Nickels Natural Health LLC

Transcription

1 CHILD S HEALTH HISTORY Patient s Name: First Middle Last Parent/guardian name: Natural medicine healthcare is possible only when the physician completely understands the patient s physical, mental, and emotional conditions. The information you provide helps your practitioner understand your needs and how to help you reach your health goals. Please write legibly and answer all questions thoroughly. Please mark anything you may have a question about. Address: City: State: Zip code: Telephone numbers: home work/cell Preferred # for appointment reminders and other messages no health information will be disclosed: ( ) - Is it ok to receive mail at home from our clinic?! Y!N Would you like to receive periodic newsletters via ?! Y!N Birth date: Age: Gender: Emergency contact: Relationship: Telephone number: Name of person responsible for payment: Relationship to patient: Phone #: Employer & address: _ I acknowledge that I am financially responsible for all charges. If it becomes necessary to effect collections of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize Dr. Melinda Nickels to release information necessary to secure payment. Signature: Date: Is your child currently receiving health care?!y!n If yes, please list current providers: If no, when and where did your child last receive medical care? Child s general state of health is: Excellent Good Fair Poor Date of last physical: Date of last dental exam if applicable: Are you aware of any allergies to food, drugs, or other environmental allergens (cats, mold, dust) That your child might have? If yes, please list and explain: How did you hear about our clinic? May we thank the person who referred you?

2 SELF & FAMILY HISTORY What is/are the main goals for your child s visit to our clinic today? What are your child s most important health problems? List as many as you can in order of importance. 1) This began 2) This began 3) This began 4) This began 5) This began 6) This began What hospitalizations or surgeries has your child had? Please list any recent labwork with any abnormal results? What diagnostic imaging studies has your child had?! Electrocardiogram! Electroencephalogram! X-rays! CT scan! MRI! Ultrasound! Other Medications and/or Supplements Does your child take or use any of the following?! Pain relievers (aspirin, ibuprofen)! Antibiotics! Laxatives! Cortisone (cream or pills)! Antacids Please list any prescription medications, over-the-counter medications, vitamins, or other supplements your child is taking with dosages and brand names if possible: Family History Please list any major illnesses or disease for your child s first degree relatives: Mother, Father, Brother, or Sister, along with age of diagnosis or death if appropriate. Prenatal History: Mother s age at child s birth: Prenatal care?!y!n Difficulty conceiving? Infertility treatments used? During pregnancy, did the mother experience?! Bleeding! Drug/Alcohol Abuse! Hypertension! Medications! Physical Trauma! Thyroid Problems! Gestational Diabetes

3 Specific food cravings/dislikes during pregnancy: Did the Mother use any of the following during the pregnancy? (Please give details) Tobacco Alcohol Recreational drugs Prescription drugs Over-the-counter medication Supplements Other Birth History: Pregnancy length: Full Premature wks Late wks Length of labor: Birth weight: Length: Was the birth:!vaginal!c-section!induced!forceps Any problems? Did the child experience any of the following symptoms after birth?!jaundice!rashes!seizures!other Feeding/Diet History: Breast Fed? How long? Formula Fed? How long? What type? What foods were introduced before 6 months (please list approximate months as well): 6-12 months? Did your child ever experience colic? How severe?!mild!moderate!severe Please list any food allergies or intolerances, along with the reaction they provoke. What foods does your child crave/insist upon? Does your child have any dietary restrictions(religious, vegetarian/vegan etc.)? Describe Child s Typical Daily Diet: Breakfast: Lunch: Dinner: Snacks: Number of bottles given per day: Number of ounces per bottle:

4 Child s Past Medical History:! Chicken pox! Measles! Mumps! Rubella! Scarlet Fever! Strep throat! Pneumonia! Colic! Croup! Bronchitis! Tonsillitis! Asthma! Allergies! Ear Infection! Roseola! Impetigo! Mononucleosis! Whooping Cough Immunization History: number received / number suggested by CDC! Diphtheria: /5! Pertussis: /5! Tetanus: /5! Polio: /4! Hepatitis B: /3! Measles: /2! Mumps: /2! Rubella: /2! Rotavirus: /3! Pneumococcal: /4! Influenza: /yearly! Varicella: /2! H. Flu: /4! Tetanus booster?! Hepatitis A: /2! Other? Please indicate any adverse reactions to vaccines How many times has your child been treated with antibiotics? When and for what reason? Health and Development: How was your child s health in the first year?!poor!fair!good!excellent!unknown If poor or fair circled, please describe: At what age did your child, first Sit up Crawl Walk Talk Describe your child s sleep pattern: How would you describe your child s temperament? How would you describe your child s behavior and performance at school? Environment: Is your child in: school (grade ), daycare/homecare, or other What are your child s favorite activities? Does your child exercise regularly?!y!n How much, how often? How much television does your child watch? hrs a day/ week How often does your child read (not for school)/how often does someone read to your child?!daily!several times a week!weekly!less than weekly Does anyone in the child s household smoke, even just outside?!y!n Are there animals in the home?!y!n

5 ! Informed Consent and Request for Naturopathic Medical Care, Classical Chinese Medicine Treatment and Acupuncture As a patient I have the right to be informed about my health condition(s) and recommended treatment. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care with Dr. Melinda Nickels, having had the opportunity to discuss the potential benefits, risks and hazards involved. I,, hereby request and consent to examination and treatment with Naturopathic Medicine, Classical Chinese Medicine (CCM) and Acupuncture with Dr. Melinda Nickels and/or other licensed doctors of naturopathic medicine or licensed acupuncturists serving as backup for her, hereafter called allied health care provider. I understand that I have the right to ask questions and discuss to my satisfaction with Dr. Melinda Nickels, and/ or with the allied health care provider providing backup: (1) my suspected diagnosis(es) or condition(s) (2) the nature, purpose, goals and potential benefits of the proposed care (3) the inherent risks, complications, potential hazards or side effects of treatment or procedure (4) the probability or likelihood of success (5) reasonable available alternatives to the proposed treatment procedure (6) potential consequences if treatment or advice is not followed and/ or nothing is done I understand that a Naturopathic evaluation and treatment may include, but are not limited to:! Physical exam (including general, musculoskeletal, EENT, heart and lung, orthopedic and neurological assessments)! Common diagnostic procedures (including venipuncture, pap smears, diagnostic imaging, laboratory evaluation of blood, urine, stool and saliva)! Soft tissue and osseous manipulation (including therapeutic massage, deep tissue massage, neuro-muscular technique, naturopathic/osseous manipulation of the spine and extremities, and cranio-sacral therapy)! Dietary advice and therapeutic nutrition (including use of foods, diet plans, and nutritional supplements)! Botanical/ herbal medicines, prescribing of various therapeutic substances including plant, mineral, and animal materials. Substances may be given in the forms of teas, pills, creams, powders, tinctures which may contain alcohol, suppositories, tropical creams, pastes, plasters, washes or other forms! Homeopathic remedies (highly diluted quantities of naturally occurring substances)! Hydrotherapy (use of hot and cold water)! Counseling (including but not limited to visualization for improved lifestyle strategies)! Over the counter and prescription medications (excluding controlled substances) The scope of practice of acupuncture is outlined below. I understand that Classical Chinese medicine and Acupuncture evaluation and treatment may include, but are not limited to:! Acupuncture (insertion of specialized disposable stainless steel sterilized needles through the skin into underlying tissues at specific points on the bodies surface)! Use of electrical, mechanical and magnetic devices! Moxa (indirect burning of herbal material in the form of a loosely compacted herb or stick)! Cupping (used to relieve symptoms of pain and chest congestion in which glass cups are placed on the skin with a vacuum created by heat)! Qigong (ancient Chinese meditative movement)! Dietary advice (based on traditional Chinese medicine theory)! Herbs (use of herbal formulas in the form of teas, powders, tinctures, pastes, and plasters, which may be taken internally or used externally as a wash. Formulas may include shells, minerals and animal materials)

6 ! Potential benefits: Restoration of the body s maximal and optimal functioning capacity, relief of pain and other symptoms of disease, assistance with injury and disease recovery, and prevention of disease or its progression. Potential risks: Pain, discomfort, blistering, minor bruising, discoloration, infections, burns, itching; loss of consciousness and deep tissue injury from needle insertions, pneumothorax, allergic reaction to prescribed herbs, supplements; soft tissue or bony injury from physical manipulations; aggravation of pre-existing symptoms. Notice to pregnant women: All female patients must alert the provider if they have confirmed or suspect pregnancy as some of the therapies prescribed 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 and any treatment intended to induce labor requires a signed letter from a primary care provider authorizing or recommending such treatment. Notice to individuals with bleeding disorders, pace makers, and/ or cancer. For your safety it is vital to alert your provider, Dr. Melinda Nickels, of these conditions. Please INITIAL the following: I understand that Dr. Melinda Nickels is not licensed to prescribe any controlled substances. I understand that Dr. Melinda Nickels, will only prescribe medications if she believes that they are in the best interest of myself, the patient. Appropriate referrals will be provided to manage my prescriptive medication needs. I understand the US Food and Drug Administration has not approved nutritional, herbal and homeopathic substances; however these have been used widely in Europe, China and the USA for years. I understand that Dr. Melinda Nickels not a psychologist or psychiatrist. Counseling services are provided for the support of improved lifestyle strategies. I do not expect Dr. Melinda Nickels, and/or any allied health care provider to be able to anticipate and explain all of the risks and complications, and I wish to rely on the provider to exercise all judgment during the course of the procedure based on the known facts. I also understand that it is my responsibility to request Dr. Melinda Nickels explain therapies and procedures to my satisfaction. I further acknowledge that no guarantee of services have been made to me concerning the results intended from any treatment provided to me. By signing below I acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I understand all of the above and give my oral and written consent to the evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment Printed Name of Patient Signature of Patient Date Printed Name of Guardian Signature of Guardian Date

7 ! ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES This document is to be signed by a person legally responsible for the patient s medical decisions relative to the treatment situation. I,, hereby acknowledge that has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact: 1703 Main Street, Suite B Vancouver WA admin@nickelsnaturalhealth.com I also understand that I am entitled to receive updates upon request if amends or changes its Notice of Privacy Practices in a material way. Signature & Relationship to Patient (if signed by someone other than patient) Date THIS SECTION IS TO BE COMPLETED BY CLINIC/PROVIDER IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGMENT FROM PATIENT I made a good faith effort to obtain a written acknowledgment of receipt of the Notice of Privacy Practices from the above-named patient, but was unable to because: [ ] Patient declined to sign this Written Acknowledgment. [ ] Other (specify): Name and title of employee Date