Patient Intake Form

Please fill out as thoroughly as possible and bring to your first visit.

 

PATIENT INFORMATION:

Name:                                                                                        DOB:                                      Age:                         Sex:  M / F

­­­­­­­­­­­­­­­­Address:                                                                                                                City/Zipcode:

Telephone: Home:                                                    Cell:                                                  Work:

At what phone numbers can we leave health-related messages? ______________________

Please check one:  Single           Married          Widowed          Separated          Other

Number of children and their ages: ______________________________________________

Occupation: ________________________________Employer: ________________________

Emergency contact: _____________Relationship: _______________Phone: _____________

How did you learn about the clinic? ______________________________________________

 

CURRENT HEALTH CONCERNS:

Please list concerns in order of priority:

Condition or Concern

Onset

Diagnosed by physician?

 

 

 

 

 

 

 

 

 

 

 

 

What is your MAIN goal for today? _________________________________________________

 

Do you already have a primary care physician?  □Yes:  Name:____________________________   □No

Have you been seen by a naturopathic physician before?  □Yes          □No

 

Please list any prescription drugs you are taking: If too many to fit, please type list.

Name

Dose

Duration of use?

 

 

 

 

 

 

 

 

 

 

List any supplements you’re taking: If too many to fit, please type list.

Name

Brand

Dose

Duration

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL AND FAMILY MEDICAL HISTORY:

Please check those that apply to you personally or your immediate family members (including grandparents).

 

 Measles                                                   Mumps                                                    Chickenpox

 Whooping cough                                   Scarlet fever                                          Diphtheria

 Smallpox                                                 Blood transfusions                                Heart Disease

 STD’s:                                                       Hives or eczema                                    Tuberculosis

 Diabetes                                                  Cancer:                                                   Polio

 Glaucoma                                                Hernia                                                     Kidney disease

 Bleeding tendency                                Anxiety                                                    Infectious Mono

 Rheumatic fever                                    Mitral valve prolapsed                         Stroke

 Hepatitis                                                  Thyroid disease                                     AIDS or HIV

 Anemia                                                    Depression                                             Auto-immune disease

 Hypertension/ High BP                         Liver disease                                          Mental illness

 Seizures                                                  Eating disorders                                   Elevated cholesterol

 

 

Please list any known allergies to medications: _______________________________________

 

List any Hospitalizations, surgeries, and previous traumas (with year): _______________________

____________________________________________________________________________

 

REVIEW OF SYSTEMS:

Please circle the condition or symptom you have personally experienced within the past 4 weeks’ time.

 

General:                                                  Skin:                                                          Head:

Weight gain                                            Rash                                                          Headache

Weight loss                                             Acne                                                          Migraine

Fatigue                                             Night sweats/Fever                                    Head trauma

                                                           Hair loss                                                   Dizziness

Neck:                                                                                                                        

Lumps                                               Mouth and throat:                                      Eyes:

Swollen lymph nodes                             Gum problems                                              Impaired vision

                                                           Dental problems                                          Increased tearing or dryness

Ears:                                                                  Frequent sore throat                                 Double vision

Impaired hearing                                 Sore tongue                                                   Glaucoma

Ringing                                             Post nasal drip                                               Cataracts

Ear pain

                                                          Nose and sinuses:                                       Respiratory:

Endocrine:                                                  Nose bleeds                                                   Cough (wet or dry?)

Hypothyroid                                           Sinus congestion                                          Wheezing

Hyperthyroid                                         Sinus infection                                              Bronchitis

Diabetes                                                                                                                  Pneumonia

Hypoglycemia                                           Musculoskeletal:                                         Emphysema

                                                                  Joint pain/stiffness                                     Difficulty breathing

Cardiovascular:                                     Broken bone(s)                                                    

Varicose veins                                       Muscle spasm/cramps                               Gastrointestinal:

Heart murmur                                       Muscle weakness                                        Heartburn/Reflux

Chest pain                                                                                                               Constipation/Diarrhea

Ankle swelling                                       Emotional:                                              Change in appetite/thirst                 

Heart palpitations                                Irritability                                                 Nausea/Vomiting

Elevated cholesterol                           Depression                                                     Blood in stool

Hypertension                                        Anxiety                                                            Belching/burping

                                                          Emotional lability                                          Gas/bloating

                                                                                                                                    Bowel movements per day:

Neurologic:                                            Urinary tract:                                                         

Seizures                                                   Frequent urination                                              

Fainting                                           Incontinence                                                         Miscellaneous:

Paralysis                                           Frequent UTI’s                                              Anemia                                    

Numbness/tingling                             Blood in urine                                                Easy bruising

Memory difficulties                            Kidney stones                                               Bone loss

Brain fog                                                                                                                  Chemical sensitivities

Loss of coordination                                                                   Frequent colds

Female reproductive:                                Cycle history:

Vaginal dryness/itching                             Last menstrual period:

 Low libido                                                Length cycle (28-30 days?):

 Pain w/ intercourse                                    Menses length (days of bleeding):

 Nipple discharge                                          Current birth control:

 PMS/painful menses                                  Number pregnancies:    

 Excessive or minimal flow                         Number miscarriages:             

                                                               

                                                                                                                                                                                                                                                                 

Please list the dates of your last exams:                                 

Full physical or Well Child: _________________________________________________________

Annual Gynecological exam with Pap smear: _________________________________________

Prostate exam: _________________________________________________________________

Bone density screening: __________________________________________________________

Screening mammogram: _________________________________________________________

Colonoscopy: ____________________________________________________________________

Eye exam: _____________________________________________________________________

Preventive dental exam: __________________________________________________________

Blood tests (what did they include?): _______________________________________________

 

Lifestyle Choices:

Tobacco use?                          yes    no              Type: __________            Frequency: _______________

Alcohol use?                           yes         no             Type: __________            Frequency: _______________

Recreational drug us?     yes    no              Type: __________            Frequency: _______________

Exercise routine?                  yes    no             Type: __________             Frequency:_______________

 

Diet:

Typical Breakfast:                                                                                     Lunch:                                                                       

Dinner:                                                                                                         Snacks:        

                             

Daily water intake (ounces):                                                           

Hours of sleep per night:

 

PEDIATRIC PATIENTS ONLY:

Nickname:                                                  Mother’s name:                         Father’s name:

Term:  □ Early  □ Full  □ Late                    Birth weight: ____lbs. ____oz.    Birth height: _____ inches  

Length of labor: _____hours

Pregnancy complications?  □ yes  □ no        Please describe: ____________________________

Labor complications?  □ yes  □ no        Please describe:  ________________________________

Breastfed?  □ yes  □ no        How long?  ________   Formula fed?  □ yes  □ no        Milk/Soy/Other

Age your child began: Solid food: ____ Sitting: ____ Crawling: ____ Walking: ____ First words: ____

 

Please indicate if your child has ever had any of the following: (circle)

Birth defects                                          Birth injuries                                          Colic

Constipation                                          Cough                                                       Cries easily

Diarrhea                                                   Fever                                                        Jaundice

Nightmares                                            Nose bleeds                                           Rash

Seizures                                                   Teeth problems                                                    Developmental issues

 

Vaccination History:

                    □ Up to Date (CDC recommended schedule)                           

                    □ Alternative vaccination schedule (Please bring records or child’s vaccine booklet)

                    □ I have chosen not to vaccinate my child

 

Is there any family history of any autoimmune, neurological or neurodevelopmental disorders?  Y/N

Has your child had any reactions to previously administered vaccinations? Y/N

  

statement of financial responsibility:

Payment Policy:

I understand that payment is expected in full at time of service and that accepted forms of payment include cash, personal checks, Visa, Mastercard and Discover. I am aware that NSF checks will be subjected to a $25 fee. I understand that Generations will bill my insurance for services rendered and further understand that Generations Natural Health Clinic does not guarantee reimbursement by my insurance company, and that it is my responsibility to determine my coverage and pay my responsibility.

I understand that I may request the fees for various procedures before they occur in order to include that information in my healthcare decision-making process. I understand that my practitioner may offer telephone consultations at an additional fee, which I will be made aware of in advance.

Cancellation Policy:

I am aware that Generations Natural Health Clinic requires at least 24 hours notice of cancellation in advance of the scheduled appointment time. I understand that missed appointments without notification may be charged the full visit fee, and cancellations with less than 24 hours notice may be billed 50% of the visit fee.

 

Patient/Guardian Signature ________________________________   Date_______________

Patent / Guardian Print Name_______________________________                                                         

Consent for Treatment:

Naturopathic medicine is considered a safe and effective method of care. Occasionally, however, complications can arise that are not predicted. Any procedure intending to help may have complications, and while the chances of experiencing such complications are small, it is the practice of this clinic to inform our patients of them.

I authorize Dr. Janel Newman-Kovacev ND to order/perform diagnostic tests and prescribe / perform treatments that I am in agreement with and that are in accordance with the Standards of Naturopathic Care for the state of Washington. Including but not exclusive of: common diagnostic procedures (venipuncture, PAP smears, lab tests), minor office procedures (wound dressing, ear lavage), medical use of nutritional therapies (therapeutic nutrition, nutritional supplements, vitamin injections), botanical medicine (plant substances prescribed as teas, alcohol or glycerite-based tinctures, capsules, tablets, powders, creams, plasters or suppositories), homeopathic medicines (the use of highly dilute quantities of natural substances to gently stimulate the body’s own healing processes), lifestyle counseling and hygiene (diet/nutrition therapy, recommendations for exercise, sleep, stress reduction and balancing of social and work activities), psychological counseling, contraceptive management, prescription medications.

 

While rare, potential risks include but are not limited to: soreness, bruising, inflammation, soft tissue injury, dizziness, allergic reactions to prescribed herbs or supplements and aggravations of pre-existing conditions.

Potential benefits include: restoration of health and the body's maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.

Notice to pregnant women: All female patients must alert the doctor if they know or suspect that they may be pregnant, since some of the therapies used could present a potential risk to your pregnancy.

If procedures are performed, I have given my permission to do so and acknowledge that full disclosure of information has been made. If I have questions about these procedures I will ask them until they are answered to my full satisfaction. I further acknowledge that there is no guarantee or warrantee, expressed or implied, concerning the outcome of any of the procedures used in the course of my care.

I understand that Generations Natural Health Clinic does not administer emergency medical care. I understand and agree that if I experience a medical emergency while under Dr. Janel Newman-Kovacev’s care, I am to immediately dial 911. After emergency care has been administered, I may seek naturopathic care to accelerate the natural healing process.

I recognize that a record will be kept of my care, and that I have the right to obtain a copy of my record upon request. I understand that obtaining a copy of my record may require payment of an administrative fee.

Patient/Guardian Signature ________________________________   Date_______________

Patient / Guardian Print Name_______________________________                                                                                                                                                                                                                                       

Insurance Information Form:

 

Please fill out this form if you DO or DO NOT have insurance coverage for your visits with Dr. Janel.

 Your name: ____________________________________________

Today’s Date: __________________________________________

Insurance: _____________________________________________

 

Have you called your insurance to see if visits with Dr. Janel are covered?

□ Yes, I have called and visits are covered

□ No, I haven’t called, but Dr. Janel is on my provider list

□ No, I haven’t called and I have no idea if visits are covered or not

 

Please fill out what you know:

Co-pay: ________________

Deductible: _______________

Percentage covered: _______________

Is there a yearly max for ND services: _______________

Coverage for preventative (annual exams, PAP’s, physical exams, well child checks): Y/N

Coverage for mental/emotional services (anxiety, depression, stress, other):  Y/N

 

If your insurance is through someone else (spouse, parent, other) please fill out the following:

Name of insured: _________________________________________

Birth date of insured: ______________________________________

Group number: __________________________________________

ID number: ______________________________________________

Employer: _______________________________________________

 

Please read, sign and date:

Generations Natural Health Clinic has a policy of offering a cash discount for services paid at the time of visit. If your insurance allows you to submit for reimbursement, you have the option of paying the discounted fee at the time of your visit. Our office will provide you with the codes needed for you to request reimbursement from your insurance company. This process is usually most beneficial for those patients who may not meet their deductible for the year. Please ask for clarification if you think you may benefit from this discount.

Please be aware that Dr. Janel may determine that some non-covered (your insurance will not pay for) tests or other services that may be important for your treatment. Dr. Janel will discuss these labs and services with you ahead of time whenever possible. By signing below, you are agreeing to pay for any testing or services that are not covered by your insurance policy and you are agreeing to not hold Generations Natural Health Clinic or Dr. Janel Newman-Kovacev responsible for payment of non-covered services.

Patient/Guardian Signature ________________________________   Date_______________

Patent / Guardian Print Name_______________________________