Other Healthcare Providers Medical Doctor: Location: Permission to contact? (Y/N) Specialist: Location: Permission to contact?
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1 Other Healthcare Providers Medical Doctor: Location: Permission to contact? (Y/N) Dr. James Yoon, ND Date of last visit: Specialist: Location: Permission to contact? (Y/N) Specialist: Location: Permission to contact? (Y/N) Date of last visit: Date of last visit: How did you hear about Dr. James Yoon, ND? Clinic Information If you were referred by another patient of the ND, who referred you? Context of Care Review As a naturopathic doctor, I believe comprehensive and effective healthcare is only possible when a doctor has a complete understanding of the patient on a physical, mental, and emotional level. The responses you provide to the following questions will assist me in understanding your health care needs and goals. Your time, thoughtfulness and honesty in completing this form is appreciated, and will provide me with great insight in order to help you feel better, sooner! Have you been to a naturopathic doctor before? Yes No Health Concerns What are your most important health concerns? Please list as many as you have in order of importance Do you have any known contagious diseases at this time? Yes No If yes, what? 1
2 Please list any diagnoses you have received (presently or in the past), who diagnosed the condition and relevant dates. Medications and Supplements Please list any prescription medications, over-the-counter medications, vitamins, or other supplements you are taking with dosage and frequency Allergies and Sensitivities (please list) Context of Care Review What 3 expectations do you have from your first visit? What long-term expectations do you have for working with a naturopathic doctor? What is your present level of commitment to address any underlying causes of your signs and symptoms that relate to your lifestyle? Rate from 0% to 100% committed. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% What behaviours or lifestyle habits do you currently engage in regularly that you believe support and benefit your health? 2
3 What behaviours or lifestyle habits do you currently engage in regularly that you believe do not support or benefit your health? What potential obstacles do you foresee in addressing the lifestyle factors that are undermining your health and adhering to the therapeutic protocols that I will be sharing with you? What do you love to do? On a scale of 1-10 (10 being unbearable), what level of personal stress are you experiencing right now? What is your main stressor? Financial Job related Marriage Health Interpersonal Unfulfilled expectations Family Height: Weight: Please rate the following on a satisfaction scale of 0-10, 10 being the most satisfied: Energy: Sleep: Mood: General Information Do you exercise regularly? Yes No If so, what type? How many hours do you sleep per night? Do you wake rested? Yes No 3
4 Family History Dr. James Yoon, ND Do you or anyone in your family have a history of any of the following? Please check and indicate who. M = Mother, F = Father, GM = Grandmother, GF = Grandfather, S = Sister, B = Brother, C = Child Anemia Eczema Hives Stroke Arthritis Epilepsy Kidney disease Substance Abuse Asthma Glaucoma Mental Illness Autoimmune disease Hay Fever Mental illness Cancer Heart Disease Psoriasis Diabetes High Blood Pressure What is your family heritage? Personal Medical History Alcohol Abuse Diabetes Hives Sinusitis Allergies Eczema Kidney Problems Skin Problems Anemia Epilepsy Liver Problems Stroke Anxiety Female Reproductive Problems Malaria Suicidality Asthma Gallstones Measles Thyroid Problems Arthritis Gout Migraines Tuberculosis Back, Muscle, Joint Pain Bladder/Urinary Problems Gum/Teeth Problems Mononucleosis Ulcers Hay Fever Mumps Venereal Disease Cancer Heart Attack Overweight Candida Heart Problems Pleurisy Chicken Pox High Blood Pressure Psychological Problems Depression High Cholesterol Rubella Do you get regular SCREENING tests done by another doctor? (PAP, blood work, breast exams, colonoscopy etc.) Yes No 4
5 Personal Health Habits Please describe your typical daily diet, including beverages: Dr. James Yoon, ND Breakfast: Lunch: Dinner: Snacks: Do you, or have you ever been a smoker? If so, how many packs per day? How long have you, or did you smoke? Do you consume alcohol? How many drinks per week (on average)? Is there anything that has not been asked that I should be aware of, or that you would like me to know regarding your life or your health? Chronological Health History This sort of history helps to establish trends in a person s health that may be relevant to present conditions. Indicate below any accidents, broken bones, falls, illnesses, hospitalizations, surgeries, and any emotional traumas (deaths, loss of jobs, divorces etc.) Age 1-5 Age 6-10 Age Age Age Age Age Age Age Age Age Age Age Age Age 71 and older 5
6 SYMPTOMS REVIEW - Please check ( ) Y if you have the symptom now, and P if the symptom is in the past. SKIN Y P NOSE & SINUSES Y P CARDIOVASCULAR Y P Rashes Frequent colds Angina Hives Nose bleeds Murmurs Acne Stuffiness Chest pain Boils Hay fever Swelling in ankles Eczema Infections Palpitation, fluttering Psoriasis Last ECG: Dry skin Itching MOUTH & THROAT Y P Lumps Hoarseness BREASTS Y P Night sweats Gum problems Do you do breast self exams? Difficulty swallowing Lumps Dental problems Pain (or tenderness) HEAD Y P Sores Nipple discharge Tension headaches Dryness Last mammogram: Migraine headaches Sore throat Head injury Loss of taste Dizziness GASTROINTESTINAL Y P Trouble swallowing NECK Y P Heartburn EYE Y P Lumps Change in appetite Impaired vision Swollen glands Nausea Use of contact lenses Goiter Vomiting Eye pain Pain or stiffness Vomiting blood Tearing Belching Dryness Passing gas Double vision RESPIRATORY Y P Abdominal pain Glaucoma Cough Indigestion Cataracts Sputum Diarrhea Blurring Spitting up blood Constipation Light sensitive Wheezing Blood in stool Itching Asthma Hemorrhoids Redness Bronchitis Black, tarry stool Discharge Pneumonia Jaundice Blind spot Pleurisy Liver disease Emphysema Gallbladder disease Difficulty breathing Food allergy EARS Y P Pain on breathing Hiatus hernia Impaired hearing Shortness of breath Last colonoscopy: Earache Shortness of breath at night Dizziness Shortness of breath when lying Discharge Positive tuberculin test BLOOD / LYMPHATIC Y P Infection Last TB Test: Anemia Excessive wax Last chest X-ray: Easy bleeding/bruising Past transfusions Lymph node swelling 6
7 URINARY Y P FEMALE REPRODUCTIVE Y P ENDOCRINE Y P Pain on urination Check sexual preference: Heat or cold intolerance Increased frequency Heterosexual Thyroid trouble Frequency at night Homosexual Excessive thirst Inability to hold urine Bisexual Excessive hunger Frequent infections Menopause Excessive urination Kidney stones Age of onset Excessive sweating Blood in urine Hormone therapy Diabetes Reduced urine flow Last gynecological exam: Hypoglycemia Last pap smear: Hormone therapy MALE REPRODUCTIVE Y P Hernia MUSCULOSKELETAL Y P EMOTIONAL Y P Testicular masses Broken bones Depression Testicular pain Muscle spasms/cramps Angry Impotence Weakness Mood swings Premature ejaculation Joint swelling Anxiety Venereal disease Backache Nervousness Discharge of sores Tension Sexually active Phobias Check sexual preference: PERIPHERAL VASCULAR Y P Insomnia Heterosexual Deep leg pain Sexual difficulties Homosexual Cold hands / feet Drug abuse Bisexual Varicose veins Psychiatric care Last Prostate exam: Thrombophlebitis Psychological counselling Last PSA level: Leg cramps Extremity numbness Extremity coldness FEMALE REPRODUCTIVE Y P Extremity swelling Age of first menses: Last menstrual period: Extremity ulcers Number of days of menses: Length of cycle: NEUROLOGIC Y P Bleeding between periods Irregular cycles Pain during intercourse Painful menses Excessive flow PMS Number of pregnancies: Number of live births: Number of miscarriages: Number of abortions: Fainting Seizure / Convulsions Paralysis Muscle weakness Numbness or tingling Loss of memory Involuntary movements Loss of balance Speech problems Difficulty conceiving Sexual difficulties Vaginal discharge Vaginal itching Sexually active 7
8 Consent to Treatment of Naturopathic Medicine This form must be signed prior to your first appointment Dr. James Yoon, ND Naturopathic medicine is the treatment and prevention of disease by natural means. Naturopathic doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-invasive techniques are generally used in order to stimulate the body s inherent healing capacity. Dr. James Yoon, ND will take a thorough case history, perform a focused physical examination and complete laboratory testing, if necessary. It is very important that you inform Dr. James Yoon, ND immediately of any disease process that you are suffering from and any medications/other-the-counter medications that you are taking. Please advise Dr. James Yoon, ND immediately if: you are pregnant, suspect you are pregnant, are trying to get pregnant, or if you are breastfeeding. Fee Schedule: Initial Consult (60 min.) Follow-Up (40 min.) Follow-Up (20 min.) Traditional Asian Medicine Acupuncture (40 min.) $160 $80 $40 $65 There will be additional charges for services, products, and testing as required. Fees may be subject to change without notice. All services, products, and testing fees require payment at time of service. Acupuncture requires an initial consult in order to assess and apply personalized treatment. Cancellation Policy: Because everyone s time is precious. We require 24 hours notice of cancellation. For missed appointments, without proper notice, a charge of $20 will be applied and is to be paid before another appointment is booked. There are some slight health risks associated with treatment by naturopathic medicine. These include, but are not limited to: Aggravation of pre-existing symptoms Allergic reaction to supplements or herbs Pain, bruising or injury from venipuncture, acupuncture or parenteral therapy Fainting or puncturing of an organ with acupuncture needles Muscles strains and sprains, disc injuries from spinal manipulation There is a very small potential for stroke in neck manipulation. Patients are thoroughly screened prior to manipulating the neck. I understand: An electronic medical record will be kept of the health services provided to me. This record will be kept in strictest confidentiality and will not be released to others unless law requires it or I give my written consent. I realize in rare instances courts may subpoena my medical records, which means that my records will have to be released. Dr. James Yoon, ND will have to report me in the following instances: when I am in imminent danger of harming myself or others, when there is reasonable suspicion that I am neglecting and/or emotionally, physically or sexually abusing a minor, and if I engage in sexual relations with any of my healthcare providers. I may access my medical records at any time and can request a copy by paying the appropriate fee. I am aware that I can purchase the products recommended by Dr. James Yoon, ND at any location of my choice and I am under no obligation to purchase products directly from Dr. James Yoon, ND. However, if I do purchase products from Dr. James Yoon, ND I am aware that they cannot be returned for refund, as they will not be resold. I understand that supplements, remedies, botanicals, specialize laboratory tests, 8
9 and other goods and services are charged separately and not included in visit fees (However, you will be informed in advance of any additional fees, and if any fees change). Just as a pharmacy cannot accept returns on pharmaceutical products, we cannot accept returns on nutraceutical products, so that they can guarantee that all of their products have been stored in appropriate conditions until they are dispensed. I also confirm that I have the ability to accept or reject this care of my own free will, and that I am not an agent of any private, local, county, provincial or federal agency attempting to gather information without stating so. I agree to abide by the financial policies as outlined and I accept full responsibility for any fees incurred during the treatment. I agree to fully discharge this responsibility at the time of the visit via cash, debit, or credit card (Visa or MasterCard). This consent will cover the entire course of your treatment but you are free to withdraw this consent and discontinue a treatment at any time. As a patient of Dr. James Yoon ND, I have read the information and understand that the form of medical care I will be receiving is based on Naturopathic principles and practices. I hereby acknowledge that I have been informed and understand the recommended diagnostic and therapeutic procedure(s)/plan and have discussed them to my satisfaction. I also recognize that even the gentlest forms of therapies have potential complications, and I release Dr. James Yoon ND from any responsibility of such complications. I acknowledge and confirm that I have been informed of the diagnostic/therapeutic procedures with respect to financial costs, potential risks and side effects, expected benefits, the likely consequences of not having/following the provided recommendations and what alternative course(s) of action are available to me. Dr. James Yoon, ND does not guarantee treatment results. I do not expect the naturopathic doctor to be able to anticipate and explain all risks and potential complications. I voluntarily consent to diagnostic and therapeutic procedures mentioned above, except for (please list, if any): I recognize that this consent form covers the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I have read this statement and agree to work within its guidelines, including the limits of confidentiality Patient Name (please print): Signature of Patient or Patient's Guardian: Date: Signature of Dr. James Yoon, ND: Date: 9
10 Patient Consent for Collection, Use and Disclosure of Personal Information Privacy and protecting your personal information is an important part and consideration of my practice as a naturopathic doctor. This privacy policy outlines what I do to ensure that: Only necessary information is collected about you; I only share your information with your consent; Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols (this includes cloud-based electronic medical records that are housed within Canada and are compliant with such legislation and privacy protocols); Privacy protocols comply with privacy legislation and standards of naturopathic doctor s regulatory body We are committed to collecting, using and disclosing your information responsibly and do so for the following purposes: To assess your health concerns, provide health care and advise you of treatment options; To establish and maintain contact with you; To remind you of upcoming appointments; To efficiently follow-up with you for treatment; To complete claims for insurance purposes; To invoice for goods and services; To process credit card payments; To collect unpaid accounts and follow-up on billing, as required; To comply with all regulatory and legal requirements including court orders, statutory requirements to advise authorities of child abuse, reportable disease and individuals who may be an imminent threat to harm themselves or others; To be used for educational and research purposes (this includes case summaries and reports, photographs, lab results and other pertinent medical information). Your identity will be protected at all times and if necessary, identifying information will be altered to protect your privacy in all the above instances. Patient Consent I, have reviewed the above information that explains how Dr. James Yoon, Naturopathic Doctor, will use my personal information and the steps that are taken to protect my information. I agree that James Yoon, Naturopathic Doctor, can collect, use and disclose personal information about my case as set out above regarding privacy policies. Patient Signature: Date: 10
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