Motivation to achieve these goals:

Transcription

1 New Patient Application and Case History (H) Name Age Sex: M F DOB Today's Date Address City State Zip Home Phone Work Phone Cell Phone May we leave a voice mail? Y N Height Weight: How Did You Hear About Us? Employer Occupation Length of Employment SSN Main Problem(s): Present Complaints 2. In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and your own opinion what do you think the real problem is? 3. Have you ever been diagnosed with a condition that would account for your 4. What are the three things your condition has caused you to miss most? inability to lose or gain weight? (If weight is a concern) 5. Symptoms (list all): 6. Severity (circle): Minimal (annoying but causing no limitation) Slight (tolerable but causing a little limitation) Moderate (sometimes tolerable but definitely causing limitation) Severe (causing significant limitation) Extreme (causing near constant limitation (>80% of the time)) 7. What relieves your symptoms or causes them to return: 8. Describe the first time you remember having symptoms: 9. If your symptoms include pain: 10. Do your symptoms occur at a specific time, place, or environment: Y N What is the quality (sharp, dull, stabbing, color, etc.): When and for how long do symptoms last each episode? Does the pain radiate: Y N where: 11. What are you hoping happens today as a result of your consultation 12. List your health goals in order of Importance: 13. If you cannot find a solution to your problem what do you think will happen? 14. Due to your condition have you lost time from? Work: Y N Describe: Family: Y N Describe: Leisure Activities Y N Describe: Motivation to achieve these goals:

2 Medical and Social History Surgeries/Hospitalizations/Trauma Date Primary Care Physician Name and Contact Information Past/Recent Illness Date Marital Status: S/ M/ W/Sep./D Spouse Children / ages: Family History (mother, father, siblings, spouse, children) Date Do you use: Alcohol Y N Tobacco Y N Caffeine Y N drinks/week pack/day cups/day Review of Systems: Past and Current (Have you ever had the following (circle P for past and C for current - leave blank if you do not or have not experienced) CONSTITUTIONAL GENITOURINARY ENDOCRINE NEUROLOG ICAL P C Fatigue P C Frequent urination P C Glandular or hormone problem P C Freq./ recurring headaches P C Recent weight change P C Burning or painful urination P C Excessive thirst or urination P C Migraine headache P C Fever P C Blood in urine P C Heat or cold intolerance P C Convulsions or seizures P C Change in force or strain urinating P C Skin becoming dryer P C Numbness or tingling EYES P C Kidney stones P C Change in hat or glove size P C Tremors P C Blurred/double vision P C Sexual difficulty P C Diabetes P C Paralysis P C Glasses/contacts P C Male : testicle pain P C Thyroid Disease P C Head injury P C Eye disease or injury P C Female: pain / irregular periods P C Light headed or dizzy P C Female: pregnant MUSCUOSKELETAL P C Stroke EAR/NOSE/MOUTH/THROAT P C Bladder Infections P C Back pain P C Swollen glands in neck P C Kidney Disease P C Joint pain HEMATOLOGIC/LYMPHATIC/OTHER P C Hearing loss or ringing P C Hemorrhoids P C Joint stiffness and swelling P C Slow to heal after cuts P C Earaches or drainage P C Muscle pain or cramps P C Easy bleeding or bruising P C Chronic sinus problems or rhinitis GASTROINTESTINAL P C Muscle or joint weakness P C Anemia P C Nose bleeds P C Abdominal pain P C Difficulty walking P C Phlebitis P C Mouth sores / Bleeding gums P C Nausea or Vomiting P C Cold extremities P C Past transfusion P C Bad breath / bad taste P C Rectal bleeding/blood in stool P C Enlarged glands P C Sore throat or voice change P C Painful BM / constipation INTEGUMENTARY (skin, breast) P C Blood or Plasma Transfusions P C Ulcer P C Change in skin color P C Hepatitis CARDIOVASCULAR P C Change in bowel movement P C Change in Hair or Nails P C Cancer P C High or Low Blood Pressure P C Frequent diarrhea P C Varicose veins P C Infectious Mono P C Shortness of breath walking/lying P C Loss of appetite P C Breast pain / discharge P C AIDS or HIV+ P C Heart disease P C Breast lump P C Venereal P C Chest pain or angina pectoris RESPIRATORY P C Hives or Eczema P C Chicken pox P C Palpitation P C Chronic or frequent cough P C Rash or itching P C Mitral Valve Prolapse P C Spitting up blood P C Feet or ankle swelling P C Pneumonia / Bronchitis ALLERGIES / OTHER (drugs, food, or environmental) P C Shortness of breath P C Shortness of breath P C Spitting up blood P C Wheezing RECENT TESTS (lab work, x-rays, CT, MRI) P C Asthma PSYCHIATRIC MEDICATION (Rx, OTC, botanicals, homeopathic, and supplements) P C Insomnia P C Memory loss or confusion P C Nervousness P C Depression Reviewing Doctor: Are you taking any blood thinners? YES NO

