Naturopathic Health Questionnaire for Dr Tiffanie Jones. Name: Date of Birth: Phone: May I communicate with you via ? yes no.

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1 Naturopathic Health Questionnaire for Dr Tiffanie Jones Today s Date: Name: Date of Birth: Phone: May I communicate with you via ? yes no Address: Emergency contact: Phone: Relationship: How did you hear about Dr Jones? Primary care doctors name: Goal for visit: Past Medical History (Serious Illness/Disorders/Diagnosis): Surgeries (age and any complications): Major Accidents/date Allergies/reaction they causes (ex. drug, environmental, animal, food): Prescription or over the counter medications, dose, and reason for taking: Supplements (ex minerals, herbs, homeopathic remedies), dose and reason for taking: Primary Health Complaint: History of present illness (please answer any that apply): When this started: Location of body: What makes it worse: What makes it better: Characteristic (describe symptoms): Timing (Do symptoms last a certain amount of time or happen a certain time of year?) If so, explain: If pain is associated, does it radiate and to where? What do you intuitively think is causing the imbalance?

2 Review of Systems: P= experienced in the past C= current Height: Weight: General P C Fatigue Frequent colds Alcoholism Drug addiction, type Night sweats Weight gain (rapid) Weight loss (rapid) Chills Hypoglycemia (low blood sugar) Generally run: hot cold neutral Gastro-intestinal Bad Breath Nausea Vomiting Heart Burn Belching Gas /Bloat Ulcers Constipation Diarrhea Stools that float Gallstones Stool color not brown, color Blood in stool Undigested food in stool Hemorrhoids (circle: internal/external) Rectal itching Head/Eyes/Ears/Nose/Throat P C Headache Ear noises/ringing Dizziness Vertigo (room spins around you) Sinus infection Ear infections Post nasal drip Loss of smell or taste (circle which apply) Eye Dryness Goiter Swollen lymph nodes Kidney/bladder Bladder infections Frequent urination Kidney infection or stones Urinary discomfort Waking to urinate, # of times Excessive thirst Dental Canker sores Root canals Bleeding gums Gingivitis (gum disease) Grinding teeth Number of silver filling # removed Chest/heart/lungs High blood pressure Low blood pressure Rapid heart beat

3 Reproductive: Women PMS Breast tenderness Breast Lumps Irregular cycles Endometriosis Uterine fibroids Excessive menstrual flow Ovarian cysts Hot flashes Painful intercourse Low libido (sex drive) Yeast infections Urinary incontinence Are you in menopause: yes no First menses age: Days between periods: Days of flow #: Cramps: yes no Severity: 1-10= worst Mid cycle bleeding: yes no Sexually active? yes no With (circle): Men Women Both Venereal disease/std, type Use contraception: yes no Type? Pregnancies #: Abortions/miscarriages(circle which applies) #: Are you pregnant now? yes no Planning on becoming pregnant? yes no Have you had a hysterectomy? yes no Date of last PAP: Abnormal PAP s: yes no If so, explain: Chest Pain Difficult breathing Coughs Excessive phlegm/mucus Palpitations Irregular heart rhythms Pneumonia Bronchitis Asthma Skin/Hair/Nails Bruise easily Dry skin Acne Itching /Rash Cancers/growths Eczema Psoriasis Loss of hair Thinning eyebrows Cold sores Fungal infection, location Musculo-skeletal/ extremities Cold hands/feet Muscle cramps Neck pain or stiffness Low back pain Sciatica Swelling of the ankles Varicose veins Pain/numbness/tingling (circle which) If so, note below: (L) left, (R) right, or (B) both Arm Shoulder Elbow Wrist/hand Leg Hips Knee Ankle Foot

4 Reproductive: Men Incontinence Difficult urination Testicular pain Testicular mass Erectile dysfunction Low libido (sex drive) Hernias, repair date: Prostate trouble If so, explain: Change in urination pattern: yes no Explain: Are you sexually active? yes no With (circle): Men Women Both Use condoms? yes no Sexual concern? yes no History of sexually transmitted disease: yes no If yes, type?: Mental/Emotional: Have you ever been diagnosed with a psychiatric illness yes no If so, type: Eating disorder: yes no If so, is this a current issue yes no Do you generally feel (circle): Happy Sad Moody Angry Anxious Depressed Alone Weepy Irritable Fearful Nervous Unable to tolerate stress Energy: Morning: (none) (abundant) Midday: (none) (abundant) Evening: (none) (abundant) Daily stress level? very high slight high moderate none Social History Live: Alone Roommate(s) Significant other ( years) Children (names and ages) Pets (names and ages) Occupation: Full Part time If you work, do you enjoy your job? yes no If no, why? Do you allow time to unwind/relax? yes no. Do you have the support of friends and family? yes no Have you ever lived/traveled outside of the United States? yes no Did you get sick while you were there or after returning? yes no

5 List any chemicals, solvents, fumes, or mold that you may be exposed to at work or with hobbies: List any emotional or personal conflicts that you may be exposed to repeatedly: Sleep: What time do you go to bed? PM. What time do you wake? AM. How long does it take you to get to sleep: (minutes). Number of times you wake:. Do you return to slumber if you wake before morning? yes no Wake feeling refreshed? yes no 3 Day Diet Recall (Please fill out the 3 Day Diet Recall to the best of your ability.) DAY 1 DAY 2 DAY 3 BREAKFAST SNACK LUNCH SNACK DINNER DESSERT/SNACK BEVERAGES ALCOHOL (type/quantity) COFFEE/TEA (type/quantity) NICOTINE (quantity/day) Water (ounces/day) Food cravings? Foods you despise?

6 What do you enjoy most in life? Do you have any questions for me or anything more you think I should know about you? Consent: Dr Tiffanie A Jones is a medically trained naturopathic physician (Bastyr University graduate). Missouri/Illinois does not license Naturopathic physicians preventing her from being able to diagnose, treat, or accept insurance. Dr Jones provides recommendations based on medical history and presentation in office. She offers nutritional blood analysis as an educational tool, not for diagnosis. Any suggestions provided by Dr Jones will be based solely on information provided by you and your physician(s). You will be responsible for discussing any suggestions or options offered by Dr Jones with your primary physician prior to taking or refraining from taking any action. Dr Jones will not be liable for any adverse effect due to actions or inactions by you in connection with the suggestions provided. After reading the above information contained in this agreement, I voluntarily consent to the above terms and conditions of this consultation agreement realizing that Tiffanie Jones, ND cannot anticipate and explain all risks and complications of my health condition(s) and its related treatments. I understand that Tiffanie Jones, ND will exercise her educated judgment during any of the above procedures and in recommending dietary supplements, natural products, and dietary and lifestyle changes for my previously diagnosed condition(s). By signing below, I acknowledge that I have been provided ample opportunity to read, or have been read, this form and had any questions answered. I agree to use this consent form to cover the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek consult with Tiffanie Jones, ND. I also understand that I am free to withdraw my consent and to discontinue participation in these consults at any time. Print Client Name Signature of Client or guardian Date Financial policy: Payment is taken when appointment is made. For credit card payments please DrTiffanieJones@gmail.com or call Initial naturopathic consultation: $125 for an hour visit (includes blood analysis) (Family discount for 4 or more member s $100/person) Follow up visits: $75/half hour Blood analysis only: $75/half hour (Family discount for 4 or more member s $60/person) Cancellation policy: 24 hour cancellation policy 50% fee if no cancellation before 24 hours. Text or Phone to reschedule: Initial here, that I have read and understand this agreement More information about Dr Jones and services provided can be found on the website or by ing DrTiffanieJones@gmail.com Thank you for taking the time to complete this form. Wishing you the best of health.