Nutrition Packet INFORMATION FOR THE DAY OF YOUR APPOINTMENT

Transcription

1 Nutrition Packet Enclosed is a packet of information for you to fill out and bring with you to your appointment. But first, a few important details before we meet: INFORMATION FOR THE DAY OF YOUR APPOINTMENT Items to bring with you: o New patient packet Please complete all included forms o Picture ID (i.e. Driver s License) o Insurance Card and co-pay o Prior medical information including relevant lab results or additional paperwork that you feel would be helpful for me to know INSURANCE AND PAYMENT INFORMATION If you have insurance know your benefits! Please contact your insurance carrier prior to your first appointment to discuss your nutrition benefits, as I am credentialed with most insurance plans. Even though you may have limited nutrition benefits or not have any nutrition benefits, I am contractually obliged to bill for my services. I do offer a prompt payment discount of 30% for payment at the time of service. When contacting your insurance company be sure to ask the following questions: o Does my plan cover visits with nutritionists or dietitians? Provide them with the CPT Code: or o Most plans will not cover weight loss issues, but will cover other diagnoses. Be sure to provide them with the diagnosis from your doctor (rheumatoid arthritis, fibromyalgia, IBS, hypercholesterolemia, etc.), or if no diagnosis, symptoms being experienced (heartburn, constipation, fatigue, muscle pain, etc.). o Do I need a referral from a doctor in order to see a dietitian? If so, contact your family doctor or referring provider to check with your insurance plan. o Is there a limit to the number of visits I can attend over the calendar year or in a lifetime? When does my plan s calendar year end/begin? o Keep record of the time, date and name of the representative providing information. If you have Medicare as your primary provider, note that I am a Medicare-credentialed provider, although my services are not typically covered benefit. If you have a secondary coverage, they will be billed after Medicare, although many will not reimburse if Medicare denies payment. CANCELLATIONS If you need to cancel your initial or follow-up appointments, please provide a 48-hour notice to avoid incurring a cancellation fee. You can call The Seattle Arthritis Clinic at for any scheduling needs. Nutrition Packet_TSAC (2-2017) FORM A-2519 Page 1 of 5

2 PERSONAL INFORMATION NAME: Last First MI Gender DOB Address: City: State: Zip: Home Phone: Work: Cell: Occupation: Height: Weight: Physician Contact: Where did you hear about this service? Reason for visit: Current Medications: Label Name Dose Frequency OR See Attached List Personal History Physical Activity Do you exercise? Yes No If yes, what types? Cardio Weights Yoga Home Exercises Other Frequency and duration of exercise: If not, explain contributing factors: Food Intolerances or Allergies Do you have any known food allergies? Yes No Please list and explain effect: Foods you avoid/dislike: Foods you crave: Gastrointestinal Health Which of the following do you experience regularly? Gas Bloating Constipation Diarrhea Heartburn Nausea or vomiting Weight History Are you currently taking or have you taken part in a weight loss program or diet? Yes No Currently Please explain: Is your weight: Stable Fluctuates Have you recently gained or lost a significant amount of weight? Yes No How many lbs? Do you have a history of emotional eating? Yes No Do you have a history of an eating disorder? Yes No Please list: Nutrition Packet_TSAC (2-2017) FORM A-2519 Page 2 of 5

3 Family History Mark S for self, F for father, M for mother, Si for sibling, or G for grandparent Alcoholism Cancer Eating Disorders Liver Disease Anemia Celiac Sprue Food Allergies Skin Rashes Arthritis Crohn s Heart Disease Sinus Issues Asthma Depression Hypertension Thyroid Bowel Disease Diabetes Hypoglycemia Other (Please list): Social and Nutritional Habits Do you use tobacco products? Daily Some Days Quit Passive (around cigarette smoke) Never Packs per Day Years Smoked Date Quit Type(s) of Tobacco: Cigarettes Cigars E-Cigarettes Chew Snuff On a scale of 1-10, rate your average level of stress (1=low, 10=high): Does your pain or physical symptoms increase the more stressed you are? Your level of energy: Yes No Living situation: Alone Partner Roommates Other: At which stores do you shop for food? Who does the shopping/cooking? Myself Roommate/Partner Other: Do you like to cook? Yes No How many times per week do you eat outside of home and where? Breakfast Lunch Dinner Frequency Locations(s) Nutrition Packet_TSAC (2-2017) FORM A-2519 Page 3 of 5

4 Diet History Please provide a 3-day food history, including 2 weekdays and 1 weekend day. If you re experiencing pain or gastrointestinal issues, include any symptoms that you experience, and note the times. Be specific and try not to change what you eat through the process. Include beverages and any snacks. Note: if time does not allow you to fill in the form prior to appointment, we will cover off-form in session. DAY 1 DAY 2 *Continued on next page Nutrition Packet_TSAC (2-2017) FORM A-2519 Page 4 of 5

5 DAY 2 (continued) DAY 3 Nutrition Packet_TSAC (2-2017) FORM A-2519 Page 5 of 5