Prozac 20mg 2x/day Feeling Down 11/2008 Alan James, MD€¦ · Sexual Activity with ☐ Male ☐ Female ... Physical Medicine, Therapeutic Exercise, Homeopathy, Psychological Counseling,

www.TodayHealthandWellness.com(503)746-588915962BoonesFerryRdSuite204,LakeOswego,OR97035 1

LegalName(FirstLast) PreferredName(ifdifferent) DateofBirth

Whatbringsyouintoday?

Concern

Startedwhen?

Howoften?

Howsevere?

YoumaylistmoreontheHealthSystemsCheck-list

Whatmedicationsareyoucurrentlytaking?(BothprescriptionsandOTC)

MedicationandDoseProzac20mg2x/day

ReasonFeelingDown

Started?11/2008

PrescribedByAlanJames,MD

Ifyouwouldlike,wecanprovideyouwithalongermedicationandsupplementform

Supplement,BrandandDoseSuperVitaminC(Thorne)500mg/day

ReasonImmuneSupport

Started?11/2008

RecommendedBySelf

PreferredPharmacy?

Name Address Phone


Allergies☐ Yes ☐ No

________________________________________________________________

Food Allergies: _____________________________________________________________________

___________________________________________________

Heart/Lungs☐ Asthma☐ Heart Disease (valve,

☐ Heart Murmur☐ High Blood Pressure☐ High Cholesterol☐ Pneumonia

Endocrine☐ Adrenal Disorders☐ Diabetes☐ Syndrome (PCOS)☐ Thyroid Disorder

Kidney☐ Chronic Kidney or Bladder Disease

☐ Kidney Stones

Ears/Eyes/Nose/Throat

☐☐ Eye Disorders (other than glasses or contacts)

☐ Hearing Loss☐ Nasal Allergies/Hayfever

Stomach/Bowel☐ Celiac Disease☐ Food Poisoning☐ Irritable Bowel Syndrome

☐ Stomach/Duodenal Ulcers

☐☐ Other Liver, Stomach, or

Bowel Disease

Neurological☐ Concussions☐ Convulsions/Seizures☐ Migraines/Severe Headaches☐☐ Muscular Dystrophy☐ Stroke/TIA

Mental Health☐ ADHD☐ Alcohol Abuse☐ Anorexia ☐ Anxiety Disorder☐ Bulimia ☐ Depression☐ Drug Dependency ☐ Other Mental Health Problems

Hematology/Oncology☐ Anemia☐ Bleeding Disorders☐ Disorders☐ Cancer☐Orthopedics☐☐ Fractures/Broken Bones

☐ Chickenpox/Varicella ☐☐☐☐ Malaria☐ Mumps☐ Tuberculosis ☐ Typhoid Fever

Skin☐ Eczema☐ Psoriasis☐ Hives

STDs☐ Chlamydia☐ Genital Herpes☐ Genital Warts☐ Gonorrhea☐ HPV☐ Other STD

Surgical History

☐ Breast Surgery☐☐

Ear Tubes

☐ Gallbladder Removal Hysterectomy

☐ Knee ACL Repair L ___ R ___☐ Knee Arthroscopy L ___ R ___☐ Organ Transplant☐ Ovarian Cyst Removal☐ Splenectomy☐ Tonsillectomy☐ Weight Loss Surgery☐ Other Prior Surgeries

OB/GYN History☐ Abnormal Pap

☐ Pregnancies #: _____

Other History☐ ________________________________________

☐ OTHER Health Problems ____________________

________________________________________

☐

Exercise History☐ Lack of exercise

☐ Exercising regularly

Moderate Exercising Walking briskly, water aerobics, etc.

☐

☐Strenuous Exercising Running, swimming laps, etc.

☐☐

☐ Endometriosis

☐ Appendectomy

Does YOUR IMMEDIATE FAMILY have any of the following? ☐ Adopted (Family history unknown)Mother Father Siblings Grandparents

Auto ImmuneAsthma

Addiction

BreastColonMelanomaOther Cancers (List Type)

DiabetesDigestive ConcernsEating DisorderHeart DiseaseHepatitisHigh Blood PressureLung Disease

Thyroid ConditionStrokeSkin Condition

Mental HealthNeurological

Can

cer

Seizures

PAST PERSONAL MEDICAL HISTORY: Have YOU EVER had any of the following?


AsaNewPatient,pleasecheckanyitemsthatareCURRENTLYconcerningyou.

GENERAL: □NOCOMPLAINTS □WEIGHTLOSS □FATIGUE □COLD/FLU □HARDERTIMEEXERCISING

□STRESS □WEIGHTGAIN □INSOMNIA □CHANGESINSTRENGTH □OTHER___________________

HEAD/EAR: □NOCOMPLAINTS □DIZZINESS □HEADACHES □HEADTRAUMA □MENTALFOG

□EARACHE □CHANGESINHEARING □RINGINGINEARS □CLOGGEDEARS □OTHER___________________

EYES: □NOCOMPLAINTS □CHANGESINVISION □BLURRINGOFVISION □EXCESSIVETEARING □OTHER____________________

□BLINDSPOTS □EYEPAIN □EYEIRRITATION □DRYEYES

NOSE/MOUTH: □NOCOMPLAINTS □FREQUENTBLEEDING □BLEEDINGGUMS □COLD/CANKERSORES □TOOTHPAIN

□BADBREATH □NASALDISCHARGE □NASALCONGESTION □DRYMOUTH/NOSE □OTHER___________________

NECK/THROAT: □NOCOMPLAINTS □NECKPAIN/STIFFNESS □LUMPS/BUMPS □POSTNASALDRIP □OTHER___________________

□SORETHROAT □DIFFICULTYSWALLOWING

CHEST/LUNG/BREAST: □NOCOMPLAINTS □BREASTTENDERNESS □PAINW/BREATHING □CHESTCONSTRICTION □SHORTOFBREATH/WHEEZING

□LUMPS/SWELLING □NIPPLEDISCHARGE □COUGH □CHESTCONGESTION □OTHER___________________

CARDIOVASCULAR: □NOCOMPLAINTS □PALPITATIONS □CHESTPAIN □HIGHBLOODPRESSURE □OTHER____________________

□IRREGULARBEAT □LEGSWELLING □LOWBLOODPRESSURE □LOSSOFCONSCIOUSNESS

ABDOMEN/DIGESTION: □NOCOMPLAINTS □ABDOMINALPAIN □DIARRHEA □HEARTBURN □BLOATING/GASBOWELMOVEMENTSPERDAY______________ □NAUSEA/VOMITING □CHANGEINAPPETITE □CONSTIPATION □BLOODINSTOOL □OTHER____________________

URINATION: □NOCOMPLAINTS □FREQUENCY □URGENCY □FREQUENTINFECTIONS

□PAINFULURINATION □INCONTINENCE □DRIBBLING □INCOMPLETEEMPTYING □OTHER____________________

WOMENSHEALTH: □NOCOMPLAINTS □PAINWITHMENSES □PELVICPAIN □DIFFICULTYCONCEIVING □CYCLELENGTH:DAYS

DAY#_________INCYCLE □CHANGEINMENSES □VAGINALDISCHARGE □DECREASEDLIBIDO □MENOPAUSE/NOPERIOD □OTHER____________________

MENSHEALTH: □NOCOMPLAINTS □ERECTILEDYSFUNC. □NIGHTIMEURINATION □OTHER________________

□DECREASEDLIBIDO □PROSTATE □____TIMESPERNIGHT

MUSCULOSKELETAL: □NOCOMPLAINTS □MUSCLEPAIN □MUSCLETENSION □NUMBNESS/TINGLING □RECENTINJURY □MUSCLECRAMPS □MUSCLEWEAKNESS □JOINTPAIN □RANGEOFMOTION □OTHER____________________

MENTAL/EMOTIONAL: □NOCOMPLAINTS □SEIZURES □MOODCHANGES □DEPRESSION □LOSSOFCOORDINATION

□MEMORYCHANGES □TREMOR □MENTALCHANGES □COGNITIVEIMPAIRMENT □OTHER_____________________

TEMPERATURE: □NOCOMPLAINTS □RUNSCOLD □NIGHTSWEATING □EXCESSSWEATING □OTHER_____________________

□COLDHAND/FEET □RUNSHOT □HOTFLASHES □LACKOFSWEATING □SPONTANEOUSSWEATING

SKIN/HAIR: □NOCOMPLAINTS □EASYBRUISING □RASH □TEXTURECHANGES □CHANGESINNAILS

□DRYNESS □SLOWHEALING □COLORCHANGES □THINNINGHAIR □OTHER_____________________


PreventativeCarePap

DateofLast

Results?

Mammogram Colonoscopy AnnualScreening DEXAScan(BoneDensity) PSA(Prostate-specificantigen) Vaccines(Flu,Shingles/Travel)

Tellusaboutyourlifestyle

Alcohol? ☐YES ☐NO Whatkind?__________________ Drinksperday________

Perweek_______

Tobacco? ☐YES ☐NO ☐FORMER Packsperday?________ Yearssmoked?________

RecreationalDrugUse? ☐YES☐NO Whatkind?_____________ Timesperweek_______

CannabisUse? ☐Recreational ☐Medical

SexualActivitywith ☐Male☐Female ☐Both ☐______________

Exercise ☐None☐Regularly☐Moderate☐Strenuous☐<3timesaweek☐>3timesaweek

Tellusabouthowyoueat

Sodas,oz/day FoodSensitivity Coffee,oz/day FoodRestrictions Water,oz/day FoodEthics □Vegan□Vegetarian□Kosher□Other:

FoodCravings

Doyoueat?□Inthecar □WatchingTV □Standing□Withothers □Onthego □Inahurry□After11pm □Inyoursleep □Onwaking

SnackFoods

TypicalBreakfast Howoftendoyoueatout?Where?

TypicalLunch

TypicalDinner


Tellusaboutyourhomelife

Withwhomdoyoulive?(Includingfamily,pets,androommates)?

Name Age Relationship Name Age Relationship

Whatisyouroccupation?

Whatarethemajorstressorsinyourlife?(work,financial,emotionalhealth,romance/love,physicalhealth,family,spiritual,other)

Howisyoursleep?Whendoyougotosleepandwakeup?

Whatdoyoudotorelax?Whatareyourhobbies?

Doyouhavereligiousorspiritualbeliefsthatmayaffectyourhealthcare?


ClinicPoliciesforNaturopathicMedicine

Wetakeapersonalapproachtocare.Itisnotthepolicyofourofficetomanagemedicalcareviaemail.Whileemailcanbeanefficientmethodofcommunicatingwebelievewecanbestserveyoufacetofaceoroverthephoneifnecessary.

Onoccasion,phoneconsultsarerequestedofourproviders.Ifsuchaconsultisrequestedyouwillberesponsibleforatelephonevisitfee,whichmaynotcoveredbyinsurance.Fromtimetotimeyourprovidermaycontactyoubyphoneforabriefexchangetoclarifyaprevioustreatmentplan.Therewouldnofeeforthiskindofclarification.

Paymentisdueatthetimeofservice.Afteryourvisit,youwillcheckoutwithourstaffandbeaskedforanycopaysorco-insurancefortheservicesperformed.Webelieveitisthepatient’sresponsibilitytounderstandtheirinsurancebenefits.Additionalfeesforoutsidelabswillmaybilledtoyoubythelabperformingthoseservices.

Yourinitialvisitwillincludeacompletediscussionofyourhealthhistoryandcurrentsymptoms.Physicalexamsrelatingtoyoursymptomswilllikelybeperformedinthisvisit.Yourproviderwillmakeatreatmentplantailoredtoyou.Yourprovidermayorderlabsinthisappointment,whichwillbereleasedanddiscussedwithyouinafollow-upofficevisit.

Ifyouneedaprescriptionrefillpleasecallyourpharmacy.Theywillfaxusyourrequestorsenditelectronically.Inorderforyourprovidertomakeaninformeddecisionwithampletimetoreviewyourmedicalrecordweneed2-3businessdaysnoticeforyourrefillornon-urgentreferralrequest.

Forrecordsrequestsforotherproviderswewilldoourbesttogettheseprocessedwithin7businessdays.However,pleasekeepinmindthatcommonstandardsallowfor30daystofulfilltheserequests.

Lettersofmedicalnecessityforsupplementswillbecompletedwithin7businessdays.

IacknowledgethatIhavereadandunderstandtheclinicpoliciesfornaturopathicmedicineatTodayIntegrativeHealth+WellnessandhavediscussedanyconcernsorquestionsIhavewiththeofficestaff.

Signature______________________________________________________Date______________________


CONSENTFORNATUROPATHICTREATMENT

GeneralInformation:TodayIntegrativeHealth+WellnessisanIntegrativeMedicalClinicwhichintegratesanumberofmedicalmodalities.DuetothediversityofmodalitiesofferedatToday,yourtreatmentmayincludeanyorallofthefollowinggeneralmodalities:NaturopathicMedicine,PhysicalMedicine,TherapeuticExercise,Homeopathy,PsychologicalCounseling,NutritionalCounseling,andIntravenousTherapies.

Methods,Procedures,andTherapeuticApproaches:Cliniciansmayperformanyofthefollowingproceduresasnecessarytogiveproperassessments,determinetreatmentapproaches,treatorotherwiseaddressyourhealthconcerns.

GeneralDiagnosticProcedures:Includingbutnotlimitedtovenipuncture,papsmears,radiography,bloodlabwork,urinelabwork,generalphysicalexams,neurologicalandmusculoskeletalassessments.

Herbs/NaturalMedicines:Prescribingofvarioustherapeuticsubstancesincludingplants,minerals,andanimalmaterials.Substancesmaybegivenintheformofteas,pills,powders,tinctures(maycontainalcohol),topicalcreams,pastes,plasters,washes,suppositories,orotherforms.Homeopathicremedies,oftenhighlydilutequantitiesofnaturallyoccurringsubstances,mayalsobeused.DietaryAdviceandTherapeuticNutrition:Theuseoffoods,dietplans,ornutritionalsupplementsfortreatment(mayincludeintramuscularinjectionorintravenoustherapies).SoftTissueandOsseousManipulation:Theuseofmassage,neuro-musculartechniques,muscleenergystretching,visceralmanipulation,aswellasmanipulationsoftheextremitiesandspineincludingtractionandcranio-sacraltherapy.PharmaceuticalMedication:Yourphysicianmayprescribemedicationforyourcarethatiswithinthescopeofpractice.

PotentialBenefits:Restorationofhealthandthebody’smaximalfunctionalcapacity,reliefofpainandsymptomsofdisease,assistanceininjuryanddiseaserecovery,andpreventionofdiseaseoritsprogression.

PotentialRisks:Pain,discomfort,blistering,discoloration,infection,burns,lossofconsciousnessordeeptissueinjuryfromneedleinsertions,topicalprocedures,heatorfrictionaltherapiesandhydrotherapies;allergicreactionstoprescribedherbsorsupplements;softtissueorboneinjuryfromphysicalmanipulations;andaggravationofpre-existingsymptoms.

NoticetoWomen:Allfemalepatientsmustalertthedoctoriftheyknoworsuspectthattheyarepregnant,sincesomeofthetherapiesusedcouldpresentarisktothepregnancyorduringbreastfeeding.

IunderstandthatImayaskquestionsregardingmytreatmentbeforesigningthisformandthatIamfreetowithdrawmyconsentandtodiscontinueparticipationintheseproceduresatanytime.Withthisknowledge,Ivoluntarilyconsenttotheaboveprocedures,realizingthatnoguaranteeshavebeengivingtomebyTodayoranyofitspersonnelregardingcureorimprovementofmycondition.Iunderstandthatarecordwillbekeptofthehealthservicesprovidedtome.Thisrecordwillbekeptconfidentialandwillnotbereleasedtoothersunlesssodirectedbymyrepresentativeormeorasotherwisepermittedorrequiredbylaw.

_________________________________________________________________________________________PatientName(PRINT) Guardian/PersonalRepresentative(PRINT)

__________________________________________________________________________________________

PatientSignature Guardian/PersonalRepresentativeSignature

__________________________________________________________________________________________

Date Relationship/RepresentativeAuthority

Documents

Prozac 20mg 2x/day Feeling Down 11/2008 Alan James, MD€¦ · Sexual Activity with ☐ Male ☐ Female ... Physical Medicine, Therapeutic Exercise, Homeopathy, Psychological Counseling,