New Patient Information - The Center for Natural Health · 2019-08-07 · ©The Center for Natural Health, LLC 163 Main Street, Westport, CT 06880 (203) 864-5762 Dr. Salvatore Fiorentino

©The Center for Natural Health, LLC

163 Main Street, Westport, CT 06880(203) 864-5762www.TheCenterForNaturalHealth.comDr. Salvatore Fiorentino

New Patient Information: (Please Print)

Name: ______________________________________________ Date of Birth: ___________________ Age: _______ Gender: M F

Address (Street): ___________________________________________________________________________________________________

City: ____________________________________________________ State: ____________________ Zip Code: _____________________

Occupation: _________________________________________________________________________________________________________

Phone (h): ________________________________ (c): ________________________________ (w): ________________________________

Preferred Method of Contact: ____________________________________________________________________________________

Email: ________________________________________________________________________________________________________________

If Minor, Name of Parent/Guardian: ____________________________________________________________________________

How did you hear about us? Who can we thank for the referral? __________________________________________

_________________________________________________________________________________________________________________________

EMERGENCY CONTACT (Name): __________________________________________________________________________________

Relationship to you: ________________________________________________________________________________________________

Phone (h): ________________________________ (c): ________________________________ (w): ________________________________

Primary Care Physician (Name & Phone #): ___________________________________________________________________

Name of Health Insurance Company: ___________________________________________________________________________

Does Your Health Ins. Co. Cover Out-of-Network Doctors? Example, PPO or POS: _______________________

I authorize The Center for Natural Health to call and/or leave a message on the following:

Home Phone: ________________________________________________________ Leave a message on this line: Yes No

Cell Phone: ___________________________________________________________ Leave a message on this line: Yes No

Office Phone: ________________________________________________________ Leave a message on this line: Yes No

Email: ______________________________________________________________________________ Leave a message: Yes No

Signature: ____________________________________ Print:___________________________________ Date: _____________________

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The Center for Natural Health 163 Main Street, Westport, CT 06880

Phone: (203) 864-5762 Fax: (203) 441-7009

Dr. Salvatore Fiorentino Naturopathic Physician

at ElixirSpa



Health Goals: ___________________________________________________________________________________________________

Are you interested in any specific therapies? Circle or write in any that you are interested in below:

Nutritional Counseling Hydrotherapy Homeopathy Radio Frequency Sessions Alternative Laboratory Testing

Physical Medicine Mercury/Toxic Metals Detox Acupuncture Whatever the doctor thinks is best

How much effort are you willing to put into feeling better? (Circle)

NO EFFORT 0 1 2 3 4 5 6 7 8 9 10 WHATEVER IS NEEDED

Continue to the Next Page →

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PERSONAL MEDICAL HISTORY

List your CHIEF (main) complaint: 1.________________________________2.______________________________

To help us evaluate you better, please place a CHECK MARK next to all the symptoms that you CURRENTLY are

experiencing, and/or those that have occurred in the PAST. If only part of the symptoms applies, ‘CIRCLE’ that particular

symptom(s).

NOW PAST EYES

Near or farsightedness

blurred or failing vision

dry, burning or itching eyes

eyes water excessively

eyes sensitive to light

night blindness

bloodshot or puffy eyes

other:

NOW PAST EARS

Earaches

noises or ringing in ears

ear discharges

loss of hearing

lots of wax

other:

NOW PAST NOSE & THROAT

hay fever, sinusitis, runny nose

nosebleeds

cracks in corners of mouth

dry or chapped lips

sore throats or tonsillitis

clear throat often

sore, red or cracked tongue

cold sores or herpes

inability to smell or taste

lots of cavities

bleeding gums

hoarseness

Root Canals or Dental Implants

Amalgam/Silver Fillings in teeth

NOW PAST GENERAL SYMPTOMS

tired, weak, lack of energy

depression, melancholy, moodiness

worry, anxiety, nervousness, irritability

sleeplessness or sleep too much

frequent colds or other illness

headaches

don’t sweat enough

sweat too much

night sweats

dizziness, fainting, convulsions

loss or gain of weight

other:

NOW PAST SKIN & HAIR

acne or pimples

skin rashes

hives

stretch marks

skin ulcers or Sores

dryness roughness or scaling skin,

scalp, elbows, knees, feet, around nose, ears, eyebrows, etc.

