Informed Consent and Request for Naturopathic Medicine

The Body Shop

Informed Consent and Request for Naturopathic Medicine

I understand that the evaluation, diagnosis and treatment by a naturopathic physician, and specifically by Dr. Winter at The Body Shop may include, but is not limited to:

§  Interview (history taking)

§  Physical examination

§  Common diagnostic procedures (such as, diagnostic imaging, laboratory evaluation of blood, urine, stool, and saliva, Pap smears)

§  Dietary advice and therapeutic nutrition (such as therapeutic use of foods, diet plans, nutritional supplements, intravenous and intramuscular injections)

§  Acupuncture

§  Prolotherapy and/or PRP Therapy

§  Botanical Medicine and nutraceuticals/supplements

§  Homeopathic remedies

§  Over the Counter medications

§  Prescription Medications to be filled at a pharmacy

I understand and informed that in the practice of Naturopathic Medicine there are risks and benefits with evaluation, diagnosis and treatment including but not limited to the following:

Potential risks: pain, discomfort, minor bruising from acupuncture, IV, or prolotherapy, allergic reaction to prescribing herbs, supplements, prescription medications; an aggravation of pre-existing symptoms.

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

Notice to all pregnant women: all female patients must alert the provider if they know or suspect that they are pregnant, since some of the therapies could present a risk to the pregnancy.

By signing below. I (print name), ______acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I also understand that it is my responsibility to request that the provider explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been given to me concerning the results intended from the treatment. I intend that this consent form is to cover the entire course of treatments for my present condition and any future conditions for which I am seeking.

______

Signature Date

______

Signature of Patient Representative or Guardian

The Body Shop

PATIENT INFORMATION FORM:

Name:______Date of birth:______Age:______

Address:______

Phone: (home) ______(mobile)______

E-mail address:______Occupation:______Name of employer:______

Name of Spouse:______

Emergency Contact Person:______Emergency Contact Phone:______

Relationships:______

I authorize employees of The Body Shop to leave a detailed message for me on a voice message device associated with the phone number listed below, regarding my:

1. Laboratory reports: ___ yes (initials______) ___no (initials_____)

2. Protected health information: ___ yes (initials_____) ___no (initials_____)

If you answered YES to either of the above on which phone number is it acceptable to leave this information?______

If you answered NO to either of the above, the physicians and/or staff members at The Body Shop will, as necessary, leave a message indicating your need to call the clinic to retrieve any of your health-related information.

Whom may we thank for referring you? ______

The Body Shop

Dr. Erin Winter NMD

New Patient Intake Form

Date:

Patient Name: DOB: Age:______

List in Order of importance what your problems are:

1)

2)

3)

4)

5)

Last time you had blood work done and with what physician:

Family History

Check YES, NO, or ? (don’t know) for blood relatives

Yes / No / ? / Who in the family: / Yes / No / ? / Who in the family:
Alcoholism / Heart Disease
Allergies / Hypoglycemia
Anemia / High Blood Pressure
Asthma / Mental Illness
Auto-immune disease / Skin Disorders
Cancer / Seizure of Epilepsy
Diabetes / Stroke
Gout / Thyroid Disorders
Glaucoma / Osteoporosis

List All Surgeries & Hospitalizations, including date occurred:

1) 4)

2) 5)

3) 6)

Please Note When & Why You Have Had Each of the Following:

X-Rays: MRI/Cat Scans:

Ultrasounds: Accidents:

TB Test: HCV:

HIV: Last Dental Visit:

Last Eye Exam:

Did you have the following Disease (D), Get Immunized (I), or Neither (N):

Measles: D I N Chicken Pox: D I N Mumps: D I N Rubella: D I N

Tetanus: D I N Whooping Cough: D I N Hemophilus (Hib): D I N Hepatits B: D I N

German Measles: D I N Any vaccination reactions:

List Yes (Y), No (N) or Past (P) regarding use of the following:

Antacids: Y N P Steroids: Y N P Smoking: Y N P Packs per day & number of years:

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 & how much if Yes/Past:

Any Alcohol Addiction: Y N P Any Alcohol Treatment: Y N P

Recreational Drugs: Y N P Any Drug Addictions: Y N P

Any Drug Treatment: Y N P

List All Allergies to Medications or Foods:

Review of Systems:

Present Weight: Weight one year ago: Height:

Maximum weight and when: Minimum weight as adult & when:

Ideal Weight:

Good Energy: Yes No Past Fatigue: Yes No Past

If you have fatigue, when is it the worst? Morning Afternoon Evening

If you have fatigue, can you do what you need to during the day? Yes No

REGARDING THE NEXT LONG SECTION: Please check any of the symptoms you’ve had in the past or have now, and explain next to it.

Skin
□ Rash
□ Hives
□ Psoriasis/Eczema
□ Dry skin
□ Cancer
□ Color change
□ Lump
□ Itchy
□Warts/moles
□ Perspiration
Head
□ Headache □ Migraines
□ Head Injury
□ Dandruff
□ Oil/dry hair
□ Hair loss
Nose
□ Frequent colds
□ Congestion
□ Polyps
□ Nosebleeds
□ Post Nasal Drip
□ Seasonal Allergies
Eyes
□ Dry/watery
□ Double Vision
□ Blurry Vision
□ Cataracts
□ Glaucoma
□ Strain
□ Itchy
□ Styes
□ Discharge
□ Dark under eyelid
Mouth and Throat
□ Sore Throat
□ Canker Sores
□ Cold Sores (fever blisters)
□ Gum Disease
□ Loss of Taste
□ Cavities
□ Hoarseness
□ Dentures
Neck
□ Stiffness
□ Full movement
□ Swollen Glands
□ Tension / Respiratory
□ Asthma
□ Bronchitis
□ Cough
□ Pneumonia
□ Painful Breathing
□ TB
□ Shortness of Breath with Exertion
□ Shortness of Breath sitting
□ Shortness of Breath lying down
□ Wheezing
Cardiovascular
□ Arrhythmias
□ Chest Pain
□ Edema
□ High Blood Pressure
□ Low Blood Pressure
□ Palpitations
□ Murmurs
□ Rheumatic Fever
Urinary Tract
□ Discharge/blood
□ Frequent Infections
□ Kidney Stones
□ Incontinence
□ Pain with Urination
□ Urgency
Gastrointestinal
Bowel Movement Frequency: ___ / day
□ Bloating
□ Constipation/Diarrhea
□ Nausea/ Vomiting
□ Change in appetite
□ Recent Bowel Changes
□ Heartburn
□ Indigestion
□ Hemorrhoids
□ Ulcers
□ Pancreatitis
□ Gall Bladder Disease
□ Liver Disease
□ Other: ______
Nervous
□ Carpal Tunnel Syndrome □ Paralysis
□ Sciatica
□ Tingling/ Numbness
□ Seizures
□ Fainting
Musculoskeletal
□ Weakness
□ Stiffness
□ Arthritis
□ Leg Cramps
□ Tremors
□ Pain / Mental/ Emotional
□ Anxiety
□ Anger/ Irritability
□ Depression
□ Eating Disorder
□ Fear/ Panic
□ High Strung/ Tense
□ Psych hospitalization
□ Suicidal
Endocrine
□ Diabetes
□ Fatigue
□ Thyroid
□ Other: ______
Male Genitalia
Sexual Orientation: Hetero Homo Bi
Sexually Active: Yes No
□ Hernia
□ Discharge
□ Impotency
□ Prostate Disease/ Symptoms: ______
□ Testicular Pain/ Swelling
□ STD: ______
Female Genitalia
Sexual Orientation: Hetero Homo Bi
Sexually Active: Yes No
Age Period began: _____
Period lasts _____ days
How often periods occur: every ____ days
□ Heavy Menstrual Bleeding
□ Menstrual Pain
□ Menstrual Cramping
□ PMS
□ Food Cravings
Number of pregnancies: _____
Number of live births: ____
Number of abortions: ____
Number of miscarriages: ___
Date of last Pap Smear: ______Normal Abnormal □ Dry Vagina
□ Pain with intercourse
□ STD: ______
□ Healthy Libido
□ Vaginitis
Age at Menopause: ____
□ Use of Hormones:______
□ Use of Birth Control: ______

How often do you exercise? What type of exercise?

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

Toxin Exposure

Did you grow up near any refinery, polluted area or in a 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 or other chemicals around your home?

Social Life

Enjoy job: Y N P Hours worked per week: Highest Level of Education:

Active spiritual practice: Y N P Quality of significant relationship:

History of sexual, mental/emotional, physical abuse: Y N P 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

List all Supplements and Medications

Name and Brand / Dose

Hormone Review

Women’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing

Men’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing

SYMPTOM / HEALTH CONCERN
Hot Flashes Night Sweats Vaginal Dryness
Incontinence / Low Estrogen
Bleeding Changes Uterine Fibroids Water Retention
Tearful Depressed Mood Swings
Tender Breasts/Fibrocystic Breasts Increased Forgetfulness Foggy Thinking / Estrogen Dominance
Stress Morning Fatigue Difficulty Sleeping
Decreased Stamina Anxious Irritable
Nervous Fibromyalgia Allergies
Headaches Sugar Cravings Dizzy Spells / Adrenals
Cold Body Temperature Goiter Hoarseness
Hair Dry or Brittle Nails Breaking or Brittle Constipation
Slow Pulse Rate Rapid Heartbeat Heart Palpitations
Infertility Problems / Thyroid
Acne Increased Facial/Body Hair Scalp Hair Loss
Weight Gain – Hips Weight Gain – Waist High Cholesterol
Elevated Triglycerides / Metabolic Syndrome/
High Androgens
Decreased Libido Decreased Muscle Size Thinning Skin
Ringing in Ears Rapid Aging Aches and Pains / Low Androgens/Other
SYMPTOM / HEALTH CONCERN
Decreased Urine Flow Increased Urinary Urge Prostate Problems
Weight Gain – Chest / Hips Weight Gain – Waist / Estrogen Dominance
Decreased Libido Decreased Erections Ringing in Ears Elevated Triglycerides High Cholesterol Hot Flashes Decreased Stamina Night Sweats Decreased Mental Sharpness Increased Forgetfulness Decreased Muscle Size Decreased Flexibility Sore Muscles Increased Joint Pain Bone Loss Rapid Aging Thinning Skin
/ Metabolic Syndrome/
Low Androgens
Burned Out Feeling Stress Morning Fatigue
Evening Fatigue Difficulty Sleeping Apathy
Depressed Mental Fatigue Anxious
Irritable Nervous Headaches
Sugar Cravings Dizzy Spells / Adrenals
Cold Body Temperature Goiter Hoarseness
Hair Dry or Brittle Constipation Slow Pulse Rate
Rapid Heartbeat Heart Palpitations Infertility problems / Thyroid

♦ 515 N. Beaver Street ♦ Flagstaff, AZ 86001 ♦ (928) 214-7303 ♦ Fax: (928) 214-0696 ♦

711 N. Beaver Street¨ Flagstaff, AZ 86001 ¨ (928) 779-3783 ¨ Fax: (928) 473-1082 ¨ www.northernaznaturalmedicine.com