Today s Date. Child s Name Date of Birth Age Sex: M F. Parent 2 Occupation. Name of Person Filling Out This Form. Address City / State Zip.
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1 family tree medicine Pediatric New Patient Intake Form Please fill out this form and bring it with you to your first office visit. Thanks! Today s Date Child s Name Date of Birth Age Sex: M F Parent 1 Parent 2 Parent 1 Legal Guardian Parent 1 Occupation Parent 2 Occupation Parent 2 Referred By: Name of Person Filling Out This Form Relationship Address City / State Zip Home Phone Mobile Phone Child s Main Health Concerns: EARLY LIFE HISTORY Pregnancy and Birth History Uncomplicated Alcohol Use Bleeding Diabetes Drug Use Early Labor Excessive Vomiting High Blood Pressure Smoking Thyroid Problems Trauma Medications during pregnancy Supplements during pregnancy Birth Weight Weeks Mother s Age at Birth Full Term Vaginal Premature Cesarean Birth, Reason Past Term
2 Post-Natal Complications None Birth Defects Birth Injuries Cardiac Gastrointestinal Jaundice Infections Respiratory Was the child breastfed? For how long? Difficulty nursing? Formula used? At what age? For how long? When were solids introduced? First Foods: Immunizations Is the child vaccinated? If yes, were boosters given? Which vaccinations has the child received? Chicken Pox DTaP Hepatitis A Hepatitis B Any adverse reactions? HiB Influenza Meningococcal MMR Pneumococcal Polio Rotavirus Has the child had any of the above conditions? Biological Family Medical Conditions Mother Father Sisters Brothers Grandmother Grandfather Allergies Anemia Asthma ADHD Birth Defects Cancer Celiac Disease Cystic Fibrosis Diabetes Depression Eczema Heart Disease High Blood Pressure Kidney Disease Learning Disability Mental Illnes Multiple Sclerosis Rheumatiod Arthritis Seisures Stroke Tuberculosis
3 General Health History Describe the child s general state of health: Poor Fair Good Excellent Have there been any serious conditions, illnesses, injuries, or hospitalizations? If yes, please describe and include approximate dates: How many times has this child been treated with antibiotics? Does this child have any allergies (food, medicine, environmental, etc.)? List all current supplements and medications (over-the-counter, Rx, vitamins, herbs, homeopathic, etc)? List past prescription medications: Interaction with other children: Very good Average Poor Describe the child s behavior: Excellent Variable Disruptive Activities this child enjoys: Regular foods in the child s diet: Does the child have any dietary restrictions? Number of bowel movements per day: Describe the child s sleep habits:
4 Symptoms and Diagnosis (Please check for current, or use P to indicate past symptoms.) Acne Asthma Abdominal Pain Allergies Anemia ADHD Anxiety Autism Blood in Stool Blood in Urine Bronchitis Bed Wetting Bleeds / Bruises Easily Body / Breath Odor Blurry Vision Chills Change in Appetite / Thirst Cravings Cough Constipation Cries Easily Cradle Cap Diabetes Diarrhea Dry Skin Difficulty Breathing Dizziness Earache / Infections Eczema Excessive Sweating Excessive Gas Fevers Fatigue Frequent Urination Headaches Hearing Problems Hives / Itching Indigestion Irritability Jaw Clicks or Pain Lack of Coordination Loss of Balance Loss of Hair Lumps, Swollen Glands Mercury Fillings Memory Problems Motion Sickness Muscle or Joint Pain Mood Changes Nose Bleeds Neck Pain Nausea Nightmares Pain on Urination Rashes Ringing in Ears Sore Throat Vision Problems Vomiting Weight Changes Please describe any other problems you would like to discuss:
5 family tree medicine Patient Consent Form PLEASE READ CAREFULLY BEFORE INITIALING OR SIGNING Consent To Treatment Naturopathic therapeutic procedures are considered safe and effective methods of care. Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to soreness, inflammation, soft tissue injury or bruising, dizziness, burns, temporary worsening of symptoms. More serious complications are extremely rare. Additional information on side effects and complications is available upon request. It is also our policy to inform you of the procedure being performed and the risks and alternative treatments available. If your physician does not explain to your satisfaction, please ask for more information. I have read and understand the above statements regarding treatment side effects and I also understand that there is no guarantee for a specific cure or result. Print Name Signature of Patient Date Agreement to Payment Policy of Family Tree Medicine Clinic By signing below, I understand that full payment for all services and products I receive from Family Tree Medicine Clinic and its practitioners is required at the time of service, except that portion billed to my insurance company. Further, I understand that Family Tree Medicine may submit my bill to my insurance carrier, if I so request, and that I am responsible for any sercives not covered by my insurance company, as well as any copay, coinsurance or deductible required by my insurance. There is a $40 fee for appointment cancellations with less than 24 hours notice. Signature of Patient Consent Regarding Use of Information Please initial if you consent to the statements below. Leave blank if you do not. Some physicians at Family Tree Medicine use to correspond with patients as a convenience. However, these s are not encrypted and could theoretically be read by a malicious outside party with the technical skills to intercept such correspondences. By initialing this line you are consenting to allow Family Tree Medicine and its physicians to correspond with you via in spite of these potential risks. Family Tree Medicine is engaging in research into the efficacy of the therapies used by practitioners working here. To gather sufficient data, it is necessary to collect information about conditions treated, therapies used, and outcomes observed from patient charts. In this process, no information that could be used to specifically identity individuals is ever used only general demographic information is attached to the clinical data. By initialing this line, you are consenting to allow Family Tree Medicine to include this anonymous data from your chart to conduct research to be published in the appropriate medical literature. Some practitioners at Family Tree Medicine have an interest in writing about alternative medicine and health care for the general public, either as fiction or nonfiction. By initialing this line, you are consenting to allow your medical history and care in our clinic to be used as an example or case history in such writing, with the understanding that all identifying information would be altered.
6 family tree medicine Consent For Purposes of Treatment, Payment & Healthcare Operations for Patients of Family Tree Medicine PLEASE READ CAREFULLY BEFORE INITIALING OR SIGNING I consent to the use or disclosure of my protected health information by Family Tree Medicine Clinic for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Family Tree Medicine. I understand that diagnosis or treatment of me by my physician(s) at Family Tree Medicine may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Family Tree Medicine is not required to agree to the restrictions that I may request. However, if Family Tree Medicine agrees to a restriction that I request, the restriction is binding on Family Tree Medicine and my physician(s) at Family Tree Medicine. I have the right to revoke this consent, in writing, at any time, except to the extent that my physician(s) at Family Tree Medicine or Family Tree Medicine has taken action in reliance on this consent. My protected health information means health information, including my demographic information, collected from me and created or received by my physician another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relate to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review Family Tree Medicine s Notice of Privacy Practices prior to signing this document. The Family Tree Medicine s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Faml8iy Tree Medicine. This Notice of Privacy Practices also describes my rights and Family Tree Medicine s duties with respect to my protected health information. Family Tree Medicine reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. O may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Signature of Patient or Personal Representative Date Printed Name of Patient or Personal Representative Description of Personal Representative s Authority
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