Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Adult Intake
Patient/Client Please fill out.
Name:
Age:
DOB (dd/mm/yy): / /
Gender:
Home phone:( )
Work:( ) Cell:( ) - Type of Smartphone:
___________________ (for food app)
Address:
City:
Postal code:
Email:
Marital status
Number of children:
Emergency contact:
Relation:
Home phone:( )
Work:( ) Occupation:
Employer:
Referral source:______________________________________________________________
Medical doctor:
Phone:( ) Fax:( ) Address:
City:
Postal code:
Other health care provider:
Address:
Annual:
physical exam
blood work
urine analysis
yes
no
Phone:(
City:
yes
no
dental exam
yes
yes
no
gynecological exam
yes
no
prostate exam
yes
no
breast exam
yes
no
)
Postal code:
no
yes
no
eye exam
Lab reports:___________________________________________________________________________
Concern
Main health concerns:
Since (mm/yy)
Cause(s)
1.
2.
3.
4.
5.
6.
7.
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Diagnosis
Medical conditions:
Date (mm/yy)
Current symptoms
Medications:__________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Diet: #Fruits/day___ #Veg/day___ #Grains/day___ #Meat/day___ #Dairy/day___ #Sweets/Day
_____________________________________________________________________________________
_____________________________________________________________________________________
Cravings:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Moods:_______________________________________________________________________________
_____________________________________________________________________________________
Supplements:__________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Sleep:________________________________________________________________________________
Stress Level 1 2 3 4 5 6 7 8 9 10 (1 is least and 10 is most)
Energy Level 1 2 3 4 5 6 7 8 9 10 (1 is least and 10 is most)
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Select ‘Y’ for symptoms you are presently experiencing (includes last 2 months).
Select ‘P’ for symptoms experienced in the past. It is possible to check both ‘Y’ and ‘P’.
GENERAL
EYES
NECK
Height
ft in Glasses or contacts
Y P Pain or stiffness
Weight
lbs
Vision deteriorating
Y P Lumps
Maximum weight
lbs
Blurring
Y P Swollen glands
Minimum weight
lbs
Blind spot
Y P Goiter
Recent weight change
Y P Double vision
Y P Other:
Recent international
Y P Sun irritates
Y P
travel
Discharge
Y P RESPIRATORY
Other:
Y P Dryness
Y P Shortness of breath
Infections
Y P Pain on breathing
Itching
Y P Chronic cough
SKIN
Acne
Y P Pain
Y P Sputum
Bumps or lumps
Y P Puffy eyes
Y P Wheezing
New spots or moles
Y P Redness
Y P Other:
Warts
Y P Tearing
Y P
Eczema
Y P Floaters
Y P CARDIOVASCULAR
Psoriasis
Y P Styes
Y P Elevated blood
Hives
Y P Dark circles
Y P
pressure
Rashes
Y P Cataracts
Y P Low blood pressure
Itching
Y P Glaucoma
Y P Angina, chest pain or
Dry skin
Y P Other:
Y P
chest tightness
Slow wound healing
Y P
Murmurs
Sweat has strong odor
Y P NOSE & SINUSES
Palpitations
Night sweats
Y P Decreased smell
Y P Red face, flush easy
Other:
Y P Stuffy or runny
Y P Swollen ankles
Allergies
Y P Cold hands and feet
Sinus problems
Y P Deep leg pain
NAILS
Bend or break easily
Y P Bleeding
Y P Varicose veins
White spots
Y P Polyps
Y P Other:
Other:
Y P Other:
Y P
BLOOD & LYMPH
Frequently ill
HEAD
MOUTH & THROAT
Dizziness
Y P Decreased taste
Y P Bleed or bruise easily
Headaches
Y P Bad breath
Y P Clotting problem
Migraines
Y P Mouth dryness
Y P Lymph node swelling
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Y
Y
Y
Y
Y
P
P
P
P
P
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
Y
Y
P
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
Y
Y
Y
Y
P
P
P
P
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Injuries
Other:
Y
Y
EARS
Decreased hearing
Excess wax
Infections
Discharge
Itching
Pain
Ringing
Other:
Y
Y
Y
Y
Y
Y
Y
Y
P Canker sores
P Cold sores
Toothache
Gum bleeding
P Frequent sore throat
P Hoarseness
P Lump in throat
P Number of metal fillings
P Other:
P
P
P
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
REPRODUCTIVE
Sexual orientation
Sexually active
Sexual difficulties
Sexually transmitted
infections
Birth control
Decreased libido
Fertility concerns
Other:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
FEMALE ONLY
Breast lumps
Breast tenderness
P Self breast exam
P Last mammogram
P Last thermogram
P
P Age of first menses
P Last menses
P Menopause
P Amenorrhea
P Regular cycle
P Length of cycle
P Length of flow
P
NEUROLOGICAL
Convulsions
Fainting
Involuntary movement
Loss of balance
Loss of memory
Numbness or tingling
Paralysis
Speech problems
Other:
GASTROINTESTINA
L
Bowel movements
how often?
Constipation
Diarrhea
Hemorrhoids
Rectal bleeding
Rectal itching
Undigested food in
stool
Blood in stool
Mucous in stool
Change in thirst
Change in appetite
Brooklyn: 135 Clarkson Ave F8, NY, 11226
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
MUSCULO /
SKELETAL
Muscle cramps
Muscle weakness
Joint pain or stiffness
Joints pop often
Joint swelling
Back pain
P Broken bones
Other:
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
MALE ONLY
Incomplete urination
Difficult urination
Dribbling
Testicular mass
Erectile dysfunction
Discharge or sores
Vasectomy
Other:
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
hetero
Y P
Y P
Y P
Y P
Y P
Y P
Y P
Y P
MENTAL &
EMOTIONAL
Y P Anxiety
Y P Depression
Y P Fatigue
mm/yy Difficulty concentration
mm/yy Mood swings
Phobias
Other:
mm/yy
Y P
Y P
Y P
days
days
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Low blood sugar
Pain in abdomen
Ulcer
Hernias
Burping
Flatulence
Bloating
Nausea
Vomiting
Heartburn
Difficulty swallowing
Breastfed as child
Other:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
P
P
Painful menses
PMS
Excessive flow
Bleeding between
menses
Vaginal discharge
Vaginal itching
URINARY
Infections
Inability to hold urine
Increased urination
Pain on urination
Urgent urination
Blood in urine
Cloudy urine
Dark urine
Kidney stones
Other:
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
# of pregnancies
# of live births
P # of miscarriages
P # of abortions
P
P HRT
P Birth control pill
P Number of years
P hormones taken:
P Other:
P
P
Planning a pregnancy
Pregnant
Due date
Y
Y
Y
P
P
P
Y
Y
Y
P
P
P
Y P
Y P
d/m/y
Y
Y
P
P
Y
P
NOTES
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
RELEASE OF RECORDS
I authorize naturopathic doctor Millennia (Millie) Lytle ND, MPH, CNS to obtain a copy of all my diagnostic test
results from the last 12 months.
Please send records to:
Dr. Millie Lytle ND, MPH, CNS
135 Clarkson Ave F8 Brooklyn, NY 11226
Tournesol Wellness 26 E. 36th St. New York, NY 10016
Or
1629 K St, #300 Washington D.C., 20006
[email protected]
Fax: 1-888-255-5088
Patient’s name: _______________________
Home phone:_________________________
Address: ______________________
DOB (dd/mm/yy): : _____________________________
_________________Zip: ______________
Medical doctor: __________________________ Phone: ____________________ Fax: _________________
Address: ________________________________________________________Zip: ____________________
Patient signature:___________________________________Date (dd/mm/yy):________________________
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Consent Form
I, (name)________________________________________________________voluntarily
consent to the procedures and treatments by Naturopathic Doctor Millie Lytle ND, MPH, CNS,
which may include any combination of the following as decided by the Doctor and myself:

medical history

physical exam

diagnostic testing

functional medicine

Nutrition- Diet and Supplements

botanical medicine

homeopathy

traditional Chinese medicine

lifestyle counseling and coaching

psychological and spiritual analysis

physical therapies and energy work

mind-body medicine

Hypnosis
Signature:
______________________________________Date (dd/mm/yy): _____________
Date (dd/mm/yy): __________________________________________________________________
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
FEE SCHEDULE
Initial Naturopathic Consultation
 Initial 120 minute consultation: $550
Subsequent Consultations
 60 minutes: $400
 1 Month (3 Visits): $1000 (including initial consultation – savings of $750)
 3 Month Health Restoration Plan (2 monthly Visits with Dr. Millie and Health Coach: $1600.00 (+ Initial
Naturopathic Consultation)
 6 Month Health Restoration Plan (2 monthly Visits with Dr. Millie and Health Coach (+ Initial Naturopathic
Consultation): $3095 (+ Initial Naturopathic Consultation)
 Spiritual Psychology and Homeopathy Program: Package of 8 sessions: $ 3100, 60 minute appointments.
Save $100 on Follows ups with Dr. Millie, no Initial required.
Eating for Meaning: Online Program $349 www.eatingformeaning.com
Health Coach One Body, One World with Vanessa Samora (Initial with Dr. Millie required)
 1 Month Coaching: 4 x 60 minute appointments over 1 month, Focused Diet goals, Fitness training $750 –
save $50


Follow up appointments: 60 minutes, $200
3 and 6 Month Health Restoration Programs – see above

Inquire about other programs and workshops
Scheduled Telephone Consultations
Same charges apply to phone calls extending beyond 5 minutes.
Cancellation of Appointments
Please give at least 48 hours notice to avoid standard charges for the appointment.
Laboratory Testing
Allergy testing IgG, IgA and IgM, urine and saliva tests are naturopathic doctor for an extra fee. Naturopathic tests
can measure toxicity level, digestive function, biological aging, stress level, nutritional status, sleep quality, stool
and digestive health, hormone balance, etc… The cost for these tests vary

Allergy Testing: 1 panel of 96 foods $250, 2 panels $400 for 96 foods
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________

Nutrigenomics and Gene SNP Program: Test, don’t guess! Includes Initial Intake, Gene Test Kit and
analysis, Follow up and treatment plan $3195 (Available in D.C. office only)
Supplements and Essential Oils (consumable)
Professional grade natural products are available through your naturopathic doctor. Most products are free of
chemicals and additives as well as hypoallergenic (do not contain yeast, corn, starch, wheat, dairy, sugar, salt or
gluten). The cost of these products varies.
Payments: All payments are processed at time of booking. In the event of a late cancellation, the fee will not be
refunded.
I, _______________________
, have read and agree to the fee schedule as listed above.

Naturopathic medicine can be used to help prevent and treat illnesses. However, Naturopathic Doctors
cannot guarantee results of treatment.

Complications are very rare when treated by a licensed Naturopathic Doctor. Naturopathic Doctors cannot
anticipate all risks and complications associated with treatment; however, they will do their best to inform me
of the most common side-effects.

I am responsible for informing the above Naturopathic Doctor if my condition or medications change,
(especially an anticipated pregnancy), as treatments may be contraindicated in some conditions.

I agree to pay for charges incurred during each visit by the end of the visit unless alternate arrangements have
been made prior to my scheduled appointment. I will be provided with a receipt upon payment so that I can
bill my insurance company. I will be charged additional fees for laboratory testing as well as
supplements/homeopathic remedies/herbal medicines. I will also be charged for missed appointments, late
cancellations (less than 48 hours) and overdue payments.

The clinic will endeavor to collect and maintain accurate personal information about me for the purpose of
assessing my health concerns, advising me of my options, providing high quality natural and professional
healthcare, maintaining contact with me, facilitating practice management and complying with naturopathic
regulations.
Patient’s name: _______________________DOB (dd/mm/yy): ______________________
Patient signature:______________________ Date (dd/mm/yy):_______________________
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Naturopathic Therapies
Licensed Naturopathic Doctors are primary care practitioners who use a combination of traditional medicine and
modern research to prevent, diagnose, and treat illness naturally for the entire family. Naturopathic Doctors
assess the whole person, taking into consideration physical, mental, emotional, and spiritual aspects. Gentle,
non-invasive techniques are used in order to stimulate the body’s self-healing capacity. One, or a combination of
the following naturopathic therapies, will be used to address your concerns.
Botanical Medicine is the use of constituents from whole plants (flowers, roots, and/or leaves) in the form of
liquid tinctures, herbal teas, tablets, salves, essential oils, and baths and is based on both traditional practices and
modern scientific research. Naturopathic Doctors are trained in the appropriate use of medicinal plants as well as
drug-herb interactions. Botanical medicine is used to support and promote the healing processes which naturally
exist within the body.
Homeopathy is a form of medicine which relies on minute amounts of substances to facilitate the body's natural
healing capacity. Homeopathic remedies are prescribed based on the understanding that ‘like cures like’ - a
principle which has been observed clinically for over 200 years. The selection of a remedy is based on the client’s
entire symptom picture. The focus of homeopathy is to restore health to the entire body.
Traditional Chinese Medicine includes acupuncture, herbal formulas and dietary changes to eliminate disease and
balance body functions. TCM involves an ancient system of diagnosis based on specific patterns and
combinations of symptoms that have been observed over thousands of years. Acupuncture refers to the insertion
of sterilized needles at specific points which modify the flow of energy through the body and stimulate organ
function. Dietary advice is based upon traditional Chinese medical theory. May require outside referral.
Clinical Nutrition is the foundation of optimal health. Many conditions may be prevented or treated by
modifications in diet alone, while others may require the prescription of specific nutrients. Nutritional analysis,
dietary plans, cleansing / detoxification programs, and supplementation are tools used by a Naturopathic Doctor
to address a variety of health concerns.
Hydrotherapy refers to the use of water applications at varying temperatures. Hydrotherapy is a noninvasive,
economical and effective therapeutic approach that acts to stimulate the immune system, facilitate detoxification,
and promote lymph drainage and circulation. May require outside referral.
Lifestyle Counseling and Coaching is used to teach a client how to incorporate balance between work, nutrition,
exercise, and activities of daily living. While the rewards are substantial, making changes in one’s lifestyle can be
a challenge. It is important that the client be supported throughout this treatment process. Naturopathic care is
a collaborative process between the client and doctor.
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Massage and Body Adjustment is the use of hands-on therapies to adjust the joints and soft tissues of the body
primarily to heal injury, manage pain and relieve stress. By referral to another practitioner.
Mind body medicine is the use of breathing, relaxation, meditation, guided imagery, and other techniques as a
means of supporting the conscious mind’s ability to stimulate healing in the rest of the body. Increasing our
awareness of how mental, emotional, social and spiritual factors affect our health enables us to enhance our
capacity for self-healing.
The following science and non-science-based services are also available:
Eating for MeaningTM is Dr. Millie’s own Nutritional Program designed to provide mindful techniques to change
your eating habits. Rather than looking at the diet from a collective standpoint, Eating for MeaningTM incorporates
the principles of whole foods nutrition, adventure, mindfulness, epigenetics and nutrigenomics to teach you to
eat according to your own best health.
Hypnotherapy is the application of hypnosis as a form of treatment. When one enters trance one's unconscious
mind is more receptive to suggestion and positive changes. Hypnotherapy can be used for relaxation, pain
reduction, addiction, weight loss, emotional or psychological conflict, anxiety, phobias, insomnia and a host of
other situations. Naturopathic Doctor Millie Lytle uses hypnotherapy to reframe the process of pregnancy and
birth for women and their partner.
BrennanTM Energy Work is a process whereby the energy worker intimately works with physical, emotional,
mental and spiritual challenges by working with levels of energy from the aura, and into the physical body, using
High Sense Perception, the ability to sense beyond our normal range.
Spiritual Psychology or Transpersonal psychology is a sub-field or "school" of psychology that integrates
the spiritual and transcendent aspects of the human experience with the framework of modern psychology. We
work on existential and spiritual sources of anxiety, depression, grief, loss and destructive habits. Dr. Millie works
Cognitive Behavioral Therapy, Dream Therapy and PsychoDynamic Psychotherapy into her counseling practice.
Angel an Oracle Card Reading provides an opportunity to connect with higher and inner wisdom, your angels, and
subtle ways of knowing what’s best.
Gene SNP DNA Analysis (**Only available in Washington D.C. Clinic) A cheek swab in my office provides DNA for
testing. In combination with interpretation from Dr. Millie, Gene SNP DNA Analysis provides valuable information
about gene expression and its impact on factors like cardiovascular, endocrine and mental/emotional health. In
addition, Gene SNP DNA Analysis also looks at select nutrients and fitness factors that may contribute to chronic
health concerns including obesity. Dietary intervention, based on knowledge of nutritional requirement,
nutritional status, and genotype can be used to prevent, mitigate or remedy chronic disease.
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088
Millennia Ruth Lytle, aka Dr. Millie ND, CNS, MPH
Naturopathic Doctor, Certified Nutrition Specialist, Hypnotherapist
www.milliesays.com
_____________________________________________________________________________________
Principles of Naturopathic Medicine
The following guiding principles are fundamental to every treatment plan.
First, do no harm
Promote optimal health with the least risk for each patient.
The healing power of nature
The healing power of nature must be respected to promote healing.
Treat the cause
Treat the fundamental cause of disease. Identify and remove the causes while avoiding the suppression of
symptoms.
Doctor as teacher
The role of doctor as teacher and role model for patient education, for the inspiration of rational hope, and to
encourage self-responsibility.
Treat the whole person
Address the unique physical, emotional, and mental factors which influence each person's well-being.
Prevention
Promote holistic health, to prevent future illness. Prevention involves individual, community, and global health
promotion.
Brooklyn: 135 Clarkson Ave F8, NY, 11226
26 E. 36th St. NY, NY 10016
1629 K St, #300 Washington D.C., 20006
Phone: TOLL-FREE for Appointments 1-844-441-9661 and Fax 1-888-255-5088