CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
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1 Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC (919) / CaryHolisticHealth.com Thank you for scheduling an appointment with. We are located at 222 Ashville Avenue, Suite 10 we share this suite with a busy family medical practice, as well as an aesthetics practice. Please let the front desk know you have arrived. If you have an appointment scheduled over the lunch hour, the front desk may be closed. Make yourself comfortable in the waiting area and Dr. Thibodeau will get you at your scheduled appointment time. Please note that we are a fragrance-free facility please refrain from wearing any perfumes, colognes or scented body lotions on the day of your appointment. Plan to spend 1 1½ hours for your initial intake. Please set aside some time prior to your initial visit to print and complete the forms included in this package and bring them with you to your first appointment: Consent to Treat form Financial Policy/ Policy Adult Intake form It is also extremely helpful to bring any recent blood work or imaging results with you. If necessary, you can download the Authorization to Receive Medical Records form to deliver or fax to your doctor to have them send records directly to our office. There is a link on our website on the New Patients page. Please bring any vitamins and supplements you are taking with you. The fee for an initial appointment is $180. Follow-up appointments are usually 45 minutes, with a fee of $90. Fees can be paid by cash, check or Visa/MasterCard. If you are unable to keep your scheduled appointment time, please give at least 48 hours notice so that we may allow other patients to have that appointment time. We look forward to working with you towards your health and well-being!
2 Page 1 of 8 Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC (919) / CaryHolisticHealth.com *Please bring all of the completed forms in this package with you to your first visit. ADULT INTAKE FORM Name Date of 1st Visit Date of Birth Age Gender: M F Address City State Zip Phone (home) (work) (cell) Would you like to receive our e-newsletter? Y N If we need to contact you, messages can be left at (circle all that apply): Work Home Cell Employer Occupation Hours per week Marital Status: Married Separated Divorced Widowed Single Partnership Number of Children: Ages: Sexes: Live with: Spouse Partner Parents Children Friends Alone How did you hear about our clinic? Has any other family member been a client at this clinic? Have you received naturopathic treatment in the past? EMERGENCY CONTACT Name Relationship Address Phone: HEALTHCARE PROVIDERS Primary Health Care Physician: Phone: When was your last physical exam? Are you currently under the care of a specialist? Name: Specialty: Phone: Name: Specialty: Phone: List your primary health concerns, in order of importance: Have you experienced any traumatic life events that you feel may be associated with any of your health concerns?
3 Page 2 of 8 PERSONAL OVERVIEW 1. Improving health by addressing underlying imbalances often requires a commitment to lifestyle change and willingness to follow therapeutic protocols. How would you describe your present level of commitment? Rate on a scale from 1 to 10, with 10 indicating 100% commitment. (0%) (100%) 2. Are there any potential obstacles you foresee in addressing the lifestyle factors that are undermining your health or in adhering to the therapeutic protocols that I will be sharing with you? 3. What expectations do you have of me personally as your Naturopathic physician? HEALTH HISTORY How would you describe your current state of health? Excellent Good Fair Poor Are you currently being treated for a health care concern by other healthcare practitioners? Please explain. Do you have any known contagious diseases at this time? Y N If yes, what? List any serious conditions, illnesses, injuries, surgeries, and/or hospitalizations that you have experienced, along with the approximate date. Date Date List any X-rays, CT scans, blood work or other studies that you have had, along with the approximate date. Study Date Study Date Has there been an event or illness from which you have never fully recovered?
