New Client Medical and Insurance Intake Form

Connected Wellness Center2227 152nd Ave NE, Redmond WA 98052 425-450-0100

New Client Medical and Insurance Intake Form

Insurance/Health Care

Client’s Name

LastFirstMiddle

Address

Street & Apt. #CityStateZip

Home Phone Cell Phone Other

Any restrictions for contacting you? No  Yes Email address:

Contact restrictions:

Age Birthdate / / Sex  Female Male

Marital Status Single Married to: Other

Client’s Employer Occupation

Work phone Ext. Okay to call you at work? Yes  No

Address

Street & Suite #CityStateZip

Emergency Contact

(not in your household) Relationship to client

Address City State Zip Phone #

How did you hear about us?(Please circle)

RadioTVMagazine adInternetOther

I allow Connected Wellness Center to use and hold this information. Connected Wellness Center values my confidentiality and will not release any of this information to any outside source without my permission.

RESPONSIBILITY: I clearly understand and agree that I am personally responsible for payment in full for all services rendered to me. I understand that I am personally responsible for payment in full for any and all services not covered by insurance. It is my responsibility to know whether or not my insurance covers the services offered by Connected Wellness Center, LLC.

I understand that I will pay the charges that I incur that are not covered by insurance. I understand that if I cannot make it to an appointment it is my responsibility to cancel at least 24 hours prior to my appointment. If I do not cancel within 24 hours I will pay a CANCELLATION FEE of $50 which will be billed to me on the day I miss the appointment.

CONSENT FOR TREATMENT: I hereby authorize Dr. Michelle Turcotte and whomever she designates as an assistant to administer various modes of therapy as she deems necessary.

Privacy: 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. You have the right to view or receive a copy of the information in your medical chart. This information is not disclosed to any other party without your written permission or court documents legally requiring this information. From time to time, you may overhear patient information within our offices; we ask that you keep it confidential.

I certify that I have read and understood the above information, and that what I have written is true and correct.

SignatureDate

Connected Wellness Center 2227 152nd Ave NE, Redmond WA 98052 425-450-0100

Health History

Name Date

Please take the time to fill out this questionnaire carefully. The information you provide will assist your provider in formulating a complete health profile for you. Please use the back of the page if you need more room to write.

When and where did you last receive medical/health care?

Present Health Concerns: (in order of importance) Duration

1.

2.

3.

Exercise:

Type of activity / Days per week / Length of workout

Nutrition/Diet History

Breakfast yesterday
Lunch yesterday
Dinner yesterday
Snacks
Water/type caffeine alcohol sugar
Diet restrictions

Allergies:(drugs, food, metal, environmental (grass/pollen, etc.) Please circle any that are life-threatening.

Are you sensitive to chemical smells?

List any chemicals, fumes, and dusts etc that you are or have been repeatedly exposed to:

Medications/Drugs: (prescription and over-the-counter, that you are now taking)

Name of drug Reason for drug Dose (mg, etc.) For how long; Prescribing doctor

Vitamins/Herbs/Supplementsthat you are taking:

Name/type: Reason for taking Dose/day (mg, etc.) For how long: Prescribing doctor

Connected Wellness Center 2227 152nd Ave NE, Redmond WA 98052 425-450-0100

Name Date

Your Family Medical History

Age (at death if deceased) / Mother / Father / Grand
Parents
Maternal / Grand
Parents
Paternal / Brother(s) / Sister(s) / Child
(NOT
Spouse)
Cancer/type:
Diabetes
Heart Disease
High Blood Pressure
Stroke
Epilepsy
Mental Illness/Depression
Asthma
Allergies
Anemia
Kidney Disease
Glaucoma
Osteoporosis
Tuberculosis
Obesity
Alcoholism
Seizure disease
Autoimmune/Arthritis
Others not listed above

Your Health History

Accidents or significant traumas (physical or emotional)

Date: / Description:

Surgeries, hospitalizations, and/or in-patient treatments

Date: / Description:

Childhood diseases:

Scarlet fever Diphtheria Measles MumpsRheumatic feverGerman measles

Other

Immunizations:

PolioTetanus MMR PertussisDiphtheriaOther

SignatureDate

Connected Wellness Center 2227 152nd Ave NE, Redmond WA 98052 425-450-0100

Name Date

Your Current Health

Conditions with which you have been diagnosed and times/ages associated with the condition:

All allergies or sensitivities that you have due to medication or other substances:

Place a checkmark next to the conditions you have experienced and note the date.

Skin and hair:

RashesUlcerations Hives/Allergic DermatitisItching

Eczema/PsoriasisDandruff Loss of hairMoles

Skin color changeAcne Change in skin/hair textureFace flushing

Dermatitis Warts Fungal infectionExcessive sweating

Head, Eyes, Ears, Nose and Throat

GlassesNight blindnessDifficulty swallowingHeadaches

Eye strainBlurred/poor visionFrequent sore throats/coldsMigraines

GlaucomaSpots in front of eyes Sore on lips/tongueRinging in ears

Eye painDouble vision Nose bleedsEar aches

Dryness in eyesDental/gum problems Grinding teethPoor hearing

CataractsSinus problemsJaw clicks/locksFacial pain

Cardiovascular

Chest pain or pressureSpontaneous sweatingVaricose/ spider veinsFainting

Cold handsSwelling of hands/feetHigh blood pressureBlood clots

Irregular heart beatAnginaLow blood pressure

Respiratory

Cough, wheezingPneumoniaAsthmaShortness of breath

Coughing bloodBronchitisPain with deep inhalationDifficulty breathing

Musculoskeletal

Joint pain/stiffnessMuscle weaknessBack painSprains/strains

Muscle pain/crampsNeck painSciaticaBroken bones

Gastrointestinal

Changes in appetiteBloating/EdemaLoose stools/diarrheaRectal pain

Excessive appetiteGasConstipationHemorrhoids

Poor appetiteBelchingChronic laxative useHernia

IndigestionBad breathGall bladder diseaseBlack stools

NauseaAcid refluxBlood in stoolLiver disease

VomitingSignificant thirstAbdominal pain/crampsUlcers

Genito-urinary (male patients)

Pain on urinationFrequent urinationBlood in urineUrgent urination

Unable to hold urineKidney stonesScanty flowCopious flow

ImpotenceSores on genitalsUrinary tract infectionBurning urination

Premature ejaculationDecreased libidoDribbling after urinationProstatitis

Nocturnal emissionPain in testiclesHerpes infections

Night urination—What time How often?

Genito-urinary (female patients)

Pain on urinationPainful intercourseFibrocystic breast tissuePMS

Unable to hold urineSore on genitalsPainful MenstruationBreast lumps

Frequent urinationVaginal drynessIrregular menstruationScanty flow

Vaginal dischargeBleeding between cyclesNipple dischargeInfertility

Urinary tract infectionUterine fibroidsBlood in urineOvarian cysts

EndometriosisBreast pain/ tenderness

Age of first menses: Date of last menses: Frequency of menses:

# of live births: # of miscarriages # of abortions Date of last PAP

Do you practice birth control? What type? How long?

Neuropsychological

Seizures/faintingAnxiety/panic attacksBad temper/irritableAreas of numbness

AlcoholismNervousnessSeasonal Affective DisorderPoor Memory

AddictionTension/stressDepressionLack of coordination

Comments:

Are there any other problems that you would like to discuss?

Connected Wellness Center 2227 152nd Ave NE, Redmond WA 98052 425-450-0100

Review of Systems

(Check if you now have, or circle if you previously have had any of the following and list the type.)

Blood/Circulatory:

Anemia

Bleeding coagulopathies/ use of anticoagulants

Blood diseases (______)

Irregular heart beat

Heart disease

Heart failure

Poor circulation

Significant swelling of ankles

Varicose veins

Digestive:

Constipation

Diarrhea

Hemorrhoids

Lasting nausea

Liver disease

Hepatitis

Stomach ulcers

Hormonal:

Diabetes

Fibrocystic breasts

Polycystic ovarian syndrome

Thyroid problems

Musculoskeletal:

Arthritis

Bursitis

Hot and swollen joint

Persistent neck/back pain or stiffness

Recurrent headaches

General:

Current pregnancy

Cancer (______)

Daily alcohol consumption

Fatigue (affecting daily living)

Immunological:

Allergies

Autoimmune disease (______)

Immune suppression

HIV/AIDS Immunosuppressive medications (______)

Neurological:

Dizziness (more than 5 seconds)

Loss of hearing

Persistent numbness or weakness

Recent loss or change in vision

Ringing in ears

Stroke

Pulmonary:

Asthma

Chronic bronchitis

Difficulty breathing

Tuberculosis

Urogenital:

Kidney stones

Kidney infection

Sexually transmitted diseases

Integumentary:

Skin problems (______)

Skin cancer (Malignant melanoma, recurrent non-melanoma skin cancer, pre-cancerous lesions)

Keloid scarring

Very dry skin

Herpes simplex virus infection

Most recent sun-tanning exposure date

Other:

I certify that this profile is complete to the best of my knowledge. I understand that providing false information or leaving out pertinent information may compromise the quality of medical care I receive.

Signed: Date: