Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION
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1 Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT Phone: (802) Fax: (866) MountainViewNaturalMedicine.com PATIENT REGISTRATION FORM PATIENT INFORMATION Name: Date of Birth: Street Address: City/State/Zip: Home Phone: Work Phone: Cell Phone: Address: May we leave a medically related message at home? at work? on cell? Emergency contact: Phone: Referred by: Pharmacy (include city): Employer: Marital status: Single / Married / Civil union / other (pls. describe) How would you like to receive appointment reminders: Text Message / / Phone RESPONSIBLE PARTY INFORMATION Name: Date of Birth: Street Address: City/State/Zip: Phone: INSURANCE INFORMATION Insurance Company: Subscriber: Address: Subscriber DOB: Patient ID#: Subscriber ID#: Group #: Patient s Relationship to Subscriber: Subscriber s Employer/Address/Phone: I authorize the release of any medical or other information necessary to process claims to my insurance carrier. I also request payment of government benefits either to myself or to the party who accepts assignment: Mountain View Natural Medicine. I authorize payment of medical benefits to Mountain View Natural Medicine for services rendered at this clinic and submitted to my insurance carrier.
2 Signature Date Mountain View Natural Medicine 185 Tilley Dr. Suite 51 S. Burlington, VT Phone: (802) Fax: (866) PATIENT INTAKE FORM Name: Would you like us to be your primary care provider? Y/N Date of Birth: Name of other PCP if applicable: Please list your health concerns in order of priority along with other practitioners you may be seeing for the condition: What do you believe is causing your most important health concerns? PAST MEDICAL HISTORY: PLEASE LIST ANY SURGERIES AND/OR MAJOR ILLNESSES: Age or date: Description: Please list any medications and supplements you are currently taking, along with doses and the reason you are taking them: Medications: Reason: Date began: Dose: Supplements: Reason: Date began: Dose: **Please list any drug allergies:
3 Patients often desire communication between their healthcare providers. Do we have your permission to communicate verbally and in writing with your other providers regarding your healthcare? yes / no FAMILY HEALTH HISTORY: (be sure to include current age or age of death, major illness history, including diabetes, heart disease, osteoporosis, cancer, allergies, etc.) Member Mother Father Siblings Living?/Age Major illness or chronic conditions Mat. Grandmother Mat. Grandfather Pat. Grandmother Pat. Grandfather PREVENTATIVE HEALTH: Please fill in what you can: Recent Past year Past 5 years Weight Height Cholesterol w/hdl,ldl Blood pressure If tested in the past 2 years, please check: Thyroid (normal? y/n) Blood sugar (normal? y/n) Anemia (normal? y/n) Date of last: Tetanus shot Colonoscopy (normal? y/n) SOCIAL HISTORY: Please list sources and amounts of: Caffeine: Alcohol: Smoking history and amount: Recreational drugs: DIET: Please describe a typical day s diet for you, (be honest). Breakfast Lunch Dinner Snacks (what hour)
4 CURRENT HEALTH CONCERNS (Review of Systems): Please check normal or abnormal and briefly explain. N AbN Constitutional (Energy, weight, body temperature, sleep, general sense of well-being) Head: headaches, vertigo, injuries etc.) Vision/eye problems: Ear/nose/throat/mouth (allergies, infections etc.) Cardiovascular: (high BP, cholesterol etc.) Respiratory Digestive tract issues: (changes in bowel habits, hemorrhoids, bloating, pain, etc. ) Musculoskeletal concerns (arthritis, joint problems, osteoporosis, muscle pain, weakness): Skin (eczema, infections, rashes, etc.) Psychological (mood changes, sadness, irritability, anxiety etc. ) Neurological (numbness, tingling, balance problems, memory etc.) Hormonal issues (diabetes, thyroid problems, menopausal, adrenal etc.) Blood or lymph issues (current anemia, swollen glands etc.) Allergies Others: WOMEN: Onset of first menses was age. Periods generally last days and occur every days. Date of last period Bleeding is Heavy Moderate Light Do you experience PMS symptoms? List: Are you currently sexually active? Partner(s) is/are Male Female Type of birth control: Are you happy with this method? Are you currently experiencing any gynecological symptoms or problems? Any problems related to sexual function? Do you have a history of sexually transmitted disease? Genital warts? Number of pregnancies? Births? Abortions? Miscarriages? Date of last Pap smear: Abnormal Pap History: Do you perform regular breast self exams? Date of last mammogram, if any: If menopausal or perimenopausal, list symptoms and concerns: MEN: Are you currently sexually active? Partner(s) is/are Male Female History of sexually transmitted diseases? Genital warts? Date of last prostate exam? PSA test? Trouble with urination? (frequency, hesitancy, pain, dribbling) Trouble with sexual function/libido? If yes, explain:
5 LIFESTYLE: What is your vocation? What are your primary sources of stress? How much do you think they impact you life? How many hours do you work per week? Number of play/relaxation hours? What do you do in order to manage stress and take care of yourself? What is your exercise routine? Do you wear seatbelts? Y/N. A bike helmet? Y/N Take a minute to imagine what good health means to you. What would it look like if all the health concerns you currently have were successfully solved? What would you be able to do? How would you feel? What specific change(s) are YOU ready to make in order for you vision of health to happen? What, if any, barriers to this exist? How could you overcome these? How ready do you feel, on a scale of 1 to 10, to make the changes above? (not sure) (depends how hard it is) (I ll do what it takes!)
6 Mountain View Natural Medicine 185 Tilley Dr, South Burlington, VT Tel: Fax: ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES This document is to be signed by a person legally responsible for the patient s medical decisions relative to the treatment situation. I,, hereby acknowledge that Mountain View Natural Medicine has provided me with a copy of its Notice of Privacy Practices that describes how medical information about me may be used and disclosed, and how I can access this information. I understand that if I have questions or complaints I may contact: Office Manager I also understand that I am entitled to receive updates upon request if Mountain View Natural Medicine amends or changes its Notice of Privacy Practices in a material way. Signature Relationship to Patient, if signed by someone other than patient. Date Patient s name if not signed by patient THIS SECTION IS TO BE COMPLETED BY Mountain View Natural Medicine IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGMENT FROM PATIENT I made a good faith effort to obtain a written acknowledgment of receipt of the Notice of Privacy Practices from the above-named patient, but was unable to because: [ ] Patient declined to sign this Written Acknowledgment. [ ] Other (specify): Name and title of employee Date
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