4 Page 3 of 8 MEDICATIONS Do you regularly use any of the following? Laxatives Pain Relievers Antacids Sleeping Pills Birth Control Pills Vitamins and Supplements Please list all vitamin/mineral supplements, herbs, and homeopathic remedies you are currently taking: Supplement (include brand) Total daily dose Reason for Use Duration of Use Prescription Medications Please list all current medications and indicate the total dosage taken in one day: Current Medications Total daily dose Reason for Use Duration of Use Please list any medications used in the past 12 months, but have now discontinued. Did you receive antibiotics frequently as a child? Have you ever taken antibiotics for an extended period of time? How many times have you received antibiotics in the past five years? Please list all known allergies (food, environmental, medications): Have you ever had an anaphylactic reaction? Which vaccinations have you had? HBV (hepatitis B) Hepatitis A Meningococcal Other: MMR (measles, mumps, rubella) Tetanus Booster Smallpox Hib (Haemophilus influenza b) Polio Typhus DPT (diphtheria, tetanus, pertussis) VZV (chicken pox) Influenza (flu shot)
5 Page 4 of 8 Adverse Reactions Please describe any adverse reactions, allergies, or sensitivities you have experienced with prescription or over-the-counter medications, recreational drugs, vaccinations (childhood, travel, flu, hepatitis), or natural medicines (herbs, vitamins, minerals, homeopathics) Name of drug, vaccine or natural medicine Describe the reaction Illnesses Please indicate if you ve had any of the following illnesses: Scarlet fever Diphtheria Rheumatic fever Mumps Measles German measles Chicken pox Shingles Tuberculosis Medical History Father Mother Grandparents Brothers Sisters Spouse Child Age (if living) Age when died Reason for death Father Mother Grandparents Brothers Sisters Spouse Child High Blood Pressure Heart Attack/ Stroke Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Y N Heart Disease Y N Y N Y N Y N Y N Y N Y N Asthma / Allergies Y N Y N Y N Y N Y N Y N Y N Mental Illness Y N Y N Y N Y N Y N Y N Y N TB Y N Y N Y N Y N Y N Y N Y N Auto-Immune Disease Y N Y N Y N Y N Y N Y N Y N Diabetes Melitus Y N Y N Y N Y N Y N Y N Y N Osteoporosis Y N Y N Y N Y N Y N Y N Y N Do you have a family history that includes any of the following? (Please circle all that apply) Cancer Cardiovascular Disease Alcoholism/Addiction Depression Diabetes Thyroid Disorder
6 Page 5 of 8 Nutrition & Lifestyle Food #/wk Food #/wk Food #/wk Fruits Soy products (tofu, soy milk, Fast food etc.) Vegetables Soft drink (regular) Coffee Luncheon meat/smoked meat Soft drink (diet) Regular (caffeinated) tea Breads and baked goods Salty snack foods (chips, etc.) Herbal tea/green tea Cow s milk Sweets (candies, cookies, etc.) Wine/beer Cheese Artificial sweeteners Other alcoholic drinks Yogurt Meal replacement bars/drinks Glasses of water/day? Is there anything about your diet you would like to change? On average how many meals do you have per day? List any foods that you crave regularly List any foods you exclude from your diet Do you follow a specific diet regime? Vegetarian Vegan Other Any known food allergies/intolerances/sensitivities? Do you exercise? Y N What type and how often? Do you spend time outdoors? How much? Are you regularly exposed to toxins or other hazards (work, home, hobbies, etc.)? Please describe. How would you describe the emotional climate of your home? How would you rate your stress level? How well do you handle these stressors? Low High Please list the 5 most significant stressful events in your life, from most recent to most distant (include date): How would you rate your energy? Low High Has you energy level changed recently? Has your weight changed by more than 10lbs in the past 6 months? Sleep How many ours of sleep do you typically get? Do you fall asleep easily and sleep soundly? Do you feel refreshed on waking? Do you have a regular sleep routine?
