• Patient Health History

  • Demographic Information

  • Birthday*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about us?*

  • Current Medical History

  • Is this visit for the purpose of obtaining a vaccine medical exemption?*
  • Date of last complete check-up*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you willing to modify your diet or living habits, if doing so would improve your health?*

  • Lifestyle and Habits

  • Diet

  • Do you eat breakfast?
  • Is there variety in your diet, or do you tend to eat a lot of the same things?

  • Supplements and Medications

  • Do you have any allergies to medications?*
  • Do you have any allergies to foods?*

  • Habits

  • Do you currently smoke tobacco in any form?*
  • Do you use cannabis?
  • Do you drink alcohol?*
  • How many servings of alcohol do you consume per day?
  • How many cups of coffee do you consume per day?
  • Do you drink soda?*
  • What type of soda do you drink?
  • How many cans of soda do you consume per day?
  • How many energy drinks do you consume per day?
  • Do you eat sweets and desserts?*
  • How many sweets or desserts do you consume per day?
  • Are there any chemicals, heavy metals, fumes, dust, etc. that you are regularly exposed to?
  • Do you have a daily bowel movement?*
  • How often are you having a bowel movement?

  • In the last 30 days...

    Please answer the following questions based on the last 30 days
  • Do you feel safe at home?*
  • Do you feel safe at work?*
  • Have you fallen or fainted?*
  • Have you had a seizure or loss of consciousness?*
  • Have you had altered mind, mood, memory, or speech?*

  • Past Medical History

  • Please check the box if you have a current or past diagnosis of any of the following conditions:

  • Review of Systems

    Please mark the first box for any problem you have had in the past but are no longer having. Please mark the second box for any problem you are currently having.
  • Head and Face
    Rows
  • Chest
    Rows
  • Abdomen
    Rows
  • Genitourinary
    Rows
  • Musculoskeletal
    Rows
  • Skin
    Rows
  • Endocrine
    Rows
  • Nervous
    Rows
  • Blood, immune
    Rows
  • Mental, Emotional
    Rows
  • Male reproductive
    Rows
  • Female reproductive
    Rows
  • Do you have a regular, predictable menstrual cycle?
  • Has menopause occurred yet?

  • Signature and Acknowledgment

  • I hereby give consent for naturopathic / natural medical care at Nature Works Best Medical Clinic. I understand that my health insurance may or may not reimburse me for the charges at this clinic for my care, and that these charges are nevertheless due in full from me at the time of service. I understand that there is no guarantee of successful results.

  • Our Privacy Policy

  • All health information in our office is treated as confidential, and we are careful in how we use it. This policy describes how your health information may be used and how you can get access to this information. This clinic strictly observes doctor-patient privilege, the US Constitution and laws, and we recognize that you control all information in your medical records and who sees it.

    We will only release a patient's health information to a third party in three kinds of situations:

    1. If the patient makes a written request to us for all or part of his or her health care records to be shared with another health care provider, imaging facility; or other entity; or
    2. If the patient arrives to our office in a state requiring emergency care, in which case we would contact 911, and may need to inform 911 of your physical state of being: or
    3. In cases of victims of abuse or threatened homicide or threatened suicide, or threatened harm to others, and in such cases, only to law enforcement agencies, 911 services and/or other emergency services.

    Other than these special situations, we always honor your right to privacy under the Fourth Amendment of the US Constitution and HIPAA law, and your control over who sees any or all of your information, as well as federal and state privacy laws and regulations in order to assure you complete confidentiality regarding all of your health care information.

    Please indicate your acceptance of this policy with your signature on the line below.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Permission to Share Medical Information

    The following individuals may have access to my medical information:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Consent and Authorization for Intravenous Therapy Procedures

  • Description of Procedure

    Nutritional IV's including high dose vitamin C with additional nutrients, including most B vitamins, amino acids and minerals, in descending order by volume, as described in detail in the Cancer & Biochemistry videos on the https://NatureWorksBest.com website and as determined prior to each visit and specifically selected for each individual's current health circumstances.

    If needed, you also consent to the administration of hydration IVs, alpha lipoic acid, and any other substance that you and your provider agree on. If agreed, this may include immunotherapy procedures.

    You have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies. procedures are not performed until you have had an opportunity to receive such information and to give your informed consent.

    The procedure involves preparation of a sterile solution of liquid, sterile, water-soluble nutrients by one of your providers, for you specifically, and then inserting a needle into your vein, port or muscle, and injecting the solutions described by your provider in writing and oral consultation, and as described in detail on the NatureWorksBest.com website, with daily updates as needed by your health circumstances.

    Risks of intravenous or intramuscular or subcutaneous therapy include:

    1. Discomfort, bruising and pain at the site of injection.
    2. Inflammation o f the vein used for injection, phlebitis.
    3. Temporary fluctuations in blood sugar, cytokine reactions or inflammation, infection from fluids injected.
    4. Severe allergic reaction, anaphylaxis, cardiac arrest and death; however, none of these have occurred a t this clinic to date.

    Benefits of intravenous or intramuscular or subcutaneous therapy include:

    1. Injectables are not affected by stomach or intestinal disease.
    2. Total amount of infusion is available to the tissues.
    3. Nutrients enter cells by means of diffusion along a concentration gradient.
    4. Higher doses of nutrients can be given than possible by mouth without intestinal irritation

    You have the right to consent to, or to refuse, any proposed treatment at any time prior to its performance. You have been informed of the means, method, medicine, substances, treatments, and the devices and instrumentality (IV content, IV preparation, needle access. IV tubing, gravity drip. IV pole, etc.).

    Your signature on this form affirms that you have given your consent to the procedure(s) described above with any different or further procedures which, in the opinion of your provider, as discussed with you, may be indicated.

    The procedure will be performed by or under the direction of a clinic healthcare provider with qualified nurses and medical assistants.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Missed Appointment Policy

  • We strive to provide all of our patients with the best care and most attention we can. To ensure this, we make sure to schedule all appointments to give patients the maximum time available with the doctor to discuss everything necessary. If a patent misses an appointment, this is unfair to the other patients, as your appointment time could have been offered to a patient who needed it.

    It is also unfair to us, because nursing and support staff must be scheduled in advance, based on the expected schedule of patients. To this end, we ask all our patients to call or email and cancel at least two working days in advance if they are not able to come to their appointment.

    This gives us the chance to offer the appointment time to someone who may not have been able to get on the schedule otherwise.

    For existing patients, if we do not receive a phone call, email or any other communication at least one working day (24 hours) before your appointment, we must charge a $75 missed appointment fee.

    For Initial Consultations, if we do not receive a phone call, email or any other communication at least one working day (24 hours) before your appointment, you will forfeit the $150 new patient deposit.

    We do understand that life is unpredictable and that emergencies can arise the same day as an appointment. These will be dealt with on a case-by-case basis. This is for true emergencies.

    If you call after we have closed for the evening, please leave a message so that our office manager will receive it in the morning. Any messages on the phone in the morning before we open does not count as 24 hour notice, except in the case of a true emergency.

    We appreciate and respect all our patients' time and ask that you please offer them the same courtesy by providing at least 24 hours notice when you are unable to make an appointment.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you scheduled with Dr. Colleen Huber, NMD, CTP for your initial consultation?*

  • Consent for Treatment with Dr. Colleen Huber, NMD, CTP

  • Naturopathic Medical Doctor, Certified Tribal Practitioner
    Medical License CTP2025004606, NPI 1053531483
    P.O. Box 5077, Salt River Pima Maricopa Indian Community, AZ 85261
    Tel: 480-839-2800 * Fax: 480-897-2453

  • Dr. Huber Practices Medicine at the Salt River Pima Maricopa Indian Community.

    I understand that Dr. Colleen Huber is a Naturopathic Medical Doctor, Certified Tribal Practitioner, licensed to practice medicine by First Nation Medical Board (FNMB). I understand that Dr. Huber works for Nature Works Best Medical Clinic, and that she practices medicine on tribal land in the Salt River Pima Maricopa Indian Community, in the Pima Medical Pavilion, Suite 115, which is near Route 101 and Via de Ventura Rd., and is close to, but not in, Scottsdale, Arizona.

    First Do No Harm.

    I understand that Dr. Huber only prescribes nutrients, herbs and medications that she considers within First Do No Harm, and that she only requisitions labs and imaging that she considers to be safe and appropriate; Dr. Huber must not be pressured into practicing medicine in any improper or unsafe way. I agree that Dr. Huber recommends that patients remain open-minded to her assessment of any prior or current diagnosis, in order to seek and arrive to root cause assessment(s) and her proposed (never-insisted) solutions. I retain the right to reject any or all of Dr. Huber’s suggestions.

    Patients’ Rights Include Privacy and Other Constitutional Rights.

    I further understand that being a patient of a Certified Tribal Practitioner, who practices on tribal land, that all of my constitutional and federal rights are intact, including those rights protected by the First and Fourth and Fourteenth Amendments to the U.S. Constitution, as well as all other constitutional rights, as well as rights protected under the 1964 Civil Rights Act, as well as the Universal Declaration of Human Rights and HIPAA. I further understand that because tribal land is outside the jurisdiction and authority of state, county and city agencies and authorities, therefore any complaint against a FNMB licensee is to be directed to FNMB at info@firstnationmedicalboard.com for dispute resolution. I further understand that my medical records are my private property, and that Dr. Huber takes responsibility to make sure that my medical records are kept confidential, in accordance with the Fourth Amendment of the U.S. Constitution, as well as doctor-patient confidentiality, which is one of the oldest principles in medical ethics. I understand that I have the ultimate decision-making power over who sees my medical records. Dr. Huber hereby agrees to respect that confidentiality, and to not share my medical records otherwise, except with personnel of Nature Works Best Clinic on only an as-needed basis, and except if I request specific record sharing with a specific outside party, or in case of emergency 911 need.

    NOTICE TO THIRD PARTIES

    Notice is hereby given to all outside parties that they may be in violation of civil and constitutional rights if they receive this Agreement or copy of it and then act under color of law to interfere with the free exercise of rights of the undersigned, under the
    Ninth Amendment. (See Title 42 U.S.C. § 1983 et seq.; see also Title 18 §§ 241-242.)

    I hereby attest that I have read the foregoing agreement, and I agree with its terms, and I agree to consider diagnosis and to consider treatment(s) by Dr. Colleen Huber, NMD, CTP.

  • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: