Health History Form Fill Please bring all prescription medication and supplements, along with pertinent lab work to appointment. Health History Summary Date(Required) MM slash DD slash YYYY Name(Required) First Last Age(Required)BirthDate(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone Number(Required)Alt. numberEmail(Required) Occupation(Required)Employer(Required)How did you hear about this office?(Required)If Internet, which website? We’d love to know the exact website please or whom we can thank for referring you. Last physician or health practitioner seen? And When?(Required)Why/Abnormal Results?(Required)When was your last lab blood test & Why?(Required)Have you ever seen a naturopathic physician before? If yes, when?(Required)Any allergies to drugs, foods, herbs, animals or other? Explain.(Required)***BRING COPIES OF RECENT LAB TESTING WITH YOU TO THE APPOINTMENT**List all prescription/pharmaceutical medication you take, the amount taken, for how long and why?(Required)List all over the counter medication (like Tylenol, Benadryl), all supplements, herbal (botanical) preparations, homeopathics and the like that you take regularly (most days), including the amount taken and why you are taking it, and if applicable, who suggested it? Bringing the bottles with you is more important than writing them down. Send over label information if appt is virtual.(Required)YOUR CURRENT HEALTH CONCERNWhat is the main reason for your visit? Please be as detailed as possible. How long has this troubled you? When did you first notice the condition? What have you tried already for treatment? What has helped? What has made it worse? Is follow up required with your medical team? Use the reverse of this sheet if necessary.(Required)Are there any other health concerns? List in order of importance:YOUR HEALTH HISTORYAny recent vaccines?Recent travel outside USA?Any recent surgeries?Hospitalization? Be specificRelevant Family History?When was your last visit to the dentist?(Required)Health of mouth?(Required)When was you last visit to the eye doctor?(Required)Any changes?The general state of your health is:(Required) Excellent Good Average Fair Poor METABOLIC ASSESSMENT FORM Give a number that reflects the last year. 0 – never 1 - rare 2 - often 3 - alwaysCategory 1Lower abdomen pain(Required) 0 – never 1 - rare 2 - often 3 - always Diarrhea(Required) 0 – never 1 - rare 2 - often 3 - always Constipation(Required) 0 – never 1 - rare 2 - often 3 - always More than 3 bowel movements a day(Required) 0 – never 1 - rare 2 - often 3 - always Itchy skin(Required) 0 – never 1 - rare 2 - often 3 - always Heartburn(Required) 0 – never 1 - rare 2 - often 3 - always Need acid reducing medication(Required) 0 – never 1 - rare 2 - often 3 - always Belch(Required) 0 – never 1 - rare 2 - often 3 - always Fart(Required) 0 – never 1 - rare 2 - often 3 - always Feel full easily(Required) 0 – never 1 - rare 2 - often 3 - always Lack of appetite(Required) 0 – never 1 - rare 2 - often 3 - always Bloating(Required) 0 – never 1 - rare 2 - often 3 - always Offensive breath or Body odor(Required) 0 – never 1 - rare 2 - often 3 - always Indigestion(Required) 0 – never 1 - rare 2 - often 3 - always Pain under ribs(Required) 0 – never 1 - rare 2 - often 3 - always Undigested bits of food in stool(Required) 0 – never 1 - rare 2 - often 3 - always Nausea(Required) 0 – never 1 - rare 2 - often 3 - always Burning pain(Required) 0 – never 1 - rare 2 - often 3 - always Feel hungry often(Required) 0 – never 1 - rare 2 - often 3 - always High fat foods cause distress(Required) 0 – never 1 - rare 2 - often 3 - always Blood in stool(Required) 0 – never 1 - rare 2 - often 3 - always How often do you have a bowel movement?(Required) 0 – never 1 - rare 2 - often 3 - always Do you have a gall bladder?(Required) Yes No Had a colonoscopy?(Required) Yes No ResultsLast antibiotic for any reason and why?CommentsCategory 2Frequent urination(Required) 0 – never 1 - rare 2 - often 3 - always Increased thirst and appetite(Required) 0 – never 1 - rare 2 - often 3 - always Difficulty losing weight(Required) 0 – never 1 - rare 2 - often 3 - always Itchy skin or Rash(Required) 0 – never 1 - rare 2 - often 3 - always Random fevers(Required) 0 – never 1 - rare 2 - often 3 - always Crave sweets(Required) 0 – never 1 - rare 2 - often 3 - always Unexplained weight loss(Required) 0 – never 1 - rare 2 - often 3 - always Feel sick(Required) 0 – never 1 - rare 2 - often 3 - always When was last cold/flu?(Required)CommentsCategory 3Fatigue?(Required) Yes No Wake up tired even with 6 or more hours of sleep?(Required) Yes No Must have caffeine to start day?(Required) Yes No How much and what kind?Dizzy(Required) 0 – never 1 - rare 2 - often 3 - always Low blood pressure(Required) 0 – never 1 - rare 2 - often 3 - always High blood pressure(Required) 0 – never 1 - rare 2 - often 3 - always Palpitations(Required) 0 – never 1 - rare 2 - often 3 - always Crave salt(Required) 0 – never 1 - rare 2 - often 3 - always Feel cold often(Required) 0 – never 1 - rare 2 - often 3 - always Hard to gain weight(Required) 0 – never 1 - rare 2 - often 3 - always Irritable if miss meals(Required) 0 – never 1 - rare 2 - often 3 - always Sweat easily(Required) 0 – never 1 - rare 2 - often 3 - always Stress often hard to manage(Required) 0 – never 1 - rare 2 - often 3 - always Panic attacks(Required) 0 – never 1 - rare 2 - often 3 - always Feel anxious(Required) 0 – never 1 - rare 2 - often 3 - always Shortness of breath(Required) 0 – never 1 - rare 2 - often 3 - always Easily agitated or upset(Required) 0 – never 1 - rare 2 - often 3 - always Nervous or emotional(Required) 0 – never 1 - rare 2 - often 3 - always Troubling thoughts(Required) 0 – never 1 - rare 2 - often 3 - always Depression(Required) 0 – never 1 - rare 2 - often 3 - always Stay asleep(Required) 0 – never 1 - rare 2 - often 3 - always Hard to wake up(Required) 0 – never 1 - rare 2 - often 3 - always Hard to go sleep(Required) 0 – never 1 - rare 2 - often 3 - always Quality of sleep is (good, poor)(Required) Good Poor Average Hours of Sleep a Night(Required)Is this a new pattern? If yes, explain.(Required)CommentsCategory 4 (women only)Last menses?Pregnant Yes No Abnormal Yes No Last Pap test?Ever abnormal Yes No Last mammogram?Abnormal Yes No Length of menstrual flow and how often (how many days in between)Irregular menses (if applicable)Heavy flow 0 – never 1 - rare 2 - often 3 - always Painful menses 0 – never 1 - rare 2 - often 3 - always Breast or other pelvic pain 0 – never 1 - rare 2 - often 3 - always Acne breakouts 0 – never 1 - rare 2 - often 3 - always Hot flashes 0 – never 1 - rare 2 - often 3 - always Diminished sex drive 0 – never 1 - rare 2 - often 3 - always Mood swings 0 – never 1 - rare 2 - often 3 - always Vaginal dryness or pain 0 – never 1 - rare 2 - often 3 - always CommentsCategory 5 (men only)Lack of energy 0 – never 1 - rare 2 - often 3 - always Hard to concentrate 0 – never 1 - rare 2 - often 3 - always Loss of muscle mass 0 – never 1 - rare 2 - often 3 - always Decrease in erections 0 – never 1 - rare 2 - often 3 - always Getting ‘man boobs’ or weight gain in belly 0 – never 1 - rare 2 - often 3 - always Pain when urinating 0 – never 1 - rare 2 - often 3 - always Feel like sitting on a ball 0 – never 1 - rare 2 - often 3 - always Involuntary discharge from penis 0 – never 1 - rare 2 - often 3 - always Urinary dribbling 0 – never 1 - rare 2 - often 3 - always How often up at night to urinate? 0 – never 1 - rare 2 - often 3 - always Last PSA?Ever abnormal Yes No If yes, comment below:GENERAL & PERSONAL LIFESTYLEWhat is your current approximate weight?(Required)Wt. year ago?(Required)Height?(Required)How many and what kind of alcoholic beverages do you consume per week?(Required)How many caffeinated beverages (coffee, tea, soda) do you consume per day?(Required)Cigarettes or other nicotine per day(Required)Recreational drugs?(Required)How much water do you drink in a typical day? (ounces/liters) and what kind of water do drink (tap, filter, bottle )(Required)Do you exercise? What kind/type? Frequency(Required)Spray herbicides or insecticides?(Required) Yes No Do you or other household member work in the presence of toxic fumes or chemicals? Mold?(Required)If yes, how frequently?What kind of home do you live in (house, apt.) How long?(Required)Are you bothered by certain odors that others don’t seem to mind? Like what (such as perfume, gasoline, etc.)?(Required)Who lives in your home with you?(Required)Pets?(Required) Yes No If yes, what typeDo you enjoy your work?(Required) Yes No Is it a desk job? Do you work from home? Explain:(Required)What are a few of your hobbies?(Required)Do you have a religious or spiritual practice?(Required)Rate your stress levels on a scale of 1-10 during an average week:(Required) 1 2 3 4 5 6 7 8 9 10 Please describe your typical reaction to stress.(Required)How do you relieve stress?(Required)DIET AND EXERCISEDo you eat breakfast?(Required) Yes No What is a typical breakfast for you? Please describe some of your most common choices(Required)What is a typical lunch for you? Please describe some of your most common choices.(Required)What is a typical dinner for you? Please describe some of your most common choices.(Required)Do you snack?(Required) Yes No When?What are your typical choices?How many times do you eat out per week & where do you go ?(Required)What do you chose from menu?(Required)CommentsHow committed are you to your health care goals?(Required)INFORMED CONSENT Please sign and date belowI hereby request and consent to the performance of naturopathic modalities and procedures by Dr. Veronica E. Hayduk, naturopathic doctor, even though the State of Maryland currently does not recognize Naturopathic doctors as primary care providers but only as Allied Health Professionals. I understand that Dr. Hayduk is licensed and registered in the State of Maryland to practice naturopathic medicine and have had the opportunity to discuss with her the nature and intent of my visit. I understand and am informed that, as in the tradition of medicine, in the practice of naturopathy there may be some risks to treatment, most common are allergic reactions to certain supplements, botanical/herbs and homeopathic preparations. I understand that this risk is minor and do not expect the doctor to be able to anticipate or explain all of the risks and complications, and I wish to rely on the doctor to exercise her best judgment during the course of the procedure and treatment which the doctor feels at the time, based upon the facts then known, is in my best interest. The focus of naturopathic care is to alleviate the underlying condition that brings on illness rather than the treatment of symptoms. While I may experience some immediate improvement from the use of herbs, diet changes, homeopathic remedies and other naturopathic methods, I understand that the most effective results occur when I make a long-term commitment to rebuild my health with the assistance of Dr. Hayduk and other members of my health team. I also understand that Dr. Hayduk does not offer after-hours services or provide any hospital-based/emergency care. I also understand that Dr. Hayduk will not be able to prescribe pharmaceutical medications or manage these medications but can send me a referral for such treatment. I have read, or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent and by signing below agree to the above and below named naturopathic procedures and treatments as deemed appropriate by Dr. Veronica Hayduk and Second Nature Health, LLC. I also agree to the following policies of Second Nature Health, LLC. A copy of this agreement will be in the new patient folder that I receive at my first appointment with Dr. Hayduk. I may also keep an electronic copy of this form for my records. Privacy will always remain confidential, unless I authorize the release of information in writing or by court order. I also understand that Dr. Hayduk may send communication to me through E-mail, I will notify the office immediately if this is not my preference. I will not email the doctor regarding emergencies and am aware that time-sensitive matters are not appropriate for email communication. Unless otherwise required by law, my record is the physical property of Dr. Hayduk, but the information belongs to me. I have the right to request a restriction on certain uses and disclosures of my information and request amendments to my health record. I may also request a copy of my medical records at any time and a small fee may apply. This organization is required to maintain privacy of my health care information. Second Nature Health is required by law to maintain the privacy & security of my protected health information. They will let me know promptly if a breach occurs, yet Dr. Hayduk does NOT maintain electronic medical charting. They will not use or share my information without my consent first. Email to communicate with the office is preferred even though Dr. Hayduk is aware that email communication is not 100% reliable or secure, but I acknowledge that the doctor and her staff assure me that they make every effort to protect my privacy. Dr. Hayduk and her staff will try to respond to email messages within 72 hours but there is no way to guarantee that will occur due to many legitimate reasons like misaddressed email, server down and/or power outages. I also agree to limit my email to clarify a current treatment plan or symptoms relating to current treatment plan. Charges are based on time to answer, which will be discussed before Dr. Hayduk answers the email. I also understand that phone calls from Dr. Hayduk are billable, and rates will be discussed before she answers. Current rates are also listed on the website. New health complaints will require an appointment, which is billable, at same hourly rate as any other office visit. All scheduled phone or office appointments, unless directly notified otherwise, are billable and payment is due at the time of service. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek treatment with Dr. Hayduk. I will continue to be monitored by a primary care physician. Any naturopathic treatment suggestions made should not replace the care and/or advice of my primary care health team. This notice is provided to you pursuant to Maryland law. Dr. Hayduk is a registered and licensed Doctor of Naturopathic Medicine (ND) but not a licensed Medical Doctor (MD/DO). Therefore, she does not practice," the application of scientific principles to prevent, diagnosis and treat physical and mental diseases, disorders, its conditions or to safeguard the life and health of any pregnant woman & infant through pregnancy and parturition." I will let Dr. Hayduk know immediately if I become pregnant or planning on conceiving; or if I become pregnant during treatment. Also, I will notify the office either in person, via phone or e-mail when I wish to terminate my care with Dr. Hayduk and Second Nature Health, LLC. Dr. Hayduk also reserves the right to discontinue this agreement at any time and will do her best to find appropriate care for my continued treatment. I understand that charges fees are due and payable on the same date that services are renderecl including all tests/ and agree to pay all such incurred in full immediately upon presentation of the appropriate statement unless other arrangements have been made in advance. Any and all lab testing must be completed within 90 days of purchase date. I also understand that in Maryland, most insurance companies do not cover naturopathic services/ but that Dr. Hayduk's office would provide me with a 'Superbill' for my submittal for reimbursement, if I chose to do so. I will NOT submit to Medicare/Medicaid. They will not reimburse and as a result this office could be penalized. Second Nature Health will not provide an insurance claim form (HFCA 1500) nor will it respond to requests for additionalinformation from insurance companies. Flexible spending and health savings accounts are accepted but I understand it's my responsibility to fill out any 'Letter of Medical Necessity' and have Dr. Hayduk sign and code it only. I understand there will be a nominal filling fee if I elect Dr. Hayduk to fill it out on my behalf. Returns must be authorized first and within three days of receipt, no return on probiotics, homeopathies or topicals. I agree to a service charge of $100 for any amount that is unpaid past 30 days and/or for returned checks or unapproved credit cards. Appropriate interest will be also added as lawful and necessary. I also agree to pay $100 for giving less than 24 hours' notice of changing or missing/no-showing an appointment. If I am late arriving to my appointment, I understand my time will not be extended and I also agree that my appointment will not be held for longer than 15 minutes after its start time. My appointment will be cancelled if I arrive too late and I will be billed.Signature(Required)Date(Required) MM slash DD slash YYYY
