Health Restore Program - New Patient Application for Care

New Patient Application for Care

Our mission is to empower individuals to regain control of their health and lives.
I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I authorize Abundant Health Physical Medicine to release my personal medical information to me.
Patient Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *
Please enter a valid phone number.
Mobile Phone Number *
Please enter a valid phone number.
Work Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Date Of Birth *

Month Day Year
Date
How did you hear about us? *
Occupation

History of Complaint *

	In order of importance, list the health problems you are most interested in correcting:	How long have you noticed these problems?
1.
2.
3.
4.

6. How much sleep do you get each night on average (number of hours)? *
7. Do you have any food restrictions? *
8. Do you smoke, drink, or use recreational drugs? *
8a. How much, how often?
8b. How much and how often do you drink caffeinated beverages?
9. Please list foods you tend to overeat or crave (Sweets, breads, fatty foods, meats, milk etc.): *
10. Are there foods that you eat on a daily or almost daily basis? *
10a. Do you "miss" these foods if you do not eat them?
11. Write briefly about your weight gain/loss history *
11a. What do you feel triggered your weight fluctuation? (Mark all that apply)

Heredity Stress Eating Habits Boredom Other
11b. Was your weight gain/loss (choose one):

Sudden Gradual Problem since childhood
12. Please list close relatives that have diabetes, heart disease or obesity:
13. What methods have you tried to lose/gain weight?

14. How is your energy level? *
14a. When during the day do you feel your best? *
14b. When during the day do you feel your worst? *
15. Are you happy in your life right now? *
16. What are your main sources of stress? *
17. How do you deal with your stress? *

List ALL allergies/sensitivites to medication, good, and other items here:

	Item you react to:	Reaction
1.
2.
3.

List the prescription drugs you are currently taking (or yo may attach a list):

	Name	Dose (mg or IU)	Times Daily
1.
2.
3.

Optional Attach Medication List Here

Cancel of

List all nutritional supplements (vitamins, herbs, homeopathics, etc.)

	Name	Dose (mg or IU)	Times Daily
1.
2.
3.

This is a confidential record of your medical history and pertinent personal information. The provider(s) reserves the right to discuss this information with medical and allied health professional per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating we may release copies by your verbal request.
Signature

Clear

Informed Consent
Abundant Health Physical Medicine - Informed Consent: REGARDING: Medical Services, Functional Medicine Services, Modalities, and Therapeutic Procedures: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I have been advised that functional medicine, like all forms of health care, holds certain risks. Treatment objectives, as well as the risks associated with functional medicine and all other procedures provided at Abundant Health Physical Medicine have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. I have reviewed and accepted informed consent.
Please sign below: *

Clear

HIPAA Personal Health Information Release
I, Type Full Name* herby authorize Abundant Health Physical Medicine to discuss with and/or release information to the following people concerning my appointments, insurance, billing, and health treatment rendered.
Spouse

First Name Last Name
Significant Other

First Name Last Name
Parent/Legal Guardian

First Name Last Name
Child or Children

First Name Last Name
Any Specified Person

First Name Last Name
INFORMATION IS NOT TO BE DISCUSSED WITH OR RELEASED TO ANYONE
Restrictions *
Messages: (Please Call) *

My home My work My mobile phone Other
If unable to reach me: *

You may leave a detailed message Please leave a message asking me to return your call Other
I understand I may terminate this consent at any time by giving written notice to Abundant Health Physical Medicine. Any changes to this form will require a new consent to be completed, signed and dated.
Signature *

Clear
Should be Empty:

	Now	Past
Is your life satisfactory
Is your life boring
Is your life demanding
Is your life unsatisfactory
Do you worry over home life
Do you worry over marriage
Do you worry over children
Do you worry over job
Do you worry over income
Do you worry over money problems
Do you often feel depressed
Do you often have anxiety
Do you often have irrational fears
Do you often feel upset
Do you often feel things go wrong
Do you often feel shy
Do you often cry
Do you often feel inferior
Have you seriously considered suicide
Have you attempted suicide

New Patient Application for Care

18. Next to each questions assign a number between 0 and 10. You should assign values as follows:

Provider will calculate the total here: ________

Informed Consent

HIPAA Personal Health Information Release