new new patient intake · 2018. 4. 23. · ears: q discharge q hearing changes q ringing in the...

NEWPATIENTINTAKE

Name:_____________________________________________________________________________________________

DateofBirth:__________________ Age__________________________ Gender_________________________

StreetAddress______________________________________________________________________________________

City____________________________ State__________________________ ZipCode________________________

Phone:(Home)__________________ (Cell)__________________________ (Work)_________________________

HIPPA compliance does not allow for email communication involving personal/identifying information, medical records, health information, or treatment recommendations. In order to communicate with your Provider via email and see medical documents such as lab results and treatment protocols, you will need to enroll in our Patient Portal. Please provide the email that you would like to use for the registration of your portal. E-mailAddress_________________________________________________________ (PLEASE NOTE, you cannot change the email once it has been registered) Sonoran Naturopathic Center may use this email for appointment reminders and other communication not involving personal/medical information YES________NO________ SocialSecurityNumber(usedforinsurancepurposes)______________________________________________________

Pharmacy:_____________________________________Phone:______________________________

Howdidyouhearaboutus?*(Ifsomeonereferredyouhere,pleasenamethemsothatwemaythankthatperson)

*FriendReferral(Pleaseletusknowwhoreferredyoutoouroffice.)___________________________________________________________________________________________________

*SocialMedia(Pleaseindicatewhichversionyouusedtofindoutaboutouroffice)

qFacebook qTwitter qYoutube qOther(Ifotherpleasespecifybelow)

___________________________________________________________________________________________________

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Name:_______________________________________________________

Date:______________________________

EMERGENCYCONTACT:

Name__________________________________________ Phone__________________________________________

Relationshiptoyou__________________________________________________________________________________

Whatareyourmainhealthconcerns?(Pleaselistyourconcernsintheirorderofimportancetoyou.Giveabriefhistoryofwhenitstarted,othertreatmentsordoctors/practitionersyouhaveseen,etc.)

1. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PASTMEDICALHISTORY:

SignificantpreviousDiagnosesorIllnesses:

Majoraccidentsortraumas:

Hospitalizations/Surgeries:(Pleaselistthedate&thenatureofthevisitorprocedure)FamilyHistory(Pleaseindicateifthefollowingfamilymembersarealiveordeceased–listtheirage,healthconcernsand/orcauseofdeath)

Mother:

MaternalGrandmother MaternalGrandfather

Father:

PaternalGrandmother PaternalGrandfather

Siblings:

Children:

Medications/Supplements:(PleaseIncludeDosage&BrandName,ifknown)

Medications(IncludingPrescriptionandOver-the-Counter)

Supplements

Allergies:(IncludeFoodand/orDrugAllergies–pleasealsodescribethetypeofreactionyouhavehad)

Social/LifestyleHistory:

Occupation:

Sleep: HoursPerNight: QualityofSleep: Wakefeelingrested?

EnergyLevel:

Scaleof1-10(10beingthemostenergy)

LivingSituation: MaritalStatus

AlcoholConsumption:

NumberofDrinksperweek:

CigaretteSmoking:(pastorpresent) Amount(packsperday): Duration(inyears):

RecreationalDrugUse:(pastorpresent)

Type DurationandFrequency

Exercise:

Type Duration&Frequency Restrictions(anytypeofactivityorexerciseyouareunabletodo)

StressLevel:

CurrentlevelofSatisfaction/Happinesswithyourlife?

TypicalDiet: Breakfast: Lunch: Dinner: Snacks:

Beverages:(pleasespecifyamountsandtypesofthefollowing)

Caffeine: Water: Juice/Soda,etc:

ENVIRONMENTALHISTORYPleasechecktheboxesbelowifyouhavecurrentorpastexposuretoanyofthefollowing:qDentalAmalgams(silver)

qCommercialhaircoloring

qHomeFragrances(i.e.SentedCandles)

qPerfumes/Colognes

qScentedLotions

qCommercialDryCleaning

qNailorHairSalons Doyouconsumeanyofthefollowing?Ifso,howoften?qRawFish/Sushi

qFarmRaisedFish

qBeef/RedMeat

qTuna qShellfish Home/OfficeEnvironmentqNewPaint

qNewCarpeting

qNewFurniture

qHomeorofficebuiltbefore1978

qComposite/SyntheticWoodFurniture Doyouuseanyofthefollowing?qShowerFilters

qHomeWaterFiltration

qHEPAAirFilters

qBottledWater

qNon-toxicHairandBodyCare

qOrganicFruitsandVegetables

qOrganicDairyProducts qOrganicMeats Whatcityandtownwereyoubornin?

Howlongdidyoulivethere?

Haveyoueverhadajobwhereyouhadknownand/ordocumentedchemicalexposure?

Haveyouhadanyreactionsorknownsensitivitiestochemicals?

Haveyoulivednearanyindustrialplantsorfactories?Ifso,whattypeofindustryandhowlongdidyoulivethere?

Haveyoueverbeentestedforheavymetals,solvents,orotherenvironmentalmedicinepanels?Ifso,werethereanysignificantfindings?

REVIEWOFSYSTEMS:

(Pleasereviewthefollowinglistandchecktheboxtoindicateifyoucurrentlyexperienceorhavepreviouslyexperiencedanyofthefollowingsymptoms.Usethespaceintherightcolumntoelaborate,ifnecessary)

(Checkpositivefindingsandcharttoright) Details/Specifics

General:qHot qCold qChillsqFever qSweats qNightsweatsqWeightloss qWeightgain qFatigueqRestlesslegs qSnoring qDifficultystayingawakeqDifficultyfallingasleepqDifficultystayingasleep

CurrentWeight:_____________________________WeightOneyearago:________________________IdealWeight:_______________________________

Skin,Hair,Nails:qDrySkin qFrequentorEasyBruisingqRashes qHairLossorThinningHairqFungalInfectionsoftheskinornailsqEczema qPoorWoundHealingqPsoriasis qItching qJaundice qBreakingNails

Anyabnormalskinlesions?_____________________Doyouseeadermatologistregularly?____________MostrecentDermatologicalExam:_______________

HEENT:Head:

qHeadache qHistoryofheadinjuryqMigraines

Eyes:

qDoublevision qBlurredVisionqCataracts qVisionchangesqPain qRednessqItching

Mostrecentvisittoeyedoctor?

Wearglassesorcontacts?Ears:

qDischarge qHearingchangesqRingingintheears qPainqDizziness

Nose:qSinusitis qDecreasedsmellqDischarge/mucus qNosebleedsqCongestion qSeasonalallergies

Mouth/Throat:qCankersores qSorethroatsqPersistenthoarsenessqDifficultyswallowingqToothache qBleedinggumsqGingivitis

Mostrecentdentalvisit?Anyfillingsordentures?NECK:qInjuries qMassesqPain qStiffness

CHEST:qAsthma qBronchitisqCOPD qChroniccoughqCoughingupblood qShortnessofbreathqSleepapnea qPain qWheezing qPneumonia

CARDIOVASCULAR:qPalpitations qMurmursqArrhythmias qChestpain/AnginaqCongestiveHeartFailureqClaudication(paininthelegswithexercise) qHeartAttack qCoronaryArteryDisease qCyanosis(bluehandsorfeet)

qDizziness qShortnessofBreathwithexercise qHighBloodPressure qDifficultyBreathingwhilelyingflatqPhlebitis qVaricoseVeins qStrokeorTIA

GASTROINTESTINAL:qConstipation qDiarrheaqBloodinthestool qGallbladderproblemsqNausea qVomiting qGasorBloating qHemorrhoids qUndigestedfoodormucusinthestool qIndigestion qBelching qAcidReflux qUlcers qAbdominalPainorCramping qIrritableBowelSyndrome

BowelMovementfrequency?

