Dr. Allison Blessing, DC Functional Medicine Practitioner 4611 S. 96 th St. Ste160 Omaha New Patient Questionnaire

Transcription

1 Dr. Allison Blessing, DC Functional Medicine Practitioner 4611 S. 96 th St. Ste160 Omaha New Patient Questionnaire My ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed during your consultations. Health issues are usually influenced by many factors. Accurately assessing all of the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance my efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist me to formulate a treatment plan. ***This form must be completed in its entirety.*** First Name: Middle: Last Name: Address: City: State: ZIP: Home Phone: ( ) - Work Phone: ( ) - Occupation: Birth Date: / / Age: month day year Place of Birth: City or town & country if not US Referred by: Height: Weight: Sex: Today s Date 1. Please check appropriate box(es): African American Hispanic Mediterranean Asian Native American Caucasian Northern European Other

2 2. Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible: DESCRIBE PROBLEM MILD/ MODERATE/ SEVERE CURRENT TREATMENT APPROACH SUCCESS Example: Post Nasal Drip Moderate Elimination Diet Moderate a. b. c. d. e. f. g. 3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.) Example: Wendy, age 7, sister 4. Do you have any pets or farm animals? Yes No If yes, where do they live? 1. indoors 2. outdoors 3. both indoors and outdoors 5. Have you lived or traveled outside of the United States? Yes No If so, when and where? 6. Have you or your family recently experienced any major life changes? Yes No If yes, please comment: 7. Have you experienced any major losses in life? Yes No If so, please comment: 8. How important is religion (or spirituality) for you and your family s life? a. not at all important b. somewhat important c. extremely important 9. How much time have you lost from work or school in the past year? a. 0-2 days b days c. > 15 days 10. Previous jobs:

3 11. Unfortunately, abuse and violence of all kinds, verbal, emotional, physical, and sexual are leading contributors to chronic stress, illness, and immune system dysfunction. Witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling me about it, so that I can support you and optimize your treatment outcomes. Please do your best to answer the following questions: a. Did you feel safe growing up? Yes No b. Have you been involved in abusive relationships in your life? Yes No c. Was alcoholism or substance abuse present in your childhood home, or is it present now in your relationships? Yes No d. Do you currently feel safe in your home? Yes No e. Do you feel safe, respected and valued in your current relationship? Yes No f. Have you had any violent or otherwise traumatic life experiences, or have you witnessed any violence or abuse? Yes No g. Would you feel safer discussing any of these issues privately? Yes No Maybe 12. Past Medical and Surgical History: ILLNESSES WHEN COMMENTS a. Anemia b. Arthritis c. Asthma d. Bronchitis e. Cancer f. Chronic Fatigue Syndrome g. Crohn s Disease or Ulcerative Colitis h. Diabetes i. Emphysema j. Epilepsy, convulsions, or seizures k. Gallstones l. Gout ILLNESSES WHEN COMMENTS m. Heart attack/angina n. Heart failure o. Hepatitis p. High blood fats (cholesterol, triglycerides)

4 q. High blood pressure (hypertension) r. Irritable bowel s. Kidney stones t. Mononucleosis u. Pneumonia v. Rheumatic fever w. Sinusitis x. Sleep apnea y. Stroke z. Thyroid disease aa. Other (describe) INJURIES WHEN COMMENTS ab. Back injury ac. Broken or fractured bones (describe) ad. Head injury ae. Neck injury af. Other (describe) DIAGNOSTIC STUDIES WHEN COMMENTS ag. Barium Enema ah. Bone Scan ai. CAT Scan of Abdomen aj. CAT Scan of Brain ak. CAT Scan of Spine al. Chest X-ray am. Colonoscopy an. EKG ao. Liver scan ap. Neck X-ray aq. NMR/MRI ar. Sigmoidoscopy as. Upper GI Series at. Other (describe) OPERATIONS WHEN COMMENTS au. Appendectomy av. Dental Surgery aw. Gall Bladder ax. Hernia ay. Hysterectomy az. Tonsillectomy

5 ba. bb. Other (describe) Other (describe) 13. Hospitalizations: WHERE HOSPITALIZED WHEN FOR WHAT REASON a. b. c. d. e. 14. How often have you have taken antibiotics? Infancy/ Childhood Teen Adulthood < 5 times > 5 times 15. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)? < 5 times > 5 times Infancy/ Childhood Teen Adulthood 16. Indicate any medications you re currently taking or have taken in the last month. Include nonprescription/ over the counter drugs. Medication Name Date started Dosage Are you allergic to any medications? Yes No If yes, please list:

6 17. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible. Vitamin/Mineral/Supplement Name Date started Dosage Childhood: Question Yes No Don t Know 1. Were you a full term baby? a. A preemie? b. Breast fed? c. Bottle fed? 2. As a child did you eat a lot of sugar and/or candy? Comment 19. As a child, were there any foods that you had to avoid because they gave you symptoms? Yes No If yes, please: name the food and symptom (Example: milk gas and diarrhea) 20. Place a check mark next to the food/drink that applies to your current diet. (List continues on next page.) Usual Breakfast Usual Lunch Usual Dinner a. None a. None a. None b. Bacon/Sausage b. Butter b. Beans (legumes) c. Bagel c. Coffee c. Brown rice d. Butter d. Eat in a cafeteria d. Butter e. Cereal e. Eat in restaurant e. Carrots f. Coffee f. Fish sandwich f. Coffee g. Donut g. Juice g. Fish h. Eggs h. Leftovers h. Green vegetables i. Fruit i. Lettuce i. Juice j. Juice j. Margarine j. Margarine k. Margarine k. Mayo k. Milk l. Milk l. Meat sandwich l. Pasta m. Oat bran m. Milk m. Potato n. Sugar n. Salad n. Poultry

7 Usual Breakfast Usual Lunch Usual Dinner o. Sweet roll o. Salad dressing o. Red meat p. Sweetener p. Soda p. Rice q. Tea q. Soup q. Salad r. Toast r. Sugar r. Salad dressing s. Water s. Sweetener s. Soda t. Wheat bran t. Tea t. Sugar u. Yogurt u. Tomato u. Sweetener v. Other: (List below) v. Water v. Tea w. Yogurt w. Water x. Other: (List below) x. Yellow vegetables y. Other: (List below) 21. How much of the following do you consume each week? a. Candy b. Cheese c. Chocolate d. Cups of coffee containing caffeine e. Cups of decaffeinated coffee or tea f. Cups of hot chocolate g. Cups of tea containing caffeine h. Diet sodas i. Ice cream j. Salty foods k. Slices of white bread (rolls/bagels) l. Sodas with caffeine m. Sodas without caffeine 22. Are you on a special diet? Yes No ovo-lacto vegetarian other (describe): diabetic vegan dairy restricted blood type diet 23. Is there anything special about your diet that we should know? Yes No If yes, please explain:

8 24. a. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.? Yes No b. If yes, are these symptoms associated with any particular food or supplement(s)? Yes No c. Please name the food or supplement and symptom(s). Example: Milk gas and diarrhea. 25. Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes No 26. Do you feel much worse when you eat a lot of : high fat foods high protein foods high carbohydrate foods (breads, pastas, potatoes) 27. Do you feel much better when you eat a lot of : high fat foods high protein foods high carbohydrate foods (breads, pastas, potatoes) refined sugar (junk food) fried foods 1 or 2 alcoholic drinks other refined sugar (junk food) fried foods 1 or 2 alcoholic drinks other 28. Does skipping a meal greatly affect your symptoms? Yes No 29. Have you ever had a food that you craved or really "binged" on over a period of time? Food craving may be an indicator that you may be allergic to that food. Yes No If yes, what food(s)? 30. Do you have an aversion to certain foods? Yes No If yes, what foods? 31. Please fill in the chart below with information about your bowel movements: a. Frequency b. Color More than 3x/day Medium brown consistently 1-3x/day Very dark or black 4-6x/week Greenish color 2-3x/week Blood is visible. 1 or fewer x/week Varies a lot. Dark brown consistently b. Consistency Yellow, light brown Soft and well formed Greasy, shiny appearance Often float Difficult to pass Diarrhea Thin, long or narrow Small and hard Loose but not watery Alternating between hard and loose/watery

9 32. Intestinal gas: Daily Present with pain Occasionally Foul smelling Excessive Little odor 33. a. Have you ever used alcohol? Yes No b. If yes, how often do you now drink alcohol? No longer drinking alcohol Average 1-3 drinks per week Average 4-6 drinks per week Average 7-10 drinks per week Average >10 drinks per week c. Have you ever had a problem with alcohol? Yes No If yes, please indicate time period (month/year): from to. 34. Have you ever used recreational drugs? Yes No 35. Have you ever used tobacco? Yes No If yes, number of years as a nicotine user. Amount per day. Year quit. If yes, what type of nicotine have you used? Cigarette Smokeless Cigar Pipe Patch/Gum 36. Are you exposed to second hand smoke regularly? Yes No 37. Do you have mercury amalgam fillings? Yes No 38. Do you have any artificial joints or implants? Yes No 39. Do you feel worse at certain times of the year? Yes No If yes, when? spring fall summer winter 40. Have you, to your knowledge, been exposed to toxic metals in your job or at home? Yes No If yes, which one(s)? lead cadmium arsenic mercury aluminum 41. Do odors affect you? Yes No If yes, please describe the effect: 42. If you are a female, please answer the following: Have you ever had an abortion? If yes, how many? Have you ever had a miscarriage? If yes, how many? Was it followed by a DNC? How many children have you given birth to? Did you use fertility drugs? How many were born via C-Section? Please tell me about any complications you have had with any of your pregnancies and/or births:

10 43. How well have things been going for you? a. At school b. In your job c. In your social life d. With close friends e. With sex f. With your attitude g. With your boyfriend/girlfriend h. With your children i. With your parents j. With your spouse Very Well Fair Poorly Very Poorly Does not apply 44. Have you ever had psychotherapy or counseling? Yes No Currently? Previously? If previously, from to. What kind? Comments: 45. Are you currently, or have you ever been, married? Yes No If so, when were you married? Spouse's occupation When were you separated? Never When were you divorced? Never When were you remarried? Never Spouse s occupation Comments: 46. Hobbies and leisure activities: 47. Do you exercise regularly? Yes No If so, how many times a week? When you exercise, how long is each session? 1. 1x 1. <15 min 2. 2x min 3. 3x min 4. 4x or more 4. > 45 min What type of exercise is it? jogging/walking basketball home aerobics tennis water sports other

11 INFORMED CONSENT Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. I, Do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physiotherapy, exercises, nutritional supplementation, or acupuncture may also be used. Although spinal and extremity manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware the there are possible risks and complications associated with these procedures as follows: Soreness/Bruising: I am aware that like exercise it is common to experience muscle soreness and occasionally bruising in the first few treatments. Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution. Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke is reported to occur once in a million to once in ten million treatments. Once in a million is about the same chance as getting hit by lightning. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death. Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase in pain and possible blistering. This should be reported to the doctor. Tests have been or will be performed on me to minimize the risk of any complication from treatment and I freely assume these risks. TREATMENT RESULTS I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty I will achieve these benefits. I realize that the practice of medicine, along with chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other persons of the doctor's choosing. ALTERNATIVE TREATMENTS AVAILABLE Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over-thecounter medications, exercises and possible surgery. Medications: Medication can be used to reduce pain or inflammation. I am aware that long term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat or home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of value but are not corrective of injured nerve and joint tissues. Surgery: Surgery may be necessary for joint instability or serious disc rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery. Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, resricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy. I have read or had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely. To attest to my consent to these procedures, I hereby affix my signature to the authorization for treatment. Signature of Patient Date Signature of Parent or Guardian (if a minor) Date

