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NEWPATIENTINTAKE
Name:_____________________________________________________________________________________________
DateofBirth:__________________ Age__________________________ Gender_________________________
StreetAddress______________________________________________________________________________________
City____________________________ State__________________________ ZipCode________________________
Phone:(Home)__________________ (Cell)__________________________ (Work)_________________________
HIPPA compliance does not allow for email communication involving personal/identifying information, medical records, health information, or treatment recommendations. In order to communicate with your Provider via email and see medical documents such as lab results and treatment protocols, you will need to enroll in our Patient Portal. Please provide the email that you would like to use for the registration of your portal. E-mailAddress_________________________________________________________ (PLEASE NOTE, you cannot change the email once it has been registered) Sonoran Naturopathic Center may use this email for appointment reminders and other communication not involving personal/medical information YES________NO________ SocialSecurityNumber(usedforinsurancepurposes)______________________________________________________
Pharmacy:_____________________________________Phone:______________________________
Howdidyouhearaboutus?*(Ifsomeonereferredyouhere,pleasenamethemsothatwemaythankthatperson)
*FriendReferral(Pleaseletusknowwhoreferredyoutoouroffice.)___________________________________________________________________________________________________
*SocialMedia(Pleaseindicatewhichversionyouusedtofindoutaboutouroffice)
qFacebook qTwitter qYoutube qOther(Ifotherpleasespecifybelow)
___________________________________________________________________________________________________
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Name:_______________________________________________________
Date:______________________________
EMERGENCYCONTACT:
Name__________________________________________ Phone__________________________________________
Relationshiptoyou__________________________________________________________________________________
Whatareyourmainhealthconcerns?(Pleaselistyourconcernsintheirorderofimportancetoyou.Giveabriefhistoryofwhenitstarted,othertreatmentsordoctors/practitionersyouhaveseen,etc.)
1. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PASTMEDICALHISTORY:
SignificantpreviousDiagnosesorIllnesses:
Majoraccidentsortraumas:
Hospitalizations/Surgeries:(Pleaselistthedate&thenatureofthevisitorprocedure)FamilyHistory(Pleaseindicateifthefollowingfamilymembersarealiveordeceased–listtheirage,healthconcernsand/orcauseofdeath)
Mother:
MaternalGrandmother MaternalGrandfather
Father:
PaternalGrandmother PaternalGrandfather
Siblings:
Children:
Medications/Supplements:(PleaseIncludeDosage&BrandName,ifknown)
Medications(IncludingPrescriptionandOver-the-Counter)
Supplements
Allergies:(IncludeFoodand/orDrugAllergies–pleasealsodescribethetypeofreactionyouhavehad)
Social/LifestyleHistory:
Occupation:
Sleep: HoursPerNight: QualityofSleep: Wakefeelingrested?
EnergyLevel:
Scaleof1-10(10beingthemostenergy)
LivingSituation: MaritalStatus
AlcoholConsumption:
NumberofDrinksperweek:
CigaretteSmoking:(pastorpresent) Amount(packsperday): Duration(inyears):
RecreationalDrugUse:(pastorpresent)
Type DurationandFrequency
Exercise:
Type Duration&Frequency Restrictions(anytypeofactivityorexerciseyouareunabletodo)
StressLevel:
CurrentlevelofSatisfaction/Happinesswithyourlife?
TypicalDiet: Breakfast: Lunch: Dinner: Snacks:
Beverages:(pleasespecifyamountsandtypesofthefollowing)
Caffeine: Water: Juice/Soda,etc:
ENVIRONMENTALHISTORYPleasechecktheboxesbelowifyouhavecurrentorpastexposuretoanyofthefollowing:qDentalAmalgams(silver)
qCommercialhaircoloring
qHomeFragrances(i.e.SentedCandles)
qPerfumes/Colognes
qScentedLotions
qCommercialDryCleaning
qNailorHairSalons Doyouconsumeanyofthefollowing?Ifso,howoften?qRawFish/Sushi
qFarmRaisedFish
qBeef/RedMeat
qTuna qShellfish Home/OfficeEnvironmentqNewPaint
qNewCarpeting
qNewFurniture
qHomeorofficebuiltbefore1978
qComposite/SyntheticWoodFurniture Doyouuseanyofthefollowing?qShowerFilters
qHomeWaterFiltration
qHEPAAirFilters
qBottledWater
qNon-toxicHairandBodyCare
qOrganicFruitsandVegetables
qOrganicDairyProducts qOrganicMeats Whatcityandtownwereyoubornin?
Howlongdidyoulivethere?
Haveyoueverhadajobwhereyouhadknownand/ordocumentedchemicalexposure?
Haveyouhadanyreactionsorknownsensitivitiestochemicals?
Haveyoulivednearanyindustrialplantsorfactories?Ifso,whattypeofindustryandhowlongdidyoulivethere?
Haveyoueverbeentestedforheavymetals,solvents,orotherenvironmentalmedicinepanels?Ifso,werethereanysignificantfindings?
REVIEWOFSYSTEMS:
(Pleasereviewthefollowinglistandchecktheboxtoindicateifyoucurrentlyexperienceorhavepreviouslyexperiencedanyofthefollowingsymptoms.Usethespaceintherightcolumntoelaborate,ifnecessary)
(Checkpositivefindingsandcharttoright) Details/Specifics
General:qHot qCold qChillsqFever qSweats qNightsweatsqWeightloss qWeightgain qFatigueqRestlesslegs qSnoring qDifficultystayingawakeqDifficultyfallingasleepqDifficultystayingasleep
CurrentWeight:_____________________________WeightOneyearago:________________________IdealWeight:_______________________________
Skin,Hair,Nails:qDrySkin qFrequentorEasyBruisingqRashes qHairLossorThinningHairqFungalInfectionsoftheskinornailsqEczema qPoorWoundHealingqPsoriasis qItching qJaundice qBreakingNails
Anyabnormalskinlesions?_____________________Doyouseeadermatologistregularly?____________MostrecentDermatologicalExam:_______________
HEENT:Head:
qHeadache qHistoryofheadinjuryqMigraines
Eyes:
qDoublevision qBlurredVisionqCataracts qVisionchangesqPain qRednessqItching
Mostrecentvisittoeyedoctor?
Wearglassesorcontacts?Ears:
qDischarge qHearingchangesqRingingintheears qPainqDizziness
Nose:qSinusitis qDecreasedsmellqDischarge/mucus qNosebleedsqCongestion qSeasonalallergies
Mouth/Throat:qCankersores qSorethroatsqPersistenthoarsenessqDifficultyswallowingqToothache qBleedinggumsqGingivitis
Mostrecentdentalvisit?Anyfillingsordentures?NECK:qInjuries qMassesqPain qStiffness
CHEST:qAsthma qBronchitisqCOPD qChroniccoughqCoughingupblood qShortnessofbreathqSleepapnea qPain qWheezing qPneumonia
CARDIOVASCULAR:qPalpitations qMurmursqArrhythmias qChestpain/AnginaqCongestiveHeartFailureqClaudication(paininthelegswithexercise) qHeartAttack qCoronaryArteryDisease qCyanosis(bluehandsorfeet)
qDizziness qShortnessofBreathwithexercise qHighBloodPressure qDifficultyBreathingwhilelyingflatqPhlebitis qVaricoseVeins qStrokeorTIA
GASTROINTESTINAL:qConstipation qDiarrheaqBloodinthestool qGallbladderproblemsqNausea qVomiting qGasorBloating qHemorrhoids qUndigestedfoodormucusinthestool qIndigestion qBelching qAcidReflux qUlcers qAbdominalPainorCramping qIrritableBowelSyndrome
BowelMovementfrequency?