hair loss or thinning

dry, coarse hair or split ends

bruise easily

nails weak, ridged or split easily

brown spots or bronzing on skin

moles, warts or skin tags

sunburn easily

cuts heal slowly or scar badly

flush easily

numb hands or feet or tingling

feet burn, athletes foot

other:

NOW PAST MALE

prostate problems

difficulty or unusual urination

discomfort or pain in genital area

difficulty getting or maintaining erection

NOW PAST MALE

diminished sexual desire

excessive sexual desire

other:

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NOW PAST MUSCULO-SKELETAL

muscle pain or stiffness

swollen, painful or stiff joints

bone pains

painful feet, ankles or calves

tremors or twitches

loss of strength

hernia

muscle wasting

other:

NOW PAST CARDIOVASCULAR

heart beats fast or irregularly

tightness in chest

discomfort at high altitude

dizzy or weak upon standing

swollen feet, ankles or legs

cold hands or feet

hands or feet turn blue

blue fingernails

leg pain when walking

varicose veins

tendency to anemia

high blood pressure

low blood pressure

other:

NOW PAST URINARY

difficulty urinating

urinate frequently at night

bedwetting

incomplete urination

pain when urinating

bladder infections

kidney infections

kidney stones

lower back pain

other:

NOW PAST RESPIRATORY

cough frequently

spitting up mucous or blood

difficulty breathing

shortness of breath on exertion

chest pain

Ever Diagnosed with Sleep Apnea

other:

NOW PAST GASTROINTESTINAL

loss of appetite

gagging, difficulty swallowing

nausea or vomiting

bad breath

metallic or bitter taste in mouth

food cravings

can’t eat fats

heartburn

indigestion

heaviness after eating

belching or gas

bloating

stomach or abdomen tender/pain

symptoms relieved by eating

symptoms worse by eating

avoid certain foods

diarrhea or loose stool

constipation

change in bowel movements

light colored or greasy stool

dark stools or blood in stool

feeling of incomplete evacuation

undigested food in stool

foul odor of stool or gas

hemorrhoids

headache, dizziness or irritability when meal skipped

NOW PAST FEMALE irregular menstruation

pain prior to or with periods

depressed, tense, or irritable around periods

painful or swollen breasts

lumps in breasts

discharge from breasts

symptoms occur in a monthly pattern

pain, discomfort or itching in genital area

Fibroids, Ovarian Cysts, PCOS, Endometr.

other:

NOW PAST FEMALE hot flashes

diminished sexual desire

excessive sexual desire

difficulty having orgasm

inability to conceive

number of pregnancies

number of children

miscarriages or abortions

vaginal discharge



1. When was your last known menses (period): _________________________________________________________________________.

2. How many days does it usually last: ____________________________________________________________________________________.

3. What is the total length of your cycle: __________________________________________________________________________________.

4. Are you currently pregnant or trying to get pregnant? ______________________________________________________________.

5. Number of pregnancies: _________________________________. 6. Number of children: __________________________________.

7. Date of last PAP Smear? ___________________________. 8. Have you ever had an abnormal PAP Smear? ____________.

9. Do you use birth control? _______________________. 10. If so, what method of birth control? ______________________.

11. For how long have you used birth control (if applicable)? ________________________________________________________.

12. How would you describe your diet (circle all that apply)?

Vegan Vegetarian Pescetariana Paleolithic Gluten-Free Dairy-Free Kosher Standard America

13. List below any foods that you tend to eat, as well as the beverages that you drink. Please be

specific. For example, if you tend to eat chicken, is it breaded? If so, what type of bread crumb is being used?

List any snacks that you eat, such as fruits, snack bars, nuts, seeds, etc. List any beverages that you consume,

including soda, fruit juices, shakes (what’s in the shake?), etc. Thank you for taking the time to list these items.

This is very important information because it can be significant when determining specific obstacles that may

be preventing you from healing. This will be explained to you in more detail during your office visit. If you

need more room, kindly attach a separate page to this form.

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

___________________________________ ___________________________________ ___________________________________

14. Please give an example of what you eat and drink on a typical day:

Breakfast: __________________________________________________________________________________________________________________

Lunch: _______________________________________________________________________________________________________________________

Dinner: ______________________________________________________________________________________________________________________

Snack: _______________________________________________________________________________________________________________________

Beverage: ___________________________________________________________________________________________________________________

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15. Do you exercise? ______________________________ 16. How many days per week? __________________________

17. Do you lift weights? ____________________________ 18. Do you Walk? Jog? Run? _____________________________

19. When you do exercise? And, how long are your sessions? __________________________________________________

20. Do you have any activity restrictions? __________________________________________________________________________

21. Relationship status & living situation? _________________________________________________________________________

22. What do you do for fun? __________________________________________________________________________________________

23. How would you describe your mood? __________________________________________________________________________

24. Do you have any known allergies? Medications (please list all)? __________________________________ ___________________________________.

