the amen clinic for behavioral medicine, inc web viewis the problem worse at any particular time ......
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T.R. Morris, ND, IFMCPNaturopathic Medical Doctor & IFM Certified Practitioner
7041 11th Ave NW Seattle, WA 98117 ~ Tel: 206-947-4915 ~ Fax: 206-274-4955 ~ Email: [email protected]
PATIENT INFORMATION |(Please use MS WORD to fill in the gray boxes, or write clearly. Do not “fix margins” when printing.)
Patient Name: Date of Birth: Marital Status: Home Address: City, State, Zip: Cell Phone: Home Phone: E-mail: Occupation: Employer / School: Work / School Phone:
PRIMARY HEALTH CARE PROVIDER /or REFERRAL SOURCEName: Address: Phone #: Fax #:
RESPONSIBLE PARTY and/or SPOUSE’S INFORMATIONSpouse or Responsible Party: (if different than patient)Case # / Date of Birth: (if different than patient)Address: (if different than patient)Phone: (if different than patient)Employer: (if different than patient)
INFORMED CONSENT TO DIAGNOSIS AND TREATMENT
The intention of this consent form is to help patients, clients, and authorized representatives become better informed so that they may give, or withhold, consent to undergo diagnosis and treatment after having an opportunity to discuss health concerns including potential benefits and risks, and treatment alternatives.
I, PATIENT, CLIENT, or AUTHORSIZED GAURDIAN or REPRESENTATIVE, (hereafter referred to as “patient or representative”) acknowledge the opportunity to read and inquire about this consent and hereby authorize Dr. T.R. Morris (hereafter referred to as “clinician”), in accordance and within the scope and limits of their clinical license(s), to perform or recommend any of the following procedures for diagnosis and treatment:
Common Diagnostic Procedures: venipuncture, radiography, laboratory, x-ray, ultrasound, etc. Alternative Diagnostic Procedures: including genetic tests and other diagnostic methods and devices that
may fall outside of the “conventional standard of care.” Lifestyle Counseling: therapeutic dietary advice and guidelines and the promotion of wellness including but
not limited to recommendations for sleep, exercise, stress management and reduction, balancing of work and self-care activities, and developing and nurturing healthy relationships and community relationships.
Medical Nutrition: therapeutic nutrition, nutritional supplementation and intramuscular vitamin, mineral, amino acid, lipid, phytonutrient, and metabolite precursor and other nutrient injections as permitted by licensure.
Botanical Medicine: medicinal herbs and plant derivatives prescribed as loose teas, alcohol or glycerin tinctures, capsules, tablets, creams, suppositories, etc.
Intravenous Therapies: including high dose vitamin, mineral, amino acid, lipid, botanical and other nutrients. Minor Office Procedures: wound dressing, ear cleansing, sutures, biopsies, immunizations, etc. Physical Medicine: massage, stretching, exercises, contrast heat/cold applications and manual or instrument-
assisted joint mobilizations (as permitted by licensure). Lifestyle and Wellness Counseling: to promote improved lifestyle strategies and wellness, but not including
the specific treatment of known or suspected mental illness. Prescription medications: As allowed by the clinician’s licensure and for both FDA approved and non-FDA
approved (i.e. “off label”) applications. Hormonal Replacement: oral, transdermal, injected or device-implanted hormonal applications indented to
restore symptomatic patients to levels at or above age-appropriate hormone levels through bioidentical, synthetic and animal derived preparations.
Group Counseling: to facilitate efficient and effective community creation and education regarding the diagnosis, treatment and management of health concerns.
Informed Consent: (Patient’s or Representative’s Initials) acknowledges the right, opportunity and responsibility to ask questions and to become informed regarding the clinician’s diagnostic and treatment recommendations to their satisfaction.