Doyouhavetostrainordoyouexperienceanypainwithpassingstool?
MostRecentColonoscopy:
GENITOURINARY:qPainwithUrination qBloodintheurineqFrequentUrination qDischargeqWakingfrequentlyatnighttourinate qChangeinfrequency qDifficultyinitiatingstream qDecreasedforceofurinestreamqIncontinence
qChronicorFrequentUTI's qKidneyStones qInterstitialCystitis
SEXUALHEALTHqGenitalPain qItchingqPainDuringIntercourseqDischarge qDecreasedLibidoqDifficultywitharousal qInabilitytoachieveorgasm
Haveyoueverbeendiagnosedortreatedforan
STD?(pleasespecifywhen&whichSTD)Numberofsexualpartnersinthepastyear:MostrecenttestingforSTD’sMethodofContraception:
BREASTS:
qDischarge qEnlargementqPain qTendernessqPriorsurgeryorbiopsy
MostRecentMammogram:
FEMALE/GYN:
NumberofPregnancies: NumberofLiveBirths: AbortionsorMiscarriages: DateofLastMenstrualPeriod: LengthofCycle:
qDischarge qShort qLongqIrregular qRegular qClotsqPainful qDischarge oFoulOdor
PMSSymptoms: Mensesstartedatage: Mensesstoppedatage: LastPapSmear: HistoryofAbnormalPaps?
GynelocialSurgeriesorProcedures(date&type)
MALE:qProstatitis qLesionsqBenignProstaticHypertrophyqErectileDysfunction qTesticularTrauma
NEUROMUSCULAR:
qNumbness qTinglingqJointPain qArthritisqJointSwelling qMusclePain qSyncope(fainting) qVertigo qWeakness qTremors qPoorBalance qLossofConsciousness
ENDOCRINE:qHeatintolerance qColdintoleranceqIncreasedThirst qIncreasedAppetiteqAnemia qExcessivebruising qEasybleeding qDiabetes qThyroidProblems qFatigue
MENTAL/EMOTIONAL:qDepression qAnxietyqPanicAttacks qBipolarDisorderqPhobias qAnger/Rage qPTSD qSchizophrenia qPoorMemory qBrainFog qBehavioralorConductDisorders qADHD/ADD
Haveyoueverhadsuicidalthoughtsorattemptedsuicide?
Wereyoueveremotionallyorphysicallyabused?
HaveyoueverbeenhospitalizedforPsychiatricReasons?
Pleasecircle,highlight,orindicateanyareasofpain,numbness,tingling,orotherconcerns.Beasspecificanddescriptiveaspossible.
Betterwith:(checkallthatapply)
qHot qCold qMotion qRest qPressure qNopressure
Anythingelsemakeitfeelbetter?
Severity_________ (onascaleof1-10,10beingtheworstpainyou’veeverexperienced)
WorstTimeofDay:qMornings qEvenings qAfternoons qNight-time
AretheseSymptoms:
qConstant qRandom qIncreasinginSeverity
Anyknowntriggers?
CLINICFEEAGREEMENT
PleasereaditemsA-Fcarefullyandinitialwhereindicated.
A. Dr.BrianPopieliscurrentlyclassifiedasoutofnetworkproviderforallinsurancecompanies.InordertopotentiallyhaveinsurancecoverageforourservicesyourinsuranceplanneedstohaveoutofnetworkcoverageandtheOONdeductiblemustbemetbeforereimbursementwillhappen.Billingforlabsishandledbythelab(s)selectedbyyourphysician.Thelab(s)willsubmitchargestoyourinsurancecompanyandcoverageisdeterminedbydeductiblestatusandyourinsuranceplanpolicies.Pleasenote,thatSonoranNaturopathicCenterisnotinvolvedinthelabbilling.Mostinsurancecompanieswillcoveralloraportionofthebillforlabservices.Beawarethatoutofpocketmedicalexpensescanbeusedastaxdeductionsinsomecircumstances.Pleasekeepyourreceiptsaswedonotkeepfinancialrecordsofyourvisits.Wewillnotbeprovidingyearendstatementsfortaxes.________(initial)
B. Dr.Popiel’sfeeforin-officeorphoneconsultationsisbasedontimeandbilledatarateof$250/perhr.There
willbeseparatecostsforcertainprocedures,supplements,IVtherapies,injections,labworkanddiagnostictesting.Followupappointmentswillbebilledatthesameratementionedabove.________(initial)
C. Werequirea24houradvancenoticetocancelappointments.ForallLATEcancels(lessthan24hrnotice)youwill
becharged$25.00.ForallNOSHOWappts,wherenoticehasnotbeenprovided,youwillbecharged$75.00.________(initial)
D. IVTHERAPY
TheIVtherapiesalreadyincludeDr.Popiel’stimeandyouwillnotbebilledforhistimetwice.ThefollowingarethechargesforIV’s.
• Nutritional/Hydration/VitaminCIV’s-$195-$250• DMPSChelation(HeavyMetalsTesting/Removal)-$95• Glutathione(Detoxification)IVPush-$45• IVOZONE-$150-$195• IVPush-$80
IVSAREMADEPRIORTOCLIENTARRIVAL.24HRNOTICEISREQUIREDTOCANCELANIVAPPT.INTHEEVENTOFANOSHOWORLATECANCEL(LESSTHAN24HRNOTICE),CLIENTSWILLBEHELDFINANCIALLYRESPONSBILEFORTHEFULLIVCOST_________(initial)
E. INJECTABLETHERAPIES/OTHER:• BloodDraw-$20• B-12/Iron/Testosteroneinjection-$20-$35• Prolotherapy-$125-$400• InfraredSauna-$25
• Acupuncture-$95(newpatients)$75(followups)• Prolozone-$125-$400• AmnioFix–Costdeterminedbyinjectionsitelocationanddoserequired_________(initial)
F. PAYMENTISDUEATTHETIMEOFSERVICE.Dr.Popielwillbillinsuranceonbehalfofthepatient,butthereisno
guaranteeofinsurancereimbursement,duetothefactthatheisanoutofnetworkprovider._________(initial)
ClientSignature:
Date
BysigningIagreetotheabovetermsasoutlined.
INFORMEDCONSENTWelcometoSonoranNaturopathicCenterandthemedicalpracticeofDr.BrianPopiel.I consent to treatmentandunderstand thatmyphysician is a licensedNaturopathicDoctorwhowill conducta thoroughcase history with me before initiating any treatment protocols. Naturopathic doctors are recognized as primary carephysicians in the stateofArizonawith theability todiagnoseand treatdisease conditions. Naturopathicdoctorsutilizeprinciplesandpracticesthattreatthewholepersonandassistinthebody’sownabilitytoheal. Evaluationanddiagnoseswillbebasedonphysicalexam,specificbloodand/orurinary laboratoryreports. Evaluationofthese laboratory reportsmay be interpreted differently from other practitioners of naturopathic or allopathicmedicine. Treatment protocolsmay ormay not be consistentwithmainstreammedical tests/evaluations and are based on clinicalexperienceandscientific/medicalliterature. Treatmentsmayincludeproceduressuchasbutnotlimitedtonutritionalsupplements,homeopathicmedicines,botanicalmedicines,intravenousvitamin/mineraltherapy,acupuncture,prolotherapyinjections,mesotherapyinjections,triggerpointinjections, and prescriptive medications (including bio-identical hormones). Certain treatments may be deemed“experimental”sincetheFDAhasnotissuedanyguidelinesorstatementsastothesafetyorefficacyofthesetreatments. IunderstandthatmydoctorwillinformmeofthepotentialrisksoftreatmentandansweranyquestionsthatImayhave. Iunderstandthateven“natural”treatmentsmayhavesideeffectsanditismyresponsibilitytoinformmydoctorinatimelymannerofanysideeffectsoradverseeffectsthatImaybeexperiencing. Iwillmakesuretoinformmydoctorofalldietarysupplements,non-prescriptivemedicinesandprescriptivemedicationsthatIamtaking;aswellasupdatinganychangestothislist. IacknowledgethatifIhaveanyquestionsorconcernsaboutmylabevaluationandtreatmentprotocol;Iwilladdressthemwithmydoctorinatimelymanner. Myconsenttotreatmentisvoluntaryandinformed. Iassumefullresponsibilityforcostsregardlessofmyinsurancecoverage;thesecostsmay includeofficevisits/proceduresandlabsnotcoveredbyinsurance,aswellasmedications,andsupplements. HIPPAcompliancedoesnotallowforemailcommunicationinvolvingpersonal/identifyinginformation,medicalrecords,healthinformation,ortreatmentrecommendations.InordertocommunicatewithyourProviderviaemailandseemedicaldocumentssuchaslabresultsandtreatmentprotocols,youwillneedtoenrollinourPatientPortal.Pleaseprovidetheemailthatyouwouldliketousefortheregistrationofyourportal. E-mailAddress_________________________________________________________(PLEASENOTE,youcannotchangetheemailonceithasbeenregistered)SonoranNaturopathicCentermayusethisemailforappointmentremindersandothercommunicationnotinvolvingpersonal/medicalinformationYES________NO________
Signature
Date
PrintName
Doctors’Signature
Date
HIPAAPrivacyAuthorizationForm**AuthorizationforUseorDisclosureofProtectedHealthInformation
(RequiredbytheHealthInsurancePortabilityandAccountabilityAct,45C.F.R.Parts160and164)
1.AuthorizationIauthorize________________________________________(healthcareprovider)touseanddisclosetheprotectedhealthinformationdescribedbelowto______________________________________________(individualseekingtheinformation).2.EffectivePeriodThisauthorizationforreleaseofinformationcoverstheperiodofhealthcarefrom:
a. □______________to______________.
ORb. □allpast,present,andfutureperiods.
3.ExtentofAuthorizationa.□ Iauthorizethereleaseofmycompletehealthrecord(includingrecords
relatingtomentalhealthcare,communicablediseases,HIVorAIDS,andtreatmentofalcoholordrugabuse).
OR
b.□ Iauthorizethereleaseofmycompletehealthrecordwiththeexceptionofthefollowinginformation:□ Mentalhealthrecords□ Communicablediseases(includingHIVandAIDS)□ Alcohol/drugabusetreatment□ Other(pleasespecify):_______________________________________________4.ThismedicalinformationmaybeusedbythepersonIauthorizetoreceivethisinformationformedicaltreatmentorconsultation,billingorclaimspayment,orotherpurposesasImaydirect.5.Thisauthorizationshallbeinforceandeffectuntil___________________(dateorevent),atwhichtimethisauthorizationexpires.
6.IunderstandthatIhavetherighttorevokethisauthorization,inwriting,atanytime.Iunderstandthatarevocationisnoteffectivetotheextentthatanypersonorentityhasalreadyactedinrelianceonmyauthorizationorifmyauthorizationwasobtainedasaconditionofobtaininginsurancecoverageandtheinsurerhasalegalrighttocontestaclaim.7.Iunderstandthatmytreatment,payment,enrollment,oreligibilityforbenefitswillnotbeconditionedonwhetherIsignthisauthorization.8.Iunderstandthatinformationusedordisclosedpursuanttothisauthorizationmaybedisclosedbytherecipientandmaynolongerbeprotectedbyfederalorstatelaw.Signatureofpatientorpersonalrepresentative__________________________________________________________________Printednameofpatientorpersonalrepresentativeandhisorherrelationshiptopatient__________________________________________________________________Date_______/_______/__________