Doyouhavetostrainordoyouexperienceanypainwithpassingstool?

MostRecentColonoscopy:

GENITOURINARY:qPainwithUrination qBloodintheurineqFrequentUrination qDischargeqWakingfrequentlyatnighttourinate qChangeinfrequency qDifficultyinitiatingstream qDecreasedforceofurinestreamqIncontinence

qChronicorFrequentUTI's qKidneyStones qInterstitialCystitis

SEXUALHEALTHqGenitalPain qItchingqPainDuringIntercourseqDischarge qDecreasedLibidoqDifficultywitharousal qInabilitytoachieveorgasm

Haveyoueverbeendiagnosedortreatedforan

STD?(pleasespecifywhen&whichSTD)Numberofsexualpartnersinthepastyear:MostrecenttestingforSTD’sMethodofContraception:

BREASTS:

qDischarge qEnlargementqPain qTendernessqPriorsurgeryorbiopsy

MostRecentMammogram:

FEMALE/GYN:

NumberofPregnancies: NumberofLiveBirths: AbortionsorMiscarriages: DateofLastMenstrualPeriod: LengthofCycle:

qDischarge qShort qLongqIrregular qRegular qClotsqPainful qDischarge oFoulOdor

PMSSymptoms: Mensesstartedatage: Mensesstoppedatage: LastPapSmear: HistoryofAbnormalPaps?

GynelocialSurgeriesorProcedures(date&type)

MALE:qProstatitis qLesionsqBenignProstaticHypertrophyqErectileDysfunction qTesticularTrauma

NEUROMUSCULAR:

qNumbness qTinglingqJointPain qArthritisqJointSwelling qMusclePain qSyncope(fainting) qVertigo qWeakness qTremors qPoorBalance qLossofConsciousness

ENDOCRINE:qHeatintolerance qColdintoleranceqIncreasedThirst qIncreasedAppetiteqAnemia qExcessivebruising qEasybleeding qDiabetes qThyroidProblems qFatigue

MENTAL/EMOTIONAL:qDepression qAnxietyqPanicAttacks qBipolarDisorderqPhobias qAnger/Rage qPTSD qSchizophrenia qPoorMemory qBrainFog qBehavioralorConductDisorders qADHD/ADD

Haveyoueverhadsuicidalthoughtsorattemptedsuicide?

Wereyoueveremotionallyorphysicallyabused?

HaveyoueverbeenhospitalizedforPsychiatricReasons?

Pleasecircle,highlight,orindicateanyareasofpain,numbness,tingling,orotherconcerns.Beasspecificanddescriptiveaspossible.

Betterwith:(checkallthatapply)

qHot qCold qMotion qRest qPressure qNopressure

Anythingelsemakeitfeelbetter?

Severity_________ (onascaleof1-10,10beingtheworstpainyou’veeverexperienced)

WorstTimeofDay:qMornings qEvenings qAfternoons qNight-time

AretheseSymptoms:

qConstant qRandom qIncreasinginSeverity

Anyknowntriggers?

CLINICFEEAGREEMENT

PleasereaditemsA-Fcarefullyandinitialwhereindicated.

A. Dr.BrianPopieliscurrentlyclassifiedasoutofnetworkproviderforallinsurancecompanies.InordertopotentiallyhaveinsurancecoverageforourservicesyourinsuranceplanneedstohaveoutofnetworkcoverageandtheOONdeductiblemustbemetbeforereimbursementwillhappen.Billingforlabsishandledbythelab(s)selectedbyyourphysician.Thelab(s)willsubmitchargestoyourinsurancecompanyandcoverageisdeterminedbydeductiblestatusandyourinsuranceplanpolicies.Pleasenote,thatSonoranNaturopathicCenterisnotinvolvedinthelabbilling.Mostinsurancecompanieswillcoveralloraportionofthebillforlabservices.Beawarethatoutofpocketmedicalexpensescanbeusedastaxdeductionsinsomecircumstances.Pleasekeepyourreceiptsaswedonotkeepfinancialrecordsofyourvisits.Wewillnotbeprovidingyearendstatementsfortaxes.________(initial)

B. Dr.Popiel’sfeeforin-officeorphoneconsultationsisbasedontimeandbilledatarateof$250/perhr.There

willbeseparatecostsforcertainprocedures,supplements,IVtherapies,injections,labworkanddiagnostictesting.Followupappointmentswillbebilledatthesameratementionedabove.________(initial)

C. Werequirea24houradvancenoticetocancelappointments.ForallLATEcancels(lessthan24hrnotice)youwill

becharged$25.00.ForallNOSHOWappts,wherenoticehasnotbeenprovided,youwillbecharged$75.00.________(initial)

D. IVTHERAPY

TheIVtherapiesalreadyincludeDr.Popiel’stimeandyouwillnotbebilledforhistimetwice.ThefollowingarethechargesforIV’s.

• Nutritional/Hydration/VitaminCIV’s-$195-$250• DMPSChelation(HeavyMetalsTesting/Removal)-$95• Glutathione(Detoxification)IVPush-$45• IVOZONE-$150-$195• IVPush-$80

IVSAREMADEPRIORTOCLIENTARRIVAL.24HRNOTICEISREQUIREDTOCANCELANIVAPPT.INTHEEVENTOFANOSHOWORLATECANCEL(LESSTHAN24HRNOTICE),CLIENTSWILLBEHELDFINANCIALLYRESPONSBILEFORTHEFULLIVCOST_________(initial)

E. INJECTABLETHERAPIES/OTHER:• BloodDraw-$20• B-12/Iron/Testosteroneinjection-$20-$35• Prolotherapy-$125-$400• InfraredSauna-$25

• Acupuncture-$95(newpatients)$75(followups)• Prolozone-$125-$400• AmnioFix–Costdeterminedbyinjectionsitelocationanddoserequired_________(initial)

F. PAYMENTISDUEATTHETIMEOFSERVICE.Dr.Popielwillbillinsuranceonbehalfofthepatient,butthereisno

guaranteeofinsurancereimbursement,duetothefactthatheisanoutofnetworkprovider._________(initial)

ClientSignature:

Date

BysigningIagreetotheabovetermsasoutlined.

INFORMEDCONSENTWelcometoSonoranNaturopathicCenterandthemedicalpracticeofDr.BrianPopiel.I consent to treatmentandunderstand thatmyphysician is a licensedNaturopathicDoctorwhowill conducta thoroughcase history with me before initiating any treatment protocols. Naturopathic doctors are recognized as primary carephysicians in the stateofArizonawith theability todiagnoseand treatdisease conditions. Naturopathicdoctorsutilizeprinciplesandpracticesthattreatthewholepersonandassistinthebody’sownabilitytoheal. Evaluationanddiagnoseswillbebasedonphysicalexam,specificbloodand/orurinary laboratoryreports. Evaluationofthese laboratory reportsmay be interpreted differently from other practitioners of naturopathic or allopathicmedicine. Treatment protocolsmay ormay not be consistentwithmainstreammedical tests/evaluations and are based on clinicalexperienceandscientific/medicalliterature. Treatmentsmayincludeproceduressuchasbutnotlimitedtonutritionalsupplements,homeopathicmedicines,botanicalmedicines,intravenousvitamin/mineraltherapy,acupuncture,prolotherapyinjections,mesotherapyinjections,triggerpointinjections, and prescriptive medications (including bio-identical hormones). Certain treatments may be deemed“experimental”sincetheFDAhasnotissuedanyguidelinesorstatementsastothesafetyorefficacyofthesetreatments. IunderstandthatmydoctorwillinformmeofthepotentialrisksoftreatmentandansweranyquestionsthatImayhave. Iunderstandthateven“natural”treatmentsmayhavesideeffectsanditismyresponsibilitytoinformmydoctorinatimelymannerofanysideeffectsoradverseeffectsthatImaybeexperiencing. Iwillmakesuretoinformmydoctorofalldietarysupplements,non-prescriptivemedicinesandprescriptivemedicationsthatIamtaking;aswellasupdatinganychangestothislist. IacknowledgethatifIhaveanyquestionsorconcernsaboutmylabevaluationandtreatmentprotocol;Iwilladdressthemwithmydoctorinatimelymanner. Myconsenttotreatmentisvoluntaryandinformed. Iassumefullresponsibilityforcostsregardlessofmyinsurancecoverage;thesecostsmay includeofficevisits/proceduresandlabsnotcoveredbyinsurance,aswellasmedications,andsupplements. HIPPAcompliancedoesnotallowforemailcommunicationinvolvingpersonal/identifyinginformation,medicalrecords,healthinformation,ortreatmentrecommendations.InordertocommunicatewithyourProviderviaemailandseemedicaldocumentssuchaslabresultsandtreatmentprotocols,youwillneedtoenrollinourPatientPortal.Pleaseprovidetheemailthatyouwouldliketousefortheregistrationofyourportal. E-mailAddress_________________________________________________________(PLEASENOTE,youcannotchangetheemailonceithasbeenregistered)SonoranNaturopathicCentermayusethisemailforappointmentremindersandothercommunicationnotinvolvingpersonal/medicalinformationYES________NO________

Signature

Date

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Doctors’Signature

Date

HIPAAPrivacyAuthorizationForm**AuthorizationforUseorDisclosureofProtectedHealthInformation

(RequiredbytheHealthInsurancePortabilityandAccountabilityAct,45C.F.R.Parts160and164)

1.AuthorizationIauthorize________________________________________(healthcareprovider)touseanddisclosetheprotectedhealthinformationdescribedbelowto______________________________________________(individualseekingtheinformation).2.EffectivePeriodThisauthorizationforreleaseofinformationcoverstheperiodofhealthcarefrom:

a. □______________to______________.

ORb. □allpast,present,andfutureperiods.

3.ExtentofAuthorizationa.□ Iauthorizethereleaseofmycompletehealthrecord(includingrecords

relatingtomentalhealthcare,communicablediseases,HIVorAIDS,andtreatmentofalcoholordrugabuse).

OR

b.□ Iauthorizethereleaseofmycompletehealthrecordwiththeexceptionofthefollowinginformation:□ Mentalhealthrecords□ Communicablediseases(includingHIVandAIDS)□ Alcohol/drugabusetreatment□ Other(pleasespecify):_______________________________________________4.ThismedicalinformationmaybeusedbythepersonIauthorizetoreceivethisinformationformedicaltreatmentorconsultation,billingorclaimspayment,orotherpurposesasImaydirect.5.Thisauthorizationshallbeinforceandeffectuntil___________________(dateorevent),atwhichtimethisauthorizationexpires.

6.IunderstandthatIhavetherighttorevokethisauthorization,inwriting,atanytime.Iunderstandthatarevocationisnoteffectivetotheextentthatanypersonorentityhasalreadyactedinrelianceonmyauthorizationorifmyauthorizationwasobtainedasaconditionofobtaininginsurancecoverageandtheinsurerhasalegalrighttocontestaclaim.7.Iunderstandthatmytreatment,payment,enrollment,oreligibilityforbenefitswillnotbeconditionedonwhetherIsignthisauthorization.8.Iunderstandthatinformationusedordisclosedpursuanttothisauthorizationmaybedisclosedbytherecipientandmaynolongerbeprotectedbyfederalorstatelaw.Signatureofpatientorpersonalrepresentative__________________________________________________________________Printednameofpatientorpersonalrepresentativeandhisorherrelationshiptopatient__________________________________________________________________Date_______/_______/__________