Functional Medicine New Patient Packet

Transcription

1 Turnpaugh Health and Wellness Center Functional Medicine New Patient Packet General Information Today s Date / / (MM/DD/YYYY) Mr Mrs Ms Dr Name Birth date / / (MM/DD/YYYY) Preferred Name Gender Male Female Genetic Background African European Native American Asian Middle Eastern Adopted Other Highest Education Level High School Under-Graduate Post-Graduate Job Title Nature of Business Primary Address City State Zip _ - - _ - - _ - _ - Home Phone Cell Phone Work Phone Ext _ - _ - Fax Physician Referred By Insurance Carrier Insurance ID# Group # info@turnpaughhwc.com Office Fax TurnpaughHWC.com Turnpaugh Health and Wellness Center 310 Lambs Gap Road Mechanicsburg, PA of 15

2 Description of Health Please provide us with a description of your health history as well as your chief complaints. What are your goals for this visit and for your care in our office? 2 of 15

3 Allergies Medication/Supplement/Food Reaction Complaints/Concerns If you could erase three problems, what would they be? When was the last time that you felt well? Did something trigger a change in your health? What makes you feel better? Please list current and ongoing problems in order of priority: Describe Problem Prior Treatment/Approach 3 of 15

4 Medical Conditions DISEASES/DIAGNOSIS/CONDITIONS Check appropriate box GASTROINTESTINAL Irritable Bowel Syndrome Inflammatory Bowel Disease Crohn s Ulcerative Colitis Gastritis or Peptic Ulcer Disease Celiac Disease Other CARDIOVASCULAR Heart Attack Other Heart Disease Stroke Elevated Cholesterol Arrythmia (irregular heartbeat) Hypertension (high blood pressure) Rheumatic Fever Mitral Valve Prolapse METABOLIC/ENDOCRINE Type 1 Diabetes Type 2 Diabetes Hypoglycemia Metabolic Syndrome (Insulin Resistance or Pre-Diabetes) Hypothyroidism (low thyroid) Hyperthyroidism (overactive thyroid) Endocrine Problems Polycystic Ovarian Syndrome (PCOS) Infertility Weight Gain Weight Loss Frequent Weight Fluctuations Bulimia Anorexia Binge Eating Disorder Night Eating Syndrome Other CANCER Lung Cancer Breast Cancer Colon Cancer Ovarian Cancer Prostate Cancer Skin Cancer Other GENITAL AND URINARY SYSTEMS Kidney Stones Gout Interstitial Cystitis Frequent Urinary Tract Infections Frequent Yeast Infections Erectile Dysfunction or Sexual Dysfunction Other MUSCULOSKELETAL/PAIN Osteoarthritis Fibromyalgia Chronic Pain Other INFLAMMATORY/AUTOIMMUNE Chronic Fatigue Syndrome Autoimmune Disease Rheumatoid Arthritis Lupus SLE Immune Deficiency Disease Herpes-Genital Severe Infectious Disease Poor Immune Function (frequent infections) Food Allergies Environmental Allergies Multiple Chemical Sensitivities Latex Allergy Other RESPIRATORY DISEASES Asthma Chronic Sinusitis Bronchitis Emphysema Pneumonia Tuberculosis Sleep Apnea Other SKIN DISEASES Eczema Psoriasis Acne Melanoma Skin Cancer Other 4 of 15

5 Medical History NEUROLOGIC/MOOD Check boxes if yes and provide date Depression Anxiety Bipolar Disorder Schizophrenia Headaches Migraines ADD/ADHD Autism Mild Cognitive Impairment Memory Problems Parkinson s Disease Multiple Sclerosis ALS Seizures Other Neurological Problems PREVENTIVE TESTS AND DATE OF LAST TEST Check boxes if yes and provide date Full Physical Exam Bone Density Colonoscopy Cardiac Stress Test EBT Heart Scan EKG Hemoccult Test - stool test for blood MRI CT Scan Upper Endoscopy Upper GI Series Ultrasound SURGERIES Check boxes if yes and provide date of surgery Appendectomy Hysterectomy +/- Ovaries Gall Bladder Hernia Tonsillectomy Dental Surgery Joint Replacement-Knee/Hip Heart Surgery-Bypass Valve Angioplasty or Stent Pacemaker Other None INJURIES Check box if yes Back Injury Head Injury Neck Injury Broken Bones Other BLOOD TYPE: A B AB O Rh+ Unknown HOSPITALIZATIONS ne Date Reason COMMENTS 5 of 15

6 Gynecologic History (for women only) OBSTETRIC HISTORY Check box if yes and provide number of Pregnancies Caesarean Vaginal deliveries Miscarriage Abortion Living Children Post Partum Depression Toxemia Gestational Diabetes Baby Over 8 Pounds Breast Feeding For how Long? MENSTRUAL HISTORY Age at First Period: Menses Frequency: Length: Pain: Yes Clotting: Yes Has your period ever skipped? Yes For how long? Last Menstrual Period: Use of hormonal contraception such as: Birth Control Pills Patch Nuva Ring How Long? Do you use contraception? Yes Condom Diaphragm IUD Partner Vasectomy WOMEN S DISORDERS/HORMONAL IMBALANCES Fibrocystic Breasts Endometriosis Fibroids Infertility Painful Periods Heavy Periods PMS Last Mammogram: Breast Biopsy/Date: Last PAP Test: rmal Abnormal Last Bone Density: Results: High Low Within Range Are you in menopause? Yes Age at menopause Hot Flashes Mood Swings Concentration/Memory Problems Vaginal Dryness Decreased Libido Heavy Bleeding Joint Pains Headaches Weight Gain Loss of Control of Urine Palpitations Use of hormone replacement therapy. How Long? Men s History (for men only) Have you had a PSA done? Yes PSA Level: Greater than 10 Prostate Enlargement Prostate Infection Change in Libido Impotence Difficulty Obtaining an Erection Difficulty Maintaining an Erection cturia (urination at night). How many times at night? Urgency/Hesitancy/Change in Urinary System Loss of Control of Urine 6 of 15

7 Medications CURRENT MEDICATIONS Medication Dose Frequency Start Date (month/year) Reason for use PREVIOUS MEDICATIONS: Last 10 years Medication Dose Frequency Start Date (month/year) Reason for use NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY) Medication Dose Frequency Start Date (month/year) Reason for use Have your medications or supplements ever caused you unusual side effects or problems? Yes Describe: Have you had prolonged regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Asprin? Yes Have you had prolonged regular use of Tylenol? Yes Have you had prolonged regular use of acid blocking drugs (Tagamet, Zantac, Prilosec, etc.)? Yes Frequent Antibiotics > 3 times/year Yes Longterm Antibiotics Yes Use of steroids (prednisone, nasal allergy inhalers) in the past Yes Use of oral contraceptives Yes 7 of 15

8 Family History Check family members that apply Mother Father Brother(s) Sister(s) Children Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunts Uncles Other Age (if still alive) Age at death (if deceased) ADHD ALS or other Motor Neuron Diseases Asthma Autism Auto Immune Diseases (such as Lupus) Bipolar Disease Breast or Ovarian Cancer Cancers Celiac Disease Colon Cancer Dementia Depression Diabetes Eczema / Psoriasis Environmental Sensitivities Food Allergies, Sensitivity, or Intolerances Genetic Disorders Heart Disease Hypertension Inflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing Sondylitis) Inflammatory Bowel Disease Irritable Bowel Syndrome Multiple Sclerosis Obesity Parkinson s Psychiatric Disorders Schizophrenia Stroke Substance Abuse (such as alcoholism) 8 of 15

9 Social History NUTRITION HISTORY Have you ever had a nutrition consultant? Yes Have you made any changes in your eating habits because of your health? Yes Describe: Do you currently follow a special diet or nutritional program? Yes Check all that apply Low Fat Low Carbohydrate High Protein Low Sodium Diabetic Dairy Wheat Gluten Restricted Vegetarian Vegan Ultrametabolism Specific Program for Weight Loss/Maintenance Type: Other: Height (feet/inches): Usual Weight Range (+/- 5 lbs): Highest Adult Weight: Current Weight: Desired Weight Range +/- 5 lbs: Lowest Adult Weight: Weight Fluctuations (>10 lbs) Yes Body Fat % How often do you weigh yourself? Daily Weekly Monthly Rarely Never Have you ever had your metabolism (resting metabolic rate) checked? Yes If yes, what was it? Do you avoid any particular foods? Yes If yes, types and reason If you could only eat a few foods a week, what would they be? Do you grocery shop? Yes Do you read food labels? Yes If no, who does the shopping? Do you cook? Yes If no, who does the cooking? How many meals do you eat out per week? More than 5 meals per week Check all the factors that apply to your lifestyle and eating habits: Fast eater Erratic eating pattern Eat too much Late night eating Dislike healthy food Time constraints Eat more than 50% meals away from home Travel frequently Non-availability of healthy foods Do not plan meals or menus Reliance on convenience items Poor snack choices Significant other or family members don t like healthy foods Significant other or family members have special dietary needs or food preferences Love to eat Eat because I have to Have a negative relationship with food Struggle with eating issues Emotional eater (eat when sad, lonely depressed, bored) Eat too much under stress Eat too little under stress Don t care to cook Eating in the middle of the night Confused about nutrition advice Do you smoke? Yes Do you Drink? Yes If yes, how much? If yes, how much? The most important thing I should change about my diet to improve my health is: 9 of 15

10 Brain Health and Nutrition Assessment Form (BHNAF) Date / / Name Age Sex (MM/DD/YYYY) Please check the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. SECTION 1 Low brain endurance for focus and concentration Cold hands and feet Must exercise or drink coffee to improve brain function Poor nail health Fungal growth on toenails Must wear socks at night Nail beds are white instead of pink The tip of the nose is cold SECTION 5 Dry and unhealthy skin Dandruff or a flaky scalp Consumption of processed foods that are bagged or boxed Consumption of fried foods Difficulty consuming raw nuts or seeds Difficulty consuming fish (not fried) Difficulty consuming olive oil, avocados, flax seed oil, or natural fats SECTION 2 Irritable, nervous, shaky, or light-headed between meals Feel energized after meals Difficulty eating large meals in the morning Energy level drops in the afternoon Crave sugar and sweets in the afternoon Wake up in the middle of the night Difficulty concentrating before eating Depend on coffee to keep going SECTION 6 Difficulty digesting foods Constipation or inconsistent bowel movements Increased bloating or gas Abdominal distention after meals Difficulty digesting protein-rich foods Difficulty digesting starch-rich foods Difficulty digesting fatty or greasy foods Difficulty swallowing supplements or large bites of food SECTION 3 Fatigue after meals Sugar and sweet cravings after meals Need for a stimulant, such as coffee, after meals Difficulty losing weight Abnormal gag reflex SECTION 7 Brain fog (unclear thoughts or concentration) Pain and inflammation Noticeable variations in mental speed Increased frequency of urination Difficulty falling asleep Increased appetite SECTION 4 Always have projects and things that need to be done Never have time for yourself Not getting enough sleep or rest Difficulty getting regular exercise Feel that you are not accomplishing your life s purpose Brain fatigue after meals Brain fatigue after exposure to chemicals, scents, or pollutants Brain fatigue when the body is inflamed SECTION 8 Grain consumption leads to tiredness Grain consumption makes it difficult to focus and concentrate Feel better when bread and grains are avoided Grain consumption causes the development of any symptoms A 100% gluten-free diet 10 of 15

11 SECTION 9 A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease Family members who have been diagnosed with an autoimmune disease Family members who have been diagnosed with celiac disease or gluten sensitivity Changes in brain function with stress, poor sleep, or immune activation SECTION 10 A loss of pleasure in hobbies and interests Feel overwhelmed with ideas to manage Feelings of inner rage or unprovoked anger Feelings of paranoia Feelings of sadness for no reason A loss of enjoyment in life A lack of artistic appreciation Feelings of sadness in overcast weather A loss of enthusiasm for favorite activities A loss of enjoyment in favorite foods A loss of enjoyment in friendships and relationships Inability to fall into deep, restful sleep Feelings of dependency on others Feelings of susceptibility to pain SECTION 11 Feelings of worthlessness Feelings of hopelessness Self-destructive thoughts Inability to handle stress Anger and aggression while under stress Feelings of tiredness, even after many hours of sleep A desire to isolate yourself from others SECTION 12 A decrease in visual memory (shapes and images) A decrease in verbal memory Occurrence of memory lapses A decrease in creativity A decrease in comprehension Difficulty calculating numbers Difficulty recognizing objects and faces A change in opinion about yourself Slow mental recall SECTION 13 A decrease in mental alertness A decrease in mental speed A decrease in concentration quality Slow cognitive processing Impaired mental performance An increase in the ability to be distracted Need coffee or caffeine sources to improve mental function SECTION 14 Feelings of nervousness or panic for no reason Feelings of dread Feelings of a knot in your stomach Feelings of being overwhelmed for no reason Feelings of guilt about everyday decisions A restless mind An inability to turn off the mind when relaxing Disorganized attention Worry over things never thought about before Feelings of inner tension and inner excitability An unexplained lack of concern for family and friends An inability to finish tasks Feelings of anger for minor reasons Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition. 11 of 15

12 Metabolic Assessment Form TM Date / / Name Age Sex (MM/DD/YYYY) PART I Please list your 5 major health concerns in order of importance: PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always. Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or fuzzy debris on tongue Pass large amount of foul-smelling gas More than 3 bowel movements daily Use laxatives frequently Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swelling Frequent bloating and distention after eating Abdominal intolerance to sugars and starches Category III Intolerance to smells Intolerance to jewelry Intolerance to shampoo, lotion, detergents, etc Multiple smell and chemical sensitivities Constant skin outbreaks Category IV Excessive belching, burping, or bloating Gas immediately following a meal Offensive breath Difficult bowel movements Sense of fullness during and after meals Difficulty digesting fruits and vegetables; undigested food found in stools Category V Stomach pain, burning, or aching 1-4 hours after eating Use of antacids Feel hungry an hour or two after eating Heartburn when lying down or bending forward Temporary relief by using antacids, food, milk, or carbonated beverages Digestive problems subside with rest and relaxation Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine Category VI Roughage and fiber cause constipation Indigestion and fullness last 2-4 hours after eating Pain, tenderness, soreness on left side under rib cage Excessive passage of gas Nausea and/or vomiting Stool undigested, foul smelling, mucus like, greasy, or poorly formed Frequent urination Increased thirst and appetite Category VII Abdominal distention after consumption of fiber, starches, and sugar Abdominal distention after certain probiotic or natural supplements Lowered gastrointestinal motility, constipation Raised gastrointestinal motility, diarrhea Alternating constipation and diarrhea Suspicion of nutritional malabsorption Frequent use of antacid medication Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome? Category VIII Greasy or high-fat foods cause distress Lower bowel gas and/or bloating several hours after eating Bitter metallic taste in mouth, especially in the morning Burpy, fishy taste after consuming fish oils Difficulty losing weight Unexplained itchy skin Yellowish cast to eyes Stool color alternates from clay colored to normal brown Reddened skin, especially palms Dry or flaky skin and/or hair History of gallbladder attacks or stones Have you had your gallbladder removed? Category IX Acne and unhealthy skin Excessive hair loss Overall sense of bloating Bodily swelling for no reason Hormone imbalances Weight gain of 15

13 Poor bowel function Excessively foul-smelling sweat Category X Crave sweets during the day Irritable if meals are missed Depend on coffee to keep going/get started Get light-headed if meals are missed Eating relieves fatigue Feel shaky, jittery, or have tremors Agitated, easily upset, nervous Poor memory/forgetful Blurred vision Category XI Fatigue after meals Crave sweets during the day Eating sweets does not relieve cravings for sugar Must have sweets after meals Waist girth is equal or larger than hip girth Frequent urination Increased thirst and appetite Difficulty losing weight Category XII Cannot stay asleep Crave salt Slow starter in the morning Afternoon fatigue Dizziness when standing up quickly Afternoon headaches Headaches with exertion or stress Weak nails Category XIII Cannot fall asleep Perspire easily Under a high amount of stress Weight gain when under stress Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with little or no activity Category XIV Edema and swelling in ankles and wrists Muscle cramping Poor muscle endurance Frequent urination Frequent thirst Crave salt Abnormal sweating from minimal activity Alteration in bowel regularity Inability to hold breath for long periods Shallow, rapid breathing Category XV Tired/sluggish Feel cold hands, feet, all over Require excessive amounts of sleep to function properly Increase in weight even with low-calorie diet Gain weight easily Difficult, infrequent bowel movements Depression/lack of motivation Morning headaches that wear off as the day progresses Outer third of eyebrow thins Thinning of hair on scalp, face, or genitals, or excessive hair loss Dryness of skin and/or scalp Mental sluggishness Category XVI Heart palpitations Inward trembling Increased pulse even at rest Nervous and emotional Insomnia Night sweats Difficulty gaining weight Category XVII (Males Only) Urination difficulty or dribbling Frequent urination Pain inside of legs or heels Feeling of incomplete bowel emptying Leg twitching at night Category XVIII (Males Only) Decreased libido Decreased number of spontaneous morning erections Decreased fullness of erections Difficulty maintaining morning erections Spells of mental fatigue Inability to concentrate Episodes of depression Muscle soreness Decreased physical stamina Unexplained weight gain Increase in fat distribution around chest and hips Sweating attacks More emotional than in the past Category XIX (Menstruating Females Only) Perimenopausal Alternating menstrual cycle lengths Extended menstrual cycle (greater than 32 days) Shortened menstrual cycle (less than 24 days) Pain and cramping during periods Scanty blood flow Heavy blood flow Breast pain and swelling during menses Pelvic pain during menses Irritable and depressed during menses Acne Facial hair growth Hair loss/thinning Category XX (Menopausal Females Only) How many years have you been menopausal? Since menopause, do you ever have uterine bleeding? Hot flashes Mental fogginess Disinterest in sex Mood swings Depression Painful intercourse Shrinking breasts Facial hair growth Acne Increased vaginal pain, dryness, or itching of 15

14 PART III How many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week? List the three worst foods you eat during the average week: List the three healthiest foods you eat during the average week: Rate your stress level on a scale of 1-10 during the average week: How many times do you eat fish per week? How many times do you work out per week PART IV Please list any medications you currently take and for what conditions: Please list any natural supplements you currently take and for what conditions: 14 of 15

15 MSQ - Medical Symptom Toxicity Questionnaire Name Date / / (MM/DD/YYYY) The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying cause of illness, and helps track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are taking after the first time, record your symptoms for the last 48 hours ONLY. Point Scale 0 = Never or almost never have the symptom 1 = Occasionally have the symptom, effect is not severe 2 = Occasionally have the symptom, effect is severe 3 = Frequently have the symptom, effect is not severe 4 = Frequently have the symptom, effect is severe DIGESTIVE TRACT Nausea or vomiting Diarrhea Constipation Bloated feeling Belching or passing gas Heartburn Intestinal/stomach pain EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss EMOTIONS Mood swings Anxiety, fear or nervousness Anger, irritability or aggressiveness Depression ENERGY/ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness EYES Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (Does not include near or farsightedness HEAD Headaches Faintness Dizziness Insomnia HEART Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain JOINTS/MUSCLES Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing MIND Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, horses, loss of voice Swollen/discolored tongue, gums, lips Canker sores NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation SKIN Acne Hives, rashes, or dry skin Hair loss Flushing or hot flushes Excessive sweating WEIGHT Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight OTHER Frequent illness Frequent or urgent urination Gentle itch or discharge GRAND TOTAL Key to questionnaire Add individual scores and total each group. Add each group scores and give a grand total. Less than 10 = Optimal = Mild toxicity = Moderate toxicity Over 100 = Severe toxicity 15 of THWC

16 Turnpaugh Health and Wellness Center Information Pertaining to Blood Work The Physicians in our office utilize lab results as an integral part of their clinical assessment. We have a full time phlebotomist in our office as a courtesy to our patients. We will try to accommodate your appointment time request. However, due to the high volume of patients requesting labs in our office, we may not have the time that you need. You can go to any other lab and take the physicians blood script. We draw the labs in our office and send them to Quest Diagnostics to process. If your insurance requires that you go to LabCorp or another lab, please inform the Doctor or staff. The cost and further responsibility of payment is a contract between you, Quest Diagnostics and your insurance company. We have an overwhelming amount of phone calls with questions about blood work bills. Please refer your questions first to your insurance company and Quest. If they cannot answer your questions, please your billing issues to info@turnpaughhwc.com. Please include your name, invoice number, date of birth and what billing problems you may be having. We will forward these concerns on to the proper representative who may be able to help. As a courtesy to patients without insurance, we have a client account with Quest Diagnostics. They provide us with discounted prices for testing and we pass these prices on to our patients. We do ask for payment at the time of testing in our office. If you have the blood drawn at another site, we will mail a bill for this cost. Payment is due within fourteen days of receipt of your invoice from our office. We cannot guarantee pricing for all tests because new tests are constantly added. If you have questions, please forward them to info@turnpaughhwc.com or choose the billing prompt when calling our office.

17 OUR PRACTICE POLICIES Our goal at the Turnpaugh Health and Wellness Center is to provide you with the highest level of personalized care. We are committed to helping you achieve optimal health. Website Information about The Turnpaugh Health and Wellness Center and all relevant patient forms are available through our website, TurnpaughHWC.com Consultations Your initial functional medicine visit will include a 60-minute consultation with a physician and a follow-up visit three weeks later to review lab results. Chiropractic initial visits are generally 45 minutes to an hour long. Initial Visits For morning appointments, you may have your blood drawn after your initial consultation. Many of the tests require an 8-hour fast. You can drink water during this fast. If you have an initial visit in the afternoon, we can schedule an appointment for you to return the following day for your blood work. Initial Consultation including first follow up visit $685 Follow-up visits for self pay patients: $285 per hour New Chiropractic Visits: $275 Chiropractic Follow-up appointments: $50 Massage and Cranial Sacral Therapy: $75 FSM: $100 per hour Payment Options Payment is due on the date of service. We will provide you with an itemized receipt with appropriate diagnosis codes and procedure codes for you to submit to your insurance company for possible reimbursement. We accept cash, checks and credit cards.. Confirmation and Cancellation of Appointments Due to the overwhelming requests for new patient consultations, there is a 48-hour cancellation policy. We will confirm your appointment via text, or phone one week ahead of time. If you need to cancel your appointment for any reason, please call our office and leave a detailed message. There will be a $75 fee for missed consultation appointments and a $35 fee for Chiropractic, FSM and Massage Therapy. Phone Calls, Messages & Faxes Office Hours: Monday through Thursday 8:00 AM-6:00 PM, Friday 8 AM-2PM Our address is info@turnpaughhwc.com for most general information or communication. Supplement refills can be ordered at order@turnpaughhwc.com. Medical Records Medical records can only be released with your authorization. Please contact your physician or other health care provider to obtain these records. Please allow hours for all requests. Your records should be mailed to our address or faxed to Letters Forms, Letters and Authorizations will be filled out per patient request. There will be a $25 charge and please allow 48 hours. Prescription Refill Request It may take up to 72 hours to process a prescription refill. Please plan ahead to avoid any interruption in your medications. Prescription refills can be faxed to our office by your pharmacy. Our fax # is Supplements Returns Supplements, unopened, may be returned for up to 30 days from the time of purchase for a refund or credit to your account. Refrigerated supplements may not be returned. Privacy A copy of our privacy policies and HIPAA policy is available upon request. Referrals Thank you for your referrals. They are the highest compliment that we can receive Please sign that you have read and acknowledge our practice policies and have read the HIPAA Privacy policy. Signature Date Print Name

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19 2017 THWC