Family Information:Marital Status
Spouse's Name: Children? Yes No Number: Age(s):
Present Health Concerns (in order of importance)1. * 2. * 3. * 4. *
Do you need refills on your current medications? Yes No If yes, please list what you need:
Females only (Indicate what is applicable) Interval between periods days.Sexually active: Yes No Date of las pap smear: Date of last mammogram: History of abnormal pap: Yes No Date of last menstrual period: Menopausal Yes No Breastfeeding Yes No History of sexually transmitted diseases Yes No Form of birth control Total pregnancies: Number of miscarriages: Number of abortions: Are you pregnant? Yes No Are you considering pregnancy? Yes No
Nutrition and Diet: Select all that apply
Exercise: Select all that apply
General: Change in appetite C P Chills C P Fatigue C P Fever C P Night Sweats C P Difficulty Falling Asleep C P Difficulty staying sleep C P Weight gain C P Weight Loss C P Allergy:Hives C P Congestion C P Itching C P Watery Eyes C P Ears/Eyes/Nose:decreased hearing C P difficulty swallowing C P Dry mouth C P Ear pain C P Nosebleeds C P Ringing of ears C P Sinusitis C P Endocrine:Cold Intolerance C P Excessive sweating C P Excessive thirst C P Frequent Urination C P Heat Intolerance C P Hair Thinning C P Respiratory:Cough C P Coughing up blood C P Pain with breathing C P Shortness of breath C P Sputum production C P Wheezing C P Cardiac:Chest pain at rest C P Chest pain with exertion C P Cyanosis (Blue Skin) C P Difficulty laying flat C P Irregular heartbeat C P Palpitations C P Gastrointestinal:Abdominal pain C P Blood in stool C P Constipation C P Decreased appetite C P Diarrhea C P Heartburn C P Nausea C P Vomiting C P Gas/bloating C P Female/Male health (as applicable):Breast lump C P Breast Pain C P Nipple discharge C P Heavy menstrual bleeding C P Irregular menses C P Missed periods C P Hot flashes C P Painful intercourse C P Genital infection C P Genital Pain C P Low sex drive C P Erectile trouble C P Genitourinary:Blood in urine C P Difficulty urinating C P Frequent Urination C P Painful Urination C P Frequent UTI's C P Musculoskeletal:Joint pain/stiffness C P Muscle cramps C P Sciatica C P Swollen joints C P TMJ Pain C P Reduced range of motion C P Skin:Acne C P Dry skin C P Rash C P Itching C P Neurological:Balance difficulty C P Difficulty speaking C P Dizziness C P Fainting C P Loss of strength C P Memory Loss C P Seizures C P Psychiatric:Anxiety C P Depressed mood C P Eating disorder C P Mental abuse C P Physical abuse C P Substance abuse C P Suicidal thoughts C P
You are almost done! Lastly, we need your signature for consent for our HIPPA practices, consent to bill your insurance and transparency around our financial practices and our promise to protect your privacy. Want a copy of these? We'd be happy to supply one.
I hereby request and consent to the performance of the following checked specific procedures on me (or on the patient named above for whom I am legally responsible) by the practitioners of Collaborative Natural Health Partners, LLC.
Primary Care, Osteopathic medicine and functional medicine: providing the standard of care for primary medicine while offering natural alternatives when possible.
Common diagnostic procedures: e.g., physical exams, venipuncture, Pap Smears, laboratory
Minor office procedures: e.g., dressing a wound, ear irrigation, suture removal, cryosurgery.
Medicinal use of nutrition: therapeutic nutrition, nutritional supplementation, nutritional consults.
Nutrigenomics: review of genetic information for nutritional purposes. The undersigned acknowledges that Collaborative Natural Health Partners, LLC does not employ any geneticists, and none of the employees of Collaborative Natural Health Partners, LLC should be considered substitutions for geneticists.
Botanical Medicine: botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets, creams, plasters or suppositories.
Homeopathic remedies: the use of highly dilute quantities of naturally occurring plants, animals and minerals to gently stimulate the body’s healing responses.
Lifestyle Counseling and Hygiene: healthy lifestyle classes, diet therapy, promotion of wellness including recommendations for exercise, sleep, stress reduction and balancing of work and social activities.
Physical Medicine: osseous manipulation, soft tissue manipulation, electrotherapies, hydrotherapies, paraffin bath, intersegmental traction, cupping, acupuncture.
Healthy Lifestyle Classes
I understand that results are not guaranteed and I recognize the potential risks and benefits of these procedures as described below:
General Potential risks: allergic reactions to prescribed herbs and supplements, side effects of natural medications, inconvenience of lifestyle changes, injury from venipuncture or procedures, fainting, aggravation of pre-existing symptoms, discomfort, pain, bruising, burns, lightheadedness.
Potential Risks of Accupunture: bruising, numbness or tingling near the needling sites, dizziness or fainting, unusual risks include nerve damage, organ punctures, spontaneous miscarriage and infection.
Potential Risks of Cupping: bruising and scarring.
Potential Risks of Taking Herbs: nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue.
I understand that Collaborative Natural Health Partners, LLC cannot anticipate and explain all risks and complications and I choose to rely on the practitioners of Collaborative Natural Health Partners, LLC to exercise their judgment during the course of the procedures which they believe at the time, based upon the facts they know, is in my best interests.
Potential benefits: restoration of health and the body’s functional 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 the doctor if they know or suspect they are pregnant, as some of the therapies used could present a risk to pregnancy.
I understand that Collaborative Natural Health Partners, LLC will report to me only such information as a reasonably prudent person in my position would consider to be significant.
Alternatives: I understand that the naturopathic physicians are not primary care physicians and the procedures that I will receive at Collaborative Natural Health Partners, LLC are supplementary care to my primary physician or specialist. It has been recommended to me that I consult with a primary care physician and/or specialist to obtain information about conventional medicine treatment alternatives available to me.
With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Collaborative Natural Health Partners, LLC or any of the personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time.
I understand that Collaborative Natural Health Partners, LLC will keep a record of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless it is required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying a fee as permitted under Connecticut law. I understand that my medical record will be kept for a minimum of seven (7), but not more than ten (10) years after the date of my last visit or as otherwise required by Connecticut law. I understand that any questions I have will be answered by the practitioners to the best of their ability.
Your physician is referring you to, or arranging for you to receive services from, a non-participating physician, provider or facility for certain healthcare services. You have the right to receive services at a participating facility or by a participating physician or provider in order to obtain full benefits under your health coverage. If you have questions or would like to locate an in-network physicians provider or facility to provide the service or procedure, please contact your insurance's member service at the telephone number listed on the back of your member ID card.
Referring physician: Collaborative Natural Health Partners, LLC
Type of referral: Non-Par Facility Referring Physician Name: Collaborative Natural Health PartnersNPI #: 1396267126
Non-Participating Facility Name:
Genova, ZRT, Medical Diagnostics, Doctor’s Data, US Biotek, Dutch, ILAIDS, other out of network testsType of Facility: Laboratory ServicesReason for non-par referral: Tests not available through in network lab
To be completed by patient or patient's legal guardian:
By placing my signature on this waiver form below, I acknowledge the following:
I am aware that the non-participating facility/provider that will be involved in my care does not participate with my insuranceI understand that I may be responsible for additional costs for all services provided by the non-participating facility/provider, as specified in my benefit contractI was given an opportunity to contact my insurance before obtaining these services to confirm my benefits for these non-network services and to obtain names of participating facilities and /or participating providers that can provide the recommended service or procedure. I understand that absent special circumstances (e.g., financial hardship), the non-participating facility/ provider is prohibited from waiving copayments, deductibles, coinsurance or other member cost sharing amountsI am voluntarily choosing on behalf of myself or my child/legal guardian to obtain the service or procedure from the non-participating facility and/or physician.