7 Page 6 of 8 Medical History Please indicate whether you experience, or have experienced in the past, any of the following. Y = current concern N = never experienced P = experienced in past Skin Eczema, hives? Y N P Lumps? Y N P Acne, boils? Y N P Hair loss? Y N P Itching? Y N P Dryness? Y N P Colour change? Y N P Night sweats? Y N P Temperature change? Y N P Change in a mole? Y N P Head/Neck Headaches? Y N P Head Injury? Y N P Migraines? Y N P Jaw/TMJ problems? Y N P Goiter? Y N P Swollen glands? Y N P Glasses/contacts? Y N P Changes in vision? Y N P Eye pain? Y N P Colour blindness? Y N P Tearing or dryness? Y N P Cataracts? Y N P Glaucoma? Y N P Blind spot? Y N P Eyes sensitive to the sun? Y N P Ringing in ears? Y N P Eye itching/redness? Discharge? Y N P Impaired hearing? Y N P Sinus problems? Stuffiness? Y N P Earaches? Y N P Frequent sore throat? Y N P Ear discharge? Y N P Teeth grinding? Y N P Ear infections? Y N P Gum problems? Y N P Nose bleeds? Y N P Amalgam fillings? Y N P Hay fever? Y N P Loss of taste? Y N P Loss of smell? Y N P Sore tongue/mouth? Y N P Hoarseness? Y N P Jaw clicks? Y N P Respiratory Cough? Y N P Pain on breathing? Y N P Spitting up blood? Y N P Sputum? Y N P Asthma? Y N P Wheezing? Y N P Pneumonia? Y N P Bronchitis? Y N P Emphysema? Y N P Shortness of breath? Y N P Tuberculosis? Y N P Shortness of breath lying down? Y N P Cardiovascular High blood pressure? Y N P Angina? Y N P Low blood pressure? Y N P Murmurs? Y N P Blood clots? Y N P Fainting? Y N P Phlebitis? Y N P Palpitations/fluttering? Y N P Rheumatic fever? Y N P Chest pain? Y N P Swelling in ankles? Y N P Past ECG (Echocardiogram)? Y N P
8 Page 7 of 8 Gastrointestinal Trouble swallowing? Y N P Change in thirst? Y N P Nausea? Y N P Change in appetite? Y N P Vomiting? Y N P Heartburn/ Indigestion? Y N P Vomiting blood? Y N P Constipation? Y N P Blood in stool? Y N P Diarrhea? Y N P Abdominal pain or cramps? Y N P Worms/Parasites? Y N P Belching or passing gas? Y N P Gall bladder disease/gall stones? Y N P Black, tarry stools? Y N P Ulcer? Y N P Jaundice (i.e., yellow skin)? Y N P Hemorrhoids/fissures? Y N P Liver disease? Y N P Hernia? Y N P Bowel movements how often? Change in bowel movements? Y N P Urinary Pain on urination? Y N P Frequent infections? Y N P Increased frequency? Y N P Inability to hold urine? Y N P Urination at night? Y N P Kidney stones? Y N P Urgency or hesitancy? Y N P Blood in urine? Y N P Male Reproduction Hernias? Y N P Prostate enlargement or disease? Y N P Testicular pain or masses? Y N P Discharge or sores? Y N P Are you sexually active? Y N P Chlamydia? Y N P Impotence? Y N P Gonorrhea? Y N P Premature ejaculation? Y N P Condyloma (i.e. genital warts)? Y N P Do you use birth control? Y N P Herpes? Y N P What type? Y N P Syphilis? Y N P Female Reproduction/Breasts Age at first menses? Are you sexually active? Y N P Age at last menses? (if menopausal) Do you use birth control? Y N P Typical duration of bleed? Days What type? Typical length of cycle? Days Difficulty conceiving? Y N P Are cycles regular? Y N P Pain during intercourse? Y N P PMS? Y N P Number of pregnancies? Painful menses? Y N P Number of live births? Heavy or excessive flow? Y N P Number of miscarriages? Bleeding between periods? Y N P Number of abortions? Clotting during menses? Y N P Gonorrhea? Y N P Unusual vaginal discharge? Y N P Herpes? Y N P Vaginal itching? Y N P Chlamydia? Y N P Date of last PAP? Condyloma? (i.e. genital warts) Y N P
9 Page 8 of 8 Abnormal PAP? Y N P Syphilis? Y N P Cervical dysplasia? Y N P Have you had a DEXA bone scan? Y N P Endometriosis? Y N P Do you do breast self-exams? Y N P Ovarian cysts? Y N P Breast pain or tenderness? Y N P Menopausal Symptoms? Y N P Breast lumps? Y N P Have you had a mammogram(s)? Y N P Nipple Discharge Y N P Musculoskeletal Joint pain or stiffness? Y N P Weakness? Y N P Broken bones? Y N P Sciatica? Y N P Muscle spasms or cramps? Y N P Backache? Y N P Joint swelling? Y N P Neck pain/stiffness? Y N P Vascular/Neurologic Easy bleeding or bruising? Y N P Anemia? Y N P Deep leg pain? Y N P Cold hands/feet/other? Y N P Varicose veins? Y N P Extremity swelling? Y N P Seizures/convulsions? Y N P Numbness or tingling? Y N P Muscle weakness? Y N P Speech problems? Y N P Vertigo? Y N P Loss of balance? Y N P Paralysis? Y N P Involuntary movement? Y N P Fatigue? Y N P Heat or cold intolerance? Y N P Excessive thirst? Y N P Hypoglycemia? Y N P Excessive hunger? Y N P Excessive sweating? Y N P Excessive urination? Y N P Immune Chronically swollen glands? Y N P Chronic infections? Y N P Frequent cold/flu? Y N P Slow wound healing? Y N P Mental/Emotional Treated for emotional issues? Y N P Memory problems? Y N P Mood swings? Y N P Anxiety or nervousness? Y N P Poor concentration? Y N P Depression? Y N P Phobias? Y N P Considered/attempted suicide? Y N P Seasonal depression? Y N P Is there anything else that you would like to add or comment on?
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