UC Health Integrative Medicine. Dear Valued Patient,
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1 UC Health Integrative Medicine UC Health Physicians Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH Dear Valued Patient, Thank you for your interest in UC Health Integrative and Functional Medicine clinical services. We are glad you are exploring your health care options and look forward to partnering with you to meet your health goals. Integrative Medicine combines conventional medicine with evidence-based complementary therapies with a focus on healthy lifestyle to address behavior, nutrition, movement, sleep, and your environment to reduce stress and promote overall wellness. To better serve you and all of our patients, UC Health Integrative Medicine kindly asks that you complete and bring with you the attached New Patient Nutrition Consult Questionnaire along with your photo ID and insurance card to your first appointment. UC Health Physicians Office South 7675 Wellness Way, 4 th Floor West Chester, OH UC Health Barrett Cancer Center 234 Goodman Street, 2 nd Floor Cincinnati, OH UC Health Hoxworth Center 3130 Highland Ave, Cincinnati, OH P (513) F (513) UCHealth.com/Integrative If you need assistance filling out this form, please contact the office at WLNS (9567). Our aim is to help people feel truly well. We look forward to your first visit and partnering with you on your wellness! If you have any questions feel free to contact us at 475-WLNS (9567) or Luke.Underhill@UCHealth.com Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 1 out of 8
2 UC Health Integrative Medicine Appointment Policy Effective April 2017 We respect your time. That is why, we are implementing an Appointment Policy to address no shows, cancellations and late arrivals. We hope this policy will help our continued focus on better serving our patients and providing excellent customer service. 1. Arrival Time: a. New Patients i. New Patients are expected to arrive 15 minutes before scheduled appointment time. This allows time for check in and optimizes time with your provider. Your new patient questionnaire should be completed and returned by your scheduled appointment time. b. Established Patients i. All Established Patients are expected to arrive minutes before scheduled appointment time. **Please be mindful of your appointment time. Arriving at the exact time of your scheduled appointment causes delays not only for you, but also for patients being seen after you.** 2. Arriving Late to Appointments: a. Patients arriving 15 minutes or later to their scheduled appointment may be asked to reschedule their appointment. 3. Cancellations & Rescheduling of Appointments: a. We require 24-hour cancellation or rescheduling notice for all office appointments. b. Cancellations less than 24 hours in advance will be considered a no show. 4. Dismissal from Practice: a. Should a patient late cancel or no show their scheduled office appointment 3 times with any of our UC Health Integrative Medicine providers, it may result in dismissal from the practice. Patient Name: Date of Birth: Patient Signature: Date: Revised 07/2/18 **This policy is subject Integrative to change Medicine at any Nutrition time. ** Consult Questionnaire Page 2 out of 8
3 UC Health Integrative Medicine 3590 Lucille Drive, Suite 2600 Cincinnati, Ohio Phone: (513) 475-WLNS (9567) UCHealth.com/Integrative Fax: (513) New Patient Nutrition Consult Questionnaire Today s Date: Name: D.O.B.: Age: Address: City: State: Zip: Occupation: Employer: Home phone: Work phone: Cell: At what number do you prefer to be contacted? Home Cell Work Marital status: Single Married Long term partner Divorced Separated Widowed Educational History: Which levels of study have you completed? Still in school/training: Middle School High School /Trade school Two-year college Four-year college Graduate school How did you learn about UC Health Integrative Medicine Nutrition Practice? Referred by: Another patient s recommendation UC Website Integrative Medicine Search Functional Medicine Search Other: INTRODUCTION How do you rate your overall health? Poor Fair Good Excellent What do you hope to achieve in your visit with UC Health Integrative Medicine Nutrition Practice? If you had the opportunity to heal three of your health concerns, what would they be in order of their importance to you? Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 3 out of 8
4 PAST MEDICAL HISTORY Please indicate if you have been diagnosed with or experienced any of the following illnesses or conditions. Behavioral Health Alcohol Dependency Substance Abuse ADD/ADHD Anxiety Depression Self-Harm Endocrine Diabetes/high blood sugar Low blood sugar Hormone Treatment Hyperthyroid (overactive) Hypothyroid (underactive) Adrenal problems Use of steroids/prednisone Gastrointestinal GERD/ Reflux Hiatal Hernia Stomach Ulcers Frequent use of antacid meds IBS Ulcerative Colitis or Crohns Hepatitis Type: Liver Disease Pancreatic Disease Gallbladder Disease Colon Polyps Hematological Anemia Blood Clots Blood Disorder Heart Abnormal EKG Atrial Fibrillation CHF (Congestive Heart Failure) Congenital Heart Disease Coronary Artery Disease Heart Attack High Blood Pressure Arrhythmias Pacemaker/Defibrillator Valve Abnormalities High Cholesterol Leg swelling Blood clots Musculoskeletal Arthritis/ Joint/s Back Problems Neck Problems Gout Osteopenia (bone thinning) Osteoporosis Neurologic Chronic Headache/migraine Parkinson s Disease Multiple Sclerosis (MS) Seizure Disorder Stroke Tremors Memory Problems Respiratory Sinus infections Asthma Bronchitis Emphysema/COPD Pneumonia History of Positive PPD or TB Pulmonary Embolism Pulmonary Hypertension Immune System Environmental Allergies Recurrent infections Autoimmune disorder Which? Psoriasis/Dermatitis Hives Joint Inflammation Sleep Sleep Apnea Insomnia Use of Sleep Aides Restless Leg Syndrome Genital/Urinary Urinary Tract Infections Frequent yeast infections Kidney Stones STI (Sexually Transmitted Infection) Kidney Failure Other CANCER HISTORY Please indicate if you have been diagnosed with cancer, including skin cancer. Diagnosis: Date: Detail: Radiation Treatment: Yes No When Chemotherapy: Yes No When Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 4 out of 8
5 ANTIBIOTIC USE HISTORY 1. Approximately how many courses of antibiotics have you had in the past 10 years: Approximately how many courses of antibiotics have you had in your life: < For which kinds of infections? 4. Approximately how many steroid/prednisone courses (by mouth or injection) have you had in the past 10 years: For which conditions? SURGICAL & PROCEDURAL HISTORY Include most recent colonoscopy, etc. Past Surgical History Please list all surgeries with approximate dates/year Surgery Date/Yr. Past Hospitalization s Please list all hospitalizations with approximate dates/year Reason for hospitalization Date/Yr PRESCRIPTIONS Please list all pills, sprays, ointments, or medications prescribed by a doctor. Medication: Dose: Frequency: Treatment For: Date/Time Last Taken: Used Since: OVER-THE-COUNTER Please list all over-the-counter pills, vitamins, supplements, sprays, and ointments used regularly. Medication: Dose: Frequency: Treatment For: Date/Time Last Taken: Used Since: Please bring bottles, labels or photos (front and back labels) of all your current supplements with you to each appointment. Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 5 out of 8
6 ALLERGIES Please list any known food or medication allergies or sensitives below Allergy Reaction No known allergies to food or medications DIGESTION/NUTRITION Height: Current Weight: Weight up or down lately? How much? 1. Do you have problems with any of the following? Indigestion/heartburn Nausea and/or vomiting Belching/burping Bloating/distended belly Diarrhea Constipation 2. Have you ever had severe: Gastroenteritis (nausea and vomiting) Diarrhea 3. Describe your bowel frequency: Once daily Several daily Once every 2-3 days Once every 4+ days 4. If you take laxatives, what type/brand and how often? 5. Would you describe your stools as (select all that apply): Formed Soft Hard Lumpy Loose Watery Floaty Easy to Pass Hard to Pass Other 6. Have you had any intestinal surgery? Gall bladder Stomach Appendix Part of intestines removed Bariatric/lap band Any scopes/ if so, when? 7. Have you made changes in your eating habits because of your health? No Yes If so, how? 8. Do you follow a certain dietary lifestyle? Vegan Vegetarian Omnivore Gluten Free 9. Do you currently follow a special diet or nutritional program? No Yes Please describe: 10. What is/are the biggest challenge(s) to reaching your nutrition goals? 11. Do you track and/or monitor your calories or food intake? No Yes If yes, what do you use? (examples: MyFitnessPal, Spark People, etc.) 12. How often do you track calories or food intake? Daily 2 3 times a week 1 time a week or less 13. How many meals do you eat daily and which ones? 14. If you use a meal replacement product/ protein shake (please describe) 15. If you snack between meals (please describe) 16. Are you able to make your own food choices and control your food environment? 17. Are you able to prepare your own meals? 18. What are your food cravings, if any? 19. Do you have problems with any foods? Dairy Eggs Fruits Nuts Meats Soy Sugar Wheat Other? 20. What are the nutrition/eating habits most challenging for you? 21. What are the nutrition/eating habits that you are most pleased with? Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 6 out of 8
7 FOOD FREQUENCY Estimated servings per day: please list amount None 1-2 per day 3-6 per day 7 or more Soda/sugary drinks/sweet tea/lemonade Sweets/deserts/candy Artificial sweeteners (Please name) Fried foods/fast food/chips/pizza Dairy products/cheese/etc. Carbs/breads/cereal/pasta Fruits/veggies Proteins Water (8 oz.) FOOD RECORD Please record all the foods and the amounts you eat for 3 consecutive days, which are part of your normal routine. For instance, if you had cereal for breakfast in a normal size bowl with a banana, please record: one and half cups of Special K with.5 cups of skim milk and a half of a banana, small coffee and 4 oz. of orange juice. When you eat casseroles please indicate what the ingredients were, baked or fried food and how much you had. DAY 1 (Date) Food/Beverage items Amount Per Meal Before Breakfast Breakfast Morning break Lunch Afternoon Snack Dinner Before bed DAY 2 (Date) Food/Beverage items Amount Per Meal Before Breakfast Breakfast Morning break Lunch Afternoon Snack Dinner Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 7 out of 8
8 Before bed DAY 3 (Date) Food/Beverage items Amount Per Meal Before Breakfast Breakfast Morning break Lunch Afternoon Snack Dinner Before bed Revised 07/2/18 Integrative Medicine Nutrition Consult Questionnaire Page 8 out of 8
If you have any questions, feel free to contact us at 475- WLNS (9567) or
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