New Patient Intake Form. Name Birthdate Gender Last First Middle Initial. Address Street City State/Prov. Zip/Postal code

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Dr. Kristi Tompkins, ND 5170 Golden Foothill Pkwy Suite 117 El Dorado Hills, CA 95762 P: (916) 235-6846 7563 Green Valley Road Placerville, CA 95667 P: (530) 622-23233 Fax: (530) 698-5127 www.doctorkristi.com Date New Patient Intake Form Name_Birthdate_Gender_ Last First Middle Initial Address Street City State/Prov. Zip/Postal code Telephone: Home Cell Email (s): Would you like to receive free email newsletters containing health related information, events, presentations, special offers and more? YES_ NO Employer Occupation Referred by (Please Circle): 1. Internet 2. Friends and Family Members 3. Professional Colleague 4. Stop in or Drive by 5. Other_ Emergency contact Name Telephone Address List the MAIN MEDICAL PROBLEMS that you are having, or reason for this appointment: PAST Medical History: (Please include approximate dates for all) Major Illnesses:

Accidents or Major Trauma Hospitalizations and Surgeries: Dental Problems, Procedures (root canals, cavities, etc.) Prescription and Over the Counter Medications (names and doses): Allergies and Sensitivities: Foods, Environmental, Medications. Please bring any tests if possible. Occupational or Environmental Exposures: Vaccinations: ( ) DPT (Diphtheria, Pertussis, Tetanus) Year(s)_ ( ) Booster (Usually DT) Year(s)_ ( ) Polio injection ( ) Polio oral Year(s)_ ( ) MMR (Measles, Mumps, Rubella Year(s)_ ( ) HBV (Hepatitis B Vaccine) Year(s)_ ( ) Other (Flu shots, etc.) Year(s)_ Women: Last Gyn/pap Exam Last Menstrual Period (First day) Breast Imaging (mammogram, ultrasound, MRI, thermography _ Married (years) Divorced Widowed Children (#)_Ages # Pregnancies Deliveries complications Men: Last Prostate Exam (DRE) PSA Test Married (years): _ Children (#) Ages Lifestyle factors (Please fill in the approximate amounts): Never Occasionally Weekly Daily Coffee_ Tea (Black, Green, White, Herbal) Please circle Tobacco Alcohol_ Type of Alcoholic Beverages Marijuana

EXERCISE: Never Minutes Hours Weekly Daily GYM Weights Run Walk_ Aerobics/Dance Cycling Golf Tennis_ Ski Swim Other SUPPLEMENTS PLEASE FILL OUT THIS FORM WITH ALL NUTRITIONAL SUPPLEMENTS THAT YOU ARE CURRENTLY TAKING. SUPPLEMENTS MANUFACTURER FORM DOSAGE FREQUENCY EXAMPLE: VITAMIN C BRONSON TABLET 500 MG 2 PER DAY

FOOD/MEALS JOURNAL Please list your typical meals for each day during the week. Provide as much information as possible. Please include beverages, i.e. water, juice, soda, coffee, alcohol. If you are following a specific Diet Program, please list that here: i.e. Paleo, South Beach, Low Carb, Gluten Free, Low Sugar, Weight Watchers, Jenny Craig, etc. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Breakfast Snack Lunch Snack Dinner Dessert

Family Medical History Please give age, any illnesses, diseases or medical conditions. If deceased, list cause, age and approximate year of death. Mother: Father: Brothers and Sisters: Possible Illnesses In Alphabetical Order: Allergies Asthma Bleeding Tendency Cancer, Type Crohns Disease Diabetes-Age at Onset Drug Abuse Epilepsy Gall Stones Glaucoma Heart Disease-Type Hearing Loss Hypoglycemia Kidney Disease Liver Disease-Type Lupus Mental Illness- Type Multiple Sclerosis Rheumatoid Arthritis Thyroid Disease Hypertension Skin Disease-Type Grandparents: Mother s Side: Grandparents: Father s Side: Your Children:

Important Information * Please Read, Initial and Sign After Reading Dr. Kristi Tompkins, ND of El Dorado Naturopathic Medicine will do her best to provide you with therapeutic and comprehensive information that can be used to help you with your health care needs and preferences. The following information is to assist you in understanding the financial policies. Payment: Appointments are paid for at the time of service. We accept credit cards (VISA, MC, AMEX, DISC), cash, money orders and checks. A $25 fee will be charged for returned checks. Appointments: We require a 24-48 hr notice if you need to change or cancel your appointment. We are understanding with unforeseen emergencies or changes and therefore willing to be flexible and reschedule appointments as needed. However, if missed appointments are consistently occurring without sufficient notification, a missed appointment fee of $50 will be billed to the patient. Medical Records: El Dorado Naturopathic Medicine maintains a confidential medical chart of your health care records. Patients are given a copy of their treatment plans upon completion of the doctor visit or within 24-48 hours if more research into your medical situation is needed. If you would like a copy of your medical records, we can provide you with a copy upon your signing an authorization form and returning it to us. Please allow up to 10 business days for us to process the request. Health Insurance: El Dorado Naturopathic Medicine does not directly bill health insurance companies. Licensed Naturopathic Doctors in California currently are not required or eligible to contract with health insurance companies. You are welcome to submit your Health Care Invoice with the corresponding ICD-10 (diagnosis) codes CPT codes (complexity/length of appointment) to your health insurance company for possible reimbursement. Patient Print Name Signature Date Dr. Kristi Tompkins Print Name Signature Date

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