New Member Forms

Transcription

New Member Forms

New Patient Packet
ofﬁce of Mark Holthouse, M.D.
Steps to complete:
1.  Download ‘New Patient Packet’ and SAVE onto your computer.
2.  While completing this ‘New Patient Packet’ be sure to frequently ‘SAVE” this document
should you decide take a break while in process of completing the form.
3.  Upon completion, submit this packet to our office no less than 5 days in advance of your
1st visit. This is very important as it allows our clinical team to be best prepared for your
visit.
4.  Once complete choose one of the of following ways to submit to our office:
a. Print & fax to:
916.358.5200
4901 Golden Foothill Parkway
b. Print & mail to:
El Dorado Hills, CA 95762
Mark Holthouse, M.D.
n1Health Center for Functional Medicine
4901 Golden Foothill Parkway | El Dorado Hills, CA 95762
p 530-676-1003 | www.MarkHolthouseMD.com
Adult Medical Questionnaire
Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a
significant extent, on your ability to respond thoughtfully and accurately to both these written questions and
those posed by the clinician during your consultations. Health issues are usually influenced by many factors.
Accurately assessing all the factors and comprehensively managing them is the best way to deal with these
health challenges. Your careful consideration of each of the following questions will enhance our efficiency and
will provide for more effective use of your scheduled consultation time. These questions will help to identify
underlying causes of illness and will help us formulate a treatment plan.
PATIENT’S PERSONAL INFORMATION:
Today’s Date: _____________
Last Name: ______________________________ First Name: _________________________ MI: __________
Mailing Address: ____________________________________________________________________________
City: __________________________________ State: _________________ Zip: ________________________
Home #: _______________________ Work #: _______________________ Cell #: ______________________
Marital Status: (circle one) S M D W
Sex: (circle one) M F
Date of Birth: ______________________________ Social Security #: _________________________________
Employer/Occupation: _______________________________________________________________________
Spouse’s Name: ________________________________ Spouse’s best phone #: _________________________
Spouse’s Social Security #: _____________________________________
PATIENT’S INSURANCE INFORMATION: Please present insurance cards to receptionist.
Primary insurance company’s name: ___________________________________________________________
Address: ______________________________ City: ___________________ State: ______ Zip: ____________
Name of Insured: ________________________________________ Date of Birth: _______________________
Relationship to insured: (circle one) Self Spouse Child Other
Insurance ID #: __________________________________ Group #: ___________________________________
Secondary insurance company’s name: __________________________________________________________
Name of Insured: ________________________________________ Date of Birth: _______________________
Relationship to insured: (circle one) Self Spouse Child Other
Insurance ID #: __________________________________ Group #: ___________________________________
EMERGENCY CONTACT:
Name of person: _____________________________________ Relationship: ___________________________
Home #: _______________________ Work #: _______________________ Cell #: ______________________
1. Please check appropriate box(es):
African-American
Native American
Hispanic
Caucasian
Mediterranean
Northern European
Asian
Other
1
2. Please list current problems in order of priority, and fill in the other boxes as completely as possible:
DESCRIBE PROBLEM
Example: Postnasal Drip
MILD/
MODERATE/
SEVERE
Moderate
TREATMENT
APPROACH
Elimination Diet
SUCCESS
Moderate
a.
b.
c.
d.
e.
f.
g.
3. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)
Example: Wendy, age 7, sister
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. Do you have any pets or farm animals?
If yes, where do they live?
Indoors
Yes
No
Outdoors
Both indoors and outdoors
5. Have you lived or traveled outside of the United States?
Yes
No
If so, when and where? ______________________________________________________________
_________________________________________________________________________________
6. Have you or your family recently experienced any major life changes?
Yes
No
If yes, please comment: ______________________________________________________________
_________________________________________________________________________________
7. Have you experienced any major losses in life? Yes
No
If so, please comment: _______________________________________________________________
_________________________________________________________________________________
8. How important is religion (or spirituality) for you and your family’s life?
Not at all important
Somewhat important
Extremely important
9. How much time have you lost from work or school in the past year?
0–2 days
3–14 days
More than 15 days
10. Previous jobs:
_________________________________________________________________________________
_________________________________________________________________________________
2
11. Unfortunately, abuse and violence of all kinds (verbal, emotional, physical, and sexual) are leading
contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can
also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now
an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and
optimize your treatment outcomes.
Please do your best to answer the following questions:
a. Did you feel safe growing up?
Yes
No
b. Have you been involved in abusive relationships in your life?
Yes
No
c. Was alcoholism or substance abuse present in your childhood home, or is it present now in your
relationships?
Yes
No
d. Do you currently feel safe in your home?
Yes
No
e. Do you feel safe, respected, and valued in your current relationship?
Yes
No
f.
Have you had any violent or otherwise traumatic life experiences, or have you witnessed any
violence or abuse?
Yes
No
g. Would you feel safer discussing any of these issues privately?
Yes
No
12. Past Medical and Surgical History:
ILLNESSES
a.
Anemia
b.
Arthritis
c.
Asthma
d.
Bronchitis
e.
Cancer
f.
Chronic Fatigue Syndrome
g.
Crohn’s Disease or Ulcerative Colitis
h.
Diabetes
i.
Emphysema
j.
Epilepsy, Convulsions, or Seizures
k.
Gallstones
l.
Gout
m.
Heart Attack/Angina
n.
Heart Failure
WHEN
COMMENTS
3
o.
Hepatitis
p.
High Blood Fats (cholesterol, triglycerides)
q.
High Blood Pressure (hypertension)
r.
Irritable Bowel
s.
Kidney Stones
t.
Mononucleosis
u.
Pneumonia
v.
Rheumatic Fever
w.
Sinusitis
x.
Sleep Apnea
y.
Stroke
z.
Thyroid Disease
aa.
Other (describe)
INJURIES
a.
Back Injury
b.
Broken Bone (describe)
c.
Head Injury
d.
Neck Injury
e.
Other (describe)
DIAGNOSTIC STUDIES
a.
Barium Enema
b.
Bone Scan
c.
CAT Scan of Abdomen
d.
CAT Scan of Brain
e.
CAT Scan of Spine
f.
Chest X-ray
g.
Colonoscopy
h.
EKG
i.
Liver Scan
j.
Neck X-ray
k.
NMR/MRI
l.
Sigmoidoscopy
m.
Upper GI Series
n.
Other (describe)
OPERATIONS
a.
Appendectomy
b.
Dental Surgery
c.
Gallbladder
WHEN
COMMENTS
WHEN
COMMENTS
WHEN
COMMENTS
4
d.
Hernia
e.
Hysterectomy
f.
Tonsillectomy
g.
Other (describe)
h.
Other (describe)
13. Hospitalizations:
WHERE HOSPITALIZED
WHEN
FOR WHAT REASON
a.
b.
c.
d.
e.
14. How often have you have taken antibiotics?
LESS THAN 5 TIMES
Infant/Child
Teen
Adult
MORE THAN 5 TIMES
15. How often have you have taken oral steroids (e.g., cortisone, prednisone, etc.)?
LESS THAN 5 TIMES MORE THAN 5 TIMES
Infant/Child
Teen
Adult
16. What medications are you taking now? Include nonprescription drugs.
DATE
DOSAGE
STARTED
MEDICATION NAME
a.
b.
c.
d.
e.
f.
g.
h.
Are you allergic to any medications? Yes
No
If yes, please list: ______________________________________________________________________
_____________________________________________________________________________________
17. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate dosage
in mg or IU and the form (e.g., calcium carbonate vs. calcium lactate) when possible.
5
a.
b.
c.
d.
e.
f.
g.
VITAMIN/MINERAL/
SUPPLEMENT NAME
DATE
STARTED
DOSAGE
18. Infancy/Childhood:
QUESTION
YES
NO
a. Were you a full-term baby?
A preemie?
b. Were you breast-fed?
Bottle-fed?
c. As a child, did you eat a lot of sugar and/or candy?
DON’T
KNOW
COMMENT
19. As a child, were there any foods that you had to avoid because they gave you symptoms?
Yes
No
If yes, please name the food and symptom (Example: milk – gas and diarrhea): __________________
_________________________________________________________________________________
_________________________________________________________________________________
20. Place a check mark next to each food/drink that is part of your current diet.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
USUAL
BREAKFAST
None
Bacon/sausage
Bagel
Butter
Cereal
Coffee
Donut
Eggs
Fruit
Juice
Margarine
Milk
Oat bran
Sugar
Sweet roll
Sweetener
Tea
√
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
USUAL LUNCH
None
Butter
Coffee
Eat in a cafeteria
Eat in restaurant
Fish sandwich
Juice
Leftovers
Lettuce
Margarine
Mayo
Meat sandwich
Milk
Salad
Salad dressing
Soda
Soup
√
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
USUAL DINNER
None
Beans (legumes)
Brown rice
Butter
Carrots
Coffee
Fish
Green vegetables
Juice
Margarine
Milk
Pasta
Potato
Poultry
Red meat
Rice
Salad
√
6
r.
s.
t.
u.
v.
Toast
Water
Wheat bran
Yogurt
Other (List below)
r.
s.
t.
u.
v.
w.
x.
Sugar
Sweetener
Tea
Tomato
Water
Yogurt
Other (List below)
r.
s.
t.
u.
v.
w.
x.
y.
Salad dressing
Soda
Sugar
Sweetener
Tea
Water
Yellow vegetables
Other: (List below)
21. How much of the following do you consume each week?
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Candy
Cheese
Chocolate
Cups of coffee containing caffeine
Cups of decaffeinated coffee or tea
Cups of hot chocolate
Cups of tea containing caffeine
Diet sodas
Ice cream
Salty foods
Slices of white bread (rolls/bagels)
Sodas with caffeine
Sodas without caffeine
22. Are you on a special diet?
Vegetarian
Diabetic
Dairy restricted
Yes
No
Vegetarian
Blood type diet
Other (describe below):
__________________________
__________________________
23. Is there anything special about your diet that we should know? Yes
No
If yes, please explain: _______________________________________________________________
_________________________________________________________________________________
24. Do you have symptoms immediately after eating, such as belching, bloating, sneezing, hives, etc.?
Yes
No
If yes, are these symptoms associated with any particular food or supplement(s)? Yes
No
If yes, please name the food or supplement and symptom(s) (Example: milk – gas and diarrhea):
_________________________________________________________________________________
_________________________________________________________________________________
25. Do you feel you have delayed symptoms after eating certain foods (symptoms may not be evident for
24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.? Yes
No
26. Do you feel much worse when you eat a lot of :
High-fat foods
High-protein foods
Refined sugar (junk food)
Fried foods
7
High-carbohydrate foods (breads, pastas, potatoes)
Other: ____________________________
1 or 2 alcoholic drinks
27. Do you feel much better when you eat a lot of :
High-fat foods
High-protein foods
High-carbohydrate foods (breads, pastas, potatoes)
Other: ____________________________
28. Does skipping a meal greatly affect your symptoms?
Refined sugar (junk food)
Fried foods
1 or 2 alcoholic drinks
Yes
No
29. Have you ever had a food that you craved or really “binged” on over a period of time?
Food craving may be an indicator that you may be allergic to that food.
Yes
No
If yes, what food(s)? ________________________________________________________________
_________________________________________________________________________________
30. Do you have an aversion to certain foods? Yes
No
If yes, what foods? __________________________________________________________________
31. Please fill in the chart below with information about your bowel movements:
a. Frequency
More than 3x/day
1–3x/day
4–6x/week
2–3x/week
1 or fewer x/week
√
c. Color
√
Medium brown consistently
Very dark or black
Greenish
Blood is visible
Varies a lot
Dark brown consistently
Yellow, light brown
Greasy, shiny appearance
Daily
Occasionally
Excessive
Present with pain
Foul smelling
Little odor
b. Consistency
Soft and well formed
Often float
Difficult to pass
Diarrhea
Thin, long, or narrow
Small and hard
Loose but not watery
Alternating between hard
and loose/watery
32. Intestinal gas:
33. Have you ever used alcohol? Yes
No
If yes, how often do you now drink alcohol?
No longer drinking alcohol
Average 1–3 drinks/week
Average more than 10 drinks/week
Have you ever had a problem with alcohol? Yes
No
If yes, please indicate time period (month/year): from ________ to ___________
8
34. Have you ever used recreational drugs?
Yes
No
35. Have you ever used tobacco? Yes
No
If yes, number of years as a nicotine user: _____ Amount per day: _____ Year quit: _____.
What type of nicotine have you used?
Cigarette
Smokeless
Cigar
Pipe
Patch/Gum
36. Are you exposed to secondhand smoke regularly?
Yes
37. Do you have mercury amalgam fillings?
No
Yes
38. Do you have any artificial joints or implants?
39. Do you feel worse at certain times of the year?
If yes, when?
Spring
Summer
Yes
No
No
Yes
No
Fall
Winter
40. Have you, to your knowledge, been exposed to toxic metals in your job or at home?
If yes, which one(s)?
Lead
Cadmium
Arsenic
Mercury
Aluminum
41. Do odors affect you?
Yes
Yes
No
No
42. How well have things been going for you?
a. At school
VERY
WELL
FAIR
POORLY
VERY
POORLY
DOES NOT
APPLY
b. In your job
c. In your social life
d. With close friends
e. With sex
f.
With your attitude
g. With your boyfriend/girlfriend
h. With your children
i.
With your parents
j.
With your spouse
43. Have you ever had psychotherapy or counseling? Yes
No
Currently Previously
If previously, from ______ to _______
What kind? ________________________________________________________________________
Comments: ________________________________________________________________________
44. Are you currently, or have you ever been, married? Yes
No
If so, when were you married? __________
Spouse's occupation: __________________
When were you separated?
__________
Never
When were you divorced?
__________
Never
9
When were you remarried? __________
Never
Spouse’s occupation ____________
Comments: ________________________________________________________________________
45. Hobbies and leisure activities: _________________________________________________________
_________________________________________________________________________________
46. Do you exercise regularly? Yes
No
If so, how many times a week? 1 time
2 times
3 times
4 or more times
When you exercise, how long is each session? Less than 15 minutes
16–30 minutes
31–45 minutes
More than 45 minutes
What type of exercise is it?
Jogging/walking
Tennis
Basketball
Water sports
Home aerobics
Other: ______________________________________
10
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Child(ren)
Child(ren)
Child(ren)
Child(ren)
Sister(s)
Sister(s)
Brother(s)
Father
Please place age at diagnosis where appropriate.
Brother(s)
GENETIC RISK ANALYSIS
Mother
47.
Age (if still alive)
Age at death
Colon Cancer
Breast Cancer
Other Cancers -‐ List Type ______________
Heart Disease
Stroke
Hypertension
Obesity/Overweight
Diabetes
High Cholesterol
Arthritis (<60 years old)
Multiple Sclerosis
Rheumatoid Arthritis / Lupus / Psoriasis
Ulcerative Colitis / Crohn's Disease
Irritable Bowel Syndrome (IBS)
Celiac Disease
Asthma / Chronic Bronchitis
Eczema/Hives
Food Allergies or Sensitivities
Environmental Sensitivities
Multiple Chemical Sensitivities
Dementia or Parkinson's
Substance Abuse (alcoholism, drugs)
Depression
Anxiety
ADHD
Autism
Thyroid Disorders
Other _____________________
Other _____________________
Other _____________________
11
ADULT TOXIN EXPOSURE QUESTIONNAIRE
If you have been exposed to any of these in the LAST 12 MONTHS please check:
 (Y) Yes
 (N) No
 (?) Unknown
 (P) for exposure more than 12 months ago
Community
Do you have regular exposure to:
Automobile exhaust
Y
N
?
P
Notes
Farm/Industrial/Power plant or lines
Radio tower
Landfill/Dump
Hydro tower
Home and/or Work Environment
Do you live in a:
House
Apartment Building
Do you work in a:
House
Office Building
Bathing/Showering water source:
Well
Public Works
Do you have regular exposure at home or work to:
Y
N
Forced air heat
Renovations (new carpets; add ons; etc…)
Basement cracks or dirt floor
Damp basement or crawl space
Wet windows or outside closet walls
Water leaks (ceilings, walls, floors)
Visible mold
Old or cracking ceiling tiles
Old or cracking vinyl linoleum flooring
Crumbling pipe insulation
Crumbling wall or ceiling insulation
Old or cracking paint
Carpets or rugs
Stagnant or stuffy air
Gas or propane stove
Coal or wood stove
Other gas appliance (water heater, furnace)
Regular contact with smokers
?
Mobile Home
Factory
Bottled
P
Notes
12
Hobby and Work Activities
Do you have regular exposure to:
Pesticides or herbicides
Harsh chemicals (varnish, glue, gas, acid…)
Welding or soldering
Metals (Lead, Mercury, etc)
Paints
Photo developing / Dark room
Airplane travel
Cleaning chemicals
Y
N
?
P
Notes
Personal - Diet
Drinking/Cooking water source:
Well
Public Works
Caffeine?
What kind:
How Much:
Do you regularly eat:
Fish (fresh, frozen, canned, etc.)
Artificial sweeteners (Circle one): NutraSweet, Equal, Aspartame, Splenda
Alcohol
Animal products
Bottled
Filtered
Y
N
?
P
Y
N
?
P
Y
N
?
P
Notes
 How often?
 What percentage of your animal product is organic?
Do you wash your produce
 What percentage of your produce is organic?
Deep fat fried foods
Sodas, juices, drinks containing High Fructose Corn Syrup – how many per day?
Do you have:
Allergies
Sensitivity to smells (gas, perfume, paint, etc…)
Artificial materials in the body (implants, pins, joints, etc…)
Immunizations
Have you ever:
Used tobacco
Experimented with recreational drugs
Led a high stress lifestyle
Experienced a stressful or traumatic event
Been under anesthesia
Had an illness during foreign travel
Had an illness while camping or hiking
Had food poisoning
13
Dental
Y
N
?
Notes
Do you currently have amalgam fillings or caps?
 How many amalgam fillings do you have now?
Have you removed or lost dental fillings or caps?
Did you have fillings as a child?
 How many fillings did you have?
Did you have your Wisdom teeth removed?
 At what age?
 Any complications such as dry socket or abscesses?
Do you have any root canal treated teeth?
 How many and when were they placed?
Did your mother have dental fillings prior to giving birth to you?
 During her pregnancy with you?
Other:
Please list all PRESCRIPTION or OVER THE COUNTER medications you currently
take on a regular basis, including birth control pills and allergy injections:
Name of medication
Dose (mg, ML, IU)
How often do you
take it?
How long have
you taken it?
If you have side effects,
please specify
Please list all VITAMINS/MINERALS, HERBS, or OTHER SUPPLEMENTS you
currently take on a regular basis:
Name of supplement
Dose (mg, ML, IU)
How often do you
take it?
How long have
you taken it?
If you have side effects,
please specify
Drug Adverse Reactions: Please list ANY medication / anesthetics / immunizations
you have had to stop taking because of side effects or allergic reactions:
Name of medication/
immunization
Type of side effects or allergic reaction that caused you to stop it
Age
Year
14
Authorization for Disclosure of Health Information
Patient Name: ______________________________________________________________________________
Date of Birth: ________________________________ Phone: ________________________________________
1. I authorize the use or disclosure of the above named individual’s health information as described below.
2. The following individual or organization is authorized to make the disclosure:
Center for Functional and Integrative Medicine, Inc.
4901 Golden Foothill Parkway
El Dorado Hills, CA 95762
3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).
_______ Complete health records*
_______ Lab results/X-ray reports
_______ Physical Exam
_______ Consultation reports
_______ Immunization record
_______ Other (please specify): ___________________
* I understand that the information in my health record may include information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also
include information about behavioral or mental health services and treatment for alcohol and drug abuse.
4. This information may be disclosed to and used by the following individuals or organization, by phone, fax, mail
and in person with patient:
Name: ____________________________________ Relationship: ___________________________
5. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this
authorization I must do so in writing and present my written revocation to the health information management
department. I understand that the revocation will not apply to my insurance company when the law provides
my insurer with the right to contest a claim under my policy.
6. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this
authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy
the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of
information carries with it the potential for an unauthorized redisclosure and the information may not be
protected by federal confidentiality rules.
_____________________________________________
Signature of patient or legal representative
_____________________________
Date
Consent for Functional Medicine Care
As a health care consumer Notice of nonstandard nature of treatment. Integrative care approaches are
often unreviewed via traditional methods and therefore unrecognized by the FDA and mainstream
medicine. These approaches are foreign to most traditionally trained western medical practitioners and
most professional medical associations. Integrative, functional medical approaches to illness are
considered in many situations as unproven therapeutic options to disease management. These
approaches are taught and practiced by highly trained physicians and other health care providers
across the globe. In addition to their traditional training in western medical approaches many, (all here
at Center for Functional and Integrative Medicine, Inc.), have received extensive, additional training in
areas such as nutrition, natural supplements, stress management and other healthy lifestyle practices.
Education and experience in the practice of integrative medicine:
Mark E. Holthouse M.D, FAAFP. Dr. Holthouse has been a leader in developing the emerging field
of Functional-Integrative Medicine. He is board certified in Family Medicine, is a Certified Functional
Medicine Practitioner, a member of the American Board of Integrative/Holistic Medicine, and is now
board-eligible to become on of the first "Specialists in Integrative Medicine by the American Board of
Integrative Medicine and the American Board of Physician Specialists.
Marc Fierro , L.Ac., P.A.- C. Licensed Physicians Assistant U.C. Davis, Licensed Acupuncturist, and
herbologist with 20 years of experience in Traditional Chinese Medicine and graduating from the Pacific
College of Oriental Medicine in 1991. (A four year post graduate degree) 3rd degree Black belt
instructor in Choi Lai fut, Tai Chi and Qi gong.
Nature of the treatment offered discussed with patient
Purpose/Risks/Benefits/Indications and alternatives discussed with patient
Conventional vs CAM options discussed
A holistic/ CAM review of symptoms does not infer that Center for Functional and Integrative
Medicine, Inc., and/or its providers are taking on your PCP (primary care physician)
responsibilities. All routine medical care is assumed to be managed by your regular provider
outside of our clinic. If you are also a primary care patient, established here and actively
receiving all routine medical care, we are also your PCP office and we accept that
responsibility.
Patient printed name______________________________________
Patient signature __________________________________ Date_________________________
Witness___________________________________ Date_____________________________
1
Informed Consent Regarding Nutritional and Herbal Supplements
According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term drug
is defined as an “article intended for use in the diagnosis, cure, mitigation, treatment, or prevention of
disease.” Technically, vitamins, minerals, trace elements, amino acids, herbs, or homeopathic remedies
are not classified as drugs. However, these substances can have significant effects on physiology and
must be used rationally. In this office, we provide nutritional counseling and make individualized
recommendations regarding use of these substances in order to upgrade the quality of foods in a
patient’s diet and to supply nutrition to support the physiological and biomechanical processes of the
human body. Although these products may also be suggested with a specific therapeutic purpose in
mind, their use is chiefly designed to support given aspects of metabolic function. Use of nutritional
supplements may be safely recommended for patients already using pharmaceutical medications
(drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all
of your healthcare providers fully informed about all medications and nutritional supplements, herbs, or
hormones you may be taking.
Sale of Nutritional Supplements at Center for Functional and Integrative Medicine, Inc.
You are under no obligation to purchase nutritional supplements at our clinic.
As a service to you, we make nutritional supplements available in our office. We purchase these
products only from manufacturers who have gained our confidence through considerable research and
experience. We determine quality by considering: (1) the quality of science behind the product; (2) the
quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the
synergism among product components. The brands of supplements that we carry in our facility are
those that meet our high standards and tend to produce predictable results.
While these supplements may come at a higher financial cost than those found on the shelves of
pharmacies or health food stores, the value must also include assurance of their purity, quality,
bioavailability (ability to be properly absorbed and utilized by the body), and effectiveness. The chief
reason we make these products available is to ensure quality. You are not guaranteed the same level
of quality when you purchase your supplements from the general marketplace. We are not suggesting
that such products have no value; however, given the lack of stringent testing requirements for dietary
supplements, product quality varies widely.
If you have concerns about this issue, please discuss them with our staff.
I, ___________________________________________________________,
have read and understand the above statement on ____________________ (date),
witnessed by ______________________________, ___________________ (date).
(to be witnesed at first appointment)
(to be completed at first appointment)
Guidelines for Use of Technology Communications
We utilize various technologies for communication as a convenience for our members.
Please follow the guidelines listed below and be aware that these guidelines may require
modification as the need arises.
1. Please keep email content to the following topics:
a. Request for prescriptions refills - triplicate requests only (others should remain
through your local or mail-away pharmacy first)
b. Request for appointments - non-urgent
c. Non-urgent related healthcare issues
d. Billing or insurance related matters
e. Membership related questions or concerns
2. Please use the general topic in the subject line of your email so that we can assist in
delivering your email to the correct staff member.
3. Our email system is not encrypted. While we will treat your communication with the
same care we do your medical records and phone calls, please do not include sensitive
information in your email. Specifically, do not include your social security numbers or
other financially sensitive information. Your communication may be viewed by your
physician and his/her staff, a covering physician, his/her medical assistant or the
practice coordinator.
4. Please keep emails brief and concise.
5. Please include your name and date of birth in the body of all email communications.
6. Please be aware that all attempts will be made to reply to emails as quickly as possible,
but replies may take more than 1 business day. Please do not include urgent or time
sensitive requests in email. Please use the telephone for all urgent requests.
7. We will not be able to respond to medical emergencies via email. The email
cannot replace the physician-patient relationship.
8. A copy of your email will be placed in your medical record.
9. I understand and consent to the use of online video technologies for visits with the
providers.
Technology Informed Consent
I herby authorize Mark Holthouse, MD and/or Mark Fiero, P.A. to communicate with me
via email/online video regarding non-urgent, non-time sensitive healthcare issues.
Signature: ____________________________________________ Date: ________________________
Print Name: ________________________________________________________________________
Email Address: _____________________________________________________________________
Wellness Assessment Form
The information collected on this Wellness Assessment Form will help inform your n1HealthCoach about
your current health status and help them get to know you. Collecting this data will assist in the
assessment of your overall wellness and in creating an exercise and nutrition plan to address your
specific needs. Please complete the entire form.
All information contained on this form will be kept strictly confidential. The services and suggestions of the
n1HealthCoach are at all times meant to help with your general feeling of wellness and are in no way meant to
diagnose or treat any disease.
Member Name: _____________________________________ Sex: _______
DOB: ___________________
Home Phone: ___________________ Work Phone: __________________ Cell Phone: ___________________
Email Address: ________________________________________ Marital Status: ________________________
Occupation: _____________________________________________ Travel Required?: ___________________
Please select the technologies you have access to:
Computer
Internet
Email
Skype
Social Media
In order of importance to you, what are your main concerns in regards to physical activity, eating right, sleeping
well, and being at a healthy weight?
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. _______________________________________________________________________________________
Do you have family to support you on your journey towards optimal health and wellness? __________________
_________________________________________________________________________________________
Dietary Habits:
How many meals do you have per day and when?: ________________________________________________
_________________________________________________________________________________________
How many snacks do you have per day and when?: _______________________________________________
_________________________________________________________________________________________
Do you usually eat meals:
_____With family
_____Home alone
_____With friends
_____In front of TV
_____At a restaurant
_____Fast food
_____On the run
_____While doing other activities
How many glasses of water do you drink per day? _________________________________________________
Do you consume beverages with your meals? _____No _____Yes If so, what do you drink? _____________
_________________________________________________________________________________________
Do you feel that there are restrictions on your diet? _____No _____Yes If so, what are they? ______________
_________________________________________________________________________________________
Describe your diet (circle one):
Meat Eater
Vegetarian
Vegan
Other: __________________________
What foods do you crave, if any?: ______________________________________________________________
Do you avoid certain foods? _____No _____Yes If so, what are they and why do you avoid them? _________
_________________________________________________________________________________________
Do you experience any symptoms after meals? _____No _____Yes If so, please explain: ________________
_________________________________________________________________________________________
Please complete a seven-day food journal and bring it to your appointment. List what you eat for breakfast,
lunch, dinner and snacks each day, noting meal times and portions whenever possible.
Lifestyle:
How many hours of sleep do you get per night? ___________________________________________________
How do you feel when you awaken? ____________________________________________________________
How often do you exercise? __________________________________________________________________
What type of exercise do you do and for how long? ________________________________________________
_________________________________________________________________________________________
Do you have access to exercise equipment? _____________________________________________________
Do you vacation regularly? _______________________ When was your last vacation? ___________________
Do you enjoy your work? _____________________ What are your typical work hours? ____________________
Do you smoke? ________________________ If so, how much? _____________________________________
Are you around second-hand smoke? _____________ Do you use recreational drugs? ____________________
What are your interests and hobbies? ___________________________________________________________
_________________________________________________________________________________________
Do you have any pets? ______________________________________________________________________
Please list how many hours you spend in a typical day doing the following:
Driving ____________ Watching TV ____________ Reading ____________ Using a computer ___________
Hobbies/Relaxing ____________
Is there anything else you would like to share with me? _____________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
2
Name:______________________________
Date of Birth:______________________
Please be honest with each of the following questions.
Place a check in the box the best describes your current state.
Physical Activity
I am not active and I do not plan to start.
Pre-Contemplation
I am not active but I am thinking about starting.
Contemplation
I am getting ready to become active.
Preparation
I do some activity but need to do more.
Action
I have been active regularly for several months.
Maintenance
Eating Well (Nutrition)
I do not eat well and don’t plan to change.
Pre-Contemplation
I do not eat well but I am thinking about changing.
Contemplation
I am planning to change my diet.
Preparation
I sometimes eat well but need to do more.
Action
I have eaten well regularly for several months.
Maintenance
Managing Stress
I do not manage stress well and plan no changes.
Pre-Contemplation
I am thinking about making changes to manage stress.
Contemplation
I am planning to change to manage stress better.
Preparation
I sometimes take steps to manage stress better but need to do more.
Action
I have used good stress-management techniques for several months.
Maintenance
Weight Management
I don not manage my weight well and plan no changes.
Pre-Contemplation
I am thinking about making changes to weight management.
Contemplation
I am planning to change to manage my weight better.
Preparation
I sometimes take steps to manage my weight but need to do more.
Action
I have used good weight-management techniques for several months.
Maintenance
Thank you for taking the time to complete this wellness assessment.
3
How Healthy Is Your Diet?
Circle your answers after careful thought, then add up your points (numbers in parentheses).
1. How many fruits do you normally eat each day (1/2 cup fresh or dried fruit, 1 medium piece,
1 cup unsweetened juice)?
A. 0 (-2)
B. 1 (0)
C. 2 to 3 (+2)
D. 4 or more (+3)
(score) _____
2. How many vegetable servings do you normally eat each day (1 cup leafy greens, 1/2 cup any
other veggie, raw or cooked)?
A. 0 (-4)
B. 1 (0)
C. 2 (+1)
D. 3 (+2)
E. 4 or more (+3)
(score) _____
3. How many different varieties of vegetables do you eat in a normal month?
A. 2 or less (-4)
B. 3 to 4 (0)
C. 5 to 6 (+1)
D. 7 to 8 (+3)
E. 9 or more (+4)
(score) _____
4. How many times do you eat dried beans or peas (legumes, lentils, chickpeas, kidney beans,
green peas, etc.) in a normal week?
A. 0 (-2)
B. 1 to 2 (0)
C. 3 to 4 (+1)
D. 5 to 6 (+2)
E. 7 or more (+3)
(score) _____
5. How many times do you eat red meat in a normal week?
A. 6 or more (-4)
B. 4 to 5 (-3)
C. 1 to 3 (-1)
D. Less than once a week (+2)
E. 0 (+3)
(score) _____
6. How many times do you eat in a fast food restaurant in a normal week?
A. 6 or more (-5)
B. 4 to 5 (-4)
C. 1 to 3 (-3)
D. Less than once a week (-2)
E. 0 (0)
(score) _____
4
7. In a typical day, what do you drink most often?
A. Soda (regular or diet) (-4)
B. Caffeinated coffee or tea (-1)
C. Decaffeinated coffee or tea (0)
D. Milk or fruit juice (0)
E. Herbal tea or water (+3)
(score) _____
8. How many 12 oz. cans of soda do you drink in a normal day?
A. 6 or more (-5)
B. 4 to 5 (-4)
C. 2 to 3 (-3)
D. 1 (-2)
E. Less than 1 (-1)
F. 0 (0)
(score) _____
9. How often do you eat fish in a typical week?
A. Never (-2)
B. Once (+1)
C. Twice (+2)
D. 3 to 5 times (+3)
(score) _____
10. In a typical week, how often do you eat whole grains (100% whole grain bread, whole oats,
brown rice, quinoa, whole rye crackers)?
A. Never (-3)
B. 1 to 2 times a week (-1)
C. 3 to 4 times a week (0)
D. 5 to 6 times a week (+1)
E. 1 or more times a day (+3)
(score) _____
11. How often do you eat sweets such as cookies, cakes, or ice cream?
A. 1 or more times a day (-3)
B. Every other day (-2)
C. Twice a week (-1)
D. Once a week (0)
E. 2 to 3 times a month (+1)
F. Rarely (+3)
(score) _____
0
Your Total Score__________________
Scoring:
22–28 – Great eating habits
17–21 – Pretty good eating habits
10–16 – Needs some improvement
9 or less – Needs much improvement; try to change one habit at a time
This document was created by the Institute for Functional Medicine. This document may be copied or printed for your own
use but cannot be resold or repurposed for commercial use.
5
MEDICAL SYMPTOM QUESTIONNAIRE
BASED ON THE PAST 48 hrs
30 DAYS rate each of the following symptoms based upon your typical health profile. NAME
DATE
Please se he scale
0
1
2
own elow o escribe he severity f our
0
Never r almost never ave e mptom
Occasionally ave t, effect is not severe
Occasionally ave t, effect is severe
Headaches
Dizziness/Faintness
Insomnia
TOTAL this section)
0
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Dark circles under eyes
Vision problems
(excluding near or farsighted) TOTAL this section)
HEAD
EYES
0
TOTAL this section)
0
Stuffy nose/Excessive mucus formation
Sinus problems
Hay fever/Sneezing attacks
Nose bleeding
TOTAL this section)
0
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen/Discolored tongue, gums, lips
Canker sores
TOTAL this section)
0
Acne
Hives, rashes, dry skin
Hair loss
Excessive hair growth
Excessive sweating/Body odor
Flushing, hot flashes
TOTAL this section)
0
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
TOTAL this section)
0
Chest congestion
Asthma, frequent bronchitis
Difficulty breathing
Frequent coughing
TOTAL this section)
NOSE
MOUTH/
SKIN
HEART
LUNGS
ch section)
3
4
Frequently have it, effect is not severe
Frequently ave t, effect is severe
0
Nausea, vomiting
Diarrhea, loose stools
Constipation, hard/infrequent stools
Bloated feeling
Belching, passing gas, burping
Heartburn/acid taste in mouth
Intestinal/stomach pain
TOTAL this section)
0
Pain or aches in joints/Arthritis
Warm, swollen joints
Stiffness or limitation of movement
Pain or aches in muscles
Muscle weakness
TOTAL this section)
0
Excessive eating/drinking
Strong/Excessive craving certain foods
Overweight/Obese
Difficulty losing weight
Water retention
Difficulty gaining weight
TOTAL this section)
0
Fatigue from mental exhaustion
Fatigue from emotional exhaustion
Hyperactivity (mind or body)
Restlessness (mind or body)
TOTAL this section)
0
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Speech difficulty
Learning disabilities
TOTAL this section)
0
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression/Sadness
Obsessive, compulsive behaviors
TOTAL this section)
0
Frequent illness
Frequent or urgent urination
Genital itch or discharge
TOTAL this section)
DIGESTIVE TRACT
JOINTS / MUSCLE
Itchy ears
Frequent ear infections
Popping of ears
Ringing in ears EARS
mptom please otal
WEIGHT
ENERGY / ACTIVITY
MIND
EMOTIONS
OTHER
SUM OF ALL SECTIONS ABOVE:
0
6
Notice of Privacy Practices
Privacy Officer: Mark Holthouse, M.D.
Effective Date: Sept. 2008
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
We understand the importance of privacy and are committed to maintaining the confidentiality of your
medical information. We make a record of the medical care we provide and may receive such records
from others. We use these records to provide or enable other health care providers to provide quality
medical care, to obtain payment for services provided to you as allowed by your health plan and to
enable us to meet our professional and legal obligations to operate this medical practice properly. We
are required by law to maintain the privacy of protected health information and to provide individuals
with notice of our legal duties and privacy practices with respect to protected health information. This
notice describes how we may use and disclose your medical information. It also describes your rights
and our legal obligations with respect to your medical information. If you have any questions about this
Notice, please contact our Privacy Officer listed above.
TABLE OF CONTENTS
A. How This Medical Practice May Use or Disclose Your Health Information
B. When This Medical Practice May Not Use or Disclose Your Health Information
C. Your Health Information Rights
1. Right to Request Special Privacy Protections
2. Right to Request Confidential Communications
3. Right to Inspect and Copy
4. Right to Amend or Supplement
5. Right to an Accounting of Disclosures
6. Right to a Paper Copy of This Notice
D. Changes to This Notice of Privacy Practices
E. Complaints
A. How This Medical Practice May Use or Disclose Your Health Information
This medical practice collects health information about you and stores it in a chart and on a computer.
This is your medical record. This medical record is the property of this medical practice, but the
information in the medical record belongs to you. The law permits us to use or disclose your health
information for the following purposes:
1
1. Treatment. We use medical information about you to provide your medical care. We disclose
medical information to our employees and others who are involved in providing the care you
need. For example, we may share your medical information with other physicians or other
health care providers who will provide services that we do not provide. Or we may share this
information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that
performs a test. We may also disclose medical information to members of your family or others
who can help you when you are sick or injured.
2. Payment. We use and disclose medical information about you to obtain payment for the
services we provide. For example, we give your health plan the information it requires before
they will pay us. We may also disclose information to other health care providers to assist them
in obtaining payment for the services they have provided to you.
3. Health Care Operations. We may use and disclose medical information about you to operate
this medical practice. For example, we may use and disclose this information to review and
improve the quality of care we provide, or the competence and qualifications of our professional
staff. Or we may use and disclose this information to get your health plan to authorize services
or referrals. We may also use and disclose this information as necessary for medical reviews,
legal services and audits, including fraud and abuse detection and compliance programs and
business planning and management. We may also share your medical information with our
“business associates”, such as our billing service, that perform administrative services for us.
We have a written contract with each of these business associates that contains terms requiring
them to protect the confidentiality of your medical information. Although federal law does not
protect health information that is disclosed to someone other than another healthcare provider,
health plan or healthcare clearinghouse, under California law all recipients of health care
information are prohibited from re-disclosing it except as specifically required or permitted by
law. We may also share your information with other health care providers, health care
clearinghouses or health plans that have a relationship with you, when they request this
information to help them with their quality assessment and improvement activities, their efforts
to improve health or reduce health care costs, their review of competence, qualifications and
performance of health care professionals, their training programs, their accreditation,
certification or licensing activities, or their health care fraud and abuse detection and compliance
efforts.
4. Appointment Reminders. We may use and disclose medical information to contact and remind
you about appointments. If you are not home, we may leave this information on your answering
machine or in a message left with the person answering the phone.
5. Sign In Sheet. We may use or disclose medical information about you by having you sign in
when you arrive at our office. We may also call out your name when we are ready to see you.
6. Notification and Communication with Family. We may disclose your health information to notify
or assist in notifying a family member, your personal representative or another person
2
responsible for your care, about your location, your general condition or in the event of your
death. In the event of a disaster, we may disclose information to a relief organization so that
they may coordinate these notification efforts. We may also disclose information to someone
who is involved with your care or helps pay for your care. If you are able and available to agree
or object we will give you the opportunity to object prior to making these disclosures, although
we may disclose this information in a disaster even over your objection if we believe it is
necessary to respond to the emergency circumstances. If you are unable or unavailable to
agree or object, our health professionals will use their best judgment in communication with your
family and others.
7. Marketing. We may contact you to give you information about products or services related to
your treatment, case management or care coordination, or to direct or recommend other
treatments or health-related benefits and services that may be of interest to you, or to provide
you with small gifts. We may also encourage you to purchase a product or service when we see
you. We will not otherwise use or disclose your medical information for marketing purposes
without your written authorization.
8. Required by Law. As required by law, we will use and disclose your health information, but we
will limit our use or disclosure to the relevant requirements of the law. When the law requires us
to report abuse, neglect or domestic violence, or respond to judicial or administrative
proceedings, or to law enforcement officials, we will further comply with the requirement set
forth below concerning those activities.
9. Public Health. We may, and are sometimes required by law, to disclose your health information
to public health authorities for purposes related to: preventing or controlling disease, injury or
disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic
violence; reporting to the Food and Drug Administration problems with products and reactions to
medications; and reporting disease or infection exposure. When we report suspected elder or
dependent adult abuse or domestic violence, we will inform you or your personal representative
promptly unless in our best professional judgment, we believe the notification would place you
at risk of serious harm or would require informing a personal representative we believe is
responsible for the abuse or harm.
10. Health Oversight Activities. We may, and are sometimes required by law, to disclose your
health information to health oversight agencies during the course of audits, investigations,
inspections, licensure and other proceedings, subject to the limitations imposed by federal and
California law.
11. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to
disclose your health information in the course of any administrative or judicial proceeding to the
extent expressly authorized by a court or administrative order. We may also disclose information
about you in response to a subpoena, discovery request or other lawful process if reasonable
3
efforts have been made to notify you of the request and you have not objected, or if your
objections have been resolved by a court or administrative order.
12. Law Enforcement. We may, and are sometimes required by law, to disclose your health
information to a law enforcement official for the purposes such as identifying or locating a
suspect, fugitive, material witness or missing person, complying with a court order, warrant,
grand jury subpoena and other law enforcement purposes.
13. Coroners. We may, and are often required by law, to disclose your health information to
coroners in connection with their investigations of death.
14. Organ or Tissue Donation. We may disclose your health information to organizations involved
in procuring, banking, or transplanting organs or tissues.
15. Public Safety. We may, and are sometimes required by law, to disclose your health information
to appropriate persons in order to prevent or lessen a serious and imminent threat to the health
or safety of a particular person or the general public.
16. Specialized Government Functions. We may disclose your health information for military or
national security purposes or to correctional institutions or law enforcement officers that have
you in their lawful custody.
17. Worker’s Compensation. We may disclose your health information as necessary to comply with
worker’s compensation laws. For example, to the extent your care is covered by workers’
compensation, we will make periodic reports to your employer about your condition. We are also
required by law to report cases of occupational injury or occupational illness to the employer or
workers’ compensation insurer.
18. Change of Ownership. In the event that this medical practice is sold or merged with another
organization, your health information/record will become the property of the new owner,
although you will maintain the right to request that copies of your health information be
transferred to another physician or medical group.
B. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in the Notice of Privacy Practices, this medical practice will not use or disclose
health information that identifies you without your written authorization. If you do authorize this medical
practice to use or disclose your health information for another purpose, you may revoke your
authorization in writing at any time.
C. Your Health Information Rights
4
1. Right to Request Special Privacy Protections. You have the right to request restrictions on
certain uses and disclosures of your health information, by a written request specifying what
information you want to limit and what limitations on our use or disclosure of that information
you wish to have imposed. We reserve the right to accept or reject your request, and will notify
you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive
your health information in a specific way or at a specific location. For example, you may ask that
we send information to a particular email account or to your work address. We will comply with
all reasonable requests submitted in writing which specify how or where you wish to receive
these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with
limited exceptions. To access your medical information, you must submit a written request
detailing what information you want access to and whether you want to inspect it or get a copy
of it. We will charge a reasonable fee, as allowed by California and federal law. We may deny
your request under limited circumstances. If we deny your request to access your child’s
records or the records of an incapacitated adult that you are representing because we believe
allowing access would be reasonably likely to cause substantial harm to the patient, you will
have a right to appeal our decision. If we deny your request to access your psychotherapy
notes, you will have the right to have them transferred to another mental health professional.
4. Right to Amend or Supplement. You have a right to request that we amend your health
information that you believe is incorrect or incomplete. You must make a request to amend in
writing, and include the reasons you believe the information is inaccurate or incomplete. We are
not required to change your health information, and will provide you with information about this
medical practice’s denial and how you can disagree with the denial. We may deny your request
if we do not have the information, if we did not create the information (unless the person or
entity that created the information is no longer available to make the amendment), if you would
not be permitted to inspect or copy the information at issue, or if the information is accurate and
complete as is. You also have the right to request that we add to your record a statement of up
to 250 words concerning any statement or item you believe to be incomplete or incorrect.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures
of your health information made by this medical practice, except that this medical practice does
not have to account for the disclosures provided to you or pursuant to your written authorization,
or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6
(notification and communication with family) and 16 (specialized government functions) of
Section A of this Notice of Privacy Practices or disclosures for purposes of research or public
health which exclude direct patient identifiers, or which are incident to a use or disclosure
otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law
enforcement official to the extent this medical practice has received notice from that agency or
official that providing this accounting would be reasonably likely to impede their activities.
5
6. Right to a Paper Copy of This Notice. You have a right to a paper copy of this Notice of Privacy
Practices, even if you have previously requested its receipt by email.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one
or more of these rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such
amendment is made, we are required by law to comply with this Notice. After an amendment is made,
the revised Notice of Privacy Protections will apply to all protected health information that we maintain,
regardless of when it was created or received. We will keep a copy of the current notice posted in our
reception area, and will offer you a copy at each appointment.
E. Complaints.
Complaints about this Notice of Privacy Practices or how this medical practice handles your health
information should be directed to our Privacy Officer listed at the beginning of this Notice of Privacy
Practices.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a
formal complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, D.C. 20201
You will not be penalized for filing a complaint.
6
Acknowledgement of Receipt of Notice of Privacy Practices
I hereby acknowledge that I have read a copy of this medical practice’s Notice of Privacy Practices. I
further acknowledge that a copy of the current notice will be posted in the reception area, and that I will
be offered a copy of any amended Notice of Privacy Practices at each appointment.
