Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Height & Weight:
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Happiest Weight
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
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Marital Status:
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Single
Married
Spouse Name
Number of Children
Phone (Please list both home & cell if you have both!)
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(###)
###
####
Email
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Reason(s) for visiting:
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List top 3-5 reasons (start with most important)
Date of onset - can you think of when these health concerns began?
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Have you sought medical treatment for your health issue? If so, what medication(s) were prescribed, or advice given? And has that provided any relief?
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What (if anything) helps alleviate the symptoms or resolves them completely?
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What do you regularly eat? Walk me through a typical week of meals:
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How much Water do you typically drink in a day
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I typically sleep through the night & feel well rested upon waking.
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Do you agree with that statement?
In your opinion what are the least 3 healthiest things you consume on a weekly bases? (list below)
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In your opinion what are the 3 healthiest things you consume on a weekly bases? (list below)
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Please briefly describe typical eating habits melow: (please mention if you are currently following any diets, or have in the past)
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Do you consume any of the following?
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Do you feel stressed often?
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Yes
No
If you answered YES, what are contributing factors to your stress?
Self-care, Hobbies, & Relaxation - what do you do for these & how often?
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How often do you exercise
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What type of exercises do you enjoy/partake in?
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Any life altering events happen in the last 2 years?
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Have you had any of the following events occur within the past 2 years?
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Do you feel like there's anything else that may be holding you back?
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Major Illnesses & Surgeries
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Please list any instances where you suffered from a major illness, were admitted to hospital, or underwent surgery from infancy to present time
Detail all CURRENT medications (prescribed/over the counter)
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Include brand & product name, Dose & frequency, Reason for taking, And Date you started taking
Detail all PAST medications (in last 5 years)
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Include brand & product name, Dose & frequency, Reason for taking, And Date you started taking
Detail all CURRENT supplements (ie. vitamins/herbal tinctures)
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Include brand & product name, Dose & frequency, Reason for taking, And Date you started taking
IMMUNIZATIONS - Please list all vaccinations you have had that you can remember & are you aware of any side effects or adverse reactions to any immunizations you have received?
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Belching or gas within one hour of eating
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Never
In the Past
Occasionally
Frequently
Heartburn or acid reflux
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Never
In the Past
Occasionally
Frequently
Stomach pains or cramps
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Never
In the Past
Occasionally
Frequently
Diarrhea, chronic
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Never
In the Past
Occasionally
Frequently
Undigested food in stools
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Never
In the Past
Occasionally
Frequently
Food allergies
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Never
In the Past
Occasionally
Frequently
Abdominal bloating 1 to 2 hours after eating
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Never
In the Past
Occasionally
Frequently
Airborne allergies
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Never
In the Past
Occasionally
Frequently
Dairy sensitivity
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Never
In the Past
Occasionally
Frequently
Use over-the-counter pain medications
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Never
In the Past
Occasionally
Frequently
Anus itches
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Never
In the Past
Occasionally
Frequently
Coating on the tongue
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Never
In the Past
Occasionally
Frequently
Stools hard or difficult to pass
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Never
In the Past
Occasionally
Frequently
Less than one bowel movement per day
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Never
In the Past
Occasionally
Frequently
Irritable bowel or mucus colitis
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Never
In the Past
Occasionally
Frequently
Raw Fruits/vegetables/stress aggravate bowel pain
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Never
In the Past
Occasionally
Frequently
History of Kidney stones
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Never
In the Past
Occasionally
Frequently
Stomach upset by greasy foods
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Never
In the Past
Occasionally
Frequently
Consume artificial sweeteners (ie. aspartame)
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Never
In the Past
Occasionally
Frequently
Gallbladder removed
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Yes
No
Hemorrhoids or varicose veins
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Never
In the Past
Occasionally
Frequently
Frequent skin rashes and/or hives
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Never
In the Past
Occasionally
Frequently
Itchy skin (dermatitis)
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Never
In the Past
Occasionally
Frequently
Tend to be a "night person"
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Never
In the Past
Occasionally
Frequently
Difficulty falling asleep
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Never
In the Past
Occasionally
Frequently
Clench or grind teeth
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Never
In the Past
Occasionally
Frequently
Please provide the necessary health care providers or persons who may need to be consulted if related to the client’s condition. They include:
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Please Sign Name below & Enter Todays Date.
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According to the Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.” A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or other Natural Remedy. Although a Vitamin, a Mineral, Trace Element, Amino Acid, or Herb may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary
treatment and or therapy for any disease or particular bodily symptom.
Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. I have read and understand the above information:
SIGN INITIALS BELOW: Will there be a potential for lab work and if so, how are labs billed? Lab work results are very important will typically assist the practitioner in determining the plan of care. If prior lab work has not been completed, we may recommend lab testing at your first appointment. This typically involves blood work or test kits.
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SIGN INITIALS BELOW: Will I need supplements, and if so, how long will I have to be on these supplements? Most patients with nutritional health concerns will have supplements recommended. Each supplement is chosen for the results of nay lab testing. We will discuss into further detail about supplements for you at your second appointment. The intent is always for the patient to eventually lessen the number and/or dosage of supplements, but the timeline for this is different for each patient and is based upon the improvement of the patient's condition over time. Often improvements are seen by 3-6 months and again at 9-12 months, however, results may take longer if patient fails to implement the dietary recommendations. Due to quality control, all supplements are non-refundable.
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SIGN INITIALS BELOW: What happens after initial appointment? After we receive your test results, we will contact you to set up your next appointment. At this appointment the practitioner will go over your test results, your plan of care, and give you can estimate for length of care. Charge of $275 ROF(report of findings)
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SIGN INITIALS BELOW: Appointment Cancellation Policy Agreement Pathway to Wellness is committed to providing exceptional care. Unfortunately, when one patient cancels without giving enough notice, they prevent another patient from being seen. Please call us ...... Two days prior to you rescheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by 2:00 p.m. on Friday. If prior notification is not given, you will be charged $100 for the missed appointment.
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SIGN INITIALS BELOW: Cash Practice Agreement Pathway to Wellness is a 100% cash-based practice. We do not accept any insurances for various reasons. Types of payment we accept include cash, check, credit card, and HSA (health savings account). *You have read the prices of all services as well
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SIGN & Date Below: NOTICE OF PRIVACY PRACTICES THIS NOTICE OF PRIVACY PRACTICES (THE "NOTICE") DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. WE CONSIDER THE PRIVACY OF YOUR HEALTH INFORMATION OF PARAMOUNT IMPORTANCE. OUR LEGAL DUTY As a recipient of health care services, you have certain rights. To learn more about these rights, we suggest you visit: https://www.hhs.gov/hipaa/for-individuals/index.html. We are required by law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We will follow the privacy practices that are described in this Notice while it is in effect. We reserve the right to change our privacy practices and the terms of this Notice at any time. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will make commercially reasonable efforts to change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. OUR USE AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you only as necessary for treatment, payment, and our healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations including without limitation, quality assessment and improvement activities, reviewing the competence or qualifications of Health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us a written authorization, you may revoke it in writing at any time, although such revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we will not use or intentionally disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree in writing that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, concerning your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will (1) disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care and (2) use our professional judgment and experience with common practice to make reasonable inferences of your best interest in allowing third parties to pick up prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when we are required to do so by law. *By signing below, I acknowledge that I have read and understand this practices Notice of Privacy Practices
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