Multi-Child New Patient Questionnaire

Welcome to Healing Family Functional Medicine

This questionnaire was designed to effectively evaluate patients, create personalized care plans, and track superior health outcomes over time. Depending on your answers, this questionnaire is 9 to 14 pages long and will ask questions from conception to now. You can save your progress at any time. Before getting started, we recommend having digital copies of your insurance card and pertinent medical records, bottles/labels of medications/supplements, and contact information for your primary care physician or referring physician. Having these items ready will allow for a quick and easy experience. Please read each question thoroughly and answer to the best of your ability.
Parent/Guardian Information
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about us?
Parent/Legal Guardian 1
Parent/Legal Guardian 2
For all virtual visits (excluding group health), we will send a text message after your visit to collect payment. Please specify which parent/legal guardian this text should go to:
If "other", please provide the name and mobile phone number for the individual you wish to send text payment notifications:
How many children under 18 will be patients of Healing Family Functional Medicine?

Billing Policy

Healing Family Functional Medicine does not accept any form of medical insurance including Medicare or Medicaid. However, we can provide you with an itemized superbill containing ICD-10 diagnostic codes and CPT procedure codes at the end of your consultation if requested. You can file this with your insurance company to request reimbursement. Reimbursement is not guaranteed and is dependent on your insurance plan/deductible. We do not assist with insurance reimbursement or prior authorization outside of providing you with the superbill. If applicable, you can use your flexible spending accounts (FSA) and health savings accounts (HSA) for our services. A letter of medical necessity for FSA/HSA can be provided to you upon request. Generally, we will try to use your insurance plan for lab tests and prescription medications when possible. It is the responsibility of the patient to check for insurance coverage for labs when applicable. We can provide a letter of medical necessity for labs, but we do not perform prior authorization. Supplements through Fullscript are not billable to insurance. We do not perform prior authorizations for supplements. We can provide a letter of medical necessity for supplements upon request if you wish to send this to your insurance company to request reimbursement, or for your flexible spending account.
I agree to the billing policy and terms
Please upload your insurance card(s)

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Privacy Policy

HEALING FAMILY FUNCTIONAL MEDICINE, LLC Policy and Procedure HIPAA/PRIVACY Notice of Privacy Practices Effective 1/5/2023
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorized Representative Name

First NameLast Name
Authorized representative signature

Ohio HIPAA Privacy Authorization Form

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** The purpose of this form is to improve care coordination for patients across multiple providers by making it easier to securely share protected health information. This allows you to specify what medical practitioners/practices you wish to share information with, for how long you wish to approve this action, and what information can/cannot be shared.
Authorization: I authorize Healing Family Functional Medicine to use and disclose the protected health information described below to:
Effective Period: This authorization for release of information covers the period of health care from:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Until:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
OR:
3) I authorize the release of my complete health record including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse
OR- I authorize the release of my complete health record with the exception of the following information:
If "other", please specify:
4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
5. This authorization shall be in force and effect until the date indicated below, at which time this authorization expires:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Name of authorized representative:

First NameLast Name
Signature

Informed Consent: Diagnosis & Treatment

The intention of this consent form is to help patients, clients and authorized representatives become better informed so that they may give or withhold consent to undergo diagnosis and treatment after having an opportunity to discuss health concerns, including potential benefits and risk, and treatment alternatives. I (Patient or authorized guardian or representative, will now be referred as “patient or representative”), acknowledge the opportunity to read and inquire about this consent and all the items addressed herein and hereby authorize Seema M. Patel, MD, MPH and staff (hereafter referred to as clinician), in accordance and within the scope and limits of their clinical license to perform or recommend any of the following procedures and or treatments:
Please mark the items you agree to:
Signature of authorized representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Functional Medicine Lab Testing

The purpose of functional medicine laboratory testing in our office is to evaluate nutrition, biochemical, and or physiological imbalance and to determine the need for medical referral and treatment. These lab tests are not intended to DIAGNOSE disease. This office uses conventional lab tests as well as Functional Medicine lab testing. Functional Medicine assessment is designed to assist your doctor in finding the underlying causes of your condition. Functional Medicine has evolved through the efforts of scientists and clinicians in the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine and a wide array of scientific disciplines. Functional Medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships. Other healthcare providers may or may not agree with the necessity for –or our interpretation of—these tests. If you have any questions, please discuss with your physician/provider.
I understand and agree to the terms
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Is there anything else you would like us to know?
Please upload any medical records pertinent to your visit (PDF Format preferred)

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Should be Empty:

Rows	Excellent	Very good	Good	Fair	Poor
In general, how would you rate your health?
In general, how would you rate your quality of life?
In general, how would you rate your physical health?
In general, how would you rate your mental health, including mood and your ability to think?
In general, how would you rate your satisfaction with your social activities and relationships?
In general, how well do you carry out your usual social activities and roles? This includes activities at home, work, community, and responsibilities as a parent, friend, spouse, employee, etc.

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Watery/Itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation

Welcome to Healing Family Functional Medicine

Parent/Guardian Information

Child 1 (Oldest)

Child 1 (Oldest) Promis- Global Health Questionnaire

Child 1: Medical Symptom/Toxicity Questionnaire (MSQ)

Child 2 (Second Oldest)

Child 2 Promis- Global Health Questionnaire

Child 2: Medical Symptom/Toxicity Questionnaire (MSQ)

Child 3 (Third Oldest)

Child 3 Promis- Global Health Questionnaire

Child 3: Medical Symptom/Toxicity Questionnaire (MSQ)

Child 4 (Fourth Oldest)

Child 4 Promis- Global Health Questionnaire

Child 4: Medical Symptom/Toxicity Questionnaire (MSQ)

Child 5 (Fifth Oldest)

Child 5 Promis- Global Health Questionnaire

Child 5: Medical Symptom/Toxicity Questionnaire (MSQ)

Child 6 (Sixth Oldest)

Child 6 Promis- Global Health Questionnaire

Child 6: Medical Symptom/Toxicity Questionnaire (MSQ)

Pediatric Timeline

Billing Policy

Privacy Policy

Ohio HIPAA Privacy Authorization Form

Informed Consent: Diagnosis & Treatment

Functional Medicine Lab Testing

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
Steroid use
Antibiotic use
Mild stress
Severe stress
Chronic disease
Mild placenta issues
Placental rupture
Rhogam use
Best rest
High blood pressure
Pre-eclampsia
Gestational Diabetes
Blood clots
Infections
Cancer
Rheumatic disease
Psychiatric disease
Recurrent hospitalizations
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
37+ weeks
34-36 weeks
32-33 weeks
Less than 32 weeks
Less than 25 weeks
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
Vaginal
Vaginal w/ vacuum
Vaginal w/ forceps
Scheduled C-section
Emergency C-section
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
Excellent
Baby had mild bruising or had mild distress- resolved quickly
Moderate bruising, moderate distress, monitored for growth in the hospital
NICU stay, no antibiotics, no ventilation
Required NICU, ventilation, steroids, antibiotics or unknown
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 5	Child 6
12 + months
6-12 months
3-6 months
< 3 months
Bottle-fed only or unknown
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
None to less than 2 times over 18 years
3-5 times total over 18 years
Used yearly during elementary years or used 6-10 times over 18 years
Used yearly 3-4x/year for various infections: strep, sinus, bronchitis, acne, etc.
Prolonged use or intermittent use for several months to treat acne or other infections over 18years
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child does not get sick, rarely gets sick or if they do get sick, it only lasted 1-2 days every few years
My child may have one to two infections per year with good recovery
My child gets sick 3-4x/year; can take awhile to recover
My child picks up every infection, I feel they are sick a lot
My child is chronically sick with viral infections; it can lead to other bacterial infections
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
Never
1-2 times episodically
3-4 times episodically
5-10 times for asthma, infection, medical condition
Prolonged used due to medical condition
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
None
Yes. It was outpatient or observation only; possible surgeries include but not limited to dental surgery mild, tonsillectomy, hernia repair; no difficulty with surgery.
Yes. They suffered a complication resulting in repeat surgery, hospitalization OR Moderate surgery requiring 2-4 days in the hospital, antibiotics, may have needed physical therapy.
Yes. It was a high risk surgery with hospital stay, appropriate therapy, may have used antibiotics or steroids but appropriate healing
Yes. High risk surgery of the heart, brain, etc., or life-threatening need, required prolonged hospital stay or rehab, may need more steroids or antibiotics for recovery
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
None
Yes. Minor falls or hit on the head with a ball as child, asymptomatic with no head/facial bruising
My child was diagnosed with a concussion diagnosis or suspected, recovered in less than week, no long term problems
My child suffered from a brain contusion, hemorrhage, more severe concussion and/or second concussion lasting up to 1-4 weeks
My child suffered a severe head trauma from MVA, penetrating brain injury, recurrent brain injuries, coup contrecoup brain injury.
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child has had no injuries or only had some minor injuries requring no medical attention such as sprains, cramps/spasms, falls, accidents
My child has had minor injuries requring medical attention for musculoskeletal injuries, falls,stitches accidents but recovered easily within 7- 10 days or less.
My child had mild to moderate injuries requiring medical attention; it took longer to recover; you may have used different therapies to help but there are no long term complications.
My child had a moderate injury requiring emergency department evaluation, requiring oral antibiotics and or steroids, possible therapy for fractures, dislocations, or minor surgery. Recovery within 2-4 months.
My child had a serious injury severe, requiring hospitalization, surgery, usually needed antibiotics, steroids, and or various therapies. It took a long time to recover.
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child does not have any mental health issues or may only suffer from episodic blues/anxiety due to school, stress, etc. lasting 2-3 days.
My child has mild symptoms sometimes, but this does not affect their life. (example, seasonal depression, not doing well in school/sports); they do not need medications and/or therapy
My child has mild to moderate persistent symptoms; They have used or are currently using medication. They are/have been in therapy. Their mood affects their life but they are able to function.
My child has severe symptoms; Providers have been worried about potential for crime risk or suicide risk; my child is in therapy and is using medications more often than not.
My child has suffered from severe grief due to trauma, death, external event, attempted suicide, or was hospitalized for mental health concerns.
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child is normal weight and height
My child may have gained or lost weight but nothing to be worried about; they can maintain a healthy weight without difficulty.
My child has/had weight issues at various times
but this does not affect their health.
My child struggled with being overweight for most of their childhood but was able to improve the weight with time.
My child struggles with an eating disorder that caused them to lose weight; they were not hospitalized for this and improved with outpatient therapy.
My child has struggled with weight (loss or gain) for most of their childhood, or my child has a serious eating disorder requiring hospitalization.
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child was on time or ahead on the developmental milestones
My child was on time/or ahead on most of the milestones; there were a few delays but nothing to be worried about.
My child had a delay in different milestones; we are or were in therapy to help them catch up.
My child is delayed and continues with therapy
My child has global delay and will be delayed life long in all aspects: motor, speech, comprehension.
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child was able to learn or was ahead of schedule; they did not have many accidents once they were toilet trained.
My child had occasional difficulties/accidents after learning, was slightly delayed in potty training.
My child had some difficulties and/or accidents after learning for some time and/or my child was delayed in potty training with some difficulties afterward.
My child had a difficult time learning; there were frequent accidents.
My child has not been potty trained or my child is older but still requires a pull up at night
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child was on time or ahead with all verbal milestones
My child had a few issues with pronouncing certain words or sounds, slight stutter but nothing to worry about.
My child has mild to moderate speech concerns, requiring speech therapy
My child has moderate to severe speech concerns, requiring speech therapy
My child is non-verbal
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child is doing well academically, getting all A's, learning is easy and/or is ahead of their class
My child does well; they usually get A's and B's; they may have some difficulty with new concepts
My child usually receives B's and may occasionally have C's; they must put in the work to learn or they are not motivated to learn
My child is struggling in school with C's and D's
My child is failing their current grade
Unknown
N/A

Rows	Child 1	Child 2	Child 4	Child 5	Child 6
My child eats >4 different colored vegetables per day
My child eats 2-3 different colored vegetables per day
My child eats one serving of vegetable most days
My child eats vegetables 3-4x/week
My child eats vegetables < 2 times per week
Unknown
N/A

Rows	Child 1	Child 2	Child 3	Child 4	Child 5	Child 6
My child eats organic, well treated animals or wild animals; wild seafood 2-3 meals per day and/or organic plant proteins 2-3x/day; can be a mixture. Never to rarely eats processed meats.
My child eats some organic meat and some not organic meat, seafood (wild and farm raised), and or organic or not organic plant protein tofu/beans/lentils, etc. They sometimes have processed proteins.
My child does not get organic meats/seafood or plant proteins (can be due to cost, availability, etc). My child eats out at least 2x/week, has processed meats 1 to 2x/week; Or sometimes my child will not eat a protein with meals
My child eats out frequently, they may have fast food > 2x/week or processed meat 2-4 times per week; or they are eating protein only once daily.
My child has a medical condition or an eating disorder and does not get enough protein
Unknown
N/A