Adult Intake Form

Please correct the errors described below.

Center for Holistic Medicine

Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will help us formulate a treatment plan.

Please check appropriate box(es):

Please list current problems in order of priority, and fill in the other boxes as completely as possible:

Unfortunately, abuse and violence of all kinds (verbal, emotional, physical, and sexual) are leading contributors to chronic stress, illness, and immune system dysfunction; witnessing violence and abuse can also be very traumatic. If you have experienced or witnessed any kind of abuse in the past, or if abuse is now an issue in your life, it is very important that you feel safe telling us about it, so that we can support you and optimize your treatment outcomes.

Please do your best to answer the following questions:

Past Medical and Surgical History

Illnesses

a. Anemia

b. Arthritis

c. Asthma

d. Bronchitis

e. Cancer

f. Chronic Fatigue Syndrome

g. Crohn’s Disease or Ulcerative Colitis

h. Diabetes

i. Emphysema

j. Epilepsy, Convulsions, or Seizures

k. Gallstones

l. Gout

m. Heart Attack/Angina

n. Heart Failure

o. Hepatitis

p. High Blood Fats (cholesterol, triglycerides)

q. High Blood Pressure (hypertension)

r. Irritable Bowel

s. Kidney Stones

t. Mononucleosis

u. Pneumonia

v. Rheumatic Fever

w. Sinusitis

x. Sleep Apnea

y. Stroke

z. Thyroid Disease

aa. Other (describe)

Injuries

a. Back Injury

b. Broken Bone (describe)

c. Head Injury

d. Neck Injury

e. Other (describe)

Diagnostic Studies

a. Barium Enema

b. Bone Scan

c. CAT Scan of Abdomen

d. CAT Scan of Brain

f. Chest X-ray

g. Colonoscopy

h. EKG

i. Liver Scan

j. Neck X-ray

k. NMR/MRI

l. Sigmoidoscopy

m. Upper GI Series

n. Other (describe)

Operations

a. Appendectomy

b. Dental Surgery

c. Gallbladder

d. Hernia

e. Hysterectomy

f. Tonsillectomy

g. Other (describe)

h. Other (describe)

Hospitalizations

Where Hospitalized

How often have you have taken antibiotics?

Infant/Child

Teen

Adult

How often have you have taken oral steroids (e.g., cortisone, prednisone, etc.)?

Infant/Child

Teen

Adult

What medications are you taking now? Include nonprescription drugs.

Medication Name

List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate dosage in mg or IU and the form (e.g., calcium carbonate vs. calcium lactate) when possible.

Vitamin/Mineral/Supplement Name

Infancy/Childhood:

Question

Place a check mark next to each food/drink that is part of your current diet.

How much of the following do you consume each week?

Please fill in the chart below with information about your bowel movements:

If yes, please indicate time period (Month/Year):

How well have things been going for you?

If previously,

For Women Only:

Place a check mark by each symptom that occurs now or that has occurred in the past 6 months

General

Head, Eyes & Ears

Musculoskeletal

Mood / Nerves

Eating

Digestion

Skin Problems

Skin, Itching

Skin, Dryness

Lymph Nodes

Nails

Respiratory

Cardiovascular

Urinary

Male Reproductive

Female Reproductive

3-Day Diet Diary

Instructions for Completing the Diet Diary

It is important to keep an accurate record of your usual food and beverage intake as a part of this study. Please complete this 3-Day Diet Diary for 3 consecutive days with 1 day being a weekend day.

  • Record information as soon as possible after the food has been consumed.
  • Do not change your eating behavior at this time unless your doctor advises you to. The purpose of this food record is to analyze your present eating habits.
  • Describe the food or beverage consumed. For example: milk – whole, 2%, nonfat; toast – whole-wheat, white, buttered; chicken – fried, baked, breaded.
  • Record the amount of each food consumed using standard measurements as much as possible, such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
  • Include any added items. For example: tea with 1 teaspoon sugar, potato with 2 teaspoons butter, etc
  • Please record all beverages, including water. List them in the “Beverage” category.
  • Please record all bowel movements and their consistency (regular, loose, firm, etc.).

Diet Diary

Bowel Movements

Center for Holistic Medicine Informed Consent

Informed Consent for Telehealth Services:

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

Patient medical records

  • Medical images
  • A visual physical examination will be performed
  • Live two-way audio and video
  • Output data from medical devices and sound and video tiles

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and ensure its integrity against intentional or unintentional corruption.

Expected benefits:

Improved access to medical care by enabling a patient to remain in his/her home or doctors office while the physician obtains test results and consults from healthcare practitioners at distant/other sites.

More efficient medical evaluation and management.

Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include but may not be limited to:

In rare cases, information transmitted may not be sufficient to allow for appropriate medical decision making for the physician and consultant(s).

Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.

Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment

In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information. The Center for Holistic Medicine uses secure HIPPA compliant encrypted audio and video transmission software to deliver telehealth.

In rare cases a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors

In addition, telehealth, may limit the doctor's ability to fully assess certain conditions. This includes lack of detailed visualization, despite advancing camera technology and lack of ability to palpate (touch) affected areas such as sprains and strained joints. There are many other benefits to seeing patient's in person that can better help a clinician treat a patient

Some conditions are best treated in a clinical environment, such as deep lacerations, mental status changes, chest pain, respiratory distress and many others. If you have any of these conditions, it is highly recommended that you seek emergency care immediately.

By signing this form, I understand the following:

  1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no infonnation obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent
  2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
  3. I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.
  4. I understand that a variety of alternative methods of medical care may be available to me that I may choose one or more of these at any time. My ophthalmologist has explained the alternatives to my satisfaction.
  5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state
  6. I understand that it is my duty to inform my doctor of electronic interactions regarding my care that I may have with other healthcare providers.
  7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

Patient Consent to the Use of Telemedicine

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I have been given the opportunity to ask questions regarding telemedicine and have no further questions regarding the use of telehealth at this time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

to use telemedicine in the course of my diagnosis and treatment.

Your information will be encrypted.

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