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Innovative Body Healing Innovative Body Healing
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FUNCTIONAL MEDICINE ADULT NEW PATIENT INTAKE

Dear Patient, Welcome! We are happy that you have chosen the path of Functional Medicine to address your health concerns. We believe Functional Medicine offers the best of both worlds: cutting-edge laboratory diagnostics based on the latest scientific research, coupled with lifestyle medicine and ancient wisdom: rest, stress management, diet, nutrition, movement, breathing, quiet time, and botanical and nutritional supplements. We are looking forward to partnering with you to achieve true wellness.

FUNCTIONAL MEDICINE INITIAL CONSULTATION:

In-depth health history intake and consult with Dr. Natalie (60 min) Review of body systems Review of relevant FM diagnostic labs Pay for consult, labs, and any supplements purchased Please plan 60 minutes for the initial consult and an additional 15-20 minutes to go over tests and/or supplements

FUNCTIONAL MEDICINE - SECOND CONSULTATION:

Consult with Dr. Natalie (45-60 min) Review lab results Review personalized treatment program created for you by Dr. Natalie Pay for follow-up and any supplements purchased Schedule follow-up appointments

FUNCTIONAL MEDICINE ONGOING CONSULTATIONS:

Consult with Dr. Natalie (45-50 min) Evaluate progress Review and/or modify treatment program as necessary Pay for follow-up and any supplements purchased Schedule follow-up appointments

PRACTICE POLICIES FOR PATIENTS

Our goal is to provide you with the highest level of personalized care possible. We are committed to helping you achieve true wellness. It is important to read all of the enclosed information carefully, complete all the forms, and bring them to your first appointment.

WEBSITE

Information about Innovative Body Healing and all relevant patient forms are available through the website:www.innovativebodyhealing.com

COPIES OF MEDICAL RECORDS & LABS FROM OUR OFFICE

You will be given a copy of your labs at each visit to keep for your records. Should you require a letter of medical necessity for any tests or supplements there will be a $30 fee and a one week turn-around time.

FUNCTIONAL MEDICINE CONSULTATION FEES

Initial Consultation with Dr. Natalie: $145 (60 min) Second Consultation with Dr. Natalie: $75 (45 min) Ongoing Consultations with Dr. Natalie: $75 (45 min)

LAB TESTS

We do not accept insurance to cover lab tests. All labs involve stool, urine, saliva, or bloodspot (skin prick) samples and can be done on your own in the comfort of your home. You will be given all lab kits and step-by-step instructions for home test kits at the time of your consultation. Once all of the final lab results are received, we will review them with you at your follow-up visits.

SUPPLEMENTS

All of the supplements that are recommended by Dr. Natalie are available for purchase in our office or online through our webstore. Supplements purchased online will be mailed directly to you. Dr. Natalie will educate you and recommend foods and nutritional supplements as part of your treatment program, but you are under no obligation to purchase supplements from our office or website.

RETURNS/REFUNDS

Supplements (except for probiotics and protein powders) and Functional Lab kits may be returned for a refund or exchange if in original condition and unopened or unused within 7 days of purchase.

CREDIT CARDS

We require a credit card number at the time of scheduling your first appointment. This credit card will be used to hold your appointment and will be kept on file to use for all appointments, labs and supplements unless otherwise specified by you at the time of check out. We do not take American Express.

CANCELLATION AND RESCHEDULING OF APPOINTMENTS

There is a 72-hour (3 business days) cancellation and rescheduling policy for Functional Medicine appointments. Your appointment must be cancelled or rescheduled at least 24 hours (1 business day) prior to your consultation time or you will be charged a $50 cancellation fee. You may cancel your appointment by calling the office at 860-999-6099 or emailing dr.natalie@innovativebodyhealing.com Your phone call to cancel or your email to cancel must be time-stamped no less than 24 hours (1 business day) prior to your appointment time or your credit card will be charged the late cancellation fee.

LATE ARRIVAL APPOINTMENTS

We are committed to being on time with patients’ appointments in order to prevent increased waiting times. If you arrive late to the office for your consult, your appointment will end at the scheduled time and you will be charged for the length of the originally scheduled visit.

