Adult Intake Paperwork

Adult Intake Paperwork
Sex
Full Legal Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Preferred name/nickname *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Work Phone *

Area Code Phone Number
Preferred Method of Contact *
Email *
example@example.com
Social Security #
Date of Birth *

Month Day Year
Date
Your Employer *
Your Occupation *
Whom to contact in case of emergency? (please list relation and best contact number) *
Please provide your insurance information below:
Primary Insurance Company: *
Group #: *
Member ID#: *
Relationship to Subscriber: *
Claims Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Subscriber Name (if other than patient): *

First Name Last Name
DOB: *

Month Day Year
Date
Secondary Insurance Company: *
Group #: *
Member ID #: *
Relationship to Subscriber: *
Claims Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Subscriber Name (if other than patient): *

First Name Last Name
DOB: *

Month Day Year
Date
Please list what brought you in today in order of priority: *

Personal Medical History
Who is your Primary Care Physician (name and title)? *
What is your Primary Care Physician’s Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please complete the attached records release form if applicable so that we may view lab results and other treatment details for better continuity of care.
Please list any allergies to medicine or foods and include the type of reaction (for example, anaphylaxis, stomach upset, rash, etc.): *
Please list your preferred pharmacy: *

Please list pharmaceutical medicines you take, along with the dose: *

Medication name

Dose

Frequency (how often you take medication)

Please list any health supplements you take, along with the dose: *

Health Supplement name

Dose

Frequency (how often you take medication)

Please list any major illnesses, accidents or hospitalizations (excluding routine childbirth) including dates: *
Date of your last physical exam: *

Month Day Year
Date
Any abnormal results? *
Date of your last blood work: *

Month Day Year
Date
Any abnormal results? *
Do you have any problems with any of the following body systems? If yes, please describe on the text box provided. The items in parentheses are only examples, please include your own/additional diagnoses as pertinent:
Constitutional: (fever/chills, weight gain or loss, weakness, fatigue) *
Head, Ears, Eyes, Nose, Throat: (headache, vision problems, hearing problems, difficulty swallowing, sinus infections) *
Cardiovascular: (heart palpitations, chest pain, cold hands and feet, varicose veins) *
Respiratory: (allergies, asthma, chronic cough) *
Digestive: (GERD, heartburn, nausea, constipation, diarrhea, gas, bloating) *
Endocrine: (thyroid, PCOS, endometriosis) *
Nervous system: (dizziness, imbalance, slow thinking, poor memory) *
Skin/hair/nails: (psoriasis, eczema, acne) *
Musculoskeletal: (chronic back or limb pain) *
Psychological: (anxiety, depression) *
Urinary: (difficulty urinating, painful urination, incontinence) *
Male reproductive history: (erectile dysfunction, testicular mass, BPH) *
Female reproductive history: (please include date of last menstrual period, date/age onset of menopause, pregnancy and birth history) *
Dental Issues: *

Family Medical History
Do any members of your immediate family suffer from any of the following health conditions? If so, please explain in the text areas provided. Please specify which family member:
Heart Disease/High Blood Pressure/High Cholesterol: *
Diabetes: *
Cancer: Type? *
Alcoholism/Drug Addiction: *
Mental Health Disorder: Type? *
Asthma/Respiratory Issues: *
COPD: *
Stroke: *
Liver Disease: *
Kidney Disease: *
Digestive Issue or Diagnosis: *
Arthritis: *
Vision Problems: *
Any other serious health conditions? *

Lifestyle
Do you use any of the following? Please indicate form and quantity per day or week.
Tobacco: *
Alcohol: *
Caffeine: *
Diet: Do you follow a specific diet? Do you have any food allergies or sensitivities, or dietary restrictions? If so, please describe here: *

Daily Diet *

Please Provide examples of typical meals

Breakfast

Lunch

Dinner

Snacks

How much water do you drink in a day? *
Do you Exercise? Please list types and amount per week. *
Do you have any problems with sleep? How many hours do you typically sleep in a night? *
Please list your health goals in order by priority *

Terms of Consent for Care
I... *

First Name Last Name
...hereby authorize Dr. Marinaro/Dr. Forman to perform the following specific procedures as necessary to facilitate my diagnosis and treatment:

Common diagnostic procedures: e.g., venipuncture, radiology, laboratory, X-ray

Minor office procedures: e.g., cleaning, dressing a wound, ear lavage, skin scraping

Medical use of nutrition: therapeutic nutrition, nutritional supplementation, and intramuscular vitamin injections.

Botanical medicine: plant substances may be prescribed as teas, alcohol-based tinctures, glycerites, capsules, tablets, creams or suppositories

Craniosacral Therapy, Visceral Manipulation: gentle forms of bodywork used to address back pain and other musculoskeletal complaints, headaches and organ dysfunction

Counseling: utilization of mental health counseling and techniques

Medical use of ozone: therapeutic ozone gas administered to isolated parts of the body, combined with depuration in an ozone sauna and injected subcutaneously or intramuscularly to address chronic pain and infections

Hydrotherapy

I recognize the potential risk and benefits of these procedures as described below:

Potential risks: allergic reactions to prescribed herbs and supplements, side effects of medications or vaccinations, aggravation of pre-existing symptoms, discomfort, pain, infection, burns, nausea, light headedness, inconvenience of lifestyle changes, injury from injections, venipuncture or procedures. Please notify Dr. Marinaro/ Dr. Forman if you experience any symptoms which may be secondary to the above procedures.

Potential benefits: restoration of health and the body’s maximal functional capacity without the use of drugs or surgery, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or it’s progression.

Notice to Pregnant Women: All female patients must alert the doctor if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by physician, or any 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 a record will be kept 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 the appropriate fee. I understand that my medical record will be kept for a minimum of three, but no more than ten years after the last day of my visit. I understand that information from my medical record may be analyzed for research purposes, and that my identity will be protected and kept confidential. I understand that any questions I have will be answered by my practitioner to the best of his/her ability.

I understand that all sales of goods and services are final.
Signature *

Clear
Date *

Month Day Year
Date

New England Naturopathic Health Policies

Please initial in the following boxes:
I understand that payment of consultation fees, lab fees, supplements and any other services are due at the time of service. *
I understand that phone consultations and phone lab reviews with Dr. Marinaro/Dr. Forman will be billed at the same rate as an in-office visit *
I understand that I may message Dr. Marinaro’s/Dr. Forman’s support staff through Patient Fusion. Email is not an acceptable communication format due to confidentiality concerns. *
I understand that any supplements purchased at NENH cannot be returned once opened. *
I understand that if I am more than ten minutes late for an appointment. I may not be seen and may be assessed a cancellation fee. *
I understand that should I miss an appointment or cancel with less than a twenty-four hours’ notice, I will be assessed a cancellation fee. *
I understand it is my responsibility to ensure insurance coverage for both office visits and labs ordered by a Naturopathic Doctor. Please refer to the Insurance Benefits Verification form for additional information. *
I understand that Naturopathic doctors in the state of Maine serve as specialists and not primary care doctors. For this reason, I understand that it is my responsibility to have a PCP, or to be actively looking to establish care with a PCP, prior to establishing care at New England Naturopathic Health. *

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Previous Name

First Name Last Name
I request and authorize...
*
... to release healthcare information of the patient named above to:
Office Name *
Fax Number
Requesting documentation regarding:

Healthcare information relating to the following treatment, condition, or dates: Labs and Imaging only Other:
Specify treatment, condition, or dates
Specify other
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. *

Yes No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. *

Yes No
Patient's Signature *

Clear
Date signed *

Month Day Year
Date

Full Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #

Area Code Phone Number
Date of Birth

Month Day Year
Date
Insured Information
Full Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone #

Area Code Phone Number
Company
Company Name
Date of Birth

Month Day Year
Date
Relationship to Insured
Insurance Company Information
Name
Phone #

Area Code Phone Number
ID #
Group #
NENH patients, it is your responsibility to be aware of your insurance benefits, including coverage, co-pay, deductible, and maximums. Please call the number listed on the back of your insurance card and fill out the information below prior to your first appointment.

Questions For Your Insurance
1. Name of Insurance Representative
2. Date of call

Month Day Year
Date
3. Beginning Date of Coverage

Month Day Year
Date
Ending Date

Month Day Year
Date
4. Does my insurance cover Naturopathic Doctors? Yes / No
5. Is New England Naturopathic Health a covered provider under my plan? Yes / No
6. Do I need a referral from my primary care physician to see an ND? Yes / No
7. What is my co-pay or % covered for:
a. Specialty Office Visits?
b. Lab Work?
c. Diagnostic Imaging?
8. What is my yearly maximum for naturopathic office visits?
9. What is my yearly maximum for naturopathic lab work/diagnostic imaging?
10. Do I have an annual deductible? Yes / No
Amount met to date:
11. Is my deductible based on calendar year?
12. Are office visits or labs subject to my deductible?
13. Please list your preferred lab below: *

I acknowledge that the above listed coverage information is valid and correct. I understand that benefit verification is not a guarantee of coverage by my insurance company, and that I am financially responsible for all services rendered to me by any provider at New England Naturopathic Health. I authorize release of information in my medical history to my insurance company and assign all benefits for unpaid services to New England Naturopathic Health. This authorization will be considered valid unless revoked by me in writing.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Adult Intake Paperwork

Personal Medical History

Family Medical History

Lifestyle

Global Health

Terms of Consent for Care

New England Naturopathic Health Policies

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Insured Information

Insurance Company Information

Questions For Your Insurance