brain Science International): $350 Neurofeedback, per session: $150 Neurofeedback (Package of 10): $1,350 Phone Consults 30 minutes: $75 60 minutes: $150

Infusion Services – Initial consult and patient’s G6PD blood test results must be received prior to vitamin C infusions 0-30 minutes: $100 0-30 minutes (Package of 10): $900 31-60 minutes: $125 31-60 minutes (Package of 10): $1,125 1-3 hours: $160 1-3 hours (Package of 10): $1,440 >3 hours: $200 Injection, singular substance: $25 Injections, 2 or more substances: $30

Prices do not include lab test costs.



follow-up nutrition appointment reminder & checklist follow up... · 2014-05-23 · ku...

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