FOLLOW-UP APPOINTMENTS

At the time of check out you will be scheduled for a follow-up appointment. We will assume you will honor this appointment time unless you notify us otherwise at least 24 hours / 1 business day prior to your scheduled appointment.

PAYMENT OPTIONS

Cash, check, and credit card (MasterCard, Visa, Discover) are all accepted methods of payment for services. When you schedule the initial visit, we request a credit card on file to hold the appointment for you. No charges will be applied to your credit card unless you miss or cancel an appointment without proper notice. On the day of your scheduled appointment, all charges for consultations, laboratory testing and nutritional supplements will be itemized and payment will be due. Over-the-phone or in-person consultations will be billed to your credit card on file unless you provide other payment information and instructions prior to your appointment. If additional lab tests are required and our office sends test kits, the appropriate fees will be charged to your account.

INSURANCE INFORMATION

Medical insurance is not accepted for Functional Medicine consultations and our office cannot assist you with claim resolution. In addition, Dr. Natalie is not a Medicare provider. If requested, we can provide you with an itemized receipt that you can submit to your insurance carrier. Dr. Natalie does not submit her Functional Medicine medical notes to insurance companies.

DISABILITY FORMS

Dr. Natalie does not fill out medical disability forms for patients, nor does she submit her Functional Medicine medical notes to support disability claims.

OFFICE HOURS

Our office hours are Tuesdays day 9:30am to 6:00pm, Wednesdays and Fridas 9:30am to 6:00pm EST. If you are going to stop by the office to pick up supplements we ask that you kindly email your order to us at dr.natalie@innovativebodyhealing.com or place an order on our online store at www.innovativebodyhealing.com prior to your visit, and notify us of the approximate time you will be stopping in. You may also call it in at (860) 999-6099.

PHONE CALLS AND MESSAGES

Phone messages will be responded to within 24 hours (during business hours). To reach the office, please call or text 860-999-6099. If you call after hours, please leave a message or feel free to text and the office staff will return your call on the next business day. If you have a medical emergency, call 911 or go directly to the nearest ER. When leaving a message, please be brief, speak slowly, and include the following information:

● Full name and date of birth
● Reason for call
● Phone number(s) - please repeat this twice
● E-mail address (if desired)

EMAIL

If you would like to schedule / reschedule / cancel an appointment, want to pick up supplements, or have questions about labs or anything administrative, please email dr.natalie@innovativebodyhealing.com. If you have a BRIEF medical question for Dr. Natalie please email her at dr.natalie.innovativebodyhealing@gmail.com. Please note that it can take Dr. Natalie up to 72 hours to respond to emails, particularly if it is the weekend. Wishing you true wellness, Dr. Natalie and Innovative Body Healing team

IMPORTANT PATIENT INFORMATION

APPOINTMENTS

● Initial consult is $145 and ongoing consultations are $75.
● There is a 24 hour / 1 business day cancellation policy (please see cancellation policy in Practice Policies for Patients).
We reserve the right to charge your credit card $50 if the appointment is not canceled or rescheduled 24 hours (1 business day) prior to your appointment. By signing below you agree to our cancelation policy and authorize Innovative Body Healing to charge your credit card on file for any missed visits.

LAB TESTS & SUPPLEMENTS

● All lab results will be reviewed with you during your second consultation (or whichever consultation immediately follows the time Dr. Natalie has received your results from the lab(s), reviewed them, and created your treatment program).
● Supplements (except probiotics and protein powders) and Functional Lab kits may be returned for a refund or exchange if in original condition and unopened or unused within 7 days of purchase.

RETURN CHECK FEE

● A $35 fee will be assessed for all checks returned for insufficient funds.

BILLING/INSURANCE

● You may request an itemized receipt at the completion of your visit that you may submit to your insurance for reimbursement. We do not help with insurance claim resolution.
● Payment for the office visit/consultation, phone consultation, or lab tests is expected at time of service. All credit card payments will be processed the same day of the visit or phone consult.
● Innovative Body Healing does not accept insurance for Functional Medicine consults.

PRIMARY CARE PHYSICIAN

Please note that Dr. Natalie is not your primary care physician and we recommend that you have a primary care physician.

Patient Signature

Date
MM slash DD slash YYYY

INFORMED CONSENT REGARDING E-MAIL OR THE INTERNET USE OF PROTECTED PERSONAL INFORMATION

Innovative Body Healing provides patients the opportunity to communicate with them by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks, both general and specific, that should be considered before using e-mail.

1. Risks:

a. General e-mail risks are the following: e-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward email to other recipients with or without the original sender(s) permission, or knowledge; users can easily misaddress an e-mail; e-mail is easier to falsify than handwritten, or signed documents; backup copies of e-mail may exist even after the sender, or recipient has deleted his/her history.

b. Specific e-mail risks are the following: e-mail containing information pertaining to diagnosis and/or treatment must be included in the protected personal health information; all individuals who have access to the protected personal health information will have access to the e-mail messages; patients who send, or receive e-mail from their place of employment risk having their employer read their e-mail.

2. It is the policy of Innovative Body Healing that all e-mail messages sent or received, which concern the diagnosis, or treatment of the patient will be a part of that patient’s protected personal health information and we will treat such e-mail messages, or internet communications, with the same degree of confidentiality as afforded other portions of the protected personal health information. Innovative Body Healing will use reasonable means to protect the security and confidentiality of e-mail or internet communication. Because of the risks outlined above, we cannot, however, guarantee the security and confidentiality of e-mail, or internet communications.

3. Patients must consent to the use of e-mail for confidential medical information after having been informed of the above risks. Consent to the use of e-mail includes agreement with the following conditions:

a. All e-mail to or from patients concerning diagnosis and/or treatment will be made a part of the protected personal health information. As a part of the protected personal health information, Dr. Natalie, other healthcare practitioners, insurance coordinators, and upon written authorization other healthcare providers and insurers will have access to e-mail messages contained in protected personal health information.

b. Innovative Body Healing practitioners may forward e-mail messages within the practice as necessary for diagnosis and treatment. We will not, however, forward the e-mail outside the practice without the consent of the patient as required by law.

c. We at Innovative Body Healing will endeavor to read e-mails promptly, but can provide no assurance that the recipient of the particular e-mail will read the e-mail message promptly. Therefore, e-mail must not be used in a medical emergency. It is the responsibility of the sender to determine whether the intended recipient received the e-mail and when the recipient will respond.

d. Because some medical information is so sensitive that unauthorized disclosure can be very damaging, e-mail should not be used for communications concerning diagnosis, or treatment of AIDS/HIV infection; other sexually transmissible, or communicable diseases, such as syphilis, gonorrhea, herpes, and the like; Behavioral health, Mental health, or developmental disability; or alcohol and drug abuse.

e. Innovative Body Healing cannot guarantee that electronic communications will be private. However, we will take reasonable steps to protect the confidentiality of the e-mail, or internet communication. However, Dr. Natalie is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence, or wanton misconduct.

f. If consent is given for the use of e-mail, it is the responsibility of the patient to inform Innovative Body Healing staff of any type of information you do not want to be sent by e-mail.

g. It is the responsibility of the patient to protect their password or other means of access to e-mail sent, or received, from Innovative Body Healing, to protect confidentiality. Innovative Body Healing is not liable for breaches of confidentiality caused by the patient. Any further use of e-mail initiated by the patient that discusses diagnosis, or treatment, constitutes informed consent to the foregoing. I understand that my consent to the use of e-mail may be withdrawn at any time by e-mail, or written communication, to Innovative Body Healing at heal@oasishealingforyou.com

I have read this form carefully and understand the risks and responsibilities associated with the use of e- mail. I agree to assume all risks associated with the use of e-mail.

Name Printed
MM slash DD slash YYYY

GENERAL INFORMATION

Full Name
MM slash DD slash YYYY
Gender
Highest Education Level
Primary Address
Physician’s Name

Who Referred you to Dr. Natalie at Innovative Body Healing?

Google
Social-Media
Family Member
Friend
Other

INNOVATIVE BODY HEALING, LLC. QUESTIONNAIRE

ALLERGIES
COMPLAINTS / CONCERNS
If you had a magic wand and could erase three problems, what would they be?
Please list top three current and ongoing problems in order of priority:
Describe Problem
Mild
Moderate
Severe
 
Prior Treatment / Therapeutic Approach
Prior Treatment / Therapeutic Approach
Excellent
Good
Fair
 

MEDICAL HISTORY - DISEASES / DIAGNOSIS / CONDITIONS

Note: Check the box next to the conditions you have and provide date of onset

GASTROINTESTINAL

Untitled
Celiac Disease
MM slash DD slash YYYY
MM slash DD slash YYYY
Inflammatory Bowel Disease
Constipation
MM slash DD slash YYYY
MM slash DD slash YYYY
Crohn’s Disease
Loose Stools
MM slash DD slash YYYY
MM slash DD slash YYYY
Ulcerative Colitis
Bloating
MM slash DD slash YYYY
MM slash DD slash YYYY
Gastritis or Peptic Ulcer Disease
Flatulence (gas)
MM slash DD slash YYYY
MM slash DD slash YYYY
GERD (reflux)
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

CARDIOVASCULAR

Heart Attack
Hypertension (high blood pressure)
MM slash DD slash YYYY
MM slash DD slash YYYY
Other Heart Disease
Rheumatic Fever
MM slash DD slash YYYY
MM slash DD slash YYYY
Stroke
Mitral Valve Prolapse
MM slash DD slash YYYY
MM slash DD slash YYYY
Elevated Cholesterol
Other
MM slash DD slash YYYY
MM slash DD slash YYYY
Arrythmia (irregular heart rate)
MM slash DD slash YYYY

METABOLIC / ENDOCRINE

Type 1 Diabetes
Weight Gain
MM slash DD slash YYYY
MM slash DD slash YYYY
Type 2 Diabetes
Weight Loss
MM slash DD slash YYYY
MM slash DD slash YYYY
Hypoglycemia
Infertility
MM slash DD slash YYYY
MM slash DD slash YYYY
Metabolic Syndrome
Frequent Weight Fluctuations
MM slash DD slash YYYY
MM slash DD slash YYYY
Insulin Resistance or Pre-Diabetes
Bulimia
MM slash DD slash YYYY
MM slash DD slash YYYY
Hypothyroidism (low thyroid)
Anorexia
MM slash DD slash YYYY
MM slash DD slash YYYY
Hyperthyroidism (overactive thyroid)
Binge Eating Disorder
MM slash DD slash YYYY
MM slash DD slash YYYY
Polycystic Ovarian Syndrome (PCOS)
Night Eating Syndrome
MM slash DD slash YYYY
MM slash DD slash YYYY
Eating Disorder (non-specific)
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

CANCER

Lung Cancer
Ovarian Cancer
MM slash DD slash YYYY
MM slash DD slash YYYY
Breast Cancer
Prostate Cancer
MM slash DD slash YYYY
MM slash DD slash YYYY
Colon Cancer
Skin Cancer
MM slash DD slash YYYY
MM slash DD slash YYYY

GENITOURINARY

Kidney Stones
Frequent Yeast Infections
MM slash DD slash YYYY
MM slash DD slash YYYY
Gout
Erectile and/or Sexual Dysfunction
MM slash DD slash YYYY
MM slash DD slash YYYY
Interstitial Cystitis
Other
MM slash DD slash YYYY
MM slash DD slash YYYY
Frequent Urinary Tract Infections
MM slash DD slash YYYY

MUSCULOSKELETAL / PAIN

Osteoarthritis
Chronic Pain
MM slash DD slash YYYY
MM slash DD slash YYYY
Fibromyalgia
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

INFLAMMATORY / IMMUNE

Chronic Fatigue Syndrome
Poor Immune Function
MM slash DD slash YYYY
MM slash DD slash YYYY
Autoimmune Disease
Food Allergies
MM slash DD slash YYYY
MM slash DD slash YYYY
Rheumatoid Arthritis
Environmental Allergies
MM slash DD slash YYYY
MM slash DD slash YYYY
Lupus SLE
Multiple Chemical Sensitivities
MM slash DD slash YYYY
MM slash DD slash YYYY
Immune Deficiency Disease
Latex Allergy
MM slash DD slash YYYY
MM slash DD slash YYYY
Herpes-Genital
Severe Infectious Disease
MM slash DD slash YYYY
MM slash DD slash YYYY
Other.
MM slash DD slash YYYY

RESPIRATORY DISEASES

Asthma
Pneumonia
MM slash DD slash YYYY
MM slash DD slash YYYY
Chronic Sinusitis
Tuberculosis
MM slash DD slash YYYY
MM slash DD slash YYYY
Bronchitis
Sleep Apnea
MM slash DD slash YYYY
MM slash DD slash YYYY
Emphysema
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

SKIN DISEASES

Eczema
Melanoma
MM slash DD slash YYYY
MM slash DD slash YYYY
Psoriasis
Skin Cancer
MM slash DD slash YYYY
MM slash DD slash YYYY
Acne
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

NEUROLOGIC / MOOD

Depression
Mild Cognitive Impairment
MM slash DD slash YYYY
MM slash DD slash YYYY
Anxiety
Memory Problems
MM slash DD slash YYYY
MM slash DD slash YYYY
Bipolar Disorder
Parkinson’s Disease
MM slash DD slash YYYY
MM slash DD slash YYYY
Headaches
Multiple Sclerosis
MM slash DD slash YYYY
MM slash DD slash YYYY
Migraines
ALS
MM slash DD slash YYYY
MM slash DD slash YYYY
ADD/ADHD
Seizures
MM slash DD slash YYYY
MM slash DD slash YYYY
Autism
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

INJURIES

Check box if yes

Back Injury
Back Injury
Back Injury
Back Injury

SURGERIES

Check box if yes and provide date of surgery

Appendectomy
Joint Replacement –Knee/Hip
MM slash DD slash YYYY
MM slash DD slash YYYY
Hysterectomy +/- Ovaries
Spinal Surgery
MM slash DD slash YYYY
MM slash DD slash YYYY
Gall Bladder
Heart Surgery–Bypass Valve
MM slash DD slash YYYY
MM slash DD slash YYYY
Hernia
Angioplasty or Stent
MM slash DD slash YYYY
MM slash DD slash YYYY
Tonsillectomy
Pacemaker
MM slash DD slash YYYY
MM slash DD slash YYYY
Dental Surgery
Other
MM slash DD slash YYYY
MM slash DD slash YYYY

SURGERIES

Check box if yes and provide date of surgery

None
List
Date:
Reason:
 
Pregnancies
Caesarean
Vaginal deliveries
Miscarriage
Abortion
Living Children
Postpartum Depression
Toxemia
Gestational Diabetes
Baby Over 8 Pounds
Breastfeeding
Breastfeeding

MENSTRUAL HISTORY

Age at First Period-Menses Frequency-Length
Pain:
Clotting:
Has your period ever skipped ?
Use of hormonal contraception such as:
Do you use contraception?
Do you use contraception?

WOMEN’S DISORDERS / HORMONAL IMBALANCES ( for women only)

Do you use contraception?
Do you use contraception?
Last PAP Test:
Are you in menopause?
Do you use contraception?
Do you use contraception?
--WOMEN’S DISORDERS / HORMONAL IMBALANCES ( for women only)
Do you use contraception?
Use of hormone replacement therapy

MEN’S HISTORY ( for men only)

Prostate Enlargement Prostate infection Change in Libido Impotence
Prostate Enlargement Prostate infection Change in Libido Impotence
Nocturia (urination at night)
Urgency/Hesitancy/Change in Urinary Stream ⍅ Loss of Control of Urine

GI HISTORY

Foreign Travel?
Wilderness Camping?
Have you ever had severe:
Do you feel like you digest your food well?
Do you feel bloated after meals?

DENTAL HISTORY

Silver Mercury Fillings:
Gold Fillings ⍅ Root Canals
Implants If yes, how many? ____________ ⍅ Tooth Pain
Implants If yes, how many? ____________ ⍅ Tooth Pain
Do you floss regularly?

MEDICATIONS

CURRENT MEDICATIONS
MEDICATION
DOSE
FREQUENCY
START DATE (mo/yr)
REASON FOR USE
 
PREVIOUS MEDICATIONS: (Last 5 years)
MEDICATION
DOSE
FREQUENCY
START DATE (mo/yr)
REASON FOR USE
 
NUTