!
Name _________________________________ Todays Date _______________
Address_________________________________________________________
City __________________________ State ________ Zip Code_______________
Tel: (c)_________________ (w)__________________ (h)__________________
E-mail address: ________________________________________________________
Age ______ Date of Birth _______________! Gender: female ____ male _____
Education _______________________________________________________
Married !
Separated !
Divorced !
Widowed !
!
Single__________ Partnership !
Live with: Spouse !
Partner !
Parents
Children !
!
Friends _______ Alone ______
Occupation ______________________Hours per week _______ Retired_____
Employer ________________________S.S.#__________________________
Work Address:
____________________________________________________________________
Health insurance co. name and address:
______________________________________________________________
Policy Holder’s name:__________________ Employer_________________________
Policy/Group #________________________ Tel: (_____)______________________
Identification/Social Security # _______________________________________
!
How did you hear about us?
______________________________________________________________!
Has any other family member already been a patient at the clinic?
!
!
!
!
!
!
!
!
Next of Kin or other to reach in case of an emergency?
!
___________________________________________________________!
!
Relationship:_________________
Phone: ________________________!
Address:_____________________________________________________!
___________________________________________________________
!
Please list with whom, other than yourself, we may discuss your personal medical
information:
1.) Name:_______________________________________________________
Tel: _________________________________________________________
2.) Name: ______________________________________________________
Tel: _________________________________________________________
!
!
In the event that we cannot speak to you directly do you wish for us to leave medical
information on your voicemail or message system?
Yes_____
No ______
If yes, what number may we leave medical information?
(c) _____
(h) _____
(w) _____
!
Do you wish to receive newsletters in the form of e-mails from our office?
Yes ______
No ______
!
Do you wish to receive text messages about appointment reminders?
Yes ______
!
!
No ______
!
!
PLEASE FILL OUT BOTH SIDES OF EACH PAGE
HEALTH HISTORY QUESTIONNAIRE
SUCCESSFUL
HEALTH CARE AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE
PHYSICIAN HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY
AND EMOTIONALLY.
POSSIBLE.
PRINT
PLEASE
COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS
ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND
WITH A QUESTION MARK.
Are you currently receiving healthcare? Y N
If yes, where and from whom?
________________________________________________________________!
________________________________________________________________!
!
If no, when and where did you last receive medical or health care?
!
________________________________________________________________!
!
________________________________________________________________
!
!
What was the reason?
________________________________________________________________!
!
Do you have any known contagious diseases at this time? Y N
!
If yes, what?_______________________________________________________
!
What are your most important health problems? List as many as you can in order of
importance.
1) _________________________________________________________!
2)
3) _______________________________________________________________
4)
!
5) ________________________________________________________!
!
For all the following sections:
Y = a current condition
N = never had
P = a past condition
!
CHILDHOOD ILLNESSES
Scarlet fever
Mumps
Y N
Y N
Diphtheria
Measles
Y N
Y N
Rheumatic fever
German measles
Y N
Y N
!
GENERAL
Weight !
!
Maximum Weight !
Goal Weight
lbs.
!
Weight 1 year ago ! lbs.
When? ______________________
Height ______________________
!
!
SCREENING
Date (most recent)
!
Dexa
Pap
Mamogram
Physical Exam
Lab work
Stress Test
Colonoscopy
Results (circle)
__________________
__________________
__________________
__________________
__________________
__________________
__________________
Normal/Osteopenia/Osteoporosis
Normal/Abnormal/Past Abnormal
Normal/Abnormal
Normal/Abnormal
Normal/Polyps
!
!
!
HOSPITALIZATION AND SURGERY
What hospitalizations or surgeries have you had?
!
!
!
!
______________ year:
year:
year:
!
__ !
!
!
X-RAYS AND SPECIAL STUDIES
X-rays, CAT scans, or other studies you have had:
_______________________________________________________________
_______________________________________________________________!
!
Electrocardiogram
Electroencephalogram
Y N
Y N
Stress test
Echocardiogram
Y N
Y N
!
IMMUNIZATIONS
!
Polio
Tetanus shot
Measles/Mumps/Rubella
Y N
Y N
Y N
Pertussis
Diphtheria
Other ! !
!
!
Y N
Y N
_________
!
!
!
!
_____
!
!
ALLERGIES
!
Are you hypersensitive or allergic to...
!
Any drugs? ! !
!
!
!
Any foods? ! !
!
!
!
Any environmental?
!
!
!
!
!
!
CURRENT MEDICATIONS
Do you take or use?
Laxatives
Tranquilizers
Cortisone
Antibiotics
! !
!
!
!
!
Y
Y
Y
Y
!
N !
N
N
N! !
!
Pain relievers.
Y
Antacids
Y
Sleeping pills
Y
Thyroid medication Y
Appetite suppressants Y
N
N! !
N
N! !
N
Please list any prescription medications, over the counter medications, vitamins or other
supplements you are taking?
1) _______________________________ 5)___________________________
2) _______________________________ 6) ___________________________
3) _______________________________ 7) ___________________________
4)___________________________________ 8) ______________________________
!
!
!
!
!
!
!
!
!
!
!
!
FAMILY HISTORY
FATHER
Age (if living) ______
Health ( G=good P=poor )
______
MOTHER BROTHERS SISTERS SPOUSE CHILD
______
______
!
Age at death (if deceased)
______ ______
!
!
Check (_) those applicable
!
!
______
!
______
______
______ ______
______ ______ ______
______
______ ______ ______
Cancer
______
______
______
______
______ ______
Diabetes
______
______
______
______
______ ______
Heart Disease ______
______
______
______
______
______
Hypertension ______
______
______
______
______
______
Stroke
______
______
______
______
______
______
Epilepsy
______
______
______
______
______ ______
Mental Illness ______
______
______
______
______ ______
Asthma/Hayfever/Hives
!
______
______
______
______
______ ______
Anemia
______
______
______
______
______ ______
Kidney Dz
______
______
______
______
______ ______
Glaucoma
______
______
______
______
______
______
Tuberculosis
______
______
______
______
______
______
Cause of Death______
______
______
______
______ ______!
!
!
!
!
!
!
TYPICAL FOOD INTAKE
Breakfast:
_______________________________________________________________
Lunch:
_______________________________________________________________
Dinner:
_______________________________________________________________
Snacks:
_______________________________________________________________!
To drink:
_______________________________________________________________
!
HABITS
Main interests
and hobbies?_________________________________________________
Do you exercise?
Y
N
If yes, what form?______________________________________________ !
!
How often? ___________________________________________________
!
!
!
Average 6-8 hrs. sleep?
Y
N
Sleep well?
Y
N
Awaken rested?
Y
N
Have a supportive relationship?
Y
N
Read?
!
Y
N
how many hours_____________
Have a history of abuse?
Y
N
Use recreational drugs?
Y P N
Been treated for drug dependence?
Y P N
Use alcoholic beverages?
Y P N
Do you use tobacco?
Y P N
how many packs per day? _______________!
how many years?________________________
Do you eat three meals a day?
Y
N
Do you go on diets often?
Y
N
Do you drink coffee?
Y P N
Number of cups?______
Do you drink tea?
Y P N
Number of cups? _____
Do you drink cola or other sodas?
Number of ounces____
Y P N
Do you drink water?
How many cups?______
Y P N
Do you add salt?
!
!
Do you eat refined sugar?
!
Do you have a religious or spiritual practice? Y N
If yes, what?__________________________
Enjoy your work?
Y
N
Take vacations?
Y
N
Spend time outside? Y
N
Watch television?
Y
N
how many hours ?________
Any major traumas?
Y P N
Treated for alcoholism? Y P N
Smoked previously?
Y P N
how long ago?_______
year quit? _______
Do you eat out often?
Y
N
Y P N
!
!
!
How does your condition affect you?
______________________________________________________________
_______________________________________________________________
_______________________________________________________________
!
!
What do you think is happening?
______________________________________________________________
_______________________________________________________________
_______________________________________________________________
!
!
Why?___________________________________________________________
_______________________________________________________________
_______________________________________________________________
!
!
What do you feel needs to happen for you to get better?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________!
!
!
What do you enjoy most in your life?
____________________________________________________________
_______________________________________________________________
_______________________________________________________________
!
!
!
!
!
!
!
How much change are you willing to make at this time for improving your health?
MINIMAL SOME COMPLETE
!
!
!
REVIEW OF SYSTEMS
FOR THE FOLLOWING, PLEASE CIRCLE
!
Y = current condition
!
!
MENTAL/ EMOTIONAL
!
N = never had
P = a past condition
Treated for emotional problems?
Mood Swings?
Considered/Attempted suicide?
Poor concentration?
Y
Y
Y
Y
P
P
P
P
N
N
N
N
Depression?
Anxiety or nervousness?
Tension?
Memory problems?
Y
Y
Y
Y
Hypothyroid?
Hypoglycemia?
Excessive thirst?
Fatigue?
Y
Y
Y
Y
P
P
P
P
N
N
N
N
Heat or cold intolerance?
Diabetes?
Excessive hunger?
Seasonal depression?
YP N
Y P N
Y P N
Y P N
Vaccinations?
Chronic Fatigue Syndrome?
Chronically swollen glands?
Y P N
Y P N
Y P N
Seizures?
Muscle weakness?
Loss of memory?
Vertigo or dizziness?
Y
Y
Y
Y
P
P
P
P
N
N
N
N
Paralysis?
Numbness or tingling?
Easily stressed?
Loss of balance?
Y P N
Y P N
Y P N
Y P N
Rashes?
Acne, Boils?
Color Change?
Lumps?
Y
Y
Y
Y
P
P
P
P
N
N
N
N
Eczema, Hives?
Itching?
Perpetual Hair Loss?
Night Sweats?
Y
Y
Y
Y
Headaches?
Migraines?
Y P N
Y P N
Head Injury?
Jaw/TMJ problems
Y P N
Y P N
!
!
ENDOCRINE
!
!
!
IMMUNE
!
!
!
NEUROLOGIC
!
!
!
SKIN
!
!
HEAD
!
P
P
P
P
N
N
N
N
Reactions to vaccinations? Y P N
Chronic infections?
Y PN
Slow wound healing?
Y P N
P
P
P
P
N
N
N
N
!
!
EYES
!
Spots in Eyes?
Impaired vision?
Blurriness?
Color blindness?
Double Vision?
!
Y
Y
Y
Y
Y
P
P
P
P
P
N
N
N
N
N
Cataracts?
Glasses or contacts?
Eye pain/strain?
Tearing or dryness?
Glaucoma?
Y
Y
Y
Y
Y
P
P
P
P
P
N
N
N
N
N
EARS
!
Impaired hearing?
Earaches?
Y P N
Y P N
Ringing?
Dizziness?
Y P N
Y P N
Frequent colds?
Stuffiness?
Sinus problems?
Y P N
Y P N
Y P N
Nose Bleeds?
Hayfever?
Loss of smell?
Y P N
Y P N
Y P N
Frequent sore throat?
Teeth grinding?
Gum problems?
Dental cavities?
Y
Y
Y
Y
N
N
N
N
Copious saliva?
Sore tongue/lips?
Hoarseness?
Jaw clicks?
Y
Y
Y
Y
Lumps?
Goiter?
Y P N
Y P N
Swollen glands?
Pain or stiffness?
Y P N
Y P N
Cough?
Spitting up blood?
Asthma?
Pneumonia?
Emphysema?
Pain on breathing?
Shortness of breath at night?
Tuberculosis?
Y
Y
Y
Y
Y
Y
Y
Y
Sputum?
Wheezing
Bronchitis?!
Pleurisy?
Difficulty breathing?
Shortness of breath?
" " " " "lying down?
!
!
NOSE AND SINUSES
!
!
!
MOUTH AND THROAT
!
NECK
!
!
!
RESPIRATORY
!
!
P
P
P
P
!
!
P
P
P
P
P
P
P
P
N
N
N
N
N
N
N
N
P
P
P
P
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
P
P
P
P
P
P
P
N
N
N
N
N
N
N
!
!
!
!
CARDIOVASCULAR
!
Heart disease?
High/Low Blood Pressure?
Blood clots?
Phlebitis?
Rheumatic Fever?
Swelling in ankles?
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
N
N
N
N
N
N
Angina?
Murmurs?
Fainting?
Palpitations/Fluttering?
Chest pain?
Trouble swallowing?
Y
Change in thirst?
Y
Nausea?
Y
Vomiting blood?
Y
Blood in stool?
Y
Is this a change____________________
Pain or cramps?
Y
Belching or passing gas?
Y
Black stools?
Y
Jaundice (yellow skin)?
Y
Liver Disease?
Y
P
P
P
P
P
N
N
N
N
N
Heartburn?
Y P N
Change in appetite?
Y P N
Vomiting?
Y P N
Bowel Movements:
Number/day_____________
P
P
P
P
P
N
N
N
N
N
Constipation?
Diarrhea?
Gall Bladder disease?
Ulcer?
Hemorrhoids?
!
!
GASTROINTESTINAL
!
!
URINARY
!
Pain on urination?
Frequency at night?
Frequent infections?
!
MEN'S HEALTH
!
Hernias?
Testicular pain?
Venereal disease?
Are you sexually active?
Sexual orientation:
Impotence?
Premature ejaculation?
Birth control? Type? !
!
!
!
!
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
P
P
N
N
N
N
N
N
N
N
N
N
Y P N
Y P N
Y P N
Increased frequency? Y P N
Inability to hold urine? Y P N
Kidney stones?
Y P N
Y P N
Y P N
Y P N
Y
N
Testicular masses?
Prostate disease?
Discharge or sores?
Chlamydia?
Gonorrhea?
Condyloma?
Herpes?
Syphilis?
!
Y P N
Y P N
Y
Y
Y
Y
Y
Y
Y
Y
P
P
P
P
P
P
P
P
N
N
N
N
N
N
N
N
!
!
!
!
!
!
WOMEN'S HEALTH
Age of first menses? !
Are cycles regular?
Bleeding between cycles?
Pain during intercourse?
Clotting?
Discharge?
PMS?
If yes, what are your symptoms?
________________________________
Birth control?
What Type? _____________________
Number of years? _____________
Number of pregnancies? ___________
Number of miscarriages?___________
Endometriosis?
Difficulty conceiving?
!
Y
Y
Y
Y
Y
Y
P
P
P
P
P
N
N
N
N
N
N
! Age of last menses? ______
Length of cycle?
________days
Duration of menses? ________days!!
Painful menses?
Y P N
Heavy or excessive flow? Y P N
Y P N
Y P N
Y P N
Cervical Dysplasia?
Sexual difficulties?
Gonorrhea?
Herpes?
Are you sexually active?
Do you do breast self exams?
Breast pain/tenderness?
Y
Y
Y
Y
Y
Y
Y
Joint pain or stiffness?
Broken bones?
Muscle spasms or cramps?
Y P N
Y P N
Y P N
Arthritis?
Weakness?
Sciatica?
Y P N
Y P N
Y P N
Easy bleeding or bruising?
Deep leg pain?
Varicose veins?
Y P N
Y P N
Y P N
Anemia?
Cold hands/feet?
Thrombophlebitis?!
Y P N
Y P N
Y P N
!
!
MUSCULOSKELETAL
!
P
P
P
P
N
N
N
N
N
P N
P N
Number of live births? _________
Number of Abortions___________
Ovarian cysts?
Y P N
Menopausal symptoms? Y P N
If yes, what?_______________
Abnormal PAP?
Y P N
Chlamydia?
Y P N
Condyloma?
Y P N
Syphilis?
Y P N
Sexual orientation: !
__
Breast lumps?
Y P N
Nipple discharge?
Y P N
!
!
!
BLOOD/PERIPHERAL VASCULAR
!
!
!
BANYAN WELLNESS CENTER
1646 N. Litchfield Road, Suite 200
Goodyear, AZ 85395
!
Terms of Agreement
!
!
Patient Name: Last_______________________ First____________________ M.I.___
!
Age:_____
Date of Birth:_____/_____/_____ Social Security #:_____/_____/_____
!
!
Welcome to the Banyan Wellness Center and thank you for choosing us for
your health care needs. We look forward to helping you recapture your life.
!
After Hours Calls: All after hours calls made to any of the providers will be assessed a
$95 fee and will be called upon to collect the following business day.
!
Office Hours: Our hours of operation shall be Monday-Thursday 8:30am-5pm and
Friday 8:30am-4pm. We are closed daily from 12:00pm-1:30pm. We reserve the right to
change our office hours at any time without prior notification.
!
Cancellation: We would appreciate the courtesy of a call if you cannot keep you
appointment as there is a wait list to see Banyan Wellness Center providers and to receive
services. Please notify our office at least 24 (twenty-four) hours prior to your
appointment time or you will be charged $95 for missed appointments or the cost of an
IV via the credit card received in advance which is included in the new patient paperwork
and required to schedule your initial consultation. If we do not receive a courtesy call for
HCG follow up visits (as part of a package), you will not receive another complimentary
follow up.
!
Fees & Financial Policy: Payment of fees is the direct responsibility of the patient.
Banyan Wellness Center does not bill insurance, however we will provide you upon
request with the necessary forms so that you may submit directly to your instance
provider. You are responsible for contacting your insurance provider to verify your
benefits. We cannot guarantee reimbursement. We are currently not covered by
Medicare and therefore are unable to provide any claim forms to submit for Medicare
reimbursement.
!
Terms: We shall collect payment for services and products at the time of service.
We accept cash, check, visa, master card, discover and American Express as forms of
payment.
!
Medicinary: To pick up refills of your medicinary items, please call the center in
advance so that we may minimize any waiting time. There are no refunds for items
purchased from our medicinary.
!
!
!
!
!
Prescriptions: If you are in need of a prescription refill please contact your pharmacy
and have them fax us a refill request. Please allow 48 hours for this process to ensure
that you will not run out of your medication.
!
Records: In the event that you should require a copy of your personal health records
there will be a $.05 charge per page and a $10 copy fee. You must allow one week for
this process. In the event that a transfer of records needs to occur, we will forward your
health records to the physician of your choice and not to the individual patient.
!
Statement: I have read and understand the above policies of Banyan Wellness Center,
LLC and agree with them. I consent to treatment from Dr. Jennifer Elton NMD, Dr.
Dorothy Preston, Ph.D., Julie Rae, L.Ac. and/or Dr. Brian Archambault, NMD. and
accept full responsibility for all expenses incurred by or on the account of the patient. In
the event of non-payment, I will bear the cost of collection and/or all court costs and legal
fees should it be required.
!
!
Due to the new privacy policies, this form must be signed by you to disclose your
private health information. A copy of our privacy policy is available upon request.
!
!
!
!
!
!
!
__________________________________________
Signature of Patient or Guardian
!!
!!
!
!
!
!
!
!
!
!
!
!
!
!
!
_______________
Date (DD/MM/YY)
!
BANYAN WELLNESS CENTER
1646 N. Litchfield Road, Suite 200
Goodyear, AZ 85395
!
!
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES SUMMARY
!
!
!
This document is to be signed by a person legally responsible for the patient’s
medical decisions relative to the treatment situation.
I, __________________________________________, hereby acknowledge that Banyan
Wellness Center has provided me with a copy of its Notice of Privacy Practices Summary
that summarizes how medical information about me may be used and disclosed. I further
acknowledge that a complete copy of Privacy Practices Policies (approx.13 pages) is
available upon request and in the waiting area.
!
I understand that if I have questions or complaints I may contact:
!
!
Privacy Officer: Malisa Goucher
Tel: 623.643.9598
I also understand that I am entitled to receive updates upon request if Banyan Wellness
Center amends or changes its Notice of Privacy Practices in a material way. Privacy
Practices Policy effective July 1, 2004.
___________________________________
Signature
_____________________________
Relationship to Patient, if signed by
someone other than patient.
___________________________________
Date
!
!
________________________________________________________________________
THIS SECTION IS TO BE COMPLETED BY THE BANYAN WELLNESS
CENTER IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGMENT FROM
PATIENT
!
I made a good faith effort to obtain a written acknowledgment of receipt of the Notice of
Privacy Practices Summary from the above-named patient, but was unable to because:
[ ] Patient declined to sign this Written Acknowledgment.
[ ] Other (specify): _______________________________________________________
!
_______________________________
Name and title of employee
_______________________
Date