To-Do List Functional Medicine (COMPREHENSIVE) patients

Transcription

1 To-Do List Functional Medicine (COMPREHENSIVE) patients A SUMMARY OF THE FORMS YOU WILL NEED TO COMPLETE BEFORE YOUR INITIAL FUNCTIONAL MEDICINE APPOINTMENT WITH DR. FENSKE, AND WHEN SHE WILL NEED TO RECEIVE THEM IN ORDER TO FULLY PREPARE FOR YOUR APPOINTMENT. FORM: DUE: Medical Record Request (separate download from other forms) Patient Acceptance Form Within TWO DAYS of scheduling your initial appointment. Within ONE WEEK of scheduling your initial appointment. Patient Health History Within ONE WEEK of scheduling your initial appointment. Nutritional Assessment Questionnaire Within ONE WEEK of scheduling your initial appointment. Diet Diary Within ONE WEEK of scheduling your initial appointment. Health Goals Within ONE WEEK of scheduling your initial appointment tel fax Info@DrFenske.com Terrace Ave. Ste 2 Middleton, WI 53562

2 Patient Acceptance Policy Functional Medicine (COMPREHENSIVE) patients (608) Name (last, first) Date: Address City, State, Zip Phone (home) Phone (cell) Sex Age Date of Birth Spouse/Partner s Name Children (ages, names) Occupation Employer/School Whom may we thank for referring you to our office? In order to best serve you, the Patient Acceptance Policy should be carefully reviewed. It is Dr. Fenske s opinion that you should be well informed on our expectations and clinical procedures. To prevent any misunderstandings or confusion on what to expect, Dr. Fenske would appreciate that you read the below steps and provide your signature. This would simply imply that you have read the Patient Acceptance Policy and understand what is expected of you. PRIOR TO FIRST APPOINTMENT: 1. Completion of the following forms: Patient Acceptance Policy, Patient Health History, Nutritional Assessment Questionnaire, Diet and Lifestyle Diary, Health Goals, Request for Records. These forms were developed to gather important information about your body. They will help Dr. Fenske more quickly zero in on the probable causes of your health problems. It is VERY important for you to carefully and thoroughly complete all of these forms and questionnaires prior to your first consultation with Dr. Fenske. 2. Medical Records and Lab Reports (see Request for Records form) Obtain medical records and lab reports from all physicians since you were first diagnosed with your health condition. We MUST receive these prior to your initial appointment. FIRST APPOINTMENT: 3. At your initial appointment Dr. Fenske will review your case with you and provide a detailed written report based on the information you have provided. The cost for the 60 to 75 minute appointment as well as Dr. Fenske s time for studying your forms / medical records is $ Based on your initial appointment and review of all your medical information Dr. Fenske may recommend various labs. These labs help uncover underlying weaknesses in the body that may result in disease. You will be presented with detailed information on the specific tests recommended. Because it varies case by case, the cost for your initial laboratory tests will be discussed at that time. SECOND APPOINTMENT: 5. The time it takes to receive the results of your tests varies based on individual test processing time as well as on when you choose to initiate the test. When results are available our staff will call to schedule your second appointment. This appointment usually takes approximately one hour. You will be presented with the possible causes of your health problem and the recommended treatment protocol. The fee for this second appointment is typically $120 to $ for approximately 30 to 60 minutes.

