Initial Intake: Patient Wellness

New Wellness Patient Intake and Consent Form
Would you like your appointment to be in-person or virtual?*

In-personVirtual
MASK REQUIREMENT: I understand that for all in-person appointments, masks be worn by all people over the age of 2. Masks must be properly fitted and cover both the nose and mouth for the duration of the appointment.*

I understand
COVID SCREENING: In the past 10 days, have you or anyone in your household experienced or been in close contact with someone who has ANY of the following symptoms: fever, chills, coughing, fatigue (not related to having a newborn), sneezing, sudden loss of smell or taste, runny or stuffy nose, congestion, headaches, shortness of breath, difficulty breathing, sore throat, nausea, vomiting, diarrhea, or body aches and pains (not on your breasts/chest and not related to childbirth)?*

YesNo
VACCINES: Are the adults coming to the appointment fully vaccinated for COVID-19?*

YesNoOther
Basic Information
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Pronouns*
Sex*
If patient is a minor, list parent/guardian

First NameMiddle NameLast Name
Parent/Guardian date of birth

MonthDayYear
Parent/Guardian Date of Birth

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Preferred Phone*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Marital Status:

SingleMarriedDivorcedWidowedSeparatedDomestic PartnerN/A - childOther
Emergency contact*

First NameLast Name
Emergency contact phone*

Area CodePhone Number
Work Status*

EmployedStay at HomeDisabled fom workWill return to part time workWill return to full time workN/AOther
Occupation*
Employer*
I was referred to this practice by:*
Primary Care Provider (PCP)*
PCP Phone Number
PCP Fax #
Medical History
In your own words describe any health issues that concern you:*
What are your health and wellness goals?*

Health History - Do you have now, or have you had in the past, any of the following issues:*

	IN THE PRESENT	IN THE PAST
Allergies
Polycystic ovarian syndrome (PCOS)
Amenia
Thyroid disorder
Blood pressure issues
Liver/gallbladder issues
Yeast infections
Abuse
Asthma
Eating disorder
Kidney/bladder issues
Autoimmune condition
Cardiac/respiratory issues
Fertility issues/trouble conceiving
Digestive issues
Pregnancy loss (abortion, miscarriage, etc)
Surgery
Herpes simplex virus
IVF/IUI conception
Vegan diet
Vegetarian diet
Alcohol use
Tobacco use
Drug use
Mood concerns (depression, anxiety, etc)
Visible/invisible disabilities
No conditions to report

Please list any other health, hormonal, dietary, or anatomical issues you wish to share:
List any medication, herbs, vitamins, or supplements, and the dosage you are taking:*
Is there a family history of the following?*

genetic issuesankyloglossia (tongue tie)allergiesthyroid disordersautoimmune issuesalcoholismOther

Endocrine/reproductive history:

	Number
Number of pregnancies
Number of live births
Number of losses

If applicable, list names and dates of birth of children:
List any pregnancy or lactation details you feel are important to share:*
Please describe your current diet, dietary restrictions, allergies, or related concerns :
Tell me about your digestion (stool patterns, indigestion, reflux, etc):

Digestion Information: *

	Please let us know if you have trouble with any of these issues and share details
Allergies
Dietary restrictions
Constipation
IBS/IBD
Diarhhea
Reflux/heartburn
Other

Current mood concerns:*

	Please let us know if you have trouble with any of these issues and share details
Anxiety
Depression
Anger
Fatigue
Insomnia
Other

Please list any current moodTell me about your mood. Are you feeling anxious, sad, depressed, angry, overwhelmed, etc?*
Do you have any religious or spiritual practices you'd like us to know about?
Do you have any experience with negative touch you would like us to know about?*
Do you have any experience with negative touch you would like us to know about?*
Is there anything else you want us to know?
Consent and Release of Information
*I understand the following: Melissa Cole, MS, IBCLC, RLC is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve issues. A visit includes a detailed history, an assessment of anatomy if required, and recommendations for management to improve and/or resolve related issues. All clients are provided with a written and/or oral care path to improve concerns. The client and the consultant each have responsibilities in this path. Resolution of a problem often takes several days or weeks and may require a change in the original recommended care path at some point.

*I understand that I am responsible for informing the consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. Phone contact during the time following the visit is crucial and considered an extension of your visit. You will be given a phone number to call to report progress or to communicate continued problems or concerns. I understand it is my responsibility to call the consultant with progress reports, questions or concerns.

*I understand any change from my physician’s recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician.

*I understand a partial or follow-up visit is sometimes necessary. I understand that supplies and/or supplements may be recommended as effective management of specific situations. Only effective supplies will be recommended and the client is never obligated to purchase or use any recommended supplies. If a client chooses to utilize any equipment, supplies or nutritional supplements risks and benefits will be discussed but the client is responsible for choosing whether or not to use these items and for any associated outcomes.

*I hereby authorize the consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay counselor, and/or our insurance company upon request. I understand the consultant may contact my physician or my child’s physician if the consultant feels it is necessary to consult with the physician.

*I have received a copy of this provider’s Privacy Practices or read them online HERE

*I understand this practice accepts only fee for service at time of service. It is my responsibility to pursue reimbursement for services from my insurance company. This practice does no billing for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but filing is suggested.
I consent to text or email follow up (which are sometimes considered unsecured forms of communication). Luna Lactation adheres to HIPAA privacy practices but realizes some patients may choose text and email contact for convenience at their own discretion.*

YesNo
I give permission for information, photos and/or videos of my visit to be used for professional, clinical research, education and/or articles. I understand all identifying factors will be removed.*

YesNoOther
I consent to an intern being present during my consultation. Please note, Luna Lactation’s current intern is a female lactation student and is fully vaccinated (as are all of Luna’s staff):*

YesNoOther
Signature - I have read the above consent and release information and agree to the terms. (Typing your name below qualifies as a digital signature)*
Date signed*

MonthDayYear
Date Signed*

MonthDayYear
Date
Should be Empty:

New Wellness Patient Intake and Consent Form

Basic Information

Medical History

Consent and Release of Information