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«NOTE: Naturopathic care is only possible when the physician has a complete picture of the patient physically, mentally, and emotionally. Therefore, ...»

Page 1 of 10

Wellspring Naturopathic Clinic

PATIENT PROFILE

Date________________________

NOTE: Naturopathic care is only possible when the physician has a complete picture of the patient physically,

mentally, and emotionally. Therefore, please take the time to carefully and thoroughly complete this health

history questionnaire. Please print and mark questions you don’t understand with a question mark (?).

Patient Name_______________________________________ Age____ Date of Birth ___/___/_____ Sex: ____ If patient is not of legal age (18): Parent or guardian name ___________________________________________

Address__________________________________ _____City ___________________ State______ Zip_______ Daytime Phone___________________ Evening Phone ___________________Cell Phone_________________

Education____________________________________ Occupation____________________________________

Employer____________________________________________ Full or Part Time ________Retired________ SSN ________/______/_________ Email Address :_______________________________________________

Emergency Contact: _______________________________Relationship____________ Phone:_____________

How did you hear about us? ___________________________________________________________________

Reason for visit today? ______________________________________________________________________

Primary Health Concerns: (In order of importance) 1. _____________________________________________________________________

2. _____________________________________________________________________

3. _____________________________________________________________________

4. _____________________________________________________________________

Page 2 of 10 Medical History The general state of your health has been: Excellent ____Good ___Fair ___Poor____ What childhood illnesses have you had?

Rubella (3-day measles) ____Measles (2-week)____Whooping Cough ____Asthma____ Rheumatic Fever ____Mumps ____ Chickenpox ____ Scarlet Fever ____ Polio ____ Other_______________

What immunizations have you had?

1. _____________________________2.______________________________

3. _____________________________4.______________________________

When and where did you last receive medical or health care?________________________________________

Reason?___________________________________________________________________________________

History of Illness Now Past Never Now Past Never ___ ___ ___ Anemia ___ ___ ___ High blood pressure

–  –  –

What happens when you have an “allergy attack”?

Please List the Medications you are currently taking: (with dosage) 1) 2) 3) 4) 5) Please list the supplements you are taking: (with dosage) 1) 2) 3) 4) 5)

–  –  –

Military Service:

When and where did you serve?

Type of discharge:

Have you traveled outside of the U.S.? When and Where?

Economic Status:

Income Sources___________________________________ Does your income cover your expenses?_________ How often do you drink - wine? __________ beer _________other alcohol__________________________

Do you use tobacco _____ If yes, how much per day?____________ How many years have you smoked_____ Do you use marijuana or other drugs?______ If yes, which and how often______________________________

How many meals do you generally eat per day______, Irregular meals? _______ Number of snacks__________ Where do you usually buy your food? __________________________________________________________

Who cooks the food you eat? __________________________________________________________________

List any foods you exclude from your diet________________________________________________________

List the primary foods included in your diet______________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

List any foods to which you have had a bad reaction________________________________________________

__________________________________________________________________________________________

List foods you crave_________________________________________________________________________

Are you satisfied with your diet as it is now? _______ If no, why not? _________________________________

__________________________________________________________________________________________

What are your hobbies or primary interests?______________________________________________________

__________________________________________________________________________________________

Do you exercise_______ What form(s)_______________________________________ How often__________ Page 5 of 10

–  –  –

We welcome you as a patient and appreciate the opportunity to provide you with our professional services. The information that follows is designed to answer most of the questions that our patients ask, and to serve as a policy statement.





OFFICE HOURS: Monday through Friday, 8:30 AM – 5:00 PM (Subject to seasonal variability) APPOINTMENTS: We try to see all patients on an appointment basis. Appointments should be made as far in advance as possible. On occasion, emergencies may prevent us from keeping an appointment; in this event you will be notified as soon as possible. If you miss an appointment or fail to cancel at least 24 hours before the scheduled time of the appointment, you will be charged at one half the hourly rate.

FOLLOW-UP VISITS, TELEPHONE CONSULTATIONS AND E-MAIL: Any call or correspondence that requires new instruction, case analysis, or prescription will be subject to a consultation charge. The fee is prorated according to the consultation time.

RESEARCH: Whenever possible the clinic manager will assist you on research requests. However, requests for more involved research by Helen Healy, N.D. may also be subject to consultation fees.

–  –  –

PAYMENTS: Payment is due at the time of the visit. Acceptable forms of payment are cash, check, Visa, MasterCard, and Discover.

INSURANCE: If you have insurance that covers naturopathic out-patient services, we prefer that you make payment at the time of the visit and handle your own reimbursement with your insurance company. There is a $14.00 charge for time spent on insurance documentation.

PAST DUE ACCOUNTS: A monthly finance charge of 1.5% is assessed to all balances 30 days past the due date (60 days). Past due accounts with no payment activity for 90 days are subject to possible third party collection efforts.

CHANGE OF ADDRESS: We request that you keep your file current by informing us of any change of address or telephone numbers.

We look forward to working with you.

I have read this policy statement and understand its contents.

Signature______________________________________________

Date__________________________________________________

–  –  –

I, (print name) ___________________________________________, UNDERSTAND THAT:

1. Helen C. Healy, ND is fully credentialed and registered to practice naturopathic medicine in the State of Minnesota, pursuant to Minnesota Statute 147E. Her active registration number is 1007.

2. Dr. Healy received her four-year naturopathic medical training at the National College of Naturopathic Medicine in Portland, Oregon, and graduated in 1983.

3. Dr. Healy passed all the Oregon Board examinations and received her Oregon license in 1983 to practice as a naturopathic doctor. She maintains this license as well.

4. Dr. Healy, to the best of her ability, will present treatment facts and options accurately, and will make recommendations according to standards of good naturopathic medical practice.

5. The scope of practice of a registered naturopathic doctor in the State of Minnesota includes, but is not limited to, the following services: (a) ordering, administering, prescribing, or dispensing for preventive and therapeutic purposes: food, nutraceuticals, vitamins, minerals, amino acids, enzymes, botanicals and their extracts, botanical medicines, herbal remedies, homeopathic medicines, dietary supplements and nonprescription drugs as defined by the federal Food, Drug, and Cosmetic Act, glandular, protomorphogens, lifestyle counseling, hypnotherapy, biofeedback, dietary therapy, electrotherapy, galvanic therapy, oxygen, therapeutic devices, barrier devices for contraception, and minor office procedures, including obtaining specimens to assess and treat disease; (b) performing or ordering physical examinations and physiological functions tests; (c) ordering clinical laboratory tests and performing waived tests as defined by the United States Food and Drug Administration Clinical Laboratory Improvement Amendments of 1988 (CLIA);(d) referring a patient for diagnostic imaging including x-ray, CT scan, MRI, ultrasound, mammogram, and bone densitometry to an appropriately licensed health care professional to conduct the test and interpret the results; (e) prescribing nonprescription medications and therapeutic devices or ordering noninvasive diagnostic procedures commonly used by physicians in general practice; (f) prescribing or performing naturopathic physical medicine; and, (g) admitting patients to a hospital if the naturopathic doctor meets the hospital’s governing body requirements regarding credentialing and privileging process.

6. A registered naturopathic doctor is not allowed to: (a) administer therapeutic ionizing radiation or radioactive substances; (b) administer general or spinal anesthesia; (c) prescribe, dispense, or administer legend drugs or controlled substances including chemotherapeutic substances; (d) perform or induce abortions; or (e) perform surgical procedures using a laser device or perform surgical procedures beyond superficial tissue.

7. A registered naturopathic doctor is not allowed to practice or claim to practice as a medical doctor, surgeon, osteopath, dentist, podiatrist, optometrist, psychologist, advanced practice professional nurse, physician assistant, chiropractor, physical therapist, acupuncturist, dietitian, nutritionist, or any other health care professional, unless the registered naturopathic doctor also holds the appropriate license or registration for the health care practice profession.

8. Potential risks include allergic reactions to prescribed herbs and supplements, side effects of natural medications, and/or the inconvenience of lifestyle changes.

9. All female patients must alert Dr. Healy if they know or suspect that they are pregnant as some of the therapies used could present a risk to the pregnancy.

10. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Helen C. Healy, ND or any of her 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 have read and understand the statements above. Dated: ________________________________________

–  –  –

From the East, take 94 West:

Take 94 West to 35E South Take the Victoria Exit, turn left. The next street is Jefferson Ave, turn right.

Office building is approximately ½ block on the right-905 Jefferson, Ste 202

From the West, take 94 East:

Take the Lexington exit; turn right (South);

Travel South crossing over Summit, Grand and St. Clair (theses are all stoplights);

The next stoplight is Jefferson, turn left.

Go down the hill under the 35E overpass;

Office building is on the left – 905 Jefferson, Suite 202

From the South, take 35E North:

Take the Randolph exit, turn right;

Go 2 blocks to Milton, turn left;

Go 4 blocks to Jefferson, turn right; office building is on the left, 905 Jefferson, Ste 202

From the North, take 35E South:

Take 35E into St Paul, take the Victoria exit, turn left;

At the first stop sign, turn right (Jefferson); office building is on the right;

905 Jefferson, Suite 202



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