THE AMEN CLINIC FOR BEHAVIORAL MEDICINE, INC



T.R. Morris, ND, IFMCPNaturopathic Medical Doctor & IFM Certified Practitioner7041 11th Ave NW Seattle, WA 98117 ~ Tel: 206-947-4915 ~ Fax: 206-274-4955 ~ Email: TR@ PATIENT INFORMATION |(Please use MS WORD to fill in the gray boxes, or write clearly. Do not “fix margins” when printing.)Patient Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Marital Status: FORMTEXT ?????Home Address: FORMTEXT ?????City, State, Zip: FORMTEXT ?????Cell Phone: FORMTEXT ?????Home Phone: FORMTEXT ?????E-mail: FORMTEXT ?????Occupation: FORMTEXT ?????Employer / School: FORMTEXT ?????Work / School Phone: FORMTEXT ?????Primary HEALTH Care Provider /or REFERRAL SOURCEName: FORMTEXT ?????Address: FORMTEXT ?????Phone #: FORMTEXT ?????Fax #: FORMTEXT ?????RESPONSIBLE PARTY and/or SPOUSE’S INFORMATIONSpouse or Responsible Party: FORMTEXT (if different than patient)Case # / Date of Birth: FORMTEXT (if different than patient)Address: FORMTEXT (if different than patient)Phone: FORMTEXT (if different than patient)Employer: FORMTEXT (if different than patient)INFORMED CONSENT TO DIAGNOSIS AND TREATMENTThe 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, FORMTEXT 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: FORMCHECKBOX Common Diagnostic Procedures: venipuncture, radiography, laboratory, x-ray, ultrasound, etc. FORMCHECKBOX Alternative Diagnostic Procedures: including genetic tests and other diagnostic methods and devices that may fall outside of the “conventional standard of care.” FORMCHECKBOX 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. FORMCHECKBOX 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. FORMCHECKBOX Botanical Medicine: medicinal herbs and plant derivatives prescribed as loose teas, alcohol or glycerin tinctures, capsules, tablets, creams, suppositories, etc. FORMCHECKBOX Intravenous Therapies: including high dose vitamin, mineral, amino acid, lipid, botanical and other nutrients. FORMCHECKBOX Minor Office Procedures: wound dressing, ear cleansing, sutures, biopsies, immunizations, etc. FORMCHECKBOX Physical Medicine: massage, stretching, exercises, contrast heat/cold applications and manual or instrument-assisted joint mobilizations (as permitted by licensure). FORMCHECKBOX Lifestyle and Wellness Counseling: to promote improved lifestyle strategies and wellness, but not including the specific treatment of known or suspected mental illness. FORMCHECKBOX Prescription medications: As allowed by the clinician’s licensure and for both FDA approved and non-FDA approved (i.e. “off label”) applications. FORMCHECKBOX 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. FORMCHECKBOX Group Counseling: to facilitate efficient and effective community creation and education regarding the diagnosis, treatment and management of health rmed Consent: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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: FORMTEXT ????? (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 FORMTEXT ????? Patient’s Physical SignatureDate___________________________Responsible Party’s Name FORMTEXT ?????Responsible Party (Signature)Date___________________________ FORMTEXT ?????Medical Intake FormsPlease e-mail (tr@) 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: FORMTEXT ????? Male FORMCHECKBOX Female FORMCHECKBOX Present Height: FORMTEXT ????? Present Weight: FORMTEXT ?????Occupation: FORMTEXT ?????Married FORMCHECKBOX , Single FORMCHECKBOX , Separated/Divorced FORMCHECKBOX ; Children FORMDROPDOWN 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) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????OPTIMAL HEALTH GOALS: Briefly describe optimal health & function for you: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????READINESS FOR CHANGERate how willing you are to do the following to improve your health 0-5? (5=very willing, 0=not willing) FORMDROPDOWN Be educated on the causes of your health or disease FORMDROPDOWN Engage in regular exercise FORMDROPDOWN Significantly modify your diet FORMDROPDOWN Modify your lifestyle (work demands, hours of sleep, avoiding stressors, etc.) FORMDROPDOWN Reduce your intake of caffeine, alcohol, tobacco, recreational drugs, and medications FORMDROPDOWN Practice a relaxation technique (conscious breathing, meditation, yoga, etc.) FORMDROPDOWN Take vitamins, minerals, herbal supplements, or hormonal support FORMDROPDOWN Have periodic lab tests to assess your progress FORMDROPDOWN Have regular follow up appointments to asses and update your treatment plan FORMDROPDOWN Inform the doctor if a treatment suggestion is not likely to be used, or is not workingPRIMARY health concern #1CONCERN #1Name the diagnosis, symptom or concern. FORMTEXT ?????LOCATION & QUALITYIf applicable, name the location and quality of the symptom (sharp, dull, constant, etc.). FORMTEXT ?????ONSET & CAUSESWhen did this start? What events preceded the symptom? “I’ve never been well since I ___.” FORMTEXT ?????SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable FORMTEXT ?????FREQUENCY & DURATIONHow frequently does it occur? How long does symptom last when it is present? FORMTEXT ?????TIMINGIs the problem worse at any particular time (day/week/month/season)? FORMTEXT ?????TRIGGERSIs there anything in particular that triggers this issue? FORMTEXT ?????AGGRAVATING FACTORSWhat treatments, activities, foods, settings, etc. make the problem WORSE? FORMTEXT ?????RELIEVING FACTORSWhat treatments, activities, foods, settings, etc. make this issue BETTER? FORMTEXT ?????ASSOCIATED SYMPTOMSAre there other symptoms that come on with or after this? FORMTEXT ?????PROGRESSIONIs the problem generally getting worse, better, or not changing? FORMTEXT ?????FAMILY HISTORYHave you or a family member had a similar concern in the past? FORMTEXT ?????YOUR OPINIONEven if you are not 100% sure, what do you think is causing and/or perpetuating this problem? FORMTEXT ?????ADDITIONAL INFORMATIONPlease give any other information you feel is important to fully understand your concern. FORMTEXT ?????PRIMARY health concern #2CONCERN #1Name the diagnosis, symptom or concern. FORMTEXT ?????LOCATION & QUALITYIf applicable, name the location and quality of the symptom (sharp, dull, constant, etc.). FORMTEXT ?????ONSET & CAUSESWhen did this start? What events preceded the symptom? “I’ve never been well since I ___.” FORMTEXT ?????SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable FORMTEXT ?????FREQUENCY & DURATIONHow frequently does it occur? How long does symptom last when it is present? FORMTEXT ?????TIMINGIs the problem worse at any particular time (day/week/month/season)? FORMTEXT ?????TRIGGERSIs there anything in particular that triggers this issue? FORMTEXT ?????AGGRAVATING FACTORSWhat treatments, activities, foods, settings, etc. make the problem WORSE? FORMTEXT ?????RELIEVING FACTORSWhat treatments, activities, foods, settings, etc. make this issue BETTER? FORMTEXT ?????ASSOCIATED SYMPTOMSAre there other symptoms that come on with or after this? FORMTEXT ?????PROGRESSIONIs the problem generally getting worse, better, or not changing? FORMTEXT ?????FAMILY HISTORYHave you or a family member had a similar concern in the past? FORMTEXT ?????YOUR OPINIONEven if you are not 100% sure, what do you think is causing and/or perpetuating this problem? FORMTEXT ?????ADDITIONAL INFORMATIONPlease give any other information you feel is important to fully understand your concern. FORMTEXT ?????PRIMARY health concernS #3CONCERN #1Name the diagnosis, symptom or concern. FORMTEXT ?????LOCATION & QUALITYIf applicable, name the location and quality of the symptom (sharp, dull, constant, etc.). FORMTEXT ?????ONSET & CAUSESWhen did this start? What events preceded the symptom? “I’ve never been well since I ___.” FORMTEXT ?????SEVERITYRate the intensity 0-10: 0 = perfect10 = worst imaginable FORMTEXT ?????FREQUENCY & DURATIONHow frequently does it occur? How long does symptom last when it is present? FORMTEXT ?????TIMINGIs the problem worse at any particular time (day/week/month/season)? FORMTEXT ?????TRIGGERSIs there anything in particular that triggers this issue? FORMTEXT ?????AGGRAVATING FACTORSWhat treatments, activities, foods, settings, etc. make the problem WORSE? FORMTEXT ?????RELIEVING FACTORSWhat treatments, activities, foods, settings, etc. make this issue BETTER? FORMTEXT ?????ASSOCIATED SYMPTOMSAre there other symptoms that come on with or after this? FORMTEXT ?????PROGRESSIONIs the problem generally getting worse, better, or not changing? FORMTEXT ?????FAMILY HISTORYHave you or a family member had a similar concern in the past? FORMTEXT ?????YOUR OPINIONEven if you are not 100% sure, what do you think is causing and/or perpetuating this problem? FORMTEXT ?????ADDITIONAL INFORMATIONPlease give any other information you feel is important to fully understand your concern. FORMTEXT ?????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 FORMCHECKBOX Fatigue (feeling tired or worn out) FORMCHECKBOX Being overweight FORMCHECKBOX Unexpected weight gain FORMCHECKBOX Unexpected weight loss FORMCHECKBOX Poor appetite FORMCHECKBOX Increased appetite FORMCHECKBOX Excessive sleeping FORMCHECKBOX Difficulty sleeping FORMCHECKBOX Unusual sensitivity to cold FORMCHECKBOX Unusual sensitivity to heat FORMCHECKBOX Cold sweats during the day FORMCHECKBOX Hot or cold spells FORMCHECKBOX Sweating excessively at night FORMCHECKBOX Excessive daytime sweating FORMCHECKBOX Lowered resistance to infection FORMCHECKBOX Flu-like or vague sick feeling FORMCHECKBOX Excessive thirst FORMCHECKBOX Other: FORMTEXT ????? Explanations: FORMTEXT ?????Neurological FORMCHECKBOX Depression, hopelessness or apathy FORMCHECKBOX Suicidal thoughts or planning FORMCHECKBOX Excess worrying, anxiety, panics FORMCHECKBOX Forgotten periods of time FORMCHECKBOX Dizziness FORMCHECKBOX Drowsiness FORMCHECKBOX Tremors (in hands or feet. etc.) FORMCHECKBOX Problems with memory FORMCHECKBOX Twitching, spasms or “tics” FORMCHECKBOX Numbness / Tingling FORMCHECKBOX Convulsions / fits FORMCHECKBOX Slurred speech FORMCHECKBOX Speech problem (other) FORMCHECKBOX Weakness in muscles FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Respiratory FORMCHECKBOX Shortness of breath FORMCHECKBOX Asthma, wheezing FORMCHECKBOX Chronic cough FORMCHECKBOX Coughing up blood or sputum FORMCHECKBOX Rapid breathing FORMCHECKBOX Repeated sinus infections FORMCHECKBOX Repeated bronchitis/pneumonia FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ?????Chest & Cardiovascular FORMCHECKBOX Ankle swelling/edema FORMCHECKBOX Rapid / irregular pulse FORMCHECKBOX Chest pain FORMCHECKBOX Palpitations FORMCHECKBOX High blood pressure FORMCHECKBOX Low blood pressure FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ?????Head, Eye, Ear, Nose, & Throat FORMCHECKBOX Frequent sore throats FORMCHECKBOX Post-nasal drip FORMCHECKBOX Disturbances in smell FORMCHECKBOX Runny nose or dry nose FORMCHECKBOX Repeated ear infections FORMCHECKBOX Hearing loss in one or both ears FORMCHECKBOX Ringing in ears / tinitus FORMCHECKBOX Headache FORMCHECKBOX Head injury FORMCHECKBOX Facial pain FORMCHECKBOX Blurry/Double vision FORMCHECKBOX Overly sensitive to light FORMCHECKBOX Dry mouth FORMCHECKBOX Sore tongue FORMCHECKBOX Trouble swallowing FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Gastrointestinal & Hepatic FORMCHECKBOX Loose/liquid bowel movements FORMCHECKBOX Constipation/Hard bowel movements FORMCHECKBOX >3 Bowel movements/day FORMCHECKBOX <7 Bowel movements/week FORMCHECKBOX Abdominal (stomach/belly) pain FORMCHECKBOX Abdominal swelling/bloating FORMCHECKBOX Slow digestion FORMCHECKBOX Nausea or vomiting (throwing up) FORMCHECKBOX Loss of bowel control FORMCHECKBOX Painful bowel movements FORMCHECKBOX Frequent belching (burps) FORMCHECKBOX Frequent flatulence (farting) FORMCHECKBOX Jaundice (yellowing of skin, eyes) FORMCHECKBOX Rectal bleeding (red or black blood) FORMCHECKBOX Rectal itching FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Musculoskeletal FORMCHECKBOX Neck pain or stiffness FORMCHECKBOX Back pain or stiffness FORMCHECKBOX Joint pain or stiffness FORMCHECKBOX Bone pain FORMCHECKBOX Leg pain FORMCHECKBOX Muscle cramps, spasm, or pain FORMCHECKBOX Muscle twitching FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Skin, Hair FORMCHECKBOX Dry hair or skin FORMCHECKBOX Itchy skin or scalp FORMCHECKBOX Easy bruising FORMCHECKBOX Excessive hair loss FORMCHECKBOX Excess hair growth FORMCHECKBOX Increased perspiration FORMCHECKBOX No perspiration FORMCHECKBOX Sun sensitivity FORMCHECKBOX Other/Explanations: FORMTEXT ?????Genitourinary FORMCHECKBOX Itchy privates or genitals FORMCHECKBOX Painful urination FORMCHECKBOX Excessive urination FORMCHECKBOX Difficulty in starting urine FORMCHECKBOX Accidental wetting of self FORMCHECKBOX Pus or blood in urine FORMCHECKBOX Decreased sexual desire FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Females FORMCHECKBOX No menses FORMCHECKBOX Menstrual irregularity FORMCHECKBOX Premenstrual Concerns: FORMCHECKBOX cramps FORMCHECKBOX headaches FORMCHECKBOX sadness/moodiness FORMCHECKBOX irritability/anger FORMCHECKBOX water retention/bloating FORMCHECKBOX breast tenderness FORMCHECKBOX Heavy menstrual periods FORMCHECKBOX Painful menstrual periods FORMCHECKBOX Abnormal vaginal discharge FORMCHECKBOX Pain during sex FORMCHECKBOX Sterility or fertility issues FORMCHECKBOX Problems with pregnancies FORMCHECKBOX Pregnancies FORMTEXT ????? FORMCHECKBOX Miscarriages FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Males FORMCHECKBOX Impotence (weak male erection) FORMCHECKBOX Inability to ejaculate or orgasm FORMCHECKBOX Scrotal pain FORMCHECKBOX Mass on testicles FORMCHECKBOX Mass in scrotum FORMCHECKBOX Pain with urination FORMCHECKBOX Decreased/absent ability to urinate FORMCHECKBOX Waking up at night to urinate FORMCHECKBOX Unable to stop urination FORMCHECKBOX Abnormal penile discharge FORMCHECKBOX Other: FORMTEXT ?????Explanations: FORMTEXT ????? Miscellaneous/OtherHealth concerns/symptoms not listed above or detailed in the top 3 concerns: FORMTEXT ?????PErSONAL & FAMILY MEDICAL HISTORYIn the table below, please indicate the medical conditions you and your family members have had.HEALTH CONDITIONSelf(current)Self(Past)RelativeDETAILS (who, onset, severity, treatment, resolution, etc.)Suicidal Thoughts/Intent FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Blood Pressure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????High Cholesterol/Lipids FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Diabetes/High Blood Sugar FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Low Blood Sugar FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Obesity/Overweight FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fatigue/Chronic Fatigue FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Heart Murmur/Arrhythmia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Blood Clots/Stroke FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Heart Attack/Coronary Dis. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Sleep Apnea/Sleep Disorder FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Asthma/COPD/Pneumonia FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Allergies/Hay Fever FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Frequent Sinus/Ear Infection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Food Allergies/Sensitivities FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Skin Conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Indigestion/Heartburn FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Ulcers (Gastrointestinal) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Liver/Gall-Bladder Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Colitis/Cohn’s Disease/UC FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Irritable Bowel (IBS) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Thyroid Conditions (high/low) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Adrenal Dysfunction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Chronic Neck/Back Pain FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Osteopenia/Osteoporosis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Osteoarthritis (joint pain) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Rheumatoid Arthritis FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Autoimmune: Lupus, MS, etc. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Kidney/Urinary Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Abuse: Physical/Sexual FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Anxiety/Depression FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Attention Deficit/ADD FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Anorexia/Bulimia/Binging FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Alcohol/Drug Addiction FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other Mental Illness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Headaches/Migraines FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Seizures FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Alzheimer’s Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Parkinson’s Disease FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Cancers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????CHILDHOOD & ADULT HISTORYPRENATAL DETAILSMother’s age, maternal health, substance use, diet, exposures, mental health, stressors, etc. FORMTEXT ?????BIRTH DETAILSFull term or premature, vaginal or cesarean, hospital or home birth, respiratory disresss, other details… FORMTEXT ?????VACCINATIONS Normal or alternate vaccination schedule? Any unusual reactions? FORMTEXT ?????CHILDHOOD ILLNESSES e.g. Colic, chicken pox, measles, major allergies, ear infections, pneumonia, leukemia, etc. FORMTEXT ?????CHILDHOOD SETTINGSLocations, environments (urban, suburban, rural, agricultural, industrial), foreign travel, etc. FORMTEXT ?????SOCIAL FOUNDATIONSingle or dual parents, siblings, birth order, adoption, extended family contact, community, etc. FORMTEXT ?????CHILDHOOD SECURITY/STRESSDid you feel safe as a child? Did you experience significant abuse, stress, or hardship? FORMTEXT ?????ALLERGIES(Drug, Food, Environmental, etc.)List all known and suspected allergies to drugs, foods and other exposures. FORMTEXT ?????INJURIES & TRAUMASe.g. head injury, car accidents, falls, broken bones, major sprains. Indicate the date and treatments. FORMTEXT ?????SURGERIES &HOSPITALIZATIONSPlease include all, and indicate the year, the cause, treatments, and outcomes. FORMTEXT ?????TRAVEL HISTORYWhere have you traveled out of the country; when and for how long? Note any illnesses or injuries. FORMTEXT ?????OCCUPATIONAL HISTORYSummarize your employment history and the TYPES of jobs you’ve had. FORMTEXT ?????KNOWN TOXIC EXPOSURESMold, Pesticides, Mercury, lead, solvents, PCBs, PBDEs, etc. FORMTEXT ?????TOBACCO USEPlease indicate past and present use FORMTEXT ?????DRUG USEPlease indicate past and present use. (For privacy, this may also be disclosed during the visit.) FORMTEXT ?????NUTRITION & LIFESTYLE FACTORSDIETARY HABITS & RESTRICTIONSFor example: vegetarian, gluten free, dairy free, food reactions, diets: (paleo, ketogenic, etc.) FORMTEXT ?????TYPICAL BREAKFASTSDo you eat breakfast? If so what are some examples? FORMTEXT ?????TYPICAL LUNCHESDescribe typical lunches. FORMTEXT ?????TYPICAL DINNERSDescribe typical dinners. FORMTEXT ?????TYPICAL SNACKSDo you snack? How often? Please give a few examples. FORMTEXT ?????HYDRATIONHow much water do you typically drink on a daily basis? (coffee & alcohol don't count) FORMTEXT ?????CAFFEINE USEInclude coffee, tea, soda and the amount per day, week or month. FORMTEXT ?????SOFT DRINKSDo you drink diet or regular soda? If so, please indicate which kinds and how much. FORMTEXT ?????FAST FOOD & PASTRIESHow often do you eat fast food or pastries (per day/week/month)? FORMTEXT ?????ALCOHOL USEPlease indicate the amount per day, week, or month. Are you concerned about over-consuming alcohol? FORMTEXT ?????SLEEP BEHAVIORUsual bedtime, duration, regularity, quality. Indicate snoring, apnea, sleepwalking, nightmares, difficulty falling/staying asleep. FORMTEXT ?????RELAXATION & RECUPERATIONWhat kinds of things do you do to unwind, relax and recharge? How often? FORMTEXT ?????CURRENT MAJOR LIFE STRESSESList major stressors: work, school, finances, children, family, relationships, caregiving, etc. FORMTEXT ?????EXERCISE & MOVEMENTIndicate frequency, intensity, type, and duration: e.g. 3x/week, 30min, moderate, aerobic (or resistance or flexibility) FORMTEXT ?????RELATIONSHIPS & NETWORKSDo you have close friends and/or family, religious connection, support groups, or other social groups available to you? FORMTEXT ?????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 TYPESTART DATE(Month &Year)END DATE(If applicable)EVENT DESCRIPTION FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INFORMATION: FORMTEXT ?????LAB TEST & IMAGING STUDIESPlease 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 PROVIDERFINDINGS (normal or abnormal; include the numbers and the normal ranges) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INFORMATION: FORMTEXT ?????MEDICATION & SUPPLEMENT HISTORYStarting 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 MEDICATIONDOSAGE & FREQUENCYSTART & END (month/year)DIAGNOSIS OR REASON FOR TAKING. INDICATE YOUR RESPONSE, SIDE EFFECTS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????ADDITIONAL INFORMATION: FORMTEXT ?????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: FORMTEXT ?????Date: FORMTEXT ????? MEDICAL RECORDS RELEASE FORMTEXT ?????(Patient Name) FORMTEXT ?????(Address) FORMTEXT ?????(Date of Birth)39433514668500HEREBY REQUESTS: FORMTEXT ?????(Health care provider) FORMTEXT ?????(Fax# / Address) FORMTEXT ?????(Health care provider #2—if needed) FORMTEXT ?????(Fax# / Address) FORMTEXT ?????(Health care provider #3—if needed) FORMTEXT ?????(Fax# / Address)39348814859000To 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: TR@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: FORMTEXT ?????Date: FORMTEXT ????? ................
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