Integrative Medicine and Holistic Wellness Center 677 West Main Street Hyannis, MA 02601
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- Dora McGee
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1 Integrative Medicine and Holistic Wellness Center 677 West Main Street Hyannis, MA Informed Consent for Health Consultation: I herby authorize my practitioner to advise the use of the following therapies. Nutritional Supplementation: concentrated dosages of vitamins, minerals, and other substances of naturally occurring foods. Botanical medicine: concentrated or un-concentrated dosages of herbs, plants, and/or their constituents. Botanical substances may be prescribed as granules, teas, alcoholic tinctures, glycerite tinctures, capsules, tablets, creams, plasters or suppositories. Homeopathic remedies: highly dilute quantities of a plant, animal, and mineral substances delivered on sucrose pellets or in 25% alcohol liquid preparations. Lifestyle counseling and hygiene: changes in diet, exercise, sleep and balancing work and social activities Psychological: stress reduction techniques. I recognize the potential risks and benefits of these therapies as described below. Potential risks: allergic reactions to prescribe herbs and supplements, side effects of natural medications, an inconvenience in lifestyle changes. I understand the U.S. Food and Drug Administration has not evaluated or approved nutritional/herbal supplements or homeopathic remedies. I understand that, as with drugs, nutritional/herbal supplements and homeopathic remedies may cause some side effects in certain sensitive individuals, may interact with certain prescription medications or lab tests, or cause symptoms due to certain pre-existing disease conditions. I do not expect my Practitioner to be able to anticipate and explain all risk potential complications. I wish to rely on my practitioner to exercise judgement in recommending therapies they feel are in my best interest, based on available knowledge. I have the opportunity to ask questions and discuss with my practitioner; 1) my condition 2)the nature, purpose and potential benefit of the proposed therapies 3) the material risks inherent in therapies 4) the probability of those risks occurring 5) the likelihood of success 6) reasonably available alternatives to the proposed therapies 7) the material risks inherent in such alternatives and the probability of such risks occurring 8)the possibility of consequences if advice is not followed and/or no therapies are undertaken. Notice to Pregnant Woman: All female patients must alert the practitioner if they know or suspect that they are pregnant, as some of the therapies used could present risk to pregnancy. With this knowledge, I voluntarily consent to the above therapies, realizing, that no guarantees have been made to me by the practitioner or any of his personnel, regarding prevention, treatment or cure of my condition or any condition. I understand that is my free will to withdraw my consent and discontinue participation in these therapies at any time. I understand that it is not being recommended for me to discontinue any other treatment or care that is being provided by any other health care professional. I understand this practitioner does not function as a primary care physician, and that he offers services in addition to other services I receive. I understand the practitioner does not replace a specialist. I will discuss all my prescription medication questions and changes with my primary care or specialist. I understand that naturopathic therapies do not replace conventional medical advice or care. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements and noncovered services. I agree to be financially responsible for any and all related charges if they are not covered by my health insurance. Patient Printed Name Patient Signature Date
2 NATUROPATHIC INTAKE FORM Patient Name: (Last/First) D.O.B: / / Street Address: City: State: Zip: Cell phone: Home Phone: Work Phone: Highest level of education: Occupation: Employer: Hours work per week: Marital Status: Single Married Other Insurance Company: Policy #: Group#: Name of Insured: Relation to Insured Social Security Number: Person to call in case of Emergency: Relationship to you: Phone number contact for them: PCP: How did you hear of the clinic: List in Order of Importance what your problems are:
3 TEL.: (508) FAX: (508) Personal and Family History Conditions Condition Self Mother 1. Allergies D D 2. Anemia D D 3. Anxiety D D 4. Arthritis D D 5. Asthma D D 6. Blood Transfusion D D 7. Cancer D D 8. Cataracts D D 9. Congestive Heart Failure D D 10. Clotting Disorder D D 11. COP 12. Depression D D 13. Diabetes D D 14. Emphysema D D 15. GER 16. Glaucoma D D 17. Heart Attack D D 18. Heart Murmur D D 19. HIV/AIDS D D 20. Hypertension D D 21. Irritable Bowel Syndrome D D 22. Kidney Disease D D 23. Meningitis D D 24. Nerve/Muscle Disease D D 25. Osteoporosis D D 26. Parkinson's/Alzheimer's D D 27. Seizures D D 28. Sickle Cell Anemia D D 29. Stroke D D 30. Substance Abuse D D 31. Thyroid Disease D D 32. Tuberculosis D D Maternal Father Sibling Grand Mother Maternal Paternal Paternal Grand Grand Grand Father Mother Father If deceased, relevant info: Mother Father Sibling Maternal grand mother Maternal grand Paternal grand Paternal grand father mother father Condition Self Mother Maternal Father Sibling Grand Mother Maternal Paternal Paternal Grand Grand Grand Father Mother Father Personal and Family History Notes 2
4 Last time you had blood work done and with what doctor: Please Note When and Why You Had Each of The Following: X-rays: MRI/Cat Scans: Ultrasounds: Accidents: Please List All Sensitivities/Allergies/Reactions Drugs: Foods: Environment: Did you have the following Disease (D), Get Immunized for it (I), or Neither (N): Measles: D I N Diptheria: D I N Mumps: D I N Tetanus: D I N Rubella: D I N Whooping Cough: D I N Chickenpox: D I N Hemophilus (Hib): D I N German Measles: D I N Hepatitis B: D I N Any vaccination reactions: List Yes, No, or Past regarding use of the following: Antacids: Y N P Steroids: Y N P Smoking: Y N P Packs per day if Yes/Past: Analgesics: Y N P Laxatives: Y N P Coffee: Y N P Cups per day if Yes/Past: Soda Pop: Y N P Ounces per day if Yes/Past: Alcohol: Y N P How often and how much if Yes/Past: Any alcohol addiction: Y N P Any alcohol treatment: Y N P Recreational drugs: Y N P Any drugs addiction: Y N P Any drug treatment: Y N P 3
5 List all Prescription Medicines and Nutrient Supplement/Herbs Taking: Review of Systems: Present Weight: Weight one year ago: Height: Maximum weight and when: Minimum Weight as adult and when: Ideal Weight: REGARDING THE NEXT LONG SECTION: Please Check Y if you have the problem NOW, N if you ve NEVER had the problem, P if you had the problem in the PAST. Good Energy: Y N P Fatigue: Y N P If you have fatigue, when in morning, afternoon, evening is it the worst? Y If you have fatigue, can you do what you need to during the day? Y N N Skin: Rash: Y N P Color Change: Y N P Hives: Y N P Lump: Y N P Psoriasis/eczema: Y N P Itchy: Y N P Dry: Y N P Warts/moles: Y N P Cancer: Y N P Perspiration: Y N P Head: Headache: Y N P Migraine: Y N P Dandruff: Y N P Head Injury: Y N P Oil/dry hair: Y N P Hair loss: Y N P Eyes: Dry/Watery: Y N P Blurry vision: Y N P Double vision: Y N P Cataracts: Y N P Glaucoma: Y N P Styes: Y N P Strain: Y N P Discharge: Y N P Itchy: Y N P Dark under eyelid: Y N P 4
6 Nose: Frequent colds: Y N P Nosebleeds: Y N P Congestion: Y N P Post nasal drip: Y N P Polyps: Y N P Seasonal allergies: Y N P Mouth/Throat: Canker sores: Y N P Cold sores: Y N P Sore throat: Y N P Gum disease: Y N P Dentures: Y N P Cavities: Y N P Loss of taste: Y N P Hoarseness: Y N P Neck: Stiffness: Y N P Swollen glands: Y N P Full movement: Y N P Tension: Y N P Respiratory: Cough: Y N P TB: Y N P Shortness of breath with exertion: Y N P Bronchitis: Y N P Shortness of breath sitting: Y N P Pneumonia: Y N P Shortness of breath lying down: Y N P Asthma: Y N P Wheezing: Y N P Painful breathing: Y N P Cardiovascular: High blood pressure: Y N P Rheumatic Fever: Y N P Low blood pressure: Y N P Murmurs: Y N P Arrhythmias: Y N P Palpitations: Y N P Edema: Y N P Chest pain: Y N P Gastrointestinal: Heartburn: Y N P Bowel movement frequency: Indigestion: Y N P Recent change in BM: Y N P Bloating: Y N P Diarrhea or constipation: Y N P Nausea : Y N P Hemorrhoids: Y N P Vomiting: Y N P Gall bladder disease: Y N P 5
7 Change in Appetite: Y N P Liver disease: Y N P Pancreatitis: Y N P Ulcer: Y N P Urinary Tract: Incontinence: Y N P Pain with urination: Y N P Frequent infections: Y N P Kidney stones: Y N P Urgency: Y N P Discharge/blood: Y N P Male Genitalia: Testicular pain/swelling: Y N P Sexually active: Y N P Hernia: Y N P Sexually transmitted disease: Y N P Discharge: Y N P Prostate disease/symptoms: Y N P Impotency: Y N P Sexual orientation: Hetero Homo Other Female Genitalia: Age periods began: How often periods occur: How long periods last: Menopausal since what age: Periods: Times Pregnant: Heavy Bleeding: Y N P How many births: Cramping: Y N P Miscarriages: Pain: Y N P Abortions: PMS: Y N P Sexual Active: Y N P Food Cravings: Y N P Healthy Libido: Y N P Last Pap Smear: Pain with Intercourse: Y N P Diagnosis: Dry Vagina: Y N P Any abnormal paps: Y N P Vaginitis: Y N P When was abnormal: Y N P Any Birth Control (please list types and ages used): Sexually Transmitted Diseases: Y N P Mammography: Y N P Dexa Scan: Y N P If Yes, what were the results: Use of Hormones: Y N P 6
8 Musculoskeletal: Weakness: Y N P Arthritis: Y N P Stiffness: Y N P Leg cramps: Y N P Tremors: Y N P Pain: Y N P Nervous: Paralysis: Y N P Sciatica: Y N P Tingling/numbness: Y N P Carpal tunnel syndrome: Y N P Seizures: Y N P Fainting: Y N P Mental/Emotional: Depression: Y N P Anger/irritability: Y N P Suicidal: Y N P High-strung/tense: Y N P Anxiety: Y N P Fear/Panic: Y N P Exercise: How often: What type(s): For How long: Hobbies: Sleep: How long per night: If you wake up frequently, what is the reason: Nightmares: Y N P Wake refreshed: Y N P Must Nap during the day: Y N P Sleep walk: Y N P Grind Teeth: Y N P Snore: Y N P Food: Appetite Good? Y N P Foods crave: 7
9 Foods Dislike: Foods that don t sit well: Toxin Exposure: Did you grow up near any refinery, or polluted area, or in home with leaded paint? If so, what sort of pollution were you exposed to?: Have you had any jobs where you were exposed to solvents, heavy metals, fumes, or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets, or did other refurbishing? Are you particularly sensitive to perfumes, gasoline, or other vapors? Do you use pesticides, herbicides, other chemicals around your home? Social Life: Enjoy job? Y N P Active Spiritual practice: Y N P Quality of most significant relationship? History of sexual, mental/emotional, physical abuse? Y N If so, at what age and by whom? What is your greatest health concern? How does it limit you the most? How committed are you towards making valuable changes: Little Moderately Very Patient Signature: Date: 8
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