• Integrative Health Consultation Intake Form & Health History

    Please complete this intake form and health history as thoroughly as possible. The form is used to learn about your unique healthcare needs. Print all information and mark anything you don't understand with a question mark. Add additional sheets as needed, and bring any lab tests or healthcare records that you want to have reviewed.
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.

  • Health History

    FOR THE FOLLOWING SECTIONS, PLEASE CHECK: Y = YES or N = NO
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  • Symptoms

    For each of the following please check Y, P, or N. Y = Yes, a condition you have now. P = A condition you have had in the Past. N = Never had. Fill in any spaces that ask for dates or numbers, if they apply.
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  • Females Only

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  • Menstrual Cycle

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  • Pregnancy, Fertility and Conception

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  • Males Only

    For each of the following please check Y, P, or N. Y = Yes, a condition you have now. P = A condition you have had in the Past. N = Never had.
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  • Symptoms Continued

    Y = Yes, a condition you have now. P = A condition you have had in the Past. N = Never had.
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  • Lifestyle Habits

  • Sleep Habits

  • Family History

    Family history is an important component of an integrative healthcare consultation. Information should be provided on biological (genetically related) relatives only. Do not provide information about adopted, foster or step-relatives. Indicate maternal half-brothers and half-sisters (same mother, different father) with 1/2 M in Age & Other column. Indicate paternal half-brothers and half-sisters (same father, different mother) with 1/2 P in Age & Other column. Write age (or age of death), as well as other conditions in Age & Other column. If there is history of cancer, write that in the Cancer column. Check Deceased if appropriate. Use additional rows in chart as needed.

  • Dietary Information

  • How often do you consume each of the following per day or per week? Indicate the amount used:

  • Medications and Supplements

    A complete list of medications and supplements is an important component of an integrative healthcare consultation. Please include 1) Name of Prescription or Supplement, 2) Dose, 3) How Often you take it, 4) How Long you have been taking it, and 5) Who started you on it (a healthcare professional or yourself).
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  • Permission and Authorization Form

  • Please read before signing:


    I specifically authorize the integrative pharmacist to perform an Integrative Health Consultation and to guide me in developing a natural, complementary health improvement program for me which may include dietary guidelines, nutritional supplements, lifestyle changes, etc. in order to assist me in improving my health, and not for the treatment, or "cure" of any disease.


    I understand that the Integrative Health Consultation is an educational consultation designed to increase my personal understanding of the body's physical and nutritional needs, and to help me understand that deficiencies or imbalances in these areas could cause or contribute to a suboptimum state of health. I understand that the Integrative Health Consultation is not a method for "diagnosing" or "treating" of any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated. The healthcare professional will not be held responsible for any pre-existing medically diagnosed conditions, nor for any medical diagnosis.

     

    I understand that there are many alternatives to the complementary health improvement program that will be discussed in the Integrative Health Consultation, and that I should consult with my primary care physician if I have any concerns about a medical condition.


    No promise or guarantee has been made regarding the results of Integrative Health Consultation or any natural health, nutritional or dietary programs recommended, but rather I understand that Integrative Health Consultation is an educational consultation which can be used as an aid to determining possible nutritional imbalances, so that a complementary health improvement program can be developed for the purpose of bringing about a more optimal state of health.

     

    I understand and agree that an integrative Health Consultation may not be billed to medical insurance but may qualify for Health Savings Account (HSA) deductions if my policy covers non-physician health consultations. I understand that I will be provided with a copy of a super bill that I can submit to my HAS, if appropriate.

     

     

    I clearly understand and agree that all services rendered to me are charged directly to me at $120 for the initial consultation, $275 for a complete follow up consultation that I am personally responsible for payment at the time the services are provided. Phone calls, texts and emails will be billed at $150/hr with a $50 minimum. I agree to provide a credit card number at the time the initial consultation is scheduled. Any preparation time will be billed to this card if the appointment is cancelled without rescheduling.

     

    I have read and understand the foregoing. By signing below, I agree to the terms set forth above. This permission & authorization form applies to subsequent visits and consultations.

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