ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY

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Transcription:

Patient Information: Name: Date of Birth: Social Security #: Gender: Marital Status: Primary Address: City: State: Zip Code: Please put a check mark next to any phone number that we may leave a message for you: Home Phone: Work Phone: Cell Phone: E-mail: May we discuss your care with anyone else? If yes, please include the person s name, phone number and relation to you. Yes No Employer: Occupation: Emergency Contact Information: Name: Relationship to you: Address: City: State: Zip Code: Phone Number: Pharmacy Phone ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY I acknowledge that I have been offered or have received a copy of the Privacy Notice and Financial Policy. Signature of Patient or Guardian: Date:

Patient Name: DOB: Patient Intake Form: What brings you to RevitaLife Wellness Center? Lifestyle Information: Tobacco use (chew, smoke, or snuff): How often? How much? Alcohol use: How many drinks currently per week? None 1-3 4-6 7-10 >10 Caffeine use (tea, coffee, or soda): How many drinks currently per week? None 1-3 4-6 7-10 >10 Exercise: Current Exercise Activity Stretching Cardio/Aerobics Strength Yoga/Pilates Sports Exercise: How often do you exercise each week? None 1-2 3-4 5-7 Sleep: Average number of hours you sleep per night >10 8-10 6-8 <6 Sleep: How would you rate your overall sleep health? Good Fair Poor Sleep: Do you snore or stop breathing when sleeping? Employment: Are you currently employed? Employment: Do you currently work 2nd or 3rd shift? Do you consume at least 5 servings of fruits and vegetables every day? Do you drink at least eight 8oz glasses of water every day? Do you regularly consume soft drinks or fruit juices?

Patient Name: DOB: Gastrointestinal Health: 1. Digestion and Absorption Frequent heartburn, burping, gas, or bloating during or immediately after meals? Been diagnosed with anemia or other nutrient deficiency? Been placed on a heartburn medication (proton pump inhibitor [PPI] or H2 Blocker) Frequently experience indigestion? 2. Elimination and Detoxification Have less than one or more than three bowl movements per day? Take a laxative more the twice per month? Sensitive to smells or fragrances? Have regular exposure to exhaust fumes, tobacco smoke, pesticides, commercial chemicals, paint, cleaning chemicals, or volatile fumes? 3. Microbial Balance Used antibiotics within the last two years? Experience abdominal bloating, pain, gas, constipation, or diarrhea? Been diagnosed with chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome? Experience poor memory, difficulty concentrating, or brain fog? 4. Barrier Function Been diagnosed with depression, anxiety, ADD, or ADHD? Suffer from multiple food sensitivities? Experience skin issues such as acne, rosacea, and eczema?

Four Key Stressors: 1. Blood Sugar Imbalance Experience symptoms of hypoglycemia such as dizziness, shakiness, or brain fog between or following meals? Frequently miss or delay meals? Frequently crave sugar or carbohydrates? Diabetic or pre-diabetic? 2. Mental and Emotional Stress Frequently experience anxiety? Suffer from depression? Suffer from mood swings? Have difficulty getting motivated? Frequently experience feelings of agitation, anger, fear, or worry? 3. Sleep Cycle Disruptions Experience problems falling asleep? Experience difficulty staying asleep? Suffer light cycle disruption or shift work issues? Frequently feel drowsy during the day? 4. Inflammation Musculoskeletal: Do you suffer from headaches, muscle, back, or joint pain? Gastrointestinal: Do you suffer from IBS, Crohn s disease, or diverticulitis? Dermatological: Do you suffer from hives, eczema, or psoriasis? Respiratory: Do you suffer from asthma, bronchitis, seasonal allergies, or hay fever? Autoimmune: Do you suffer from any auto-immune condition such as MS, Lupus, or Rheumatoid Arthritis? Immunological: Do you suffer from food allergies, chronic infections, or frequent illness?

Patient Name: DOB: Hormone Therapy/Weight Loss: Please check if you have had these symptoms in the past 6 months Decreased sense of well being Difficulty sleeping Decreased energy Decreased memory Heat or cold intolerance Night sweats Mood swings Decreased sex-drive Decreased muscle strength Increased fat deposits Thinning or loss of hair Sadness, depression Hot flashes Prolonged exercise healing Past and Current History: Are you currently seeing any other doctors? If yes, please list below Doctor s names: Allergies: Please list all allergies and what reaction occurred (if any) 1. 2. 3. Reaction Herbal/Supplements: Please list all Herbal/Supplements that you are currently taking 1. 2. 3. 4. 5. 6. Reason for use

Patient Name: DOB: Medication: Please list all prescription medications you are currently taking 1. 2. 3. 4. 5. 6. 7. 8. 9. Dose Frequency Reason for Use Medical condition: Please list all medical conditions that you have or had in the past: 1. 2. 3. 4. 5. Surgeries: Please list all surgeries you have had: Date Surgery Preventative/Diagnostic Testing: Please check the box if you have had any of the following Colonoscopy Date: Bone Density Date: Cardiac Stress Test Date: Hemoccult Test Date: Cholesterol Date: Level:

Patient Name: DOB: MEN S Preventative Testing: Please check box if yes and provide the date PSA date: PSA Level: 0-2 2-4 4-10 >10 Prostate exam (rectal) date: WOMEN S Preventative Testing: Please check box if yes and provide the date Mammogram date: Need a Biopsy? date: PAP Test date: Normal Abnormal Family History: Please list any illness that the following members of your family have/had: Mother: Age of death if applicable: Father: Age of death if applicable: Siblings: Age of death if applicable: Children: Age of death if applicable: Women Only Age of first period: Age of last period: Date of last period: Are your periods regular? Any PMS symptoms? Are you sexually active? Are you trying to get pregnant? Men Only Have you ever had trouble passing urine or had to take Flomax or Avodart? Have you completed your family?

RevitaLife Advanced Beneficiary Notice (ABN) DOB: Patient Name: This notice is to inform you that your insurance company may not pay for all of the services that you receive in the course of your treatment at our clinic. This may include, but is not limited to: Genova Testing Additional Blood Testing Pellets Injections Medical Weight Loss Programs Food B12 Medication Cosmetic Services Supplements Skin Care Office Visits EKG IV Nutrition Each insurance s out of network benefits are unique as to what services you could be reimbursed for. Treatments that are not reimbursable by any insurance to you will be your full responsibility at the time of service. By signing this notice, you agree to take financial responsibility for the costs of supplies or services provided. Patient Signature: Date Signed: * A copy of this notice will be kept in your patient file. You may request a copy of this notice at any time.

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