All of the enclosed paperwork. We require a completed Informed Consent prior to treatment.

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Transcription:

Hello and Welcome to Vermont Naturopathic Clinic, We are dedicated to providing excellent health care that is tailored to your specific needs. In order to do so, we ask that you please fill out the accompanying paperwork. Please take the time to fill the information out thoroughly. You may even benefit from having someone help you who knows your health history. Sometimes you may not consider an aspect of your health significant although it may be so from another s perspective. Please bring to your appointment: All of the enclosed paperwork. We require a completed Informed Consent prior to treatment. A complete list of medications and supplements including dosages. There is a form in the enclosed paperwork for this. Copies of any lab work, x ray reports, MRI reports, CT scan reports, EMG reports, etc. reports pertinent to your complaint(s) regardless of time completed or generally completed in the last year for other complaints or prevention screening. Insurance card: If you are covered by Worker s Compensation or Personal Injury (auto insurance), bring your claim information including claim number, adjustor contact and referral/approval letter. Note that Medicare does not cover our services, but many insurance companies do. Check your policy for details. Dress Appropriately: If you are coming in for evaluation of a particular area of your body please bring or wear clothing that comfortably allows examination of that area. If you are coming for acupuncture and/ or manual therapy you will need to bring these each visit. If you have further questions, please contact our office at 802 448 3388. We look forward to meeting with you and helping you reach your goals in health and wellness. In Health, The providers and staff of Vermont Naturopathic Clinic Vermont Naturopathic Clinic 41 IDX Drive Suite 220 South Burlington, VT 05404 802 448 3388 v / 3387 f

PATIENT INFORMATION Patient Name Mailing Address Email: City State Zip Code Date of Birth Sex: M / F Preferred contact #: Home Work Cell Phone: Home Work Cell: Emergency Contact Phone Relationship Office Policies and Notice of Privacy Practices Financial Policy: Payment for services and dispensary items are due at time of service (insurance information, cash, check, Visa, MasterCard). You are responsible for knowing the extent of your insurance coverage, cost of co pays and all payments. Co pays are due at time of service. Dispensary Returns: Any unopened item may be returned for a refund within 30 days of purchase. For mail order items the return must be postmarked by 30 days from the date of purchase. Return postage is nonrefundable. Cancelled Appointments: We require a minimum of 24 hours notice if you need to cancel or reschedule an appointment. Failure to cancel within this time period will result in a $75 late cancellation charge. Privacy Practice: I acknowledge that Vermont Naturopathic Clinic (VNC) has provided me with a copy of its Notice of Privacy Practices (available in the office and at http://naturopathicvermont.com/blog1/visit information/ ) that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact VNC at 802 448 3388. I also understand that I am entitled to receive updates upon request if VNC amends or changes its Notice of Privacy Practices in a material way. I authorize the release of any information necessary to process my claims. Signature of Patient or Guardian Date Relationship, if signed by someone other than patient.

THIS SECTION IS TO BE COMPLETED BY THE OFFICE IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGMENT FROM PATIENT I made a good faith effort to obtain a written acknowledgment of receipt of the Notice of Privacy Practices from the above named patient, but was unable to because: [ ] Patient declined to sign this Written Acknowledgment. [ ] Other (specify): Name and signature and employee Date Mandatory Disclosure of Information and Informed Consent for Treatment by Vermont Naturopathic Clinic PLC You are the most important person on your health care team. You are entitled to receive clear and understandable information about the options for and methods of therapy, techniques used, and duration of therapy. If you have questions about your treatment, please contact your VNC provider. You may seek a second opinion from another healthcare professional, or terminate therapy at any time. I understand that methods of treatment may include, but are not limited to: diet and lifestyle therapies, nutritional counseling, therapeutic use of nutrients (including oral, injection or intravenous therapy), herbal/supplement based therapy, acupuncture, moxabustion, cupping, electrical stimulation, infrared, soft tissue manipulation and/or joint manipulation or prescription medications. Naturopathic Dispensary: Herbal Medicine: I understand that some herbs may need to be prepared. I understand that herbal tinctures are usually prepared with alcohol and will inform the physician if I cannot use them. I understand that some herbal medicines may have an unpleasant smell, taste or texture, which is not a reason for returning an item. I also acknowledge that unanticipated or unpleasant effects associated with a treatment are not cause for returning an item and should such a reaction occur I will immediately notify my doctor at VNC. Acupuncture: I understand that there is some minor risk attendant to acupuncture treatment including, but not limited to, light headedness, bruising of the skin (hematoma) or slight bleeding. I understand that the risk of infection is negligible as VNC uses needles that are sterile and disposable. I understand that while this document describes the common risks of treatment, other side effect and risks may occur. I do not expect my VNC provider to be able to anticipate and explain all risks and complications of treatment, and I wish to rely on them to exercise judgment during the course of treatment, which the doctor thinks at the time is in my best interest based upon the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and to discuss with my VNC provider the nature, purpose, risks and benefits of treatments provided. I understand that not all of the above named procedures may be utilized for my treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I understand that results are not guaranteed. I hereby request and consent to the treatment and use of the procedures listed above on me (or on the patient named below, for whom I am legally responsible). Patient Signature (or guardian) Date Printed Name (minor if applicable)

ADULT PATIENT HEALTH HISTORY Name: Date of Birth Date: Referring Doctor Phone Number If you were not referred how did you hear about our clinic? ad: friend web site MAIN HEALTH PROBLEMS/ REASONS FOR THIS APPOINTMENT: (rank in terms of importance to you) 1. 2. On going Medical Issues (list all current diagnoses, with date of onset): Are you experiencing any of these symptoms in relation to your main health problem? (please circle) Constitutional symptoms: fever, extreme fatigue Ears, Nose, Mouth, Throat: sore throat, runny nose, ear pain, tinnitus Eyes: visual disturbances, discharge, redness Heart: chest pain, palpitations, dizziness, high blood pressure, high cholesterol Lungs: cough, wheezing, shortness of breath, asthma Digestive system: nausea, vomiting, abdominal pain, constipation, loose stool, diarrhea, mucus or blood in stools, hemorrhoids, bloating, excessive gas, heart burn Musculoskeletal: joint pain, muscle pain, muscle weakness, decreased range of joint motion Skin: rash, changing mole/ other lesion Women: irregular menses, vaginal bleeding after menopause; frequent or painful urination, bloody urine. Other menstrual problem: Men: frequent or painful urination, bloody urine, erectile dysfunction Nervous system: headache, sleep complaints, vertigo, neuropathy Mental health: depression, anxiety, little interest or pleasure in doing things Hormonal: excessive thirst, feel hot or cold, breast mass, excessive urination or appetite, diabetes Blood and vessels: unusual bruising or bleeding, enlarged lymph nodes, edema, varicose veins, Allergies and Immune system:: seasonal/ persistent allergies, chronic infection: Circle the level of stress you are experiencing on a scale of 1 to 10 (1 lowest): 1 2 3 4 5 6 7 8 9 10 Identify the major causes of stress (e.g., changes in job, residence or finances):

Name: Height: Weight: Do you consider yourself: Underweight Overweight Healthy weight Unintentional weight loss or gain of 10 pounds or more in the last three months? yes no Over the past two weeks how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing 0 1 2 3 things: Feeling down, depressed or hopeless 0 1 2 3 Past Medical History: List prior illnesses, injury, hospitalization, and surgery Event Date Metal objects or implants, artificial joints: FAMILY HISTORY: Alcoholism Asthma Auto immune disease Cancer ( what type? ) COPD / Emphysema Dementia Diabetes Heart Disease Hepatitis High Blood Pressure High Cholesterol Liver Disease Rheumatoid arthritis Stroke Other: Children Mother Father Sisters, How many: Brothers How many: Grand parents Mat. Pat.

Name: PREVENTIVE CARE: Primary Doctor Have you had any of the following? If yes, please list month/year: Annual Physical Glucose/ HA1c Cholesterol/ Lipids Mammogram Pap smear DXA/ bone scan Colonoscopy Hepatitis C screen (if born between 1945 and 1965) Are your vaccinations up to date? yes no not sure HIV screen (ages 18 to 65) Women: age at first menses: Last period: #Pregnancies: # Live births SOCIAL HEALTH HISTORY Occupation: Marital Status: Single Married Partnered Who are you living with? Alone Spouse/Partner Children Roommate Children: How many Ages What do you do for exercise? How long? How often? Do you have advance directives? yes Dietary Restrictions : no Tobacco: never smoked/chewed former current: packs/cans per day How many years have/ did you smoke/chew? How much do /did you smoke/chew? How much alcohol do you consume per week? (1 serving= 12oz beer, 6oz wine, 1oz liquor) How many servings of caffeine do you consume per day? (i.e., coffee, tea, chocolate, soda) Medications, herbs, supplements, etc., Including strength Dosag e Date Started Indicatio n Prescribing Physician Medication Allergies I don t have medication allergies Reaction Severity (mild, moderate, severe)

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