Potential Risks: (Patient’s or Representative’s Initials) acknowledges and accepts that there are risks to the diagnosis and treatment measures that fall within and outside the conventional standard of care, and that these risks may include: unintended exacerbation of symptoms, new symptoms, allergic and other unintended injury and side effects from exercise, lifestyle modifications, dietary modifications, herbal and nutritional supplements, injected or intravenous therapies, hormonal therapies, adverse interactions with drugs, herbs and/or nutrients. No Guarantee of Potential Benefits: (Patient’s or Representative’s Initials) acknowledges that treatment may result in the restoration of health and optimal functional capacity, relief of pain and symptoms, injury and disease recovery, and prevention or reversal of disease or disease progression and ALSO that no expressed or implied guarantees can or have been made by the clinician or any affiliated staff regarding the cure or improvement of the patient’s condition.
Limitations of Full Disclosure: (Patient’s or Representative’s Initials) acknowledges that the clinician cannot know or anticipate and explain every possible risk or complication, and that the patient or representative willingly chooses to rely on the clinician to exercise their best judgment and within the bounds of their licensure for any of the above.
Responsibility to Report Possible Pregnancy: (Patient’s or Representative’s Initials) agrees to alert the clinician should they suspect that they are pregnant in acknowledgement that some of the diagnostic or therapeutic techniques could present risks to a pregnancy.
Disclosure Coverage: (Patient’s or Representative’s Initials) acknowledges and agrees that consent form will cover the entire course of treatment for present condition and for any future condition(s) for which treatment is sought.
Willing Participation: (Patient’s or Representative’s Initials) understands that they are free to discontinue participation in any and all aspects of the medical care provided by the clinician at any time, and that the patient or representative is responsible for informing the clinician of the adherence to or discontinuation of any and all aspects of care. It is also understood that the choice to discontinue treatments may create the risk of adverse effects for which the patient or representative bears full and sole responsibility.
Clinician Collaboration: (Patient’s or Representative’s Initials) understand that the clinician may consult with preceptors, clinical students, residents and colleagues related to the care provided and that the patient or their authorized representative have the right to decline their presence or involvement during any aspect of the patient’s care.
Agreement to be Contacted: (Patient’s or Representative’s Initials) understand and accept that the clinician or affiliated staff may contact the patient or representative (e.g. by phone, email, voicemail, SMS text message) to consult or exchange information related to the patient’s care.
Remote Consultations: (Patient’s or Representative’s Initials) At times, consultation may be provided remotely and without direct contact with clinician. In such cases, the patient or their representative agree to maintain direct contact with a licensed health care provider that is appropriate for the patient’s age, gender and known or suspected health conditions.
Medical Record Keeping and Privacy: (Patient’s or Representative’s Initials) understand that records of the health services provided will be kept for a minimum of three, but no more than ten years after the date of the last visit or consultation. The patient or representative also acknowledge that information within the record may be analyzed for research purposes, and that in such case, the patient’s identity (name, address, exact birthdate) will be kept confidential. Otherwise, this record will be kept securely and confidentially and without release to others unless so directed by the patient or representative, as may be required by law, or as necessary for insurance claim or other payment processing.
Patient’s Responsibility to Disclose Information: (Patient’s or Representative’s Initials) understands that they bear full responsibility for any adverse effects experienced during or after the course of treatment that was reasonably deemed to be caused or related to a deficit in the full, accurate and timely disclosure of symptoms and other medical information to the best of the patient’s or representative’s ability.
Responsibility for Payment: (Patient’s or Representative’s Initials) understands that some or all of the visits and recommended diagnostic and treatment procedures may not be covered by the patient’s insurance, and in such event that that the patient accepts full responsibility for all associated costs and fees.
Dispute Resolution: (Patient’s or Representative’s Initials) agrees that any complaint or dispute that arises related to the diagnosis or treatment from clinician will be settled through binding mediation in the state which the clinician is licensed.
Patient’s Name Patient’s Physical Signature Date___________________________
Responsible Party’s Name Responsible Party (Signature) Date___________________________
MEDICAL INTAKE FORMS
Please e-mail ([email protected]) or fax (206-274-4955) these forms back to Dr. Morris before your initial visit. If this is not possible, please mail the forms. If none of these options are possible, please bring your completed forms to your first office visit, and contact the office to let us know this is what you are doing.
Current Age: Male Female
Present Height: Present Weight: Occupation: Married , Single , Separated/Divorced ; Children
CURRENT HEALTH CONCERNS: Please list your primary heath concerns in order of importance or severity. Associated Concerns can be listed together, and Additional Concerns can be indicated or added to the Review of Systems (page 8)
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OPTIMAL HEALTH GOALS: Briefly describe optimal health & function for you:
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READINESS FOR CHANGERate how willing you are to do the following to improve your health 0-5? (5=very willing, 0=not willing)
1) Be educated on the causes of your health or disease
2) Engage in regular exercise
3) Significantly modify your diet
4) Modify your lifestyle (work demands, hours of sleep, avoiding stressors, etc.)
5) Reduce your intake of caffeine, alcohol, tobacco, recreational drugs, and medications
6) Practice a relaxation technique (conscious breathing, meditation, yoga, etc.)
7) Take vitamins, minerals, herbal supplements, or hormonal support
8) Have periodic lab tests to assess your progress
9) Have regular follow up appointments to asses and update your treatment plan
10) Inform the doctor if a treatment suggestion is not likely to be used, or is not working
PRIMARY HEALTH CONCERN #1
CONCERN #1 Name the diagnosis, symptom or concern.
LOCATION & QUALITY
If applicable, name the location and quality of the symptom (sharp, dull, constant, etc.).
ONSET & CAUSES
When did this start? What events preceded the symptom? “I’ve never been well since I ___.”
SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable
FREQUENCY & DURATION
How frequently does it occur? How long does symptom last when it is present?
TIMINGIs the problem worse at any particular time (day/week/month/season)?
TRIGGERS Is there anything in particular that triggers this issue?
AGGRAVATING FACTORS
What treatments, activities, foods, settings, etc. make the problem WORSE?
RELIEVING FACTORS
What treatments, activities, foods, settings, etc. make this issue BETTER?
ASSOCIATED SYMPTOMS
Are there other symptoms that come on with or after this?
PROGRESSION Is the problem generally getting worse, better, or not changing?
FAMILY HISTORY
Have you or a family member had a similar concern in the past?
YOUR OPINION
Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem?
ADDITIONAL INFORMATION
Please give any other information you feel is important to fully understand your concern.
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PRIMARY HEALTH CONCERN #2
CONCERN #1 Name the diagnosis, symptom or concern.
LOCATION & QUALITY
If applicable, name the location and quality of the symptom (sharp, dull, constant, etc.).
ONSET & CAUSES
When did this start? What events preceded the symptom? “I’ve never been well since I ___.”
SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable
FREQUENCY & DURATION
How frequently does it occur? How long does symptom last when it is present?
TIMINGIs the problem worse at any particular time (day/week/month/season)?
TRIGGERS Is there anything in particular that triggers this issue?
AGGRAVATING FACTORS
What treatments, activities, foods, settings, etc. make the problem WORSE?
RELIEVING FACTORS
What treatments, activities, foods, settings, etc. make this issue BETTER?
ASSOCIATED SYMPTOMS
Are there other symptoms that come on with or after this?
PROGRESSION Is the problem generally getting worse, better, or not changing?
FAMILY HISTORY
Have you or a family member had a similar concern in the past?
YOUR OPINION
Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem?
ADDITIONAL INFORMATION
Please give any other information you feel is important to fully understand your concern.
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PRIMARY HEALTH CONCERNS #3
CONCERN #1 Name the diagnosis, symptom or concern.
LOCATION & QUALITY
If applicable, name the location and quality of the symptom (sharp, dull, constant, etc.).
ONSET & CAUSES
When did this start? What events preceded the symptom? “I’ve never been well since I ___.”
SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable
FREQUENCY & DURATION
How frequently does it occur? How long does symptom last when it is present?
TIMINGIs the problem worse at any particular time (day/week/month/season)?
TRIGGERS Is there anything in particular that triggers this issue?
AGGRAVATING FACTORS
What treatments, activities, foods, settings, etc. make the problem WORSE?
RELIEVING FACTORS
What treatments, activities, foods, settings, etc. make this issue BETTER?
ASSOCIATED SYMPTOMS
Are there other symptoms that come on with or after this?
PROGRESSION Is the problem generally getting worse, better, or not changing?
FAMILY HISTORY
Have you or a family member had a similar concern in the past?
YOUR OPINION
Even if you are not 100% sure, what do you think is causing and/or perpetuating this problem?
ADDITIONAL INFORMATION
Please give any other information you feel is important to fully understand your concern.
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REVIEW OF SYSTEMSPlease check the boxes that apply and explain the problem areas further at the bottom of each section. No additional explanation is necessary here if the problem was one of the 3 major heath concerns detailed earlier.
General Fatigue (feeling tired or worn out) Being overweight Unexpected weight gain Unexpected weight loss Poor appetite Increased appetite Excessive sleeping Difficulty sleeping Unusual sensitivity to cold Unusual sensitivity to heat Cold sweats during the day Hot or cold spells Sweating excessively at night Excessive daytime sweating Lowered resistance to infection Flu-like or vague sick feeling Excessive thirst Other:
Explanations:
Neurological Depression, hopelessness or apathy Suicidal thoughts or planning Excess worrying, anxiety, panics Forgotten periods of time Dizziness Drowsiness Tremors (in hands or feet. etc.) Problems with memory Twitching, spasms or “tics” Numbness / Tingling Convulsions / fits Slurred speech Speech problem (other) Weakness in muscles Other:
Explanations: Respiratory
Shortness of breath Asthma, wheezing Chronic cough Coughing up blood or sputum Rapid breathing Repeated sinus infections Repeated bronchitis/pneumonia Other:
Explanations:
Chest & Cardiovascular Ankle swelling/edema Rapid / irregular pulse Chest pain Palpitations High blood pressure Low blood pressure Other:
Explanations:
Head, Eye, Ear, Nose, & Throat Frequent sore throats Post-nasal drip Disturbances in smell Runny nose or dry nose Repeated ear infections Hearing loss in one or both ears Ringing in ears / tinitus Headache Head injury Facial pain Blurry/Double vision Overly sensitive to light Dry mouth Sore tongue Trouble swallowing Other:
Explanations: Gastrointestinal & Hepatic
Loose/liquid bowel movements Constipation/Hard bowel movements >3 Bowel movements/day <7 Bowel movements/week Abdominal (stomach/belly) pain Abdominal swelling/bloating Slow digestion Nausea or vomiting (throwing up) Loss of bowel control Painful bowel movements Frequent belching (burps) Frequent flatulence (farting) Jaundice (yellowing of skin, eyes) Rectal bleeding (red or black blood) Rectal itching Other:
Explanations:
Musculoskeletal Neck pain or stiffness Back pain or stiffness Joint pain or stiffness Bone pain Leg pain Muscle cramps, spasm, or pain Muscle twitching Other:
Explanations:
Skin, Hair Dry hair or skin Itchy skin or scalp Easy bruising Excessive hair loss Excess hair growth Increased perspiration No perspiration Sun sensitivity Other/Explanations:
Genitourinary Itchy privates or genitals Painful urination Excessive urination Difficulty in starting urine Accidental wetting of self Pus or blood in urine Decreased sexual desire Other:
Explanations: Females
No menses Menstrual irregularity Premenstrual Concerns: cramps
headachessadness/moodinessirritability/angerwater retention/bloatingbreast tenderness
Heavy menstrual periods Painful menstrual periods Abnormal vaginal discharge Pain during sex Sterility or fertility issues Problems with pregnancies Pregnancies Miscarriages Other:
Explanations: Males
Impotence (weak male erection) Inability to ejaculate or orgasm Scrotal pain Mass on testicles Mass in scrotum Pain with urination Decreased/absent ability to urinate Waking up at night to urinate Unable to stop urination Abnormal penile discharge Other:
Explanations: Miscellaneous/OtherHealth concerns/symptoms not listed above or detailed in the top 3 concerns:
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PERSONAL & FAMILY MEDICAL HISTORYIn the table below, please indicate the medical conditions you and your family members have had.
HEALTH CONDITION Self(current)
Self(Past) Relative DETAILS (who, onset, severity, treatment, resolution, etc.)
Suicidal Thoughts/Intent Blood Pressure High Cholesterol/Lipids Diabetes/High Blood Sugar Low Blood Sugar Obesity/Overweight Fatigue/Chronic Fatigue Heart Murmur/Arrhythmia Blood Clots/Stroke Heart Attack/Coronary Dis. Sleep Apnea/Sleep Disorder Asthma/COPD/Pneumonia Allergies/Hay Fever Frequent Sinus/Ear Infection Food Allergies/Sensitivities Skin Conditions Indigestion/Heartburn Ulcers (Gastrointestinal) Liver/Gall-Bladder Disease Colitis/Cohn’s Disease/UC Irritable Bowel (IBS) Thyroid Conditions (high/low) Adrenal Dysfunction Chronic Neck/Back Pain Osteopenia/Osteoporosis Osteoarthritis (joint pain) Rheumatoid Arthritis Autoimmune: Lupus, MS, etc. Kidney/Urinary Disease Abuse: Physical/Sexual Anxiety/Depression Attention Deficit/ADD Anorexia/Bulimia/Binging Alcohol/Drug Addiction Other Mental Illness Headaches/Migraines Seizures Alzheimer’s Disease Parkinson’s Disease Cancers Other: Other: Other:
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CHILDHOOD & ADULT HISTORY
PRENATAL DETAILS
Mother’s age, maternal health, substance use, diet, exposures, mental health, stressors, etc.
BIRTH DETAILSFull term or premature, vaginal or cesarean, hospital or home birth, respiratory disresss, other details…
VACCINATIONS Normal or alternate vaccination schedule? Any unusual reactions?
CHILDHOOD ILLNESSES
e.g. Colic, chicken pox, measles, major allergies, ear infections, pneumonia, leukemia, etc.
CHILDHOOD SETTINGS
Locations, environments (urban, suburban, rural, agricultural, industrial), foreign travel, etc.
SOCIAL FOUNDATION
Single or dual parents, siblings, birth order, adoption, extended family contact, community, etc.
CHILDHOOD SECURITY/STRESS
Did you feel safe as a child? Did you experience significant abuse, stress, or hardship?
ALLERGIES(Drug, Food, Environmental, etc.)
List all known and suspected allergies to drugs, foods and other exposures.
INJURIES & TRAUMAS
e.g. head injury, car accidents, falls, broken bones, major sprains. Indicate the date and treatments.
SURGERIES &HOSPITALIZATIONS
Please include all, and indicate the year, the cause, treatments, and outcomes.
TRAVEL HISTORYWhere have you traveled out of the country; when and for how long? Note any illnesses or injuries.
OCCUPATIONAL HISTORY
Summarize your employment history and the TYPES of jobs you’ve had.
KNOWN TOXIC EXPOSURES
Mold, Pesticides, Mercury, lead, solvents, PCBs, PBDEs, etc.
TOBACCO USE Please indicate past and present use
DRUG USEPlease indicate past and present use. (For privacy, this may also be disclosed during the visit.)
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NUTRITION & LIFESTYLE FACTORS
DIETARY HABITS & RESTRICTIONS
For example: vegetarian, gluten free, dairy free, food reactions, diets: (paleo, ketogenic, etc.)
TYPICAL BREAKFASTS
Do you eat breakfast? If so what are some examples?
TYPICAL LUNCHES Describe typical lunches.
TYPICAL DINNERS Describe typical dinners.
TYPICAL SNACKS Do you snack? How often? Please give a few examples.
HYDRATIONHow much water do you typically drink on a daily basis? (coffee & alcohol don't count)
CAFFEINE USE Include coffee, tea, soda and the amount per day, week or month.
SOFT DRINKSDo you drink diet or regular soda? If so, please indicate which kinds and how much.
FAST FOOD & PASTRIES
How often do you eat fast food or pastries (per day/week/month)?
ALCOHOL USEPlease indicate the amount per day, week, or month. Are you concerned about over-consuming alcohol?
SLEEP BEHAVIORUsual bedtime, duration, regularity, quality. Indicate snoring, apnea, sleepwalking, nightmares, difficulty falling/staying asleep.
RELAXATION & RECUPERATION
What kinds of things do you do to unwind, relax and recharge? How often?
CURRENT MAJOR LIFE STRESSES
List major stressors: work, school, finances, children, family, relationships, caregiving, etc.
EXERCISE & MOVEMENT
Indicate frequency, intensity, type, and duration: e.g. 3x/week, 30min, moderate, aerobic (or resistance or flexibility)
RELATIONSHIPS & NETWORKS
Do you have close friends and/or family, religious connection, support groups, or other social groups available to you?
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TIMELINE OF SIGNIFICANT MEDICAL & LIFE EVENTSPlease list and describe all significant Medical & Life Events. Please indicate the EVENT TYPE and list a start date.
EVENT TITLE EVENT TYPE START DATE(Month &Year)
END DATE(If applicable) EVENT DESCRIPTION
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ADDITIONAL INFORMATION:
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LAB TEST & IMAGING STUDIES Please locate your previous lab and imaging studies—and have them faxed, emailed, or mailed in. In the table below, please enter the most relevant results in chronological order (recent first).
LAB TESTS &IMMAGING STUDIES
DATE(month & year)
PRESCRIBING PROVIDER
FINDINGS (normal or abnormal; include the numbers and the normal ranges)
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ADDITIONAL INFORMATION:
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MEDICATION & SUPPLEMENT HISTORY Starting with medications, hormones & supplements you currently take, list your current regimen. Indicate the diagnosis or reason you take/took the medication or supplement and your response. Afterwards, list medications and supplements you took in the past—including ones you had a bad reaction to. Please bring your current supplements with you to our first appointment, or have them nearby for remote consults.
SUPPLEMENT OR MEDICATION
DOSAGE & FREQUENCY
START & END (month/year)
DIAGNOSIS OR REASON FOR TAKING. INDICATE YOUR RESPONSE, SIDE EFFECTS
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ADDITIONAL INFORMATION:
By responding below, the patient/guardian indicates that the information given in these intake forms above is correct and complete to the best of their ability and agree that any problems that arise due to incomplete or incorrect information are the responsibility of the patient or guardian.
Patient OR Guardian: Date:
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MEDICAL RECORDS RELEASE
(Patient Name)
(Address)
(Date of Birth)
HEREBY REQUESTS:
(Health care provider)
(Fax# / Address)
(Health care provider #2—if needed)
(Fax# / Address)
(Health care provider #3—if needed)
(Fax# / Address)
To release any and all information contained in my medical records to:
Timothy R. (T.R.) Morris, NDNaturopathic Medical Doctor7041 11th Ave NW, Seattle, WA 98117Phone: 206-947-4915Fax: 206-274-4955Email: [email protected]
I understand that this authorization (unless expressly limited by me in writing) extends to all aspects of my medical records including test results, imaging, prescriptions and past treatment recommendations and chart notes.
Patient Signature: Date:
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