Adult Naturopathic Intake Form

Transcription

1 1915 I Street NW, Suite 700 Washington, DC Adult Naturopathic Intake Form (please use this form for ages 13 and older) Today s Date: Personal History Name: Age: Date of Birth / / Sex: M F Gender Identification: M F Other (please specify): Mailing Address: Street and Number City State Zip Home Phone: Cell Phone: Work Phone: If you would like to opt out of my mailing list, please check here: Occupation: Hours worked per week: Marital Status: Single Married Separated Divorced Widowed Weight: Height: Emergency Contact Relationship to Patient: Contact s Phone: Contact s Who can I thank for this referral? What are your goals for this visit? Health Concerns List in order of importance your primary health concerns: How long have these problems persisted? Allergies Please list any LIFE-THREATENING ALLERGIES:

2 Other allergies, sensitivities or intolerances (e.g. food, medication, environmental, chemical, etc.): Medications List any medications you are currently taking. Please bring these medications with you to your first appointment. Medication Form Dosage Frequency Date Started Supplements List any vitamins, minerals, herbal supplements, homeopathic medicine or any other supplements you are currently taking. Please bring these supplements with you to your first appointment. Supplement Example: Vitamin C Manufacturer Vital Nutrients Form capsule Dosage 500mg Frequency once per day Current Health Care Team Primary Care Physician: Office Number: P a g e 2

3 Specialist Physician: Specialty: Office Number: Specialist Physician: Specialty: Office Number: Other Health Care Team Members (Ex: massage therapist, nutritionist, acupuncturist, etc.): Practitioner Name: Office Number: Practitioner Name: Office Number: Date of last physical exam? Date of last blood test? Operations/surgical procedures/blood transfusions/major injuries (include year): Hospitalizations and Major Injuries Date Immunizations/Vaccines: Vaccine reactions? Yes No If yes, please describe: Family History Family Member Major illnesses/cause of death Current age/ Age at death Mother Father Siblings Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather P a g e 3

4 Females Are you pregnant? Yes No Are you breast feeding? Yes No Date of last menstrual period: Are your cycles: Light Medium Heavy Review of Systems: Please check all that apply to you CURRENTLY: General: Weakness Fatigue Change in weight/appetite Fever/chills Night sweats Hot/cold intolerance Increased thirst/hunger/urination Change in sleeping habits Anemia Bleeding tendencies Skin: Rashes Lumps Sores Itching Dryness Change in moles Changes in hair/nails Easy bruising Head: Head injury Headache Migraines Dizziness Head Injury Hair Loss History of loss of consciousness Seizures Eyes: Watery/itchy/red eyes Discharge from eyes Double Vision Blurriness in vision Use of glasses/contacts Cataracts Glaucoma Sensitivity/pain to light or vision changes Date of last eye exam: Other: Ears: Ear pain Discharge Infection Hearing changes/impairment Tinnitus Vertigo Nose/Sinuses: Chronic sinusitis Hay fever Decreased smell Excessive congestion Nosebleeds Nasal fractures Mouth/Throat: Tenderness or lesions Sore throats Burning sensation of tongue Difficult/painful swallowing Persistent hoarseness Tooth pain Bleeding gums Brush/floss daily Dentures Root canal Dental implant P a g e 4

5 Neck: History of injury Masses Pain Stiffness Chest: Cough Chest pain Shortness of breath Wheezing Sputum History of asthma Bronchitis Coughing up blood Pneumonia Tuberculosis (TB) Cardiac: High blood pressure Low blood pressure History of chest pain Murmurs Palpitations Dizziness Fainting Shortness of breath with exertion (DOE) Congestive Heart Failure Shortness of breath while lying down (orthopnea) Coronary Artery Disease Stroke/TIA Heart attack Vascular: Pain in legs/hips while walking Edema Coolness/discoloration of legs/arms Loss of hair on legs Blue/purple colored skin (cyanosis) Ulcers/non-healing wounds Varicose veins Deep vein thrombosis (blood clots) Gastrointestinal: Abdominal pain Nausea/vomiting Change in appetite Food intolerance Heartburn Vomiting blood (hematemesis) Excessive belching Excessive passing gas Constipation Diarrhea Change in stool Hemorrhoids Rectal bleeding/pain Have you gained or lost over ten pounds in the past year? Yes No Was this on purpose? Yes No Esophagogastroduodenoscopy (EGD): Yes No Year: What were the findings? Colonoscopy: Yes No Year: What were the findings? Urinary: Pain with urination (dysuria) Frequent urination Urgency Blood in urine Change in urine color/odor Infections Kidney stones Difficulty initiating stream Incontinence Musculoskeletal: Weakness Muscle/joint pain or stiffness Limitation of movement Arthritis Back pain Muscle cramps P a g e 5

6 Neurological: Fainting Dizziness Blackouts Paralysis Numbness Tingling/burning Tremors Speech disorders Memory loss Mood changes Psychiatric disorders Hallucinations Seizures MALES: Pain/lesions on genitals Discharge from penis Erectile dysfunction Deceased libido Testicular masses/pain/swelling Hernias Decreased force of urinary stream Sexually transmitted infection Prostate Disease Sexually active Do you have sex with: Men Women Both Date of last prostate or rectal exam: What were the findings? FEMALES: Breasts: Lumps Discharge Pain Prior surgery or biopsy Breast cancer Family history of breast cancer Mammogram: Yes No Year: What were the findings? Thermography: Yes No Year: What were the findings? Female health: Vaginal discharge Vaginal itching/burning Lesions on genitalia Pain with sexual intercourse Low libido Sexually transmitted infection Pregnancy: Complications Birth Difficulties How many pregnancies? How many live births? How many abortions? How many miscarriages? Any complications: Menses: Menstrual cramps Menstrual pain PMS Food Cravings Heavy bleeding Decreased libido Breast tenderness Breast Lumps Edema Irritability Depression Age of first period: Are you sexually active? Yes No Do you have sex with: Men Women Both Birth Control/contraception (type): Date of last Pap Smear: Have you ever had an abnormal Pap? If so, when? Menopause: Vaginal dryness Pain with intercourse Hot flashes Weight gain Irritability Night sweats Menopausal since: Hormone Replacement Therapy (type/duration) P a g e 6

7 Have you had a hysterectomy? Yes No Year: If yes, do you have ovaries? Yes No Bone Density (DEXA): Yes No Year: What were the findings? Please list any other information you feel is important to share: I have indicated all of my known medical conditions above. I will alert the practitioner to any changes in my health status. It is my choice to receive naturopathic care. Patient Name: Signature: Legal Guardian Name (if needed): Signature: Date: Legal Guardian s Relationship to Patient: Notice of Privacy Practices This notice, and the accompanying Practices Regarding Disclosure of Client Health Information, describes how health information about you may be used and disclosed, and how you can get access to your health information. Copies are given to all individuals receiving care. Please review this information carefully. Understanding your health record: A record is made each time you come to Dr. Berkeley for a treatment or consultation. Your symptoms, the practitioner s assessment, and a plan of services are recorded. This record forms the basis for planning your care and treatment/consultation at future visits, and also serves as a means of communication among other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used will assist you to ensure it is accurate and make informed decisions about who, what, when, where, and why others may be allowed access to your health information. Understanding your health information rights: Your health record is the physical property of Dr. Anne Berkeley, PLLC, but the content is about you, and therefore belongs to you. You have the right to review or obtain a paper copy of your health record. You have the right to request restrictions, to authorize disclosure of the record to others and be given an account of those disclosures. Other than activity that has already occurred, you may revoke any further authorizations to use or disclose your health information. Our responsibility: Dr. Berkeley is required to maintain the privacy of your health information and to provide you with this notice of our privacy practices. We re required to follow the terms of this notice and to notify you if we are unable to grant your request to disclose or restrict disclosure of your health information to others. Dr. Berkeley reserves the right to change her practices and promises to make a good faith effort to notify you of any changes. Other than for the reasons described in this notice, Dr. Berkeley agrees not to use or disclose your health information without your consent. P a g e 7

8 Informed Consent for Consultation and Treatment (continued on next page) I,, hereby authorize Dr. Anne Berkeley, PLLC to perform the following specific procedures and services as necessary to facilitate in the treatment of myself or my minor child: Physical exam: e.g., general, musculoskeletal, cardiovascular, abdominal, respiratory Medicinal use of nutrition: therapeutic nutrition, nutritional supplementation Botanical medicine: botanical substances may be prescribed as teas, alcoholic tinctures, glycerite tinctures, capsules, tablets, creams, plasters, solid extracts, or suppositories Hormone therapies: natural, bio-identical hormone therapies Homeopathic medicine: the use of highly dilute quantities of naturally occurring plant, animal and/or mineral substances to gently stimulate the body s healing responses Lifestyle, nutritional and psychological counseling: diet therapy, nutritional supplementation, recommendations for exercise, sleep, stress reduction, and balancing of work and social activities, mind-body supportive counseling Hydrotherapy: recommendations to use hot or cold water to stimulate circulation in the body and relieve congestion Venipuncture: blood draw to be submitted for tests ordered I understand that the focus of naturopathic care is to alleviate the underlying conditions that can bring about illness rather than the treatment of symptoms. While I may experience some immediate improvement from the use of naturopathic methods, I understand that the most effective results occur when I make a long-term commitment to rebuild my health. It is my responsibility as a patient to follow-up within a recommended time period for evaluation of treatment results or to change treatment protocols as necessary. I understand that Dr. Berkeley does not offer after-hour services or provide any hospital-based services. If I have difficulty with any of the remedies or other aspects of my treatment, I understand I should call during business hours to discuss concerns I may have. I recognize that, as with any method of care, there may be risks. The potential risks and benefits are described below: Potential Risks: allergic reactions and side effects to natural medications, supplements, homeopathic medications, prescription medications; inconvenience of lifestyle changes; and/or injury from procedures. I understand that it is my responsibility to alert Dr. Berkeley of any adverse effects or reactions. Potential Benefits: restoration of health and the body s maximal functional capacity; relief of pain and symptoms of disease; assistance in injury and disease recovery; and prevention of disease or its progression Notice to Pregnant Women: All female patients must alert Dr. Berkeley if they know or suspect that they are pregnant, as some of the therapies used could present a risk to the pregnancy. Notice of Degree and License: I understand that Dr. Berkeley holds a degree of Doctor of Naturopathic Medicine (ND) and is a licensed, board-certified Naturopathic Physician in the District of Columbia. Insurance and Payment Notices: I understand that Dr. Berkeley does not work with insurance companies and Medicare will not reimburse for services rendered with Dr. Berkeley. Payment in full is required for all services, P a g e 8

9 products and treatments provided at each visit. Payment is accepted in the form of check, Visa, MasterCard, Discover and American Express. Cancellation and Rescheduling of Appointments Policy: I understand that my appointment time is reserved especially for me and, oftentimes, my appointment is prepared for days in advance. I understand that if I don t show up for my scheduled appointment, that time cannot be used to help other patients in need. Dr. Berkeley requests 24-hours notice (1 business day) for canceling or rescheduling appointments. For any visits cancelled with less than 24-hours notice, the patient will be charged the full amount of the original visit fee. This charge will be billed directly to the client. Late arrivals will not receive an extension of scheduled service times and will be responsible for the full visit fee. In the event legal action is required to collect payment, I agree to be responsible for attorney fees and costs. I understand that if I arrive late to a scheduled appointment, I may or may not be seen depending on the Doctor s availability and will be charged for the full duration of my scheduled visit. Supplement/Natural Medicine Policy: Dr. Berkeley researches the highest quality supplements and natural medicines currently available on the market, many of which are only sold to doctors (not commercially available to the public or retail merchants like health food stores). I understand that Dr. Berkeley is unable to offer refunds or returns on any supplements or natural medicine products. Laboratory Policy: Dr. Berkeley offers a variety of labs, both conventional and specialty. Collection methods include saliva, urine, stool, and blood. Most salivary, urine, and stool tests are take home tests. If this is the case, I will get a test kit from the doctor, take it home, collect the sample(s), and mail the kit in to the lab (in a prepaid package via UPS or FedEx). For these tests, I am responsible for payment directly to the lab. For blood tests, I understand Dr. Berkeley will refer me to a laboratory facility with a requisition (order form). For these labs, I will either pay the lab or Dr. Berkeley directly for the actual test, depending on the type of test. Insurance sometimes covers lab fees. This depends on an individual s insurance carrier and particular plan. I understand that the time needed to process different labs varies greatly, from a few business days to a few weeks. When test results are ready, they will be sent to Dr. Berkeley for review. Once the labs have been reviewed, Dr. Berkeley will arrange a follow-up appointment to go over these findings. This follow up appointment is not included in the initial cost of the lab. I will be issued a copy of the results during the follow-up appointment. I understand that I will be provided with a copy of my lab test results. If lab results, chart notes, or any other information contained in my patient file must be copied, scanned, faxed or mailed, I will be charged a $25 processing fee to cover administrative costs. I understand that it is not being recommended to me to discontinue any other treatment or care being provided by any other health care professional. I understand that Dr. Berkeley does not function as a primary care physician, and that she offers her services in addition to other services I receive. I understand that Dr. Berkeley does not replace the service of my primary care physician. I agree to follow-up on referrals for medical care when necessary. I have been provided with a copy of the Notice of Privacy Practices and understand that it describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations with Dr. Berkeley. This Notice of Privacy Practices also describes my rights and duties with respect to my protected health information. Dr. Berkeley reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office of Dr. Berkeley and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. P a g e 9

10 I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless directed by myself or my representative or unless required by law. I understand that my medical record will be kept for a minimum of three, but no more than ten years after the date of my last visit. I understand that full disclosure of information has been made to me and all my questions have been answered to my full satisfaction. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Dr. Berkeley regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I have read and understand the above statements. Patient Name: Signature: Legal Guardian Name (if needed): Signature: Date: P a g e 10

11 Consent for the Collection, Use and Disclosure of Personal Information I understand the importance of protecting the privacy of your personal information and I am committed to collecting, using and disclosing your personal information responsibly. I am aware of the sensitive nature of the information that you have disclosed to me; therefore, I strive to ensure that: Only necessary information is collected about you. I only share your information with your consent. Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols. My privacy protocols comply with privacy legislation, the standards of our regulatory body, and the law. I will collect, use, and disclose information about you for the following purposes: To assess your health needs and advise you of health management options. To communicate with you and remind you of upcoming appointments. To communicate with all other health care providers in your health care team. To allow me to efficiently follow up for health management, care and billing. To assist in complying with all regulatory requirements and the law, including requirements to advise authorities of child abuse and to report diseases and individuals who may be an imminent threat to themselves or others. To invoice for goods and services, process payments, and collect unpaid accounts. If a new purpose arises, I will seek your written approval in advance. I will not, under any circumstances, supply your insurer with your confidential medical history. In the event that this kind of request is made, I will forward the information directly to you for review and for your specific consent. Patient Consent: I have reviewed the above information that explains how my naturopathic doctor will use my personal information. Should the need arise, I agree that my naturopathic doctor can me and I understand that this is not considered a secure form of communication. I agree that my naturopathic doctor can collect, use and disclose my personal information for the purposes listed above. Patient Name: Signature: Legal Guardian Name (if needed): Signature: Date: P a g e 11

12 Communication Consent offers an easy and convenient way for patients and doctors to communicate. In many circumstances, it has advantages over office visits or telephone calls, but here are important differences. is not the same as calling our office; there is no person at the other end of the call just a computer. You can t tell for certain when your message will be read, or even if your doctor is in the office or on vacation. Nonetheless, we believe that the ease of communication affords is a benefit to patient care. It will further assist us if you could identify the nature of your request in the subject line of your message. Below are our rules for contacting us using . is NEVER appropriate for urgent or emergency problems. Please use the telephone or go to the Emergency Department for emergencies. is great for asking those little questions that don t require a lot of discussion. s should not be used to communicate sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability or substance abuse. is not confidential. You should also know that if sending s from work, your employer has a legal right to read your . may become a part of the medical record when we use it; a copy may be printed and put in your chart. is not a substitute for seeing a doctor. If you think that you might need to be seen, please call and book an appointment. In cases where an response would not be appropriate or sufficient, you may be asked to schedule an appointment to ensure that your concerns get properly addressed. For more complex inquiries that require the doctor to review your medical chart and provide an in depth response, it is my policy to charge $30 for this service. I have read this Communication Consent form and understand the limitations of security on information transmitted. I understand that my doctor may not be able to communicate with me electronically about my specific condition if I live outside of the state in which my doctor is licensed. Date: State of Residence: Address: Patient Name: Signature: Legal Guardian Name (if needed): Signature: P a g e 12