Identifying Data

Bothell Natural Medicine

Medical History Today’s Date:______IDENTIFYING DATA: Name: ______Birth date: ______Address: ______City: ______State: ____ Zip: ______Phone number: ______Gender: Male Female Other______Email: ______Preferred Contact Method: Email Phone Due to doctor’s inability to guarantee confidentiality, emails are not HIPAA-compliant. Initial if you grant your permission for email communications: ______Occupation(s):______Current employment: Full Time Part Time Unemployed Retired Disabled Emergency contact: (Name, Relationship, Phone) Check if ok to share details with this person ______Were you referred? Yes No If yes, by whom?______

DEMOGRAPHIC INFORMATION: Marital status: Single Married Partner Widowed Divorced Separated Living Situation: alone with spouse partner with parent(s) with children with friend(s) Domicile: house mobile home apartment institution homeless Other______Household members: first name, age and relationship ______

GENERAL INFORMATION: Do you have medical insurance? Yes No Primary care physician or clinic name:______Phone:______Address ______City ______Zip ______Specialist / Consultant, Name and Location:______Specialist / Consultant, Name and Location:______

Chief Complaint(s): What is the main problem for which you seek evaluation and treatment today? ______

Current Prescription Medications: List names, dosage, frequency of use, and how long 1. ______Dosage ______Frequency ______Duration ______2. ______Dosage ______Frequency ______Duration ______3. ______Dosage ______Frequency ______Duration ______4. ______Dosage ______Frequency ______Duration ______

Over-the-Counter and Herbal Medications: List products that you use currently. ______

ALLERGIES: Medication Intolerance: Yes No Explain: ______Food Allergies: Yes No Explain: ______

OTHER DRUG USE: Tobacco: Yes No Cigarettes / day ______Years of smoking ______Quit date ______Alcohol: Yes No Drinks / day or week ______Years of drinking _____ Quit date ______Caffeine: Yes No Cups / day [Coffee __Tea __Soda __] Years of drinking __ Quit date _____

1 [Type text] [Type text] [Type text] Hallucinogens/Cocaine/Other drugs: Yes No Type(s) used______FEMALE REPRODUCTIVE HISTORY (females only): Number of pregnancies _____ Number of children ____ Children's present ages______Are you pregnant now? Yes No Are you planning a pregnancy? Yes No Are you currently breastfeeding? Yes No

PAST SURGICAL HISTORY: Please list surgeries and approximate dates. ______

Conditions: Check [X] conditions you currently have or have had this past year. AIDS Glaucoma HIV Positive Pacemaker Thyroid Issues Alcoholism Goiter Kidney Disease Pneumonia Tonsillitis Anemia Gonorrhea Liver Disease Polio Tuberculosis Anorexia Gout Measles Prostate Typhoid Appendicitis Heart Migraines Problem Ulcers Arthritis Disease Miscarriage Psychiatric Vaginal Infections Asthma Hepatitis Mononucleosis Care Venereal Disease Bleeding Hernia Multiple Sclerosis Rheumatic Disorders Herpes Mumps Fever Breast Lump High Scarlet Fever

Cholesterol Stroke Suicide Attempt

NATUROPATHIC CONSENT TO TREATMENT FORM 2 Bothell Natural Medicine

Naturopathic Medicine is the treatment and prevention of diseases by natural means. Naturopaths assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non- invasive techniques are generally used in order to stimulate the body’s inherent healing capacity.

A number of different approaches are used. Diet and nutritional supplements, botanical medicine, homeopathy, hydrotherapy and lifestyle counseling are the mainstays of naturopathic medicine.

Individual diets and nutritional supplements are recommended to address deficiencies, treat disease processes and promote health. The benefits include increased energy, optimized gastrointestinal function, improved immunity and general well being.

Botanical Medicine is a plant-based medicine using herbal teas, tinctures, capsules and other forms of herbal preparations to assist in the recovery from injury and disease. These compounds are also used to boost the body’s immune system and prevent disease.

Homeopathy is a form of medicine based on the Law of Similars- that is, the use of extremely diluted doses of plant, animal or mineral origins to stimulate the body’s ability to heal itself. Homeopathy is a powerful tool and affects healing on a physical and emotional level.

Hydrotherapy refers to the use of hot and cold water applications to improve circulation and stimulate the immune system.

As naturopathic medicine is a holistic approach to health, lifestyle is considered relevant to most health problems. I will try to help you to identify risk factors and make recommendations to help you optimize your physical, mental and emotional environment.

I will take a thorough case history, do a screening physical examination and develop a treatment plan.

Even the gentlest therapies have their complications in certain physiological conditions such as: pregnancy and lactation, in very young children, or in those with multiple medications. Some therapies must be used with caution in certain diseases such as diabetes, heart, liver or kidney disease. It is very important that you inform me immediately of any disease process that you are suffering from or if you are taking any medications. If you are pregnant, suspect you are pregnant or you are breast-feeding please inform me as well.

There are some slight health risks to treatment by naturopathic medicine. These include but are not limited to: Temporary aggravation of pre-existing symptoms Allergic reactions to herbs or supplements Bruising from intramuscular injection, mesotherapy and neural therapy Aggravation from homeopathic remedy

A record will be kept of health services provided to you. This record will be kept confidential and will not be released to others unless you give your consent or the law requires it. You may look at your medical record at any time and can request a copy of it by paying the appropriate fee for copying charges.

I ______understand that my naturopathic doctor will answer any questions to the best of her ability. I understand that results are not guaranteed. I do not expect my naturopath to be able to anticipate and explain all risks and complications. I will rely on my naturopathic doctor to exercise judgment during the course of the procedure which they feel at that time is in my best interests based on the facts then known. With this knowledge, I voluntarily consent to diagnostic and therapeutic procedures mentioned above, except for: (please list any exceptions): ______

I understand this consent form to cover the entire course of my treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. Patient Name: (please print) ______

Signature of Patient or Guardian: ______Date:______