Dr. Nicole Sundene Natural & Prescription Family Medicine

Dr. Nicole Sundene Natural & Prescription Family Medicine

Date:______

Name: ______

Age: ______DOB: ______Sex: Male _____ Female _____

Address: ______City ______State: ___ Zip: ______

Home Telephone: ______Work: ______Cell: ______

Email: ______

Permission to leave detailed messages regarding your medical care at:

___ home ___ work ___ cell

If minor, name of parent/guardian(s) ______

Emergency Contact: ______Relationship: ______

Telephone: home ______cell______work______

Whom May we Thank for Referring You? ______

Primary Care Physician: ______Last Exam __/___/______

Y/N Dr. Sundene will be my Primary Care Physician

Physicians on Care Team______

______

Insurance: ______Lab Coverage: Labcorp/Sonora

Pharmacy______Phone______

Please list your health concerns, in order of importance:

1.______

2.______

3.______

4.______

5.______

How would you rate your health overall? Circle One Excellent Good Fair Poor

How committed are you towards making changes in your health: Little Moderate Very

PAST MEDICAL HISTORY

Frequent ear infections, colds, illness, eczema, or asthma as a child? Y N

Were you breastfed? Y N

Vaccinated? Y N

Any difficulties with your birth or your mother’s pregnancy with you? Y N

Ever taken antibiotics for a prolonged period of time? Y N

For what condition? ______

Surgeries/Hospitalizations/Past Disease?______

______

History of Abuse? Emotional/Physical/Sexual/Neglect Y N ______

Past Trauma? Death/Divorce/Major Accidents/Etc Y N ______

CURRENT MEDICATIONS

List all drugs, vitamins, or supplements:______

______

______

ALLERGIES TO MEDICATIONS? Y N ______

Food or Environmental Allergies: ______

______

FAMILY HISTORY

Please list ages, any major health problems, and if deceased, what they died from and at what age.

Mother ______

Father______

Your Sisters______

Your Brothers ______

Mother’s Side: ______

Grandfather ______

Grandmother ______

Father’s Side: ______

Grandfather: ______

Grandmother______

Cigarettes: Y N P # Packs/Day? ______# Years? ______

Marijuana/Cocaine/Other Drugs: Y N P Frequency:______

Alcohol: Y N P Drinks per week? ______Type of alcohol: ______

History of eating disorder? Y N

Present Weight: ______Height: ______Weight one year ago: ______Ideal Weight: ______

Do you exercise? Y N How often? ______

What do you do for fun or to relax? ______

FEMALE HEALTH

Date of Last Menstrual Period ______Periods last #______Periods every ______days

# of Pregnancies _____ # of children ____ Miscarriages/abortions ______

Date of last PAP ______History of Abnormal PAP Y N P When ______

SLEEP HISTORY

Average hours per night?____ Quality of sleep ______Wake rested Y N

Do you have difficulty falling asleep? Y N If so, what keeps you awake? ______

Do you wake up during the night? Y N If so, what time(s) and how often? ______

ENVIRONMENTAL EXPOSURE HISTORY

Jobs or hobbies where you were exposed to solvents, heavy metals, fumes or other toxic materials? Y N______

Health problems fromnew carpeting, new paint, new cabinets or did other refurbishing? Y N______

Year your home was built: ______

Are you particularly sensitive to mold, perfumes, gasoline or other vapors? Y N

ADDITIONAL HISTORY

Occupation: Employer/Business: ______

Hours worked per week: ______Enjoy work: Y N P

Stress level 1-10 (10=Worst)______Energy 1-10 (10=Best)______Mood 1-10 (10=Best)______

Active spiritual practice: Y N P

Marital Status (circle): Single Married Partnered Separated Divorced Widow(er)

Children: Y NNumber of children: ______Age(s): ______

Quality of significant relationship: GOOD GREAT POOR ______

Do you feel safe in your home? Y N Is your home peaceful? Y N ______

DIET

Numbers of meals eaten daily 1 2 3 more than 3

Typical Daily Diet: Breakfast: ______

Lunch: ______

Dinner: ______

Snacks: ______

Beverages: ______

How many cups per day/week: Coffee ____ Energy Drinks ____ Black Tea ____ Soda ____

Water ______(Circle one)TapFilteredBottled

Foods craved: ______

Foods avoided: ______

Please circle (Y) if you CURRENTLY HAVE THE PROBLEM, (N) if you have NEVER had the problem, (P) if you had the problem in the PAST.

GENERALDry HairY N PEar infectionsY N P

FatigueY N PHair LossY N PRinging In EarsY N P

Frequent ColdsY N PExcess HairY N PHearing LossY N P

Poor MemoryY N PHead & Neck`Excessive ear waxY N P

Poor SleepY N PHeadachesY N PNose, Mouth, Throat

Night SweatsY N PMigrainesY N PCongestionY N P

FaintingY N PSwollen GlandsY N PPolypsY N P

DizzinessY N PHead InjuryY N PNosebleedsY N P

Poor ConcentrationY N PDandruffY N PPost-Nasal DripY N P

Skin & HairY N PNeck StiffnessY N PSeasonal AllergiesY N P

RashesY N PEyes & EarsSinusitisY N P

Color ChangeY N PBlurry VisionY N PCanker SoresY N P

HivesY N PItchingY N PCold SoresY N P

Skin CancerY N PDryY N PLoss of taste/smellY N P

Psoriasis/EczemaY N PWateryY N PBleeding GumsY N P

ItchingY N PGlaucomaY N PDry MouthY N P

Dry SkinY N PCataractsY N PHoarse VoiceY N P

Warts, molesY N PDischargeY N PSore ThroatY N P

Weak, brittle nailsY N PSensitive to LightY N PCavitiesY N P

Excessive PerspirationY N PDark circles under eyesY N PToothacheY N P

RESPIRATORYVomitingY N PDischarge or BloodY N P

CoughY N PChange in AppetiteY N PFrequent urination at nightY N P

AsthmaY N PPancreatitisY N PMUSCULOSKELETAL

Shortness of BreathY N PUpset with fatty food Y N PLoss of StrengthY N P

BronchitisY N PDifficulty Swallowing Y N PStiffness of jointsY N P

PneumoniaY N PLiver Disease Y N PTremorsY N P

TuberculosisY N PGall Bladder Disease Y N PPainY N P

Chemical exposureY N PConstipation Y N PArthritisY N P

WheezingY N PDiarrhea Y N PLeg CrampsY N P

Painful BreathingY N PHemorrhoids Y N PSwelling of joinsY N P

CARDIOVASCULARUlcer Y N PMuscle PainY N P

High Blood PressureY N PMucous in stool Y N PNERVOUS SYSTEM

Low Blood PressureY N PBlood in stool Y N PParalysisY N P

Irregular Heart BeatY N PUse antacids Y N PTingling/NumbnessY N P

Swollen feet or ankles Y N PFeel bad if skip a meal Y N PSeizuresY N P

Varicose Veins Y N PExcessive gas Y N PSciaticaY N P

Rheumatic Fever Y N PAnal Itching Y N PCarpal Tunnel SyndromeY N P

Murmurs Y N PChanges in BM frequencyFaintingY N P

Y N P

Palpitations Y N P# Bowel movements/day MENTAL/EMOTIONAL

Chest Pain Y N PURINARY TRACTDepressionY N P

Leg Pain with walking Y N PFrequent Infections Y N PAnxietyY N P

GASTROINTESTINALIncontinence Y N PSuicidal ThoughtsY N P

Heartburn Y N PUrgency Y N PPanic AttacksY N P

Indigestion Y N PPain in Urination Y N PAnger/IrritabilityY N P

Bloating Y N PIncreased Frequency Y N PHigh-strung/tenseY N P

Nausea Y N PKidney Stones Y N PFear/phobiasY N P

Patient or Responsible Party Signature ______

Fountain Hills Naturopathic Medicine

16719 E Palisades Blvd Suite 205

Fountain Hills, AZ 85268

(480) 837-0900

Clinic Policies

_____ Payment: Payment is expected at the time of service. Patients are to assume all financial responsibility for all office visits, supplements and services rendered at the time of service. We accept cash, personal checks, and all major credit cards. Returned checks are subject to $25 return fee and no further personal checks will be accepted.

_____ Cancellation Policy: There is no charge if an appointment is cancelled with 24 hours notice. If we are not given adequate notice the full visit fee will apply.

______Lab Services: Follow up visits are required on all blood work due to the detailed nature of care we provide unless labs are normal and no adjustment to the treatment plan is required. Labcorp is our preferred lab. It is the patient’s responsibility to notify the doctor if Labcorp is not contracted with their insurance and of any changes in their insurance plan. Specialty tests considered “elective” by major insurance plans such as food allergy and neurotransmitter testing require payment at the time of service and will be discussed with the patient for approval before performed.

______Phone Calls: Phone calls requiring the doctor to diagnose or treat you over the phone will be charged at the same rate as office visits. We prefer you come in to the office for proper care. Clarifications on existing treatment plans and courtesy calls are not charged unless the patient asks the doctor to change their treatment plan or asks for additional care or extensive clarifications at the time of the courtesy call.

_____ Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant, as some of the therapies used could present a risk to the pregnancy.

_____ Emergency Care: Our clinic supplies urgent care for coughs, colds, flu’s, diarrhea, bladder infections, headaches, back and neck pain and so forth but does not administer emergency medical care such as casting and suturing. In the case of an emergency such as chest pain or sudden and severe abdominal pain please go to the emergency room and have the attending doctor fax us your visit notes and labs. After emergency care has been administered please schedule a follow up visit.

______Treatment: Treatment at this clinic requires an agreement between you, the patient, and Dr. Nicole Sundene. Any therapy will proceed only with mutual consent. It is possible that certain adverse effects may result from treatments. These could include, but are not limited to, local skin irritation, bruising, temporary pain or discomfort, adverse reactions to prescribed herbs or supplements such as allergic reaction, headache, nausea; and the possible temporary aggravation of symptoms existing prior to treatment. Because of the possibility of drug interaction with herbal formulas, we require our patients to inform the practitioner of any medications they may be taking, including any dietary supplements and herbs.

Patient’s Signature: ______Date:______

HIPPA Notice of Privacy Practices

This Notice explains how our office may use and disclose your protected health information and your rights regarding how we protect your health information. “Protected health information,” Including demographics, can be reasonably used to identify you, relates to your past, present or future physical or mental health condition, the provision of care to you, or the payment for that care. We reserve the right to change the terms of this Notice and our privacy policy at any time. Any changes will apply to all protected health information that we maintain effective the date of a new Notice. New Notices will be posted at Dr. Nicole Sundene’s Office and you may obtain one at any time. This Notice goes into effect August 1, 2010.

Uses and Disclosure

We may use and disclose your health information for different reasons:

Treatment: To assist in your diagnosis and treatment

.

Payment: In order to bill and collect payment for services provided. For example, to claims processing companies, others that participate in the claims payment process and your health insurance plan to get reimbursed for services.

Health Care Operations: For activities necessary such as quality management, utilization review, anti-fraud and claims payment, provider credentialing activities, and as required by industry or government regulators such as state licensing boards, insurance regulatory agencies, and the sponsor of your health plan.

Our office may not use or disclose any more of your protected health information than is necessary to accomplish the purpose of the use or disclosure, except for treatment purposes.

We must disclose, when required by law, for the following examples:

Avoid threat to health or safety. To law enforcement personnel or persons able to prevent or lessen a serious threat to public safety.

Coroners, Funeral Directors, Organ Donation. To said professionals such that they can carry out their duties.

Health oversight activities. To assist the government agencies, such as when it conducts an investigation or inspection of a health care organization.

Health oversight activities. To assist the government agencies, such as when it conducts an investigation or inspection of a health care organization.

Health-related Benefits or Services. We may contact you as a reminder that you have an appointment for treatment or medical care at our clinic, or tell you of or recommend possible treatment options or alternatives that may be of interest to you. We also may tell you about health related benefits, services, or health care education classes that may be of interest to you.

Law Enforcement, Judicial and Administrative Proceedings. In response to a subpoena, discovery request, in response to a warrant, to identify or locate a suspect, to provide information about a victim of a crime, or other lawful process.

National Security and Intelligence Activities. As required by military officials for security and military purposes.

Public health activities. To public health agencies for reasons such as preventing or controlling disease, injury or disability.

Research. For medical research – Such circumstances include taking steps to protect your privacy.

Victims of abuse, neglect or domestic violence. To government agencies and law enforcement personnel as required by law.

Workers’ compensation. In compliance with workers’ compensation laws.

Authorization

Any uses or disclosures other than those described above will be made only with your prior written authorization, unless otherwise permitted or required by law. In the event that you authorize us to use your protected health information for other uses, you have the right to revoke any authorization by delivering a written revocation statement, except to the extent that we have already disclosed the information or are allowed by law to use the information to contest a claim or coverage.

Patient Rights

Right to request restrictions on uses and disclosures: To request a restriction, please write a request to Dr. Nicole Sundene. Upon receiving your request, we will put the limits and terms in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required to make.

Right to receive confidential communications: This includes the right to direct where communications are sent. For example, you may request that information be sent to our work address rather than your home address or via email than by regular mail. To verify or modify where or how you would like communication sent, contact Dr. Nicole Sundene. Unless requested otherwise, we will direct mailings and telephone messages to the address/telephone number we have on record.

Right to inspect and copy: Includes the rights to see and get copies of your information that we maintain. Submit your request in writing to Dr. Nicole Sundene and we will respond to you within 30 days of receipt of your written request. We will charge you a reasonable copying fee for each page and mailing costs but will inform you of that fee in advance.

Right to amend: If you believe there is a mistake or missing information, you have the right to request that we correct or add to your file. You must provide the request in writing to Dr. Nicole Sundene. We will respond within 60 days of receipt of your written request. We may deny your request in writing if your information is 1) correct and complete, 2) not created by us, 3) not allowed to be disclosed, or 4) not part of our records. Upon approval, we will make the changes, inform you when the changes are complete, and inform others that need to know about the change in a timely manner. Our written denial will state the reason for the denial and explain your right to file a written statement of disagreement with the denial. You also have the right to request that copies of your initial request and our denial be attached to all future disclosures of your information.

Right to receive an accounting of disclosures. This will not include uses or disclosures made for treatment, payment or health care operations, disclosures made directly to you, those you have already authorized, those made for national security reasons or to law enforcement that has lawful custody over you. We will respond within 60 days of receiving written request. Please include the time period for which you want the accounting (can be no longer than 6 years and may not include dates before August 1, 2010).

The accounting will include the date of the disclosure, to whom information was sent, a brief description of the information disclosed, and a brief statement of the purpose for the disclosure. We will provide the first accounting at no charge. For additional accountings, we may charge you a fee but will inform you of that fee in advance.

Right to get a paper copy of this Notice. At any time even if you previously agreed to receive an electronic copy.

Right to file a complaint. If you believe your health information has been improperly used or disclosed, or that your privacy rights have been violated, you may file a privacy complaint with us. Contact Dr. Nicole Sundene. You also have the right to file a complaint with the Secretary of the US Department of Health and Human Services. We will take no retaliatory action against you if you file a complaint with us or the DHHS.

Note: If this acknowledgment is being signed by a legal representative, you must provide a copy of the power of attorney or other relevant document(s) designating you as the legal representative.

By signing, I acknowledge I have read and understood the above statements.

Patient’s Signature: ______

Print Name: ______

Date: ______