PATIENT RECORD OF DISCLOSURE
Signed: ________________________________________
Date: ________________________
Print name: _____________________________________
Phone: _______________________
Name and Address of Patient:
__________________________________________________________________________________
If not signed by the patient, please indicate relationship:
______ Parent or guardian of minor patient
______ Guardian or conservator of an incompetent patient
I wish to be contacted in the following manner (check all that apply)
□ O.K. to leave message with detailed information □ On answering machine
□ Leave message for me to call the office
□ Do not mail to my home address
□ O.K. to leave message with ______________________________________________
I authorize this office to release medical information to the following person(s):
__________________________________________________________________________________
__________________________________________________________________________________
Record of Disclosures of Protected Health Information
Date
Disclosed to Whom, Address, Phone #
What and Why Disclosed
Who Sent
1
Patient Consent to Treatment
I, the undersigned, hereby consent to the following Treatment:
• Administration and performance of all treatments
• Administration of any needed anesthetics
• Performance of such procedures as may be deemed necessary or advisable in the treatment of
this patient
• Use of prescribed medication
• Performance of diagnostic procedures/tests and cultures
• Performance of other medically accepted laboratory tests that may be considered medically
necessary or advisable based on the judgment of the attending physician or their assigned
designees
I fully understand that this is given in advance of any specific diagnosis or treatment.
I intend this consent to be continuing in nature even after a specific diagnosis has been made and
treatment recommended. The consent will remain in full force until revoked in writing.
I understand that Center for Functional and Integrative Medicine, Inc., may include consent at
satellite offices under common ownership.
I, the undersigned, authorize Center for Functional and Integrative Medicine, Inc., to use and
disclose my information for the purposes of treatment, payment, and healthcare operations as
described in the Notice of Privacy Practices.
A photocopy of this consent shall be considered as valid as the original.
MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security
Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services
to Center for Functional and Integrative Medicine, Inc.
I acknowledge that I have been given the Center for Functional and Integrative Medicine, Inc. Notice of
Privacy Practices. I understand that if I have questions or complaints that I should contact the Privacy
Official.
Patient Initial: ________________
I certify that I have read and fully understand the above statements and consent fully and voluntarily to
its contents.
_____________________________________________
_____________________________
Date
2
Personality Test
Patient Name: _______________________
Please visit this link and complete your Personality Test online:
http://www.humanmetrics.com/cgi-win/JTypes2.asp
After you have completed your Personality Test, you will be provided with a four-letter type
formula. Please note your type formula below.
My Type Formula is: _______________
3
Request to Release Medical Records
I, the undersigned patient, request a copy of my records:
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
__________________________________________________________________________________________
Date of Birth: ___________________________ Social Security Number: _______________________________
Date of request:
Date Records Needed:
To: (Name of Provider or Facility): _______________________________________________________________
Address: __
______________________________________________________________________
__________________________________________________________________________________________
Phone:_________________________________________ Fax:_______________________________________
Types of records requested:
❐ Treatment Summary
❐ Specific Information:
❐ Procedure report
❐ History and Physical
❐ X-ray reports
❐ Other:
❐ All Medical Records related to a Specific illness or injury
❐ Physical Therapy
❐ Lab Test Results
I understand that:
§ My right to healthcare treatment is not conditioned on this authorization.
§ I may cancel this authorization at any time by submitting a written request to the address provided at the top
of this form, except where a disclosure has already been made in reliance on my prior authorization.
§ If the person or facility receiving this information is not a health care or medical insurance provider covered
by privacy regulations, the information stated above could be redisclosed.
§ Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment
information requires additional authorization.
§ There may be a charge for the requested records.
Please release the requested information to:
Center for Functional and Integrative Medicine, Inc.
4901 Golden Foothill Parkway | El Dorado Hills, CA 95762 Phone:
530-676-1003 | Fax: 916-358-5200
Records may also be sent via email to [email protected]
Please process this request within 15 calendar days, as provided by law. A copy of this authorization shall be
deemed as valid as an original.
I hereby authorize you to furnish the medical information requested to Center for Functional and Integrative
Medicine, Inc., including the results of laboratory tests for infectious disease, if applicable.
_____________________________________________
_____________________________
Date
4
Screening Tool for Sleep Apnea
Developed by David White, M.D., Harvard Medical School, Boston, MA
In whom should apnea be considered? If you suspect sleep apnea, ask you patient the following questions:
1.
Snoring:
a) Do you snore on most night (>3 nights per week)
Yes (2)
No (0)
__________
b) Is your snoring loud? Can it be heard through a door or wall?
Yes (2)
2.
Occasionally (3)
Frequently (5)
__________
more than 17 inches (5)
more than 16 inches (5)
__________
__________
What is your collar size?
Male: Less than 17 inches (0)
Female: Less than 16 inches (0)
4.
__________
Has it ever been reported to you that you stop breathing or gasp during sleep?
Never (0)
3.
No (0)
Do you occasionally fall asleep during the day when:
a) You are busy or active?
Yes (2)
No (0)
__________
b) You are driving or stopped at a light?
Yes (2)
5.
No (0)
__________
Have you had or are you being treated for high blood pressure?
Yes (1)
No (0)
__________
_____________________________________________________________________________________
Score
9 points or more:
6 - 8 points
5 points or less
Refer to sleep specialist or order sleep study
Gray area, use clinical judgment
Low probability of sleep apnea
5
n1Health Center for Functional Medicine 4901 Golden Foothill Parkway | El Dorado Hills, CA 95762
Pa5ent Name ______________________________ Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Breakfast Lunch Dinner Snack Snack Exercise 6
Review of Current Symptoms
Please check any current problems you have on the list below:
Constitutional
Fevers/chills/sweats
Unexplained weight loss/gain
Brittle nails
Dry Skin
Change in skin texture
Change in hair texture
Inability to stand heat
Inability to stand cold
Change in egergy/increased weakness
Excessive thirst or urination
Cough/wheeze
Difficulty breathing
Snoring
Sleep apnea/CPAP
Eyes
Change in Vision (Explain) ___________________
Ear/Nose/Throat
Difficulty hearing/ringing in ears
Hay fever/allergies
Bleeding gums
Cardiovascular
Chest pain/discomfort
Palpitations
Swelling in feet or legs or ankles
Varicose Veins
Pain in extremities with exercise
Skin
Acanthosis nigricans (dark lines around neck &
under arms)
Skin tags
Flattening of nail beds
Genitourinary
Unusual frequency of urination
Change in stream
Sexual
Problems with erectile dysfunction
Gastrointestinal
Abdominal Pain
Blood in bowel movements
Heartburn
Nausea/vomiting
Diarrhea/constipation
Psychiatric
Problems with sleep
Depression
Panic attacks
Mania
Anxiety
Anger Issues
Blood/Lymphatic
Easy bruising/bleeding
Unexplained Lumps
Neurologic
Light-headedness
Headaches
Memory Loss
Loss of coordination
Balance Problems
Tingling, pain, or numbness in hands or feet
Any other symptoms? If so please list them:
7

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