___________________________________ ___________________________________ ___________________________________,

___________________________________ ___________________________________ ___________________________________,

Foods:

___________________________________ ___________________________________ ___________________________________,

___________________________________ ___________________________________ ___________________________________,

___________________________________ ___________________________________ ___________________________________,

___________________________________ ___________________________________ ___________________________________,

Other:

___________________________________ ___________________________________ ___________________________________,

___________________________________ ___________________________________ ___________________________________,

25. Do you currently use any of the following? Y (Yes) or N (No) Have used in the past?

______ Cigarettes/Tobacco ______ Pack per week _______ # of years

______ Coffee or Black Tea ______ Cups per day _______ Yes or No

______ Alcohol (beer, wine, etc.) ______ Times per day _______ For how long (years?)

______ Marijuana ______ Times per day _______ Yes or No

______ Other Recreational Drugs ______ Times per day _______ Yes or No

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26. Please list if you take any of the following:

Prescription Medication: Dosage: Vitamins and Mineral: Dosage:

1. ________________________________ __________________ 1._________________________________ ___________________

2.________________________________ ___________________ 2._________________________________ ___________________

3. _______________________________ ___________________ 3._________________________________ ___________________

4. _______________________________ ___________________ 4._________________________________ ___________________

5.________________________________ ___________________ 5._________________________________ ___________________

6.________________________________ ___________________ 6._________________________________ ___________________

7.________________________________ ___________________ 7._________________________________ ___________________

Over –The – Counter Medications: Botanicals / Herbs: Dosage:

1.___________________________________________________ 1._________________________________ ___________________

2.___________________________________________________ 2._________________________________ ___________________

3.___________________________________________________ 3._________________________________ ___________________

4.___________________________________________________ 4._________________________________ ___________________

5.___________________________________________________ 5._________________________________ ___________________

6.___________________________________________________ 6._________________________________ ___________________

7. ___________________________________________________ 7._________________________________ ___________________

27. Have you ever had any vaccinations? _________________________________________________________________

28. Have you had the Hepatitis B vaccinations? __________________. If so, When? _______________________

29. Please list if you ever been hospitalized, had any surgeries, serious illnesses, accidents:

List Dates, and What or How it occurred (if applicable):

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

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Lyme disease and/or Co-infections section:

1. Have you ever been bitten by a tick? ___________________ 2. If so, when?_________________________________________________

3. Have you ever been tested for Lyme disease? ____________________________________________________________________________

4. If yes, when? __________________________________________________________________________________________________________________

5. Which lab(s) were used (ex. Quest, Labcorp, IGeneX, Galaxy, etc.? ______________________________________________________

6. Which lab(s) was/were used? ______________________________________________________________________________________________

7. When was your official diagnosis (if this applies)? ________________________________________________________________________

8. Did you get tested for any of the Co-infections, ex. Babesia, Bartonella, etc.? __________________________________________

9. If yes, when? __________________________________________________________________________________________________________________

10. Did your test results indicate you had Lyme disease and/or Co-infections? __________________________________________

11. Which lab(s) were used (ex. Quest, LabCorp, IGeneX, Galaxy, etc.? _____________________________________________________

12. When was your official diagnosis (if this applies)? ______________________________________________________________________

13. Did you start on any treatment plans for Lyme disease and/or Co-infections? ______________________________________

14. If so, which antibiotics have you used in the past, or are still using? And for how long did you use each of them?

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

15. Have you been treated through alternative medicine(s)? If so, which alternative therapies did you use? And,

for how long did you treat with each approximately?

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

16. Have you tried Acupuncture, Far-Infrared Sauna Detox, Rife Machine, etc.? __________________________________________

17. If yes to the above question, which one(s) have you tried? _____________________________________________________________

____________________________________________________________________________________________________________________________________

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ENVIRONMENTAL HISTORY

Questions:

Answers:

1. Recent Insect bite(s)?

2. Water Source at home?

3. Is the place where you live new

(within the last 5 years) or Older

(over 20 years old)?

4. Heating source at home (oil, gas,

electric?

5. Does your house/apartment use

forced air or baseboard to circulate

the heat around living area?

6. Do you have carpets (especially new

carpets) in your home (If So, in what

rooms)?

7. Do you know if your plumbing uses

plastic or copper piper?

8. Do you use pesticides (kills insects)

and/or herbicide (kills plants) in

your home?

9. Have you recently painted

anywhere in your home (over the

last year)? If so, did you use No VOC

paints? Low VOC paints? Or you

don’t know?

10. Have you ever had Botox injected in

your body?

If so, do you still have it done?

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FAMILY HISTORY

23. Has a blood relative ever had any of the following?

Which Relative(s)? Details:

Autoimmune Disorder

Ex. MS, Lupus,

Arthritis etc.

Lyme disease

Stroke

Epilepsy

Migraines

Thyroid Disease

Cancer

Hepatitis

Tuberculosis

Diabetes

Heart Disease

High Blood Pressure

Gallbladder Disease

Allergies/Hay Fever

Asthma

Kidney Disease

Mental Illness

Suicide

Osteoporosis

Alcoholism/Addition

Panic Attacks

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CONSENT TO TREATMENT AND ACKNOWLEDGEMENT I, __________________________________________________, as a patient, have the right to be informed about my condition and recommended care. This disclosure’s purpose is to help me become better informed so that I may make the decision to give, or withhold, my consent to undergo care, having had the opportunity to discuss the potential benefits, risks, and hazards involved. A naturopathic physician/doctor (N.D.) is trained as a physician specializing in natural and preventive medicine and is recognized as such by medical licensing laws in the state of Connecticut. In order for Connecticut to issue a naturopathic medical license, the physician must have graduated from a four-year, graduate level naturopathic medical college and successfully completed both the National and the Connecticut Naturopathic Physicians Licensing Exams. Dr. Fiorentino is a licensed naturopathic physician in the state of Connecticut. I understand that I have the right to ask questions and discuss to my satisfaction with The Center for Natural Health, LLC and Dr. Fiorentino regarding the following: (1) my suspected diagnosis or condition, (2) the nature, purpose and potential benefits of the proposed care, (3) the inherent risks, complications, potential hazards, or side effects of treatment or procedure, (4) the probability or likelihood of success, (5) the reasonable available alternatives to the proposed treatment or procedure, and (6) the possible consequence if treatment or advice is not followed and/or nothing is done. I,__________________________________________________, hereby authorize the doctor(s) of The Center for Natural Health, LLC and Dr. Salvatore Fiorentino, ND to perform the following specific procedures as necessary to facilitate my diagnosis, treatment, and/or sessions. Procedures include, but are not limited to, the following: (1) Intake of present illness and medical history (2) Common diagnostic procedures: may include, but not limited to, laboratory evaluation of blood, urine, stool, hair, saliva, and physical exam. (3) Minor office procedures: e.g., ear cleaning, nasosympatico. (4) Therapeutic use of Nutrition and Dietary advice: therapeutic nutrition/use of foods, diet plans, and nutritional supplementation. (5) Botanical Medicine: therapeutic substances, including plant, mineral and animal materials given in the form of teas, pills/tablets, capsules, powders, and tinctures which may contain alcohol, topical creams, pastes, plasters, washes, suppositories, or other forms. (6) Homeopathic medicine/remedies: often highly diluted quantities of naturally occurring substances/elements to gently stimulate the body’s healing processes, given orally or topically. (7) Naturopathic Hydrotherapy: the therapeutic use of electromagnetic therapies, of hot and cold water applications, thermal or cryo-applications to stimulate healing. (8) Counseling and stress management and the ordering of lab procedures: including, but not limited to, imagery (including X-Rays, Ultrasound, Thermal Imaging, and other imaging), visualization and breathing exercises for improved lifestyle strategies and wellness. (9) Naturopathic soft tissue Manipulation: including, but not limited to, massage, myofascial release, and cranio-sacral therapy. (10) Naturopathic Physical Manipulation: specific manipulation of muscles and joints or soft tissue. (11) Radio Frequencies Sessions: sessions consist of radio frequencies through either contact method, plasma tube method, or both.

Please initial each page: _____________ Date: ______________

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I understand, recognize and am informed that in the practice of Naturopathic Medicine there are benefits and risks with evaluation and treatment, including, but not limited to, the following: Potential risks: sensitivities and/or allergic reactions to prescribed botanicals/herbs and/or nutritional supplements; sensitivities, incompatibilities, and/or reactions to prescribed botanicals/herbs and/or nutritional supplements when used in conjunction with other undisclosed prescriptions and/or over-the-counter medications; pain, discomfort, minor bruising, discoloration, and/or emotional upset from soft tissue manipulation; and an aggravation of preexisting symptoms, any reactions to radio frequencies sessions, as well as healing reaction as defined below, inconvenience of lifestyle changes, or procedures. Healing Reaction: Natural healing may occasionally generate a “healing reaction.” If this is anticipated, we will offer you specific information about this phenomenon. Generally, this will occur as a flu-like state with fever or a worsening of symptoms for a few days. It can also, however, be different than this and may require expert attention and guidance. 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 pregnant women: all female patients must alert Dr. Fiorentino if they know or suspect that they are pregnant, since some of the therapies could present a risk to the pregnancy. Notice to individuals with bleeding disorders, cancer, pace makers, electronic pumps, , and any internal metal devices -staples – screws – etc. for your safety, it is important to alert Dr. Fiorentino of these conditions immediately. I have been informed of and understand the following: (1) the treatment or therapies rendered or recommended by Dr. Fiorentino may be different than those usually offered by a medical doctor or other licensed healthcare practitioner; (2) Dr. Fiorentino is not a medical or osteopathic physician (M.D. or D.O.); since he is not licensed to practice those forms of medicine, I understand that Dr. Fiorentino may refer me to a medical doctor for diagnostic procedures, as well as for conditions requiring conventional medication; (3) Dr. Fiorentino’s care does not replace the care of my primary care physician, and his recommendations will be complementary to my conventional care; (4) Dr. Fiorentino will not suggest or recommend that I refrain from seeking or following the advice of another licensed healthcare professional; and (5) Dr. Fiorentino is not a psychologist or psychiatrist; his counseling services are intended for improving lifestyle strategies and promoting wellness. I hereby request and voluntarily consent to examination and treatment with Naturopathic Medicine by Dr. Salvatore Fiorentino. I understand that unanticipated risks and complications can occur in treatment, and I wish to rely on Dr. Fiorentino to exercise all judgment during the course of treatment, based on the known facts. I understand that it is my responsibility to request that Dr. Fiorentino explain therapies and procedures to my satisfaction. I further acknowledge that no guarantees have been made to me concerning the results intended from the treatment by the doctor(s) or staff of The Center for Natural Health. By signing below, I acknowledge that I have been given ample opportunity to read this form or that it has been read to me. I understand the above and give my oral and written consent to the evaluation and treatment. I intend for this consent form to cover the entire course of treatments for my present condition and any future condition for which I seek treatment. Print Patient Name ______________________________________________ Date ______________________________

Signature of Patient/Guardian _____________________________________ Relationship to Patient: ______________


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NOTICE OF PRIVACY PRACTICE

To our patients: This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

We realize these laws are complicated, but we must provide you with the following information:

The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies which are authorized by law to collect information.

2. Lawsuits and similar proceedings in response to a court administrative order.

3. If required to do so by a law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to prevent the threat.

5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

6. To federal officials for intelligence and national security activities authorized by law.

7. To correctional institutions or law enforcement officials, if you are an inmate or under the custody of a law enforcement official.

8. For Workers’ Compensation and similar programs.

Your rights regarding your health information:

1. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have a right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to: The Center for Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838.


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4. Note: We must respond to this request within 30 days.

5. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to The Center for Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838. You must provide us with a reason which supports your request for amendment.

Note: We must respond within 60 days. The Privacy Officer or the patient’s doctor will usually do this. If the doctor believes the information is complete and accurate, the doctor can refuse to make any changes.

6. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact the front desk receptionist/office manager.

7. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Dr. Fiorentino at The Center for Natural Health, LLC, P.O. Box 413, Greens Farms, CT 06838. Complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received the Notice of Privacy Practices and I have been provided an opportunity to view it. Name: __________________________________________________________ Birthdate: _______________________________________ Signature: _____________________________________________________ Date: ______________________________________________


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Documents

New Patient Information - The Center for Natural Health · 2019-08-07 · ©The Center for Natural Health, LLC 163 Main Street, Westport, CT 06880 (203) 864-5762 Dr. Salvatore Fiorentino