Be Well Natural Health Clinics

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Transcription:

Be Well Natural Health Clinics 25283 Cabot Road, Suite 114 Robert Abell N.D., L.Ac. Laguna Hills, California 92653 Lisa Abell L.Ac Phone (949)206-9090 Fax (949)206-9092 Introduction Letter Thank you for choosing our clinic to help you with your medical needs. We are here to help in any way possible. If you have any questions, please feel free to ask. We are enclosing a new patient information packet which contains 1) History and Intake forms, 2) Patient Payment Responsibility, 3) Acknowledgment of Receipt of Notice of Privacy Practices and 4) Consent for Complementary and Alternative Services. All of these forms need to be filled out completely. If the forms are not filled out completely we will ask you to finish them before you see your doctor. This may take up some of the appointment time reserved for you. Our clinic requires a minimum 24 hour notice to cancel your appointment. There is a $250.00 missed appointment fee for new patients and a $105.00 missed appointment fee for follow ups. We require a credit card to secure your appointment date and time, your credit card will be automatically charged for a missed appointment. If you have any questions please feel free to contact the office during our office hours. Monday through Thursday 10am to 5pm and Fridays 10am to 1pm. We also ask that you please not wear any perfume or strong smelling lotions. Thank you. Sincerely, Be Well Natural Health Clinics

1 Be Well Natural Health Clinics 25283 Cabot Road, Suite 114 Laguna Hills, California 92653 Phone (949)206-9090 Fax (949)206-9092 Name Date Address City State Zip Code Telephone Number (home) (Work) (Cell) Email Address Date of Birth Age Identification/ Social Security # Gender: Male Female Single Married Partnership Separated Divorced Occupation Hours Per week Retired Employer Work address Work Phone Number How did you hear about our office? Has any other family member already been a patient at the clinic? Emergency contact Relationship Phone # Address

2 Health History Questionnaire SUCCESSFUL HEALTH AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE DOCTOR HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON T UNDERSTAND WITH A QUESTION MARK. Are you currently receiving healthcare? If yes, where and from whom? If no, when and where did you last receive medical or health treatment? What was the reason? What are your most important health problems? List in order of importance: 1) 2) 3) 4) 5) Do you have any known contagious diseases at this time? If yes, what?

3 Family History Age (if living) Health (G=good/P=poor) Age at death Check those applicable Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Mental Illness Asthma/Hay fever/hives Anemia Kidney Disease Glaucoma Tuberculosis Cause of death Father Mother Brother Sister Spouse Child For all the following sections please write Y, P or N on the line: Y= a condition you have now P= a condition you have had N= never had Childhood Illness Scarlet fever? Diphtheria? Rheumatic fever? Mumps? Measles? German measles? Hospitalizations and Surgery What hospitalizations or surgeries have you had?

4 X-Rays and Special Studies X-rays, CAT scans, or other studies you have had: Electrocardiogram? Electroencephalogram? Immunizations Polio? Pertussis? Tetanus Shot? Diphtheria? Measles? Other? Allergies Are you hypersensitive or allergic to: Any drugs? Any foods? Any environmental? Current Medications Do you take or use? Laxatives? Pain Relievers? Antacids? Cortisone? Appetite Suppressant? Antibiotics? Tranquilizers? Thyroid Medication? Sleeping Pills? Prednisone? Hormone Replacement Therapy? Birth Control? Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking. 1) 2) 3) 4) 5) 6)

5 Breakfast: Lunch: Dinner: Snacks: Drinks: Foods you crave: Foods you dislike: Foods you are allergic/sensitive to: Typical Food Intake General Height: Weight: Weight 1 yr ago: Max Weight: When: When during the day is your energy the best? The worst? Mental /Emotional Treated for emotional problems? Mood Swings? Considered/Attempted Suicide? Poor concentration? Depression? Anxiety? Tension? Memory Problems? Endocrine Hypothyroid? Hypoglycemia? Excessive thirst? Fatigue? Heat or cold intolerance? Diabetes? Excessive Hunger? Seasonal Depression? Immune Vaccinations? Chronic fatigue Syndrome? Chronically swollen glands? Reactions to vaccinations? Chronic Infections? Slow wound healing?

6 Seizures? Muscle weakness? Loss of memory? Vertigo or dizziness? Neurological Paralysis? Numbness or tingling? Easily stressed? Loss of balance? Joint pain or stiffness? Broken bones? Muscle spasms or cramps? Muscoskeletal Arthritis? Weakness? Sciatica? Easy bleeding or bruising? Deep leg pain? Varicose Veins? Blood/Peripheral vascular Anemia? Cold hands/feet? Thrombophlebitis? Skin Rashes? Eczema/Hives? Acne/Boils? Color change? Perpetual hair loss? Lumps? Night sweats? Head Headaches? Head injury? Migraines? Jaw/TMJ problems? Spots in eyes? Impaired vision? Blurriness? Color blindness? Double vision? Eyes Cataracts? Glasses or contacts? Eye pain/strain? Tearing/dryness? Glaucoma?

7 Nose and Sinus Frequent colds? Stuffiness? Sinus Problems? Nose bleeds? Hay fever? Loss of smell? Mouth and Throat Frequent sore throat? Teeth grinding? Gum problems? Dental cavities? Copious saliva? Sore tongue/lips? Hoarseness? Jaw clicks? Neck Lumps? Goiter? Swollen glands? Pain/Stiffness? Respiratory Cough? Spitting up blood? Asthma? Pneumonia? Emphysema? Pain on breathing? Shortness of breathing at night? Sputum? Wheezing? Bronchitis? Pleurisy? Difficulty breathing? Shortness of breath? Shortness of breath lying down? Cardiovascular Heart disease? High blood pressure? Murmurs? Fainting? Rheumatic fever? Swelling in ankles? Angina? Low blood pressure? Blood clots? Phlebitis? Palpations/Fluttering? Chest pains?

Gastrointestinal 8 Trouble swallowing? Change in thirst? Nausea? Vomiting blood? # of Bowel Movements per week? Is this a change? Constipation? Diarrhea? Gall bladder disease? Ulcer? Hemorrhoids? Heartburn? Change in appetite? Vomiting? Blood in stool? Pain/Cramps? Belching/Gas? Black stools? Jaundice? Liver disease? Urinary Pain on urination? Frequency at night? Frequent infections? Increased frequency? Inability to hold urine? Kidney stones? Male Reproduction Hernias? Testicular pain? Venereal disease? Are you sexually active? Sexual orientation? Impotence? Premature ejaculation? Syphilis? Testicular masses? Prostate disease? Discharge/sores? Chlamydia? Gonorrhea? Condyloma? Herpes? Birth control? What type?

9 Female Reproduction Age of 1 st menses? Are cycles regular? Bleeding between cycles? Painful menses? Heavy/Excessive flow? PMS? PMS Symptoms? Birth Control? Number of pregnancies? Number of miscarriages? Endometriosis? Date of last menses? Length of cycle? Duration of menses? Clotting? Discharge? Sexually active? What type? Number of live births? Number of abortions? Ovarian cysts? Difficulty conceiving? Menopausal Symptoms? Pain during intercourse? Chlamydia? Herpes? Syphilis? Sexual orientation? Cervical Dysplasia? Abnormal PAP? Sexual difficulties? Gonorrhea? CondylomA? Do you do breast exams? Breast tenderness/lumps? Nipple discharge?

10 Habits Main interest and hobbies? Do you have a religious or spiritual practice? Do you exercise? What kind of exercise? How often? What? Hours of sleep? Sleep well? Awaken rested? Have a supportive relationship? Have a history of abuse? Any major traumas? Used recreational drugs? Been treated for drug dependence? Do you eat three meals a day? Do you go on diets often? Do you drink coffee? Do you drink black/green tea? Do you drink cola/soda? packs per day? Do you eat refined sugar/artificial sweeteners? Do you add salt? How does your condition affect you? Enjoy your work? Take vacations? Spend time outside? Watch television? How many hours? Read? How many hours? Use alcoholic beverages? Treated for alcoholism? Do you use tobacco? Smoked previously? How many years? How many

11 What do you think is happening? Why? What do you feel needs to happen for you to get better? What do you enjoy most about your life? How much effort are you willing to make at this time to improve your health? [ ] Minimal [ ] Some [ ] Complete

12 Please write any additional information below: Welcome! Please bring in any and all medications, vitamins or supplements you are currently taking. If you have any questions, please ask!

13 Patient Payment Responsibility Agreement Dear Patient, This letter is to keep you informed of the policies regarding your payment responsibilities. AS a patient of Be Well Natural Health Clinics you are responsible for the total charges incurred from each visit to your practitioner. Charges are to be paid at the time of each visit. We recognize and appreciate that health care can involve major financial commitment. We aim to provide you with effective and affordable health care. Visa, MasterCard, Discover, American Express, Checks and Cash are all acceptable forms of payment. For insurance companies that cover alternative and complementary services we will assist you in billing your insurance company. Please remember that you have the primary relationship with your insurance company and you are responsible for the total amount owed at the time of your visit. We will provide you with the appropriate super-bill with the appropriate codes needed for you to be reimbursed by your insurance company. You will need to mail the super-bill provided to your insurance company and your insurance company will reimburse you for all the amounts covered. Before your first visit contact your insurance company or refer to your insurance contract agreement regarding coverage for Alternative and Complementary medical services. Items to note are: 1)the service is covered, 2)for which diagnosis is covered, 3) how many visits are allowed per calendar year, 4) the amount of your deductible, 5) are there any limitations. Answers to these questions will help clarify treatment and financial responsibility. Patients will be billed a missed appointment fee for any missed appointment or cancellation with less than a 24 hour notice. This charge will not be submitted to your insurance. Payment for all pharmacy items is due at the time of the visit. Most insurance companies do not cover Naturopathic pharmacy items. Please sign this form acknowledging you have read and agreed to the above notice. Please feel free to contact us regarding any questions. Signature: I have read the above stated policies of Be Well Natural Health Clinics and will comply with them henceforth.

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