3 If you are currently suffering from any transmittable diseases please list them: If none please initial Race: American Indian/Alaska Native Asian Black/African American White Native Hawaiian/Pacific Islander Other Decline to answer Ethnicity: Hispanic/Latino Not Hispanic or Latino I decline to answer I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. Amy Valente all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature Date Relationship to Patient Doctor s Notes (For Office Use Only)

4 North Georgia Functional Medicine Notice of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This privacy of your health information is important to us. OUR LEGAL DUTY We are required by applicable federal and state 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 must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 5/25/2011 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make 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 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. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment and 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. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. To Your Family and Friends: We must use or 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 healthcare or with payment for your healthcare, but only those names that you list at the end of this Notice. 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, of 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 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 healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up medical supplies, x-rays or 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. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards or letter). We may also send notice of clinic events, monthly newsletters and referral appreciations. Schedules: We may use or disclose your health information to post the current day s schedules behind the front desk or on the computer screens PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. Office policy states that we require a 24 hour notice to produce medical records, including x-rays. Electronic Notice: If you receive this Notice on our Website or by electronic mail ( ) you are entitle to receive this Notice in written form.

5 QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the Notice. You may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Complaint forms are located at the front desk, and should be filed with our contact officer. Contact Officer: Elizabeth Dombi Telephone: Fax: Address: 4900 Ivey Rd., Suite 1220 Acworth, GA LIST OF FRIENDS OR FAMILY MEMBERS APPROVED FOR DISCLOSURE: I ACKNOWLEDGE THAT I HAVE RECEIVED, REVIEWED, UNDERSTAND AND AGREE TO THE NOTICE OF PRIVACY PRACTICES OF NORTH GEORGIA FUNCTIONAL MEDICINE, LLC WHICH DESCRIBES THE PRACTICE S POLICIES AND PROCEDURES REGARDING THE USE AND DISCLOSURE OF ANY OF MY PROTECTED HEALTH INFORMATION CREATED, RECEIVED OR MAINTAINED BY THE PRACTICE. Patient Signature Date signed Print Patient Name North Georgia Functional Medicine Notice of Privacy Practices

6 This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This privacy of your health information is important to us. OUR LEGAL DUTY We are required by applicable federal and state 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 must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 5/25/2011 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make 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 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. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment and 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. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. To Your Family and Friends: We must use or 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 healthcare or with payment for your healthcare, but only those names that you list at the end of this Notice. 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, of 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 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 healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up medical supplies, x-rays or 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. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards or letter). We may also send notice of clinic events, monthly newsletters and referral appreciations. Schedules: We may use or disclose your health information to post the current day s schedules behind the front desk or on the computer screens. PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. Office policy states that we require a 24 hour notice to produce medical records, including x-rays. Electronic Notice: If you receive this Notice on our Website or by electronic mail ( ) you are entitle to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us.if you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the Notice. You may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. Complaint forms are located at the front desk, and should be filed with our contact officer. Contact Officer: Telephone: Fax: Address: 4900 Ivey Rd., Suite 1220, Acworth, GA LIST OF FRIENDS OR FAMILY MEMBERS APPROVED FOR DISCLOSURE: I ACKNOWLEDGE THAT I HAVE RECEIVED, REVIEWED, UNDERSTAND AND AGREE TO THE NOTICE OF PRIVACY PRACTICES OF NORTH GEORGIA FUNCTIONAL MEDICINE, LLC WHICH DESCRIBES THE PRACTICE S POLICIES AND PROCEDURES REGARDING THE USE AND DISCLOSURE OF ANY OF MY PROTECTED HEALTH INFORMATION CREATED, RECEIVED OR MAINTAINED BY THE PRACTIC. Patient Signature Date signed

7 North Georgia Functional Medicine 4900 Ivey Rd., Suite 1220 Acworth, GA PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Patient Name: DOB: I acknowledge that I have reviewed the Notice of Privacy Practices of North Georgia Functional Medicine. Please initial below: I have received a copy of the Privacy Notice. I acknowledge that it is the policy of North Georgia Functional Medicine to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Privacy Officer, Katrina Smith, about my concerns. Signature of Patient/Guardian Date Witness (Office Staff) Date

8 CONSENT TO CARE A patient coming to the doctor gives him/ her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, deformities or pathologies, may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/ she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/ she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. I have read and understand the foregoing. Patient s Signature Date

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