Dr Saxena Patient Intake Form

8/3/2019 Dr Saxena Patient Intake Form

1/16

Name: PreferredName:PrimaryStreetAddress: Apt.No.:

City: State: ZipCode:DateofBirth: SS#:

Age: Gender: MaritalStatus:Ethnicity: Race:

HomePhone: PreferredLanguage:WorkPhone: Bestwaytoreachyou:

CellPhone: Besttimetoreachyou:EMailAddress:

CurrentOccupation: Employer:mergencyContact Name: Phone:

Relationship:

Address: Apt.No.:City: State/Zip:

Name: Phone#:City:

Referredby Name:maryInsuranceCo. Name: Phone#:

InsuranceCo.Address:Policy#: Group#:

InsuredName: Relationship:InsuredDateofBirth: InsuredSS#:

InsuredAddress (ifdifferentfrompatient):condaryInsuranceCo. Name: Phone#:

CompanyAddress:Policy#: Group#:

InsuredName: Relationship:InsuredDateofBirth: InsuredSS#:

InsuredAddress (ifdifferentfrompatient):rsonResponsibleforBill: Relationship:

Address: Phone:

e1 2011SevaMedInstitute

(ifapplicable)

CurrentPrimaryCarePhysician

Congratulations on your dec ision to move further on the p ath to op tima l hea lth! Were here to

ed uca te and supp ort you as pa rt of our commitment pa rtnering with you in ma nag ing your health.

The following informa tion is nec essary in order for us to op timize your ca re. Please fill out this form as

c omp letely and as ac c urate ly as po ssible.

New Pa tient Pac ket

GENERAL INFORMATION

o Female o Male


2/16

NAME DATE

0 Neveroralmostnever havethesymptom 3 Frequently haveit,effectisnotsevere1 Occasionally haveit,effectisnotsevere 4 Frequently haveit,effectissevere2 Occasionally haveit,effectissevere

HEAD Headaches Nausea,vomiting

Dizziness/Faintness Diarrhea,loosestools

Insomnia Constipation,hard/infrequentstools

TOTAL(thissection) BloatedfeelingBelching,passinggas,burping

EYES Wateryoritchyeyes Heartburn/acidtasteinmouth

Swollen,reddenedorstickyeyelids Intestinal/stomachpainDarkcirclesundereyes TOTAL(thissection)Visionproblems

(excludingnearorfarsighted) Painorachesinjoints/ArthritisTOTAL(thissection) Warm,swollenjoints

Stiffnessorlimitationofmovement

EARS Itchyears Painorachesinmuscles

Frequentearinfections Muscleweakness

Poppingof

ears TOTAL(thissection)

Ringinginears

TOTAL(thissection) WEIGHT Excessiveeating/drinkingStrong/Excessivecravingcertainfoods

NOSE Stuffynose/Excessivemucusformation Overweight/Obese

Sinusproblems Difficultylosingweight

Hayfever/Sneezingattacks Waterretention

Nosebleeding Difficultygainingweight

TOTAL(thissection) TOTAL(thissection)MOUTH/ Gagging,frequentneedtoclearthroat Fatiguefrommentalexhaustion

Sorethroat,hoarseness,lossofvoice Fatiguefromemotionalexhaustion

Swollen/Discoloredtongue,gums,lips Hyperactivity(mindorbody)

Cankersores Restlessness(mindorbody)

TOTAL(thissection) TOTAL(thissection)SKIN Acne MIND Poormemory

Hives,rashes,dryskin Confusion,poorcomprehension

Hairloss Poorconcentration

Excessivehairgrowth Poorphysicalcoordination

Excessivesweating/Bodyodor Difficultymakingdecisions

Flushing,hotflashes Speechdifficulty

TOTAL(thissection) LearningdisabilitiesTOTAL(thissection)

HEART Irregularorskippedheartbeat

Rapidorpoundingheartbeat EMOTIONS Moodswings

Chestpain Anxiety,fear,nervousness

TOTAL(thissection) Anger,irritability,aggressivenessDepression/SadnessUNGS Chestcongestion Obsessive,compulsivebehaviors

Asthma,frequentbronchitis TOTAL(thissection)Difficultybreathing

Frequentcoughing OTHER Frequentillness

TOTAL(thissection) FrequentorurgenturinationGenitalitchordischarge

TOTAL(thissection)

SUMOFALLSECTIONSABOVE:age2 2011SevaMedInstitute

JOINTS/MUSCLE

ENERGY/ACTIVITY

DIGESTIVETRACT

Rateeachofthefollowingsymptomsbaseduponyourtypicalhealthprofile FORTHEPAST30DAYS

Pleaseusethescaleshownbelowtodecribetheseverityofyoursymptom (pleasetotaleachsection)

ifyouaredealingwithmorethanonesymptomlistedbelowthenpleasecircleallthatapply):

MEDIC AL SYMPTOM QUESTIONNAIRE


3/16

Name: Date:

Problem#1:

Problem#2:

Problem#3:

PREVENTIVETESTS DATE SURGICALHISTORY DATE

Checkbox

if

yes

and

provide

date

Check

box

if

yes

and

provide

date

FullPhysicalExam Appendectomy

BoneDensity Hysterectomy

Colonoscopy Ovariesremoved:

CardiacStressTest Right/Left/Both

EKG GallBladder

Hemoccult (stooltestforblood) Hernia

Mammogram Tonsillectomy/Adenoidectomy

PAPSmear JointReplacement Knee/Hip

PSA HeartSurgery(type)________________

Other___________________ AngioplastyorStent

Pacemaker

Other ____________________

HOSPITALIZATIONS

Date ReasonforHospitalization

SPECIALISTCARE Pleaselistallphysiciansthatmanageyourcare.PhysicianName MedicalSpecialty Issue(s)BeingManaged

age3 2011SevaMedInstitute

HEALTH GOALS

MEDICAL CARE HISTORY

Pleasedescribethetopthree(3)symptoms/conditionsyouseektoimproveatouroffice(inorderofimportance). Pleaseprovideabrieftimelineorreviewofthecontributingfactorsasyouseeit.


4/16

DISEASES/DIAGNOSIS/CONDITIONS =PastCondition(pc) =OngoingCondition(oc)pc oc GASTROINTESTINAL dateofonset pc oc GENITALANDURINARYSYSTEMS dateofonset

IrritableBowelSyndrome KidneyStones

Crohn'sDisease InterstitialCystitis

UlcerativeColitis FrequentUrinaryTractInfections

GastritisorPepticUlcer FrequentYeastInfections

GERD(AcidReflux) ErectileorSexualDysfunction

CeliacDisease UrinaryIncontinence

Other______________________ Other_____________________

pc oc CARDIOVASCULAR dateofonset pc oc MUSCULOSKELETAL/PAIN dateofonsetHeartAttack Osteoarthritis

PoorCirculation Fibromyalgia

Stroke Gout

HighCholesterol ChronicPainSyndrome

Arrhythmia(irregularbeat) Other_____________________

Hypertension(highbloodpressure) pc oc INFLAMMATORY/AUTOIMMUNE dateofonsetHeartValveDisease ChronicFatigueSyndrome

Other ______________________ Autoimmune

Disease

pc oc METABOLIC/ENDOCRINE dateofonset RheumatoidArthritisType1Diabetes Hashimoto'sThyroiditis

Type2Diabetes Psoriasis

Hypoglycemia(lowbloodsugar) FoodAllergies

MetabolicSyndrome EnvironmentalAllergies

InsulinResistanceorPrediabetes MultipleChemicalSensitivities

Obesity/Overweight Other_____________________

Hypothyroidism(underactive) pc oc RESPIRATORYDISEASES dateofonsetHyperthyroidism(overactive) Asthma

PolycysticOvarianSyndrome(PCOS) ChronicSinusitis

Infertility Bronchitis

Other _______________________ COPDorEmphysema

pc oc NEUROLOGIC/PSYCHIATRIC dateofonset PneumoniaDepression SleepApnea

Anxiety Other_____________________

BipolarDisorder pc oc SKINDISEASES dateofonsetHeadaches Eczema

Migraines Vitiligo

ADD/ADHD Acne

Autism Other_____________________

MultipleSclerosis pc oc CANCER dateofonset

Seizures LungCancer

EatingDisorder(Anorexia/Bulimia) BreastCancer

Other _______________________ ColonCancer

OvarianCancer

ProstateCancer

SkinCancer

Other_______________________

age4 2011SevaMedInstitute

CheckappropriateboxandprovidedateofonsetMEDICAL HISTORY


5/16

OBSTETRICHISTORY (Checkboxifyesandprovidenumberoftimes) Pregnancies__________ Cesarean __________ VaginalDeliveries__________

Miscarriage__________ Abortion __________ LivingChildren__________

PostpartumDepression Toxemia GestationalDiabetes Babyover8lbs

Breastfeeding ForHowLong?__________

MENSTRUALHISTORYAgeatfirstperiod ________ MensesFrequency ________days MensesLength________days

Describeyourcurrentmenstrualcycle

Details:

LastMenstrualPeriod: DateofLastPAP:

HistoryofAbnormalPAP? If yes,dateofabnormalPAP:

Currentcontraception?

Totalyearsofhormonalcontraceptionuse?_______

WOMEN'SDISORDERS/HORMONALIMBALANCES(checkallthatapply) FibrocysticBreasts Endometriosis Fibroids Infertility

PainfulPeriods HeavyPeriods PMS

AreyouinMenopause(nomensesinlast12months)? (ifyes,Whatage?_______)

Ifyes,

Currentuseofhormonereplacementtherapy?

(HowLong?_______ )

(HowLong?_______ )

Previoususeofhormonereplacementtherapy?

(How

Long?

_______

)

(HowLong?_______ )

MenopausalSymptoms: Checkallthatapply HotFlashes MoodSwings Concentration/MemoryProblems VaginalDryness

NightSweats sleepproblems Postmenopausalbleeding LossofControlofUrine

Headaches Palpitations WeightGain DepressionorAnxiety

Have

you

had

a

PSA

done?

(

Date

of

last

PSA?

_______________________

) PSALevel

Checkallthatapply

ErectileDysfunction

Nocturia(urinationatnight) Howmanytimespernight?________

Urgency/Hesitancy/ChangeinUrinaryStream

EnlargedProstate

age5 2011SevaMedInstitu

o Regular o Irregular

o None o Condom o Diaphragm o IUD o Vasectomy

o No o Yes

MALE HISTORY

o No

o Yeso 01 o 24 o 510 o >10

FEMALEHISTORY

o Natural o Surgicalremovalofovaries

o None

o TraditionalPrescription

o Yes o No

o Bioidentical HormoneReplacementTherapy

o None

o TraditionalPrescription

o Bioidentical HormoneReplacementTherapy

o Birth ControlPill

o Absent


6/16

Pleasedescribeyourtypicaldailydiet byindicatingyourusualdailyservings:

Vegetables: _______ Dairy: _______

Fruits: _______ Potatoes: _______

Beans: _______ Fats/Oil: _______

Nuts/Seeds: _______ FastFood: _______

WholeGrains: _______ RefinedGrains: _______

AnimalProtein: _______ ProcessedFoods: _______

Overall,doyoufeelthatyoueat... (checkallthatapply)

Doyoufeellikeyoudigestyourfoodwell?

Doyoufeelbloatedaftermeals?

Ifyes,

Werethereyearswhereyoutookmorethan3coursesofantibioticsperyear?

Doyou

experience

frequent

yeast

infections

or

toe

fungal

infections/athlete's

foot?

Doyougetsickfromstrongsmells,chemicalsormedicationseasierthanmostpeople?

Aretheresomefoodstowhichyouareallergic,intolerantorjustseemtobotheryou?

Explain:________________________________________________________________________________________

Doyousufferfromallergies?

Ifenvironmental,arethey...

Doyoueverfindbloodinyourstool?

Howmanybowelmovementsdoyouhaveinatypicalday?

Ifyouanswered


7/16

SMOKING

CurrentlySmoking? Howmanyyears? Packsperday:

Attemptstoquit: Usingwhatmethods:_________________________

PreviousSmoking? How

many

years? Packs

per

day:

QuitDate:____________

2ndHandsmokeexposure?

ALCOHOLINTAKEHowmanydrinkscurrentlyperweek? (1drink=5ozwine,12ozbeer,1.5ozliquor)

Doyoufrequently(morethan2x/week)take:

Previousalcoholintake?

Doyoueverfeelguiltyaboutyouralcoholconsumption?

Doyounoticeatolerancetoalcohol(youcan"hold"morethanothers)?

Doyounoticeyou'feel'youralcoholatverylowamounts?

OTHERSUBSTANCESCaffeineintake

Cupsperday: (

CaffeinatedorDietBeveragesperday

List

favorite

type

(e.g.

Diet

Coke,

Pepsi,

Red

Bull,

Monster,

etc) Doyouoftentakecaffeinetoavoidfatigue?

EXERCISE

CurrentExerciseProgram: Activity(listtype,numberofsessions/week,anddurationofactivity)

Activity Type Frequency/week DurationinMinutesStretching

Cardio/Aerobics

Strength

Yoga/Pilates

Sports/Leisure

Activities (golf,tennis,rollerblading,etc)

Doyoufeelunusuallyfatiguedafterexercise?

Ifyes,pleasedescribe:

Doyouusuallysweatwhenexercising?

Page7 2011SevaMedInstitute

LIFESTYLE INFORMATION

o Yes o No

o None o 13 o 46 o 710 o >10 ;

o Mild o Moderate o Higho None

o Yeso No

o Coffee:________ o Tea:_______

o 1 o 2 o 3

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Low o Medium o Higho None

o None

o >1drinkper dayforfemales

o >2 drinksperdayformales

o > 4

o throughouttheweek o weekendsmostly

o Yes o No

o Herbal o NonHerbal)


8/16

STRESS/COPING

Haveyoueversoughtcounseling?

Doyoufeelyouhaveanexcessiveamountofstressinyourlife?

Doyoufeelyoucanmanagethestressinyourlife?

Doyoufeelyoumakeunhealthychoicesduetohighstress?

DailyStressors: (Rateonascaleof110 1=lowest,10=highest)

Work Family Social Finances Health OtherDoyoupracticemeditationorrelaxationtechniques?

Checkallthatapply:

SLEEP/REST

Howlikelyareyoutodozeofforfallasleepinthefollowingsituationsusingthescalebelow?

0=Wouldneverdoze 2=Moderatechanceofdozing

1=Slightchanceofdozing 3=Highchanceofdozing

Sittingandreading

Watchingtelevision

Sittinginactiveinapublicplace(ex,atheaterormeeting)

Lyingdowntorestintheafternoonwhencircumstancespermit

Sittingandtalkingtosomeone

Sittingquietlyafteralunchwithoutalcohol

Inacar,whilestoppedforafewminutesintraffic

Asapassengerinacarforanhourwithoutabreak

Averagenumberofhoursyousleeppernight?

Doyouhavetroublefallingasleepatnight?

Ifyes,howlongdoesitusuallytaketofallsleep? _________

Doyouhavetroublestayingasleepatnight?

If

yes,

how

long

are

you

awake

throughout

the

night?

_________

Howmanytimesdoyouawakenthroughoutthenight? _________

Pleaselistanysleepaids(prescriptionornatural)orothermethodstried:

Rateonascaleof5(verywilling)to1(notwilling)

Inordertoimproveyourhealth,howwillingareyouto:

Educateyourselfonyourcondition

Significantly

modify

your

dietModifyyourlifestyle(workdemands,sleep,etc)

Practicearelaxationtechnique

Takeseveralnutritionalsupplementseachday

Engageinregularexercise

Haveperiodiclabteststoassessyourprogress

Comments

Page8 2011SevaMedInstitute

LIFESTYLEINFORMATION

o Yes o No

o Yes o No

o Yes o No

o Yes o No

o Yoga o Meditation o Breathing o TaiChi o Prayer o Other________

READINESS ASSESSMENT

o

5o

4o

3o

2o

1o 5 o 4 o 3 o 2 o 1

o 5 o 4 o 3 o 2 o 1

o 5 o 4 o 3 o 2 o 1

o 5 o 4 o 3 o 2 o 1

o 5 o 4 o 3 o 2 o 1

o >10 o 810 o 68 o


9/16

Pleaseplaceageatdiagnosis whereappropriate. Formultiplesiblings/children,placemultiplechecksage. Mo

ther

Fa

ther

Broth

er(s)

Sist

er(s)

Ch

ild(r

en)

M

atern

alGrandm

oth

er

M

atern

alGrandfath

er

Patern

alGrandm

oth

er

Patern

alGrandfath

er

Aunt(s)

Un

cle(s)

Age(ifstillalive)

Ageatdeath

ColonCancer

Breast Cancer

OtherCancers ListType______________

HeartDisease

Stroke

Hypertension

Obesity/Overweight

Diabetes

HighCholesterol

Arthritis (


10/16

Attachseparatepageasneeded

CURRENTMEDICATIONSStartDate

Medication Strength DosingSchedule (month/year) ReasonforUse?

PREVIOUSMEDICATIONS (Last10years)StartDate

Medication Strength DosingSchedule (month/year) ReasonforStopping?

CURRENTNUTRITIONALSUPPLEMENTS(VITAMINS/MINERALS/HERBS/HOMEOPATHY)Start

DateSupplement Strength DosingSchedule (month/year) BrandofSupplement

ALLERGIES(ENVIRONMENTAL,FOOD&DRUGS)Allergen Treatmentneeded,ifapplicable

e10 2011SevaMedInstitu

AssociatedSymptoms

MEDICATION HISTORY


11/16

Page 11 2011 SevaMed Institute

Office Policies & Consent

____________________________________________________________________________________________________________________________

I ac cep t tha t Seva Med Institute, P.A., is a unique ed uc at ion-ba sed me d ic al prac tice requiring m eto be a full pa rtner in my he althc are b y ma inta ining a n a c tive LivingWellnessUniversity.com yea rlyme mb ership. I understand the fo llow ing:

The e duc at ion offe red a t LivingWellnessUniversity.com is a com prehensive toolde veloped by Dr. Saxena that fac ilitate s be tter understand ing o f the key conc ep tsregarding health promotion and disease management of the most commonprima ry c are c ond itions that ma y affec t m e o r my fa mily mem be rs.

LWU provides the key medical information that allows me to better understand mycondition and associated treatment options so that I can best participate in theshared d ec ision making required of a therapeutic d oc tor-pa tient relationship.

LWU allows Seva Med Institute, P.A. to p rovide an ab ove ave rag e a mo unt ofinformation including functional, integrative and conventional medicineperspectives that is unable to be achieved during the typical insurance-baseddo c tors visit t ime p eriod .

Dr. Saxena spec ializes in ident ifying and c orrec ting und erlying c auses of illness andfostering hea lth p rom otion in ad dition to chronic disea se ma nage me nt. Experienc eshows that patients who understand their condition(s) have better outcomesbecause they more fully participate in the lifestyle change recommendations thata re essent ial to b et te r hea lth sta tus.

If you choose to opt out of LWU or fail to maintain your active LWU membership,Seva Med Institute, P.A. wo uld b e unab le to p rovide the op tima l ed ucat ion-ba sedmedical care and partnership we require and will result in a recommendation toselect a prac tic e w hic h b etter ma tc hes your healthca re p hilosop hy.

Paym ent is due at the t ime o f service. Non-covered lab fees must be p aid to the c linic a t the timeyour provider orders them as the c linic will be inc urring lab charges on your beha lf. We a cc ep t

Ca sh, Check, Ma sterCa rd a nd Visa. Any unpa id ba lance a fter 120 da ys from the d ate of servic e isthe respo nsib ility of t he p at ient/ gua rant or.

All ba lanc es are due p rior to your ap po intment. Any unpaid b alanc e is subject to ap po intmentcancellation.

It is your responsibility to no tify Seva Me d Institute o f any changes to yo ur insuranc e c ove rage a ndpersona l informa tion, immed iate ly to avo id b illing issues.

App ointment c anc ellations must b e m ad e m ore tha n one business da y in adva nce of a ll routine,sc heduled ap po intments to a void pe nalty. Any routine a pp ointme nts that a re c anc elled or missedwith less than one business day w ill autom at ic ally be c ha rge d a $25 ca nc ellat ion fee fo r 20 minuteap po intments and $50 for 40 minute app ointments.

If you are more tha n 15 minutes late for your ap po intment, you ma y be a sked to resc hed ule. In thisevent, the ap propriate ca nce llation fee will be ap plied .

After hours ac c ess: If you have a n eme rge nc y, plea se c all 911. If you have a n urge nt me dic alma tter, plea se c all our ma in offic e numb er and follow the rec orded direc tions. Be sure to leaveyour nam e, phone number and rea son fo r your ca ll. As this service is stric tly for urgent ma tte rs,please do not leave messages for prescription refills, appointments, referrals or other non-urgentma tte rs. Please c a ll during norma l business hours to address those non-urgent situat ions.


12/16

Page 12 2011 SevaMed Institute

Refill requests: All loc a l pha rmac y refill requests require at least 3 business days no tice. Allow 1-2we eks notice for ma il-order presc riptions, or mo re ba sed on your ma il-order pha rma c y guidelines.

All req uests for med ica l rec ords beyo nd a single o ffice visit will be a ssessed a fe e o f $1 per pa ge forthe first 25 pa ge s and $.25 pe r pa ge thereafte r.

All evaluation forms req uired to b e c omp leted by a health ca re p rovider must b e d one during anoffice visit. Othe r forms ma y req uire a $25 or more c om pletion fee ba sed upo n p rofessional timespent.

All d iagno stic te st results req uire do c tor review/ interpretation b efore c op ies will be provided to you.Seva Med requires an o ffic e visit to rece ive interpreta tion and trea tme nt guida nce for all ab normalresults. Normal lab results c an b e mailed upon request. Medic al rec ords fees ma y ap ply for ala rge volume req uest.

Any prescribed medical foods, nutrient therapy or hormonal creams must only be taken undermed ic al supervision a nd as such, must b e d ispe nsed from an ap proved c omp ounding p harmac yor d irec tly from Seva Me d Institute.

Hea lthca re is not a n exac t sc ience a nd, therefore, I ac knowledge tha t no gua rantee s are mad e tome as to the results of the e xaminations, tests, diag noses or trea tment by Seva Med Institute o r any

rep resenta tive thereof.

Any p resc ription med ica tions p resc ribed by ano ther physician should not be disc ontinued withoutthe c onsent o f the p resc ribing c linic ian.

If you d o not ha ve a Prima ry Ca re d esignat ion w ith Dr. Saxena , she highly rec om me nds that youshare your care plan and treatment plan with your primary care physician and medical specialistsfor safety purposes.

I unde rstand o ffice te rms and c ond itions ma y be upd ate d p eriod ica lly and I will be respo nsible andad here to the mo st c urrent ve rsion which w ill be p osted on w ww .seva me dinstitute.com .

I fully unde rstand a nd a c c ep t the a bo ve listed po lic ies, and I do he reb y voluntarily c onsent to e va luat ion and

ca re w ith Seva Med Institute inc luding physica l exam and a ny mutua lly ag reed up on d iagno stic testing andtrea tment reco mm end ations.

_______________________________ _______________________Pa tient/G uardian Signature Date

______________________________ _______________________Printed Nam e Patient Date of Birth


13/16

Pag e 13 2011 Seva Me d Institute

New Patien t Consent to the Use a nd Disc losure of Hea lth Informa tion for Treatm ent, Pay ment,

or Healthcare Operations

I, ____________________________, understa nd tha t a s part o f my he a lth c a re, Seva Me d Institu teoriginates and maintains paper and/or electronic records describing my health history,

symptoms, examinations, test results, diagnoses, treatment and any plans for future care or

treatment.

I understand a Notice of Privac y Prac tices is ava ilab le for my review. It p rovide s a c om plete

desc ription of information use a nd d isc losure (a c op y ca n be p rovided upo n my req uest). I

und erstand tha t I have the follow ing rights and p rivileg es:

The right to review the no tice p rior to signing this c onsent The righ t to o b jec t to the use o f my hea lth informa tion for direc tory purposes, and The right to req uest restrictions as to how my he a lth informa tion ma y be used or

disc losed to c a rry out trea tment p ayme nt or health ca re o pe rations.

I understand tha t Seva Med Institute is not req uired to agree to the restrictions req uested

below. I und erstand tha t I ma y revo ke this c onsent in writing, exce p t to the extent tha t the

orga niza tion has a lrea dy taken a c tion in relianc e the reon. I a lso und erstand tha t by refusing

to sign this consent or revoking this consent, this organization may refuse to treat me as

permitted by Sec tion 164.506 of the Code of Fed eral Reg ula tions.

I further und erstand tha t Seva Med Institute reserves the right to c hange their notic e and

p rac tic es prior to impleme ntation in ac c ordanc e with Sec tion 164.520 of the Cod e of Fed eral

Reg ula tion. Should Seva Med Institute cha nge their notic e, they will send a c op y of anyrevised notice to the a dd ress I ha ve p rov ided , (US ma il or e-ma il).

I w ish to have the fo llow ing restric tions for the use a nd d isc losure of my hea lth informa tion:

I understand tha t as part of this orga niza tions trea tme nt, pa yment, or hea lth ca re operations,

it ma y be c om e ne c essary to d isc lose m y protec ted hea lth informa tion to ano ther entity, and

I c onsent to suc h d isc losure for these p ermitted uses, inc luding d isc losure via fa x.

I fully unde rstand and ac c ep t the te rms of this c onsent.

____________________________________ _____________________

Pa tient/ Gua rd ian Signa ture Date

____________________________________

Patient Name


14/16

Pag e 14 2011 Seva Med Institute

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

I, __________________________________, g ive permission to Seva Med Institute to release any

information, verbally or written, on my behalf to the following persons.

PLEASE PRINT

Name: ____________________________________________________________________________

Phone : ( ) _ Rela tionship to Patient : ______________________________

Name: ____________________________________________________________________________


Name: ____________________________________________________________________________


This notice will expire upo n w ritten notice as provided by p atient to Seva Med Institute.

_______________________________ __________

Patient/ Gua rdian Signature Date

_______________________________

Printed Patient s Nam e

_______________________________ __________Witne ss Signa ture Date


15/16

Educ ation-Based Prac tice

Frequently Asked Questions

Why is SevaMed Institute bec oming an educ ation-based prac tice?- In me dic ine, it is fairly typica l for pa tients to b e sec ond a ry de c ision ma kers in their c are. Onc e

a physician feels tha t they ve identified the prob lem, they o rde r testing, write presc riptions andsc hed ule p roc ed ures tha t they feel a re nec essary with pa tient c onsent . We believe tha t

pa tients have ma ny critic al p iec es of informa tion a bo ut their bo dy tha t w ould ma jorly imp ac t

the de c ision ma king proc ess. How ever, without prope r ed ucat ion of the hea lth cond ition,

patients might not be able to process their thoughts, participate in a productive 2-way

c onversation w ith their do c tor and c rea te the be st p lan for them.

This is where ed uc a tion c om es in. Living Wellness University (LWU) has bee n developed from Dr.

Saxena s yea rs of expe rience a nd listening to pa tients and their most c om mon c onc erns and

questions. She is very c on fiden t tha t this is the w ay med icine w ill be p rac ticed in the future and

is committed to revolutionizing using the most effective and productive partnerships between

do c tor and pa tient seen a t any do c tors office .

Will Seva Med Institute c ontinue to take insuranc e?- Ab solute ly. In fac t, sta ying insuranc e-based is extreme ly important to Dr. Saxena. Ac tua lly, the

vast majority of physicians who practice Functional or Integrative Medicine are cash only and

do no t ac cep t insuranc e for their servic es. Dr. Saxena feels very pa ssiona tely tha t this type o f

c are should rema in ava ilab le to eve ryone a nd is keep ing Seva Med Institute a va ilable to all

pa tients who rely on insurance to rec eive their medic al c are .

What does it mea n to be a n educ ation-ba sed practice?- An e duc ation-ba sed p rac tic e finally place s the pa tient at the c enter of his/ her c are. We wa nt

you to understand important details about your conditions so you can sit with us side-by-side in

the dec ision ma king p roc ess. Living Wellness University is how we c an he lp you .

As part o f your care a t Seva Med Institute, you w ill be required to reg ister with Living WellnessUniversity so you can view certain lectures, doing your part in bringing a solid foundation of

knowled ge ab out the a ssigned top ic(s) to your app ointment. For examp le, if your most rec ent

blood work shows a newly diagnosed diabetes problem, you may be assigned lectures related

to diabetes, diabetes medications, heart disease and/or lifestyle solutions related to lowering

blood suga r nat ura lly. Know ing this informat ion in ad vanc e of your ap p ointment, you will best

c ontribute tow ards the mo st prod uc tive, intelligent and respe c tful rec om mendat ions for you.

We will be educating and transitioning our current patients on this change and are excited to

have all interested patients join us in this new partnership-based approach. Although we will

begin recommending LWU lectures through the rest of the year, we are providing time for

current patients to process our change and will formally require patients to register with Living

LWU as of January 1, 2012 if they a re on b oa rd w ith us. All new pa tients w ill be required topa rticipa te in the ed uca tion-ba sed a pp roa c h upon reg istrat ion with Seva Med Institute.

How is LWU different than WebMD or other medical information internet sites?- As Spec ialists in Func tiona l and Integ rative me d icine, all of the e duc a tiona l ma terial at Living

Wellness University provide d by Dr. Saxena is based on Func tiona l and Integrat ive med icine

perspec tives and p rincip les tha t pa tients see k a t Seva Med Institute. These innova tive, less

medication focused approaches are not found on traditional medical information sites.

Additionally, the educational material on Living Wellness University is easy to understand,

provides the c onvent ional, functiona l and Integ rat ive perspec tive all in one p lac e. The audio-

visual lectures delve much deeper into each health topic with the intent of answering your

questions and reducing anxiety, not creating more questions and increasing fears like most other

websites.


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Pag e 2: Educ ation Based Prac tice- Frequently Asked Questions

What should I exp ec t in my visits?- When patients come to their appointments with a strong understanding of their issues, the visit is

more collaborative and medical decisions are made in an informed, educated manner.

Pa tients also e njoy the a bility to c rea te w ell-prep ared que stions and conc erns, and alwa ys have

the ability to go above and beyond with their education at home, not being limited by the

c onstraints of the app ointment time, insuranc e and financ es related to multiple doc tors visits.

At your app ointment, you ca n expec t an enha nced , deepe r d isc ussion with your provider. You

will no longer feel that you have to make on-the-spot decisions with not-enough information,

later festering a bo ut whethe r you made the right cho ice or not. As we know , pe op le are less

committed to following through on their decisions if they are not confident they are the best

one s. This leaves both p a tient and p hysician in more risky situat ions. We are excited to

streng then this c omm on sense need for co mp rehensive, easy-to-ac cess hea lthca re information

to you in the c onvenienc e of your ow n home.

How is my c are managed?

- Your spec ific, individualized c are p lan is organized and led by Dr. Saxena and then put intoac tion by the ap prop riate spec ialists on our tea m. Every memb er of the Seva Med Tea m hastheir ow n a rea of p assion & e xpertise, and the timing o f whe n you see them is de termined during

our wee kly tea m m eet ings whe n we d isc uss & c oo rdinat e our pa tients pe rsona lized ca re p lans.

So rather than b eing c ared fo r by one d oc tor, your c are is c arefully orchestrat ed am ong a te am

of experts, ea c h with some thing unique to a dd to your expe rience .

-How do I register for Living Wellness University?- Registra tion is simp le. Visit LivingWellnessUnive rsity.c om o r click here to register. Follow the

promp ts to purchase sec urely online. We req uire only one mem bership per househo ld. In this

wa y, all the memb ers of your family tha t reside tog ethe r will benefit with only one reg istrat ion.

What if I am unab le to a fford the Living Wellness University reg istration fees?

- We have priced this comprehensive, online medical information tool in a way that allows thema jority of our pa tients to p a rticipa te w ith minima l yea rly expense. How eve r, we und erstandthat some families might have significant hardships at this time and considerations will be made

with do cumented p roo f of financ ial hardship. We will use a slid ing sc ale fee system a nd/ or

pa yment p lans to he lp fac ilitat e a c c ess to this req uired information. Please c all the offic e if you

be lieve you qualify for mo re d irec tion.

What if I dont have a comp uter or internet acc ess?- For these patients, we will have DVD versions of the lectures available to sign out at the office.

This w ill ensure your reg istration still ac hieves the goa l of ed uc ating you on your hea lthcare

conditions.

What happ ens if I dont register or cancel my registration?- We are deeply com mitted to c hang ing the way we p rac tice me d icine for ma ny rea sons. First,we ve experienc ed how well it w orks we know that b etter educ ate d pa tients, get he althier.

Weve a lrea dy rece ived such p ositive feed ba c k reg arding o ur ed uca tion-based method s and

wa nt the involveme nt of our entire pa tient com munity. Finally, we d on t believe the current

mode l wo rks we ll for us either we wa nt you to b e a n ed ucat ed pa rtner in your c are so tha t we

c an o p timize our visits with you and feel good abo ut the d ec isions we ma ke togethe r. Living

Wellness University truly helps both patient and provider to work closer together for the best

results for you.

We also und erstand tha t this ed uca tion-ba sed a pp roa ch is not for everyone. If you choo se to

not register or cancel your registration, we strongly recommend that you seek the services of

ano ther physician or prac tice tha t isa be tter fit for your healthca re p hilosop hy and needs

Documents

Dr Saxena Patient Intake Form