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The Body Shop Informed Consent and Request for Naturopathic Medicine I understand that the evaluation, diagnosis and treatment by a naturopathic physician, and specifically by Dr. Winter at The Body Shop may include, but is not limited to: Interview (history taking) Physical examination Common diagnostic procedures (such as, diagnostic imaging, laboratory evaluation of blood, urine, stool, and saliva, Pap smears) Dietary advice and therapeutic nutrition (such as therapeutic use of foods, diet plans, nutritional supplements, intravenous and intramuscular injections) Acupuncture Prolotherapy and/or PRP Therapy Botanical Medicine and nutraceuticals/supplements Homeopathic remedies Over the Counter medications Prescription Medications to be filled at a pharmacy I understand and informed that in the practice of Naturopathic Medicine there are risks and benefits with evaluation, diagnosis and treatment including but not limited to the following: Potential risks: pain, discomfort, minor bruising from acupuncture, IV, or prolotherapy, allergic reaction to prescribing herbs, supplements, prescription medications; an aggravation of pre-existing symptoms. Potential benefits: restoration of the body’s maximal functioning capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery and prevention of disease or its progression. Notice to all pregnant women: all female patients must alert the provider if they know or suspect that they are pregnant, since some of the therapies could present a risk to the pregnancy. By signing below. I (print name), _________________________acknowledge that I have been provided ample opportunity to read this form or that it has been read to me. I also understand that it is my responsibility to request that the provider explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been given to me concerning the results intended from the treatment. I intend that this consent form is to cover the entire course of treatments for my present condition and any future conditions for which I am seeking. ________________________________________ Signature ______________________ Date _______________________________________ Signature of Patient Representative or Guardian 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 The Body Shop PATIENT INFORMATION FORM: Name:______________________________Date of birth:_____________Age:______________ Address:______________________________________________________________________ Phone: (home) _________________________(mobile)_________________________________ E-mail address:_________________________________________________________________ Occupation:___________________________Name of employer:_________________________ Name of Spouse:________________________________________________________________ Emergency Contact Person:_______________________________________________________ Emergency Contact Phone:_______________________________________________________ Relationships:__________________________________________________________________ I authorize employees of The Body Shop to leave a detailed message for me on a voice message device associated with the phone number listed below, regarding my: 1. Laboratory reports: 2. Protected health information: ___ yes (initials______) ___no (initials_____) ___ yes (initials_____) ___no (initials_____) If you answered YES to either of the above on which phone number is it acceptable to leave this information?_________________________ If you answered NO to either of the above, the physicians and/or staff members at The Body Shop will, as necessary, leave a message indicating your need to call the clinic to retrieve any of your health-related information. Whom may we thank for referring you? ___________________________________ 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 The Body Shop Dr. Erin Winter NMD New Patient Intake Form Date: Patient Name: DOB: Age:_________________ List in Order of importance what your problems are: 1) 2) 3) 4) 5) Last time you had blood work done and with what physician: Family History Check YES, NO, or ? (don’t know) for blood relatives Yes No ? Alcoholism Allergies Anemia Asthma Auto-immune disease Cancer Diabetes Gout Who in the family: Yes No ? Who in the family: Heart Disease Hypoglycemia High Blood Pressure Mental Illness Skin Disorders Seizure of Epilepsy Stroke Thyroid Disorders Glaucoma Osteoporosis List All Surgeries & Hospitalizations, including date occurred: 1) 2) 3) 4) 5) 6) Please Note When & Why You Have Had Each of the Following: X-Rays: Ultrasounds: TB Test: HIV: Last Eye Exam: MRI/Cat Scans: Accidents: HCV: Last Dental Visit: Did you have the following Disease (D), Get Immunized (I), or Neither (N): Measles: D I N Tetanus: D I N German Measles: D I N Chicken Pox: D I N Whooping Cough: D I N Any vaccination reactions: Mumps: Hemophilus (Hib): D I N D I N Rubella: Hepatits B: List Yes (Y), No (N) or Past (P) regarding use of the following: Antacids: Y N P Analgesics: Y N P Soda Pop: Y N P Alcohol: Y N P Any Alcohol Addiction: Recreational Drugs: Any Drug Treatment: Steroids: Y N P Smoking: Y N P Packs per day & number of years: Laxatives: Y N P Coffee: Y N P Cups per day if Yes/Past: Ounces per day if Yes/Past: How often & how much if Yes/Past: Y N P Any Alcohol Treatment: Y N P Y N P Any Drug Addictions: Y N P Y N P List All Allergies to Medications or Foods: 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 D I N D I N Review of Systems: Present Weight: Weight one year ago: Maximum weight and when: Minimum weight as adult & when: Ideal Weight: Good Energy: Yes No Past Fatigue: Yes No Past If you have fatigue, when is it the worst? Morning Afternoon Evening If you have fatigue, can you do what you need to during the day? Yes No Height: REGARDING THE NEXT LONG SECTION: Please check any of the symptoms you’ve had in the past or have now, and explain next to it. Skin □ Rash □ Hives □ Psoriasis/Eczema □ Dry skin □ Cancer □ Color change □ Lump □ Itchy □Warts/moles □ Perspiration Respiratory □ Asthma □ Bronchitis □ Cough □ Pneumonia □ Painful Breathing □ TB □ Shortness of Breath with Exertion □ Shortness of Breath sitting □ Shortness of Breath lying down □ Wheezing Head □ Headache □ Migraines □ Head Injury □ Dandruff □ Oil/dry hair □ Hair loss Cardiovascular □ Arrhythmias □ Chest Pain □ Edema □ High Blood Pressure □ Low Blood Pressure □ Palpitations □ Murmurs □ Rheumatic Fever Nose □ Frequent colds □ Congestion □ Polyps □ Nosebleeds □ Post Nasal Drip □ Seasonal Allergies Eyes □ Dry/watery □ Double Vision □ Blurry Vision □ Cataracts □ Glaucoma □ Strain □ Itchy □ Styes □ Discharge □ Dark under eyelid Mouth and Throat □ Sore Throat □ Canker Sores □ Cold Sores (fever blisters) □ Gum Disease □ Loss of Taste □ Cavities □ Hoarseness □ Dentures Neck □ Stiffness □ Full movement □ Swollen Glands □ Tension Urinary Tract □ Discharge/blood □ Frequent Infections □ Kidney Stones □ Incontinence □ Pain with Urination □ Urgency Gastrointestinal Bowel Movement Frequency: ___ / day □ Bloating □ Constipation/Diarrhea □ Nausea/ Vomiting □ Change in appetite □ Recent Bowel Changes □ Heartburn □ Indigestion □ Hemorrhoids □ Ulcers □ Pancreatitis □ Gall Bladder Disease □ Liver Disease □ Other: _____________________ Nervous □ Carpal Tunnel Syndrome □ Paralysis □ Sciatica □ Tingling/ Numbness □ Seizures □ Fainting Mental/ Emotional □ Anxiety □ Anger/ Irritability □ Depression □ Eating Disorder □ Fear/ Panic □ High Strung/ Tense □ Psych hospitalization □ Suicidal Endocrine □ Diabetes □ Fatigue □ Thyroid □ Other: ______________________ Male Genitalia Sexual Orientation: Hetero Homo Bi Sexually Active: Yes No □ Hernia □ Discharge □ Impotency □ Prostate Disease/ Symptoms: _______ □ Testicular Pain/ Swelling □ STD: ____________ Female Genitalia Sexual Orientation: Hetero Homo Bi Sexually Active: Yes No Age Period began: _____ Period lasts _____ days How often periods occur: every ____ days □ Heavy Menstrual Bleeding □ Menstrual Pain □ Menstrual Cramping □ PMS □ Food Cravings Number of pregnancies: _____ Number of live births: ____ Number of abortions: ____ Number of miscarriages: ___ Date of last Pap Smear: ________ Normal Abnormal □ Dry Vagina □ Pain with intercourse □ STD: ___________ □ Healthy Libido □ Vaginitis Age at Menopause: ____ □ Use of Hormones:________________________ □ Use of Birth Control: ______________________ Musculoskeletal □ Weakness □ Stiffness □ Arthritis □ Leg Cramps □ Tremors □ Pain 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 How often do you exercise? For how long? How long per night? Nightmares: Y N P Sleep walk: Y N P What type of exercise? Hobbies: Sleep If you wake up frequently, what is the reason? Wake Refreshed: Y N P Must nap during the day: Y N P Grind teeth: Y N P Snore: Y N P Toxin Exposure Did you grow up near any refinery, polluted area or in a home with leaded paint? If so, what sort of pollution were you exposed to? Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, gasoline or other vapors? Do you use pesticides, herbicides or other chemicals around your home? Social Life Enjoy job: Y N P Hours worked per week: Highest Level of Education: Active spiritual practice: Y N P Quality of significant relationship: History of sexual, mental/emotional, physical abuse: Y N P If so, at what age and by whom: What is your greatest health concern: How does it limit you the most: How committed are you towards making valuable changes: Little Moderately Very List all Supplements and Medications Name and Brand Dose 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 Hormone Review Women’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing SYMPTOM HEALTH CONCERN Hot Flashes Incontinence Night Sweats Bleeding Changes Tearful Tender Breasts/Fibrocystic Breasts Uterine Fibroids Depressed Increased Forgetfulness Water Retention Mood Swings Foggy Thinking Estrogen Dominance Stress Decreased Stamina Nervous Headaches Morning Fatigue Anxious Fibromyalgia Sugar Cravings Difficulty Sleeping Irritable Allergies Dizzy Spells Adrenals Cold Body Temperature Hair Dry or Brittle Slow Pulse Rate Infertility Problems Goiter Nails Breaking or Brittle Rapid Heartbeat Hoarseness Constipation Heart Palpitations Thyroid Scalp Hair Loss High Cholesterol Metabolic Syndrome/ High Androgens Acne Weight Gain – Hips Elevated Triglycerides Increased Facial/Body Hair Weight Gain – Waist Decreased Libido Ringing in Ears Decreased Muscle Size Rapid Aging Vaginal Dryness Thinning Skin Aches and Pains Low Estrogen Low Androgens/Other Men’s Hormonal Symptoms: Please review the symptom checklist below and circle any symptoms you are experiencing SYMPTOM HEALTH CONCERN Decreased Urine Flow Weight Gain – Chest / Hips Increased Urinary Urge Weight Gain – Waist Prostate Problems Estrogen Dominance Decreased Libido Elevated Triglycerides Decreased Stamina Increased Forgetfulness Sore Muscles Rapid Aging Decreased Erections High Cholesterol Night Sweats Decreased Muscle Size Increased Joint Pain Thinning Skin Ringing in Ears Hot Flashes Decreased Mental Sharpness Decreased Flexibility Bone Loss Metabolic Syndrome/ Low Androgens Burned Out Feeling Evening Fatigue Depressed Irritable Sugar Cravings Stress Difficulty Sleeping Mental Fatigue Nervous Dizzy Spells Morning Fatigue Apathy Anxious Headaches Adrenals Cold Body Temperature Hair Dry or Brittle Rapid Heartbeat Goiter Constipation Heart Palpitations Hoarseness Slow Pulse Rate Infertility problems Thyroid 515 N. Beaver Street Flagstaff, AZ 86001 (928) 214-7303 Fax: (928) 214-0696 711 N. Beaver Street Flagstaff, AZ 86001 (928) 779-3783 Fax: (928) 473-1082 www.northernaznaturalmedicine.com