12 Patient Health Information and Privacy Policy This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient's rights concerning those records. You must read and consent to this policy before receiving services. A complete copy of the Health Information Portability and Accountability Act (HIPAA) is available here: Final Rule as seen in Federal Register 2/20/ The patient understands and agrees to allow this office to use their PHI for the purpose of treatment, payment, health care operations and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment. 2. The patient has the right to examine and obtain a copy of their health records at any time and request corrections. The patient may request to know what disclosures have been made, and submit in writing any further restrictions on the use of their PHI. This office is not obligated to agree to those restrictions. 3. The patient's written consent shall remain in effect for as long as the patient receives care at this office, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services. 4. This office is committed to protecting your PHI and meeting its HIPAA obligations: Staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures. 5. Patients have the right to file a formal complaint with our privacy official about any suspected violations. 6. This office has the right to refuse treatment if the patient does not accept the terms of this policy. Consent to Professional Treatment The patient certifies that all information provided to this office is true and correct, to the best of their knowledge. The patient grants their consent to this office and its staff to render treatment as deemed necessary by the attending physician. If the patient is a minor child, under the age of eighteen (18) at the date of treatment, I hereby stipulate that I am the legal guardian of the child, and grant my consent for the treatment of the child as provided for herein. The patient may refuse treatment at any time. Assignment of Benefits and Release of Records The patient hereby assigns benefits to be paid directly to this provider by all of their third party payors. This assignment is irrevocable. Failure to fulfill this obligation will be considered a breach of contract between the patient and this office. The patient authorizes this office to release any information required by a third party payor necessary for reimbursement of charges incurred. Financial Obligation and Appointment Policy The patient accepts full financial responsibility for services rendered by this practice. This office reserves the right to charge fair market value for missed appointments or appointments canceled without any advanced notification required by this office. Payment in full is required for all services rendered at the time of visit, unless alternative arrangements have been agreed to in advance. Patient accepts full responsibility for any fees incurred, including but not limited to legal fees, collection agency fees, and any and all other expenses incurred in the collection of past due accounts. Patient should direct any questions regarding this financial obligation and appointment policy to the clinic manager or physician. The patient further authorizes the practice to retain credit card, debit card, checking account or other payment source(s) supplied by patient to the practice for current and future charges, when incurred.

13 Allison Blessing, DC Functional Medicine LLC Financial Disclaimer Collection of Patient Balance Functional medicine office visits are not covered by insurance. Charges are the responsibility of the patient and are to be collected at the time of service. The charges are as follows: Initial Visit (includes consult, exam, and lab reading fees done outside of the office visit) = $ Hour Follow-up Office Visits = $ Minute Follow-up Office Visit = $60.00 All balances remaining unpaid after 30 days may be reported to a credit bureau and affect your credit rating. Returned Checks A fee of $25.00 will be collected for any checks that are returned. This is to cover any fees that apply from the transaction. By signing below, the patient acknowledges that he/she understands and will comply with the financial policies. Patient signature Date Attestation and Consent for Treatment I certify that the information I have supplied is accurate, complete and true. I authorize that Dr. Blessing and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give my consent for Dr. Blessing to retrieve and review my medication history. I understand that this will become part of my medical record. I acknowledge that I have had the opportunity to review Dr. Blessing s Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records. I authorize Dr. Blessing to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize Dr. Blessing to release any information required in obtaining procedure authorization or the processing of any insurance claims. I understand that Dr. Blessing will not release my Protected Health Information to any other party (including family) without my completing a written Patient Authorization for Use and Disclosure of Protected Health Information form, available at its facility and on its website. Printed name: Signature: Date: