Dr. Hayley Owens ND Naturopathic/Acupuncture Intake Form Personal Information
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1 Dr. Hayley Owens ND Naturopathic/Acupuncture Intake Form Personal Information Name: Today s Date: Gender: M F How did you hear about Dr. Owens? Age: DOB: Address: City: Province: Postal Code: Home Phone: Marital Status: Single Married Divorced Work Phone: Cell Phone: Emergency relationship: Primary care doctor: Occupation: Spouse/Partner: Emergency contact: Emergency phone: Phone: Address: Please list any other health care providers: (name, title, phone #) Where can we leave information concerning your health? Work # Cell # Home # Other: Correspondence? Yes No Dr. Owens may correspond with me at the above address. Cancellation Policy: Dr. Owens requires a minimum of 24 hours notice for any cancellations or changes to your appointment. A fee will be charged to your account for missed appointments. Signature: Any life threatening allergies drug, food, other? Yes No To what? If you are female, are you pregnant or breastfeeding? Yes No Maybe How many times have you been on antibiotics? Do you follow a special diet? Date of Last Physical Exam? Date of Last Blood Work? Present Health Concerns/Goals (Please begin with the most important) 1) Is the condition: Better Worse Same How long: 2) Is the condition: Better Worse Same How long: 3) Is the condition: Better Worse Same For how long: 4) Is the condition: Better Worse Same For how long: 5) Is the condition: Better Worse Same For how long: Have any these conditions been evaluated? Yes No Condition: Is your goal in receiving Naturopathic treatment to resolve just the issues presented above, or to achieve optimal health?
2 Medical History (Check all that apply in past 12 months) General Allergies food Seasonal Chills Fainting or Dizziness Fatigue Fever Forgetfulness/Difficulty concentrating Headache Intolerant to exercise Change in appetite Loss of sleep Weight change loss gain Numbness Chemical/metal exposures Sweats (Night/Day) Cold Intolerance(Night/Day) Whole body Hands/Feet Other: Heat Intolerance(Night/Day) Whole body Hands/Feet Other: Muscle/joint/Bone Pain, stiffness, weakness or numbness in Arms Hips Back Legs Feet Neck Hands Shoulders Other: Pain or swelling in joints Loss of range of motion Bone pain Genitourinary Blood in urine Color change in urine Frequent urination: day/night Lack of bladder control Painful Urination Difficulty Urinating Kidney Stones Gastrointestinal Appetite, poor Bowel changes Constipation Diarrhea Excessive hunger Excessive thirst Cravings: Gas or Bloating Belching, excessive Hemorrhoids Indigestion Reflux or Heartburn Nausea Rectal bleeding Stomach Pain Vomiting Vomiting blood Blood or mucous in stool Other: # of bowel movements per day: Cardiovascular Chest pain Heart flutters or skips High blood pressure Irregular heart beat Low blood pressure Poor circulation Rapid heart beat Swelling of ankles Water retention Varicose veins Anemia Pulmonary Persistent cough Spitting up blood /phlegm Shortness of breath Difficulty breathing Frequent colds/flu (>2/year): # Eye/ Ear, Nose, Throat Painful/Bleeding gums Loss of taste Sore lip/tongue/mouth Metal fillings Difficulty swallowing Hoarseness Feeling of lump in throat Enlarged glands Dental problems Jaw pain Ear ache/plugged Ear discharge Ringing in the ears Loss of hearing Loss of balance Nasal congestion Post-nasal drip Nose bleeds Sinus problems Loss of smell Hay fever Crossed eyes Eye: pain, swelling, red, dry or itchy Double vision Vision-Blurry, Flashes or Halos Vision-Light Sensitivity Skin/Hair/Nails Acne Bruise easily Discoloration of skin Hair loss or excess Excessive Dryness Hives Itching Change in moles Rash Scars / Stretch marks Sore that won t heal Weak: brittle nails/hair Eczema or Psoriasis Men Only Urgency/frequency Erection difficulties Lump or pain in testicles Penis discharge Sore on penis Other Last PSA: Women Only Abnormal pap smear Bleeding between periods Breast lump Breast Tenderness Extreme menstrual pain Hot flashes Irregular menses Miscarriages Nipple discharge Osteoporosis Vaginal discharge Vaginal itchiness Vaginal dryness Other: Last period: Last PAP: Last Mammogram: Are you pregnant Y N Number of children: Sexual/Emotional Low or High sex drive Painful intercourse History STI (STD) Depression Anxiety or worry Irritability/Anger Any form of abuse Using contraception Past surgeries, hospitalizations, accidents or major illnesses (including food poisoning etc.) Medical Diagnosis Date
3 Personal Health History Smoker: Y N Quit what yr: How many years: Amount per day: Alcohol: Y N Type: Frequency: Recreational Drugs: Y N Type: Frequency: Coffee/Soda/Tea Y N Type: Amount per day: Typical diet: Breakfast: Lunch: Dinner: Snack: Sleep: Restful Y N Time to bed: Rise? Hours per night: Water consumption/day: Regular exercise Y N Type and frequency of activity: Stress level 1(low) (high): How do you manage stress? Greatest cause of stress: Who do you have for support? Please list the two most stressful events in your life: Have you had any travel related illnesses? Prescriptions Medications (Currently on) Medication name Reason for taking it? Dose Prescribing doctor Start date Does it work, any side effects? Nutritional Supplementation (Currently on) Supplement Reason for taking it? Dose How long? Response/Reactions
4 Family History (Please mark all that apply) Condition Mother Father Sibling Maternal Grandparent Paternal Grandparent Heart Disease Cancer Hypertension Diabetes Stroke Asthma Substance abuse Osteoporosis Depression Migraines Allergies Other: The information above is correct to the best of my knowledge
5 FINANCIAL POLICY MSP POLICY FOR B.C RESIDENTS Non-Insured Fee (Office Fee): Naturopathic Doctors are registered with the College of Naturopathic Physicians of British Columbia. There is a fee charged for consultations based on the amount of time spent with the ND. Please review the information below for more details. Insured Fee (MSP Fee): If you have a valid BC Medical card and are receiving MSP premium assistance, you will be reimbursed $23 for each consultation (up to a combined maximum of 10 visits). Premium assistance patients are insured for a total of 10 visits per calendar year for any combination of services provided by the following licensed health professionals: Naturopathic Physicians, Chiropractors, Registered Massage Therapists, Physiotherapists, and Podiatrists. For example: 8 visits to a Naturopathic Doctor, 2 visits to a Chiropractor equals the 10 visits insured maximum limit. If you have used up your allowable visits for the year then no more reimbursements can be issued. You can fill out your MSP claims electronically online at under opted-out services. PLEASE NOTE: As of January 2002, only patients who have MSP Premium Assistance are eligible for reimbursement. Extended Health Coverage: Most extended health care plans cover naturopathic doctors, usually between $ per year. Some plans also include lab and diagnostic testing coverage. Please verify with you Extended Healthcare provider whether consultations, testing, and/or treatments are covered under your plan. We will issue a receipt for you to submit to your extended health insurance carrier at each visit. NATUROPATHIC SERVICES Adult Consultation Fees Duration Fee Initial visit 60 minutes $185 Follow-up visit 60 minutes $185 Follow-up visit 45 minutes $135 Follow-up visit 30 minutes $98 Follow-up visit 15 minutes $60 Acupuncture Duration Fee Follow-up visit 45 minutes $75 Intravenous Vitamins IV Drip 30 minutes $95 IV Push 15 minutes $75 Additional charges may apply for medicines prescribed and/or labs tests recommended by Dr. Owens. You will be informed of the costs and have the right to refuse purchase.
6 CONSENT FOR TREATMENT I hereby authorize Dr. Hayley Owens to perform the following specific procedures as necessary to facilitate my diagnosis and treatment: General Diagnostic Procedures (including but not limited to venipuncture, pap smears, radiography, and blood and urine lab work, general physical exams, neurological and musculoskeletal assessments) Psychological Counseling; Lifestyle Counseling; Exercise Prescriptions Herbs/Natural Medicines: Prescribing of various therapeutic substance including plants, minerals and animal materials. Substances may be given in the form of teas, pills, powders, tinctures may contain alcohol; topical creams, pastes, plasters, washes, suppositories or other forms. Homeopathic remedies, often highly dilute quantities of naturally occurring substance, may also be used. Dietary Advice and Therapeutic Nutrition: Use of foods, diet plans or nutritional supplements (Eastern/Western) for treatment may include intramuscular vitamin injections. Soft Tissue and Osseous Manipulation: Use of massage, cupping, Tui Na, neuro-muscular techniques, muscle energy stretching or visceral manipulation, as well as manipulations of the extremities and spine including traction and craniosacral therapy. Acupuncture: The insertion of pre-sterilized, disposable needles through the skin into the underlying tissues at specific points on the surface of the body Electromagnetic and Thermal Therapies: Includes the use of ultrasound, low and high volt electrical muscle stimulation, Electroacupuncture transcutaneous electrical stimulation, microcurrent stimulation, diathermy, and infrared and ultraviolet therapies or moxa warming or indirect burning of an acupuncture point and hydrotherapies. Vitamin Injection Therapies: Intramuscular (IM) and Intravenous (IV) injections involving high dose vitamins and minerals are used to treat deficiencies, aid in detoxification, support the immune system and improve overall energy. Bioidentical Hormones: Structurally identical to hormones produced naturally by the human body, bioidentical hormones are a safer alternative to the synthetically modified hormones that have been used in the past with Hormone Replacement Therapy (HRT). Prescriptive Medicines: In 2010, the BC government granted NDs prescriptive drug rights. Dr. Owens chooses to prescribe pharmaceutical medicines when required. Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant, since some of the therapies used could present a risk to the pregnancy. Labor-stimulating techniques or any labor-inducing substances will not be used unless the treatment is specifically for the induction of labor. A treatment intended to induce labor requires a letter from a primary care provider authorizing or recommending such a treatment. Consultation Visits Consultations with Dr. Owens will vary depending on your requirements and requests. Initial consultations usually require 60 minutes while most follow-up consultations are approximately 30 minutes. The initial consultation may include an extensive health history review, a detailed discussion of your main health concerns, physical examination as required, recommendation for lab testing as required, and a naturopathic treatment plan. You will be informed of the cost of all tests and supplements before they are performed/dispensed and have the right to refuse to purchase. Dr. Owens may request information pertaining to your case from your healthcare providers (medical, doctor, chiropractor, etc.) in order to create a complete health profile. In these cases you will be asked to sign a release of records form, which will be sent to your healthcare provider to obtain your health records.
7 Potential Treatment Risks: Naturopathic medicine utilizes primarily non-invasive and low-risk treatment modalities. You will be informed of the cost of all treatments before they are performed and have the right to refuse any treatment. All therapies are associated with some potential risk. Side effects from naturopathic treatments are relatively uncommon but can include (but not limited to): Aggravation of symptoms, allergic reactions to herbs, supplements or allergy testing, complications from acupuncture (pain, bruising, bleeding, lightheadedness, fainting, nausea, vomiting, puncture of internal organs), injury to soft tissue and/or joints/bone/spine arising from the use of physical medicine, accidental burns associated with moxa, unforeseen interactions between recommended herbs/supplements and over the counter or prescription medications, or pain, bruising, infiltration, bleeding, lightheadedness or fainting arising from injection treatments. 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. Confidentiality A record of all interactions with Dr. Owens, including health history, exams/tests performed and treatments recommended will be kept by Dr. Owens at Healing Cedar Wellness ( St. John s Street, Port Moody, BC). This record is kept strictly confidential and is not released to others without written consent provided by you or your representative or unless Dr. Owens is required to do so by law. In the event that you require naturopathic consultation and/or treatment and Dr. Owens is not available, the ND substituting for Dr. Owens will be permitted full access to your naturopathic health record for the purposes of providing you with appropriate advice and/or treatment. Statement of Consent I understand the description of the treatment modalities that Dr. Owens may recommend for me. I understand that there may be potential risks and side effects of naturopathic treatment and that Dr. Owens cannot anticipate and/or explain all risks and complications that may arise. I agree that any questions or concerns that I may have about naturopathic care will be addressed with Dr. Owens immediately. I understand that Dr. Owens, similarly for all medical professionals, cannot guarantee results. I further understand that advice and/or treatments offered to me by Dr. Owens are not intended to substitute for or replace advice and/or treatment provided by my other healthcare practitioners. With this knowledge I voluntarily consent to the diagnostic and therapeutic procedures outlined above which may be recommended by Dr. Owens except for (please list exceptions, if any): This consent form is intended to apply to my entire course of my care by Dr. Owens (and/or the ND substituting for her). I understand that at any time I may withdraw my consent for any further treatment and discontinue at any time. Signature of Patient or Guardian: Date: S a i n t J o h n s S t r e e t P o r t M o o d y B C
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Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :
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MICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P.
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Ayurvedic Intake Form
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CHIROPRACTIC ASSOCIATES CLINIC
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Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
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Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
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Chiropractic Patient Admittance Form
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Creve Coeur Family Medicine, LLC
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What do you believe is causing your most important health concern?
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Holistic Health Care New Patient Intake Form
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BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
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Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
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Windrose Naturopathic Clinic Family Practice Preventative Care 1137 W Garland Ave, Spokane WA (509) (509) (fax)
NEW PEDIATRIC PATIENT INFORMATION Date: To be filled out by parent or guardian: Child s Name: Age: DoB: Height: Weight: Address: City, State, Zip Male Female Parent / Guardian Information: Name: Phone:
Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
Reason forappointment:
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Health Intake Form. List your top five concerns or reasons for requesting your appointment with Dr. Weiss
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Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
Successful healthcare and preventive medicine require a healthy relationship between provider and patient. Your responses to the following questions will significantly contribute to your doctor's understanding
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
ACTIVE EDGE CHIROPRACTIC
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Active-Med Health and Wellness Centre Leslie St, Unit 7 Richmond Hill, ON L4S0B City Province Apt # Postal Code. Name.
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