Ann Hathaway MD
PATIENT INFORMATION
First Name: _______________ Middle: ____________ Last :___________________
Address
Street:____________________ City:________________ State:_________ Zip:______
Home Phone: (____) ____________________
Referred by: ________________________
Cell Phone: (____) _____________________
Occupation: ________________________
Work/Other Phone (____) _____________________
Email address: _______________________________
Birth Date: __________________________________ Age: __________
Place of Birth: ________________________________ Ethnic roots: ______________
City or town & country if not U.S.
Emergency Contact ________________________ Contact Phone # ________________
Height: _______’ _____” Weight lbs. ______Sex: ______
Physician-Client Understanding
I, __________________________, do hereby acknowledge that Dr. Ann Hathaway practices nutrition-based medicine. Diet and life style are core health issues. Genetic, biochemical and hormonal individuality will be addressed. This method of practice is often referred to as Integrative, Functional, or Alternative Medicine.
I understand that Dr. Hathaway uses specialty laboratories that collect information that is not generally utilized in conventional medical practices. I realize that Dr. Hathaway's therapeutic recommendations are most often nutritional, both dietary and supplements.
I further understand that she prescribes natural or bio-identical hormones if a deficiency exists and that every effort will be made to assure patient safety while on hormone replacement. I am aware that she will use pharmaceuticals only when there are no effective alternatives.
I understand that Dr. Hathaway has a consultation practice and does not provide hospital coverage. Dr. Hathaway will not usually be available nights and weekends, however she will attempt to answer all calls, especially urgent calls, in a timely manner.
I am aware that Dr. Hathaway's office does not bill any insurance or Medicare and that I am responsible for all fees at the time of service. I further understand that Dr. Hathaway does not provide medical chart notes to insurance companies. If medical chart information is requested for another physician and the chart is extensive there will be a copying fee.
Signature ______________________________ Date ______________
Ann Hathaway MD
25 Mitchell Blvd. #3
San Rafael, CA 94903
415.499.0966
Dear _________________________________,
This is to confirm your appointment on:
________________________________ at _____________ am / pm
I very much look forward to meeting with you.
Please note: Due to some patient’s severe allergies, please avoid all scented body/hair products on day of visit.
Please let me know as soon as possible if you are not able to keep your appointment. Give a minimum of 48 hours notice for cancellation.
Directions to my office:
From south of San Rafael: Proceed north on Hwy101 to the Smith Ranch Rd. exit and then take the first right on to Smith Ranch Rd. See “From Smith Ranch Rd.” below.
From north of San Rafael: Proceed south on Hwy 101 to the Lucas Valley-Smith Ranch Rd exit. Go right on to Lucas Valley Rd. toward Smith Ranch Rd and cross under the freeway. The road will change names to Smith Ranch Rd. See “From Smith Ranch Rd.” below.
From San Francisco or the Peninsula: Proceed over the Golden Gate Bridge and follow the directions above for “From south of San Rafael” above.
From East Bay: Proceed over the Richmond-San Rafael Bridge to Hwy 101 North, then follow “From south of San Rafael” above.
From Smith Ranch Rd.: Take the first right on to Redwood Highway and continue to the light at Mitchell Blvd. Go left on to Mitchell Blvd. and then take an immediate left onto the parking lot behind the West America Bank. Suite #3 is located directly across the parking lot from the West America Bank.
My fees are as follows:
$435.00 per hour * Please note that a 1st appointment is usually 1½ hours at $620.00. One hour appointments are available on request.
Bredesen Protocol Consultations: 1 hour $500, 1 ½ hour $700, 2 hours $860.
What to Bring:
• Medical history and symptom check list
• Read and sign the physician-client understanding
• 2-day diet history
• List of all of your vitamins and supplements, with doses, or bring all your supplements with you.
• All prescription medications
• Any lab work or special tests from the last year (or more)
If you cancel your appointment for any reason with less than 48 hours notice there is a late cancellation fee of $150.00 for a first appointment a and $100.00 for a follow up appointment.
I look forward to the opportunity to work with you to improve your health.
Ann Hathaway M.D.
Medical History
Name Date
Birth Date
Major problems or health concerns:
1.
2.
3.
Please feel free to use another page to provide more information. I am interested in all your symptoms.
Prior medical problems or severe illnesses:
Surgery:
1. Date
2. Date
Allergies:
To Drugs:
To foods or other substances:
Family History:
yes/no who yes/no who
Heart Disease Diabetes
Alcoholism Arthritis
Cancer Depression
Severe allergies Alzheimer’s
Blood clots Stroke
Thyroid Osteoporosis
High blood pressure Obesity
Other major problems ___ ________________
Medicines - prescription and over the counter meds (like Tylenol)
1. 2. 3.
1. 2. 3.
Major accidents/physical or emotional trauma_________________________________________
What is your stress level (1=lowest 10=highest) _______________________________________
Frequent antibiotics as a child or teen _____________ teen acne
Recent antibiotics __________ If yes what for?___________ past or recent herpes___________
Recurrent pneumonia/bronchitis ____________ urinary infections ________ sinusitis________
Past or current psychiatric medications
How many dental fillings _______ crowns _______ root canal_______ dental problems_______
Do you have TMJ? _________gingivitis____________ receding gums ___________________
Is your home damp/cold/moldy_________ Water leaks or flooding of your home____________
Have you any exposures to toxic chemicals? ______________ photo/printing?
dyes/paints___________ hair dye ___________ pesticides ___________ lead
mercury ______________ cleaning chemicals ________________ farming
golf course ______________ industrial exposure _______________ tick bite
Women:
Number of pregnancies __________________ number of births
Age at 1st period ___________ # days in cycle __________ age at last period
Past gynecological problems/pregnancy complications__________________________________
History of breast problems
Birth control pills _____________ # of years ________________ IUD
Past prostate problems
Men:
Slowing or splitting of urinary stream
Diet and Habits:
Quantity of: beer __________wine __________ hard liquor ________coffee _____________
tea _____________ sugar/honey/candy/chocolate/other sweets _____________ milk_________
other dairy______________ artificial sweeteners __________ soda ________ diet soda_______
gum_______ bread__________ pasta__________ eggs_________ fish ______ chicken______
vegetables________ margarine ________ junk food/which type?_______ butter/ghee _____
cigarettes _________________ prior cigarette use _________________ when quit
Past excess alcohol
Past or current recreational drug use (optional)________________________________________
Do you have regular sun exposure?
Exercise routine and frequency_____________________________________________________
Faintness Headaches Fatigue after eating
Dizziness Rapid heart Apathy
Insomnia Chest pain Hyperactivity
Itchy eyes Asthma Restlessness
Swollen eyes Bronchitis Poor attention
Bags/dark circles Nausea/vomiting Poor memory
under eyes Diarrhea Confusion
Blurred vision Constipation Brain fog
Itchy ears Bloating Poor coordination
Ear infections Belching/gas Stuttering
Ringing in ears Heartburn Slurred speech
Hearing loss Intestinal pain Learning disabilities
Stuffy nose Binge eating Mood swings
Hay fever Binge drinking Anxiety
Sneezing Crave alcohol Fear
Coughing Crave sweets Anger/aggressive
Gagging Crave bread Irritability
Sore throat Crave salt Depression
Hoarseness Crave chocolate No motivation
Swollen tongue, Excessive weight Frequent illness
gums, or lips Water retention Frequent urination
Canker sores Joint pain Genital itch
Acne Muscle pain Women only:
Hives, rashes Joint stiffness Irregular menses
Dry skin Weakness Heavy bleeding
Hair loss Fatigue No menses 6 mo
Hot flashes Fatigue after stress Painful periods
Decreased libido Fatigue after exercise PMS symptoms
Poor sexual function Morning fatigue Urinary incontinence
Excess sweating Afternoon fatigue Excess hair
Irregular heart Feel Cold Often___________ Bone loss
Ann Hathaway MD
25 Mitchell Blvd. #3
San Rafael, CA 94903
415.499.0966
Appointment Cancellation Policy
We understand that everyone has unplanned events that demand immediate attention and do require cancellation of appointments. Please understand that we schedule a 1 to 2 hour first appointment and 30 to 60 minute follow ups—much longer appointments than most doctors. When you cancel, it puts a large hole in our schedule.
We ask that if you must cancel with less than 48 hours notice that you share the economic burden with us 50-50 and reimburse us for 50% of your scheduled time as follows.
• $200.00 for a new patient appointment
• $175.00 for a one-hour return appointment
• $85.00 for a half-hour return appointment
Patient Signature ______________________________
Date ________________________________________
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Note that I am interested in so-called minor symptoms as well as in major problems. I know that in many doctor’s offices there is some tendency not to mention too many symptoms for fear that the doctor will take you for a hypochondriac. The rules here are different. I am interested in any message you are getting from your body, even though it may be considered irrelevant to “making a diagnosis” or it may seem to you to be of no consequence to your health. Some such symptoms are useful clues in the kind of medical detective work we do.
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