3 6. Your recommendations may consist of personalized dietary and lifestyle changes as well as nutritional supplements. 7. After this second appointment, you may meet with our patient educator to discuss implementation of specific recommendations. SUBSEQUENT APPOINTMENTS: 8. Follow-up consultations will be scheduled every 3, 6 or 12 weeks allowing you the opportunity to discuss your progress and any concerns with Dr. Fenske. Dr. Fenske will at this time determine what direction to take to help you continue your progress. Your cooperation in taking personal responsibility in your health care will go a long way in getting better. Consultations may be conducted either by phone or in person at our office. The fee for follow-up consultations is based on the time required for the appointment (typically $ to $240). 9. Abnormal laboratory tests will need to be re-evaluated. The success of your treatment will not only be measured on the reduction or elimination of your physical symptoms, but on abnormal laboratory tests returning to a normal status. Laboratory fees can vary depending on what needs to be re-tested. Our goal at Fenske Holistic Healthcare Center is to provide high quality, personal service that is responsive to the healthcare needs of our patients. We require payment for services at the time they are provided. Insurance companies do not cover Functional Medicine consultations, nutritional supplements, or preventative lab services. Any specific questions you may have about coverage for our services should be directed to your insurance provider. Note: prices are subject to change without notice, the duration of each visit is approximate, and 24-hour notice is required to cancel an appointment without incurring a charge. Prices not only reflect the time spent with each patient but also the time studying your case between visits and the advanced training, expertise, and effort required to treat complex health conditions. We accept payment by cash, check, or credit card (Mastercard and Visa). I have read and fully understand the Patient Acceptance Policy. Patient (Parent/Guardian) Signature Date (The signature of Parent/Guardian hereby authorizes Dr. Nicole Fenske to provide care for the minor child listed as Patient). Fenske Holistic Healthcare Center 2 Patient Acceptance Policy (FM Comprehensive)

4 (608) Patient Health History Functional Medicine (COMPREHENSIVE) patients Name Date Date of Birth Age Height Weight Blood Type Occupation Race/Ethnicity(circle one): White/Caucasian Black/African Amer. Asian Hispanic/Spanish Native Hawaiian Amer. Indian What brings you to our office? List your major health problems/concerns: Describe the causes of these concerns (if known or suspected): Have you had the same (or similar) problem before (circle one)? Y / N What activities aggravate your problem(s)? What activities improve your problem(s)? Are your problems getting progressively worse? Y / N Are your problems interfering with (check all that apply): Work Daily Routine Sleep Other If your condition involves pain please characterize type: Ache Sharp Radiating Constant Intermittent Please rate the amount of pain you are generally experiencing: (circle one) mild severe Please use the diagram to the right to indicate areas of involvement (mark: P for pain, T for tightness, N for numbness).

5 Previous Treatment for Health Problems Were you previously treated for the above problems? Y / N (if no, skip to Health Maintenance Update section below) Name of practitioner Date first seen Date last seen Condition or diagnosis How was the condition treated Results of treatment: Good Fair Poor Please list below other practitioners seen for this condition: (or check here for none ) Name Date (approx.) Testing/Treatment Additional remarks about previous treatment Current primary care physician Do you suffer from any other health problems from which you are not seeking consultation with us? Y / N If yes, please itemize below: Condition Date of onset (approx.) Practitioner Health Maintenance Update Please indicate approximate dates and results of last: Physical exam Spinal exam _ Dental exam Cholesterol profile Other blood tests Chest X-ray _ Spinal X-ray _ Bone density (DEXA) scan Mammogram Eye exam Colonoscopy or flexible sigmoidoscopy Other Fenske Holistic Healthcare Center 2 Patient Health History (FM Comprehensive)

6 List all medications you are currently using, or have used recently. Include all over-the-counter medications. List dosages and approximate length of time you have used each medication: List (include name, brand, dosage) all vitamins, minerals, herbs, and other natural products you are currently using: List medication/supplement/environmental allergies or intolerances and associated reactions: List past or present exposure to harmful chemicals: Surgical History Please list all major and minor surgeries you have undergone with approximate dates: Fenske Holistic Healthcare Center 3 Patient Health History (FM Comprehensive)

7 Previous Chiropractic Care Have you previously had chiropractic care? Y / N (if no, skip to Serious Accidents section below) Chiropractor Date first seen Date last seen Under treatment for what condition at that time Were X-rays taken? Y / N If yes, please indicate approximate date and region(s) X-rayed: Cause of condition as explained by doctor Results of treatment: Good Fair Poor Serious Accidents and Falls Have you ever been in an auto accident? Y / N Date(s) Describe Have you had any significant sports injuries? Y / N Date(s) Describe Have you had any work accidents? Y / N Date(s) Describe Please describe any other accidents, falls, or injuries (include dates): Please list all fractures you have sustained and when they occurred: Early Health History List any known problems your mother had during her pregnancy with you (illness, stress, medication, smoking, alcohol, traumatic delivery): Were you breast fed? Y / N. If yes, please indicate duration if known Was your home life as a child loving/supportive? Y / N If there were significant stresses please describe Please check if you had any of the following childhood illnesses: Frequent ear infections Colic Eczema Recurrent colds Bronchitis Pneumonia Meningitis Other As a child were you on frequent or prolonged antibiotic therapy? Y / N Did you receive immunizations? Y / N Did you experience any adverse reactions to immunizations? Y / N / NA If yes, please describe Fenske Holistic Healthcare Center 4 Patient Health History (FM Comprehensive)

8 Please check all of the following conditions that you have experienced: Alcohol/drug addiction Allergies Anemia Anxiety, reoccurring Asthma Blood fats, high (cholesterol, triglycerides) Blood pressure, high Blood pressure, low Bone loss Cancer Depression Diabetes Emphysema Environmental sensitivities Epilepsy Fatigue, chronic Gallstones Headaches, reoccurring Heart attack Heart disease Heart palpitations Insomnia Kidney disease Mental health problems Pneumonia Sexually transmitted infection Sinus congestion, chronic Skin problems Thyroid disorder Ulcer Urination problems Other (please describe): Female Health History Age at first period Date of last period Number of pregnancies Number of live births Date of last Pap test History of abnormal Pap tests? Y / N History of irregular periods? Y / N Menstrual cycle length: days. Duration of menstrual period: days. Do you experience significant menstrual cramping? Y / N Is heavy bleeding a problem? Y / N Do you have a history of endometriosis? Y / N Do you have a history of yeast infections? Y / N Do you have a history of infertility? Y / N Do you have excessive unwanted hair growth? Y / N Do you have a tendency toward premenstrual syndrome? Y / N If yes, please describe symptoms: Do you have a family history of (check all that apply): breast cancer ovarian cancer osteoporosis Describe any current menstrual or menopausal symptoms or concerns: Describe any current breast problems: Did you breast feed? Y / N If yes, please indicate duration for each child: Digestive Function Describe any food intolerances you have: Describe any digestive problems: Your usual bowel movement frequency is (check one): >2 times daily 1 time daily 1time every 2 days <1 time every 2 days. Fenske Holistic Healthcare Center 5 Patient Health History (FM Comprehensive)

9 Do you usually have to strain to have a bowel movement? Y / N Are your bowel movements chronically loose? Y / N Do you ever have blood with bowel movements? Y / N Are your stools ever black or tarry? Y / N When was the last time you received antibiotics? Family Health History Review the conditions below. Indicate if a family member has ever had a condition with an X in the appropriate space. Leave blank any spaces that do not apply. CONDITION Father Mother Spouse Brother(s) Sister(s) Children Age Age Age Age(s) Age(s) Age(s) Acne Alcoholism/addiction Allergies/hay fever Alzheimer s Disease Arthritis Asthma Bedwetting Cancer (specify type ) Depression Diabetes Digestive problems Ear infections Female problems Headaches Heart disease High blood pressure Insomnia Kidney problems Liver disease Mental health problems Migraine Muscle pain/cramps Osteoporosis Spinal curve Thyroid problems Other (specify ) Other (specify ) If any of the above family members are deceased, please list their age at death and specify cause of death. Other pertinent family history: Fenske Holistic Healthcare Center 6 Patient Health History (FM Comprehensive)

10 Stress Factors Please indicate if any of the major stresses listed below apply to you (check all that apply): Job New retirement New baby Change of marital status Health problems Family stress Financial concerns Abusive relationship Other:. Please describe the quality of major relationships in your life:. Indicate job satisfaction (if applicable): Excellent Good Fair Poor Have you experienced physical, emotional, sexual, or verbal abuse? Y / N Lifestyle Habits Describe your sleep pattern: Time arise Time retire Naps? Y / N Your quality of sleep is: Well-rested Tired upon awakening Awaken during night Do you: Sleep in total darkness Sleep near electric clock, outlet, or other electronic device Your typical sleep position is: Side Back Stomach Is your mattress firm? Y / N Pillow type (check all that apply): Firm Soft Thick Thin Feather Synthetic Orthopedic What is the frequency of your vacations: times / year. How frequently do you travel: Annually Semi-annually Monthly Weekly Do you live/work in a damp or moldy home/office? Y / N Do you exercise? Y / N If yes Type: Frequency: times per week/month (circle one). How do you relax or relieve stress? Do you use tobacco? Y / N If yes, list amount you smoke/chew per day and week Years using tobacco, if you no longer use it, when did you quit Do you use recreational drugs? Y / N If yes, list type and frequency Did you formerly use recreational drugs? Y / N If yes, specify Diet History Describe your typical: breakfast lunch dinner snack How frequently do you dine out: Daily Weekly Monthly Rarely/never How frequently do you eat fast food: Daily Weekly Monthly Rarely/never How much water do you drink daily: < 1 qt. 1 qt. 2 qt. > 2qt. Is it filtered water? Y / N Foods you avoid and why (i.e. allergies, diet, dislike): Foods you crave: Do you have (or have you had) an eating disorder? Y / N Do you drink coffee? Y / N if yes, how many cups daily of decaf and caffeinated Do you drink tea? Y / N if yes, what kind and how many cups do you drink daily Do you drink soda? Y / N if yes, what kind and how many do you drink daily Do you drink alcohol? Y / N if yes, list type and amount per day and week Do you have (or have you had) a problem with alcohol overuse? Y / N Fenske Holistic Healthcare Center 7 Patient Health History (FM Comprehensive)

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17 Establishing Your Health Goals Functional Medicine (COMPREHENSIVE) patients (608) Name Date: Personal Message Before You Begin Before you begin our journey together, I would like to discuss something very important that will have a major impact on your ability to recover and achieve maximum improvement. After many years in private practice, I have had the opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms it s about living a life of vibrant health. I ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality, a discussion of how you have lived your life up to this point and how you will live it in the future. Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want you to be honest with yourself and really dig deep inside yourself for the answers. 1. Have you made the decision to change? To do what it takes to get well? Yes No I have read something interesting: The definition of insanity is to keep doing the same thing and expecting different results. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination. Most people I ask tell me they have made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having reasons to actually do it. When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieve health and wellness. So now I ask: 2. List up to 5 things that you have been unable to do as a result of your present symptoms. Please be specific. (Use extra pages if necessary)

18 3. List up to 5 things that you plan to do once you are feeling better. Please be specific. (Use extra pages if necessary) 4. Please check off the following that you would like to achieve with my help: o Increase energy o Sleep better o Have better digestion o Be able to eat more foods o Get rid of my allergies o Have a better immune system (i.e. less colds /coughs) o Not be dependent on laxatives or stool softeners o Be able to work out again o Have better muscle tone o Be in less pain o No longer use pain medication o No longer use allergy medication o No longer use sleep medication o To feel less sleepy in the afternoon o Lose weight o Increase my sex drive o Increase my metabolism to burn more fat o Increase my flexibility o Reduce my stress o Improve my memory o Improve my focus o Improve my mood o Reduce my risk of developing a chronic disease o I want to work on an anti-aging program o I want to detoxify my body o I want to improve my diet o I want to clear up my skin 5. Are there any other health goals you want to achieve? Fenske Holistic Healthcare Center 2 Health Goals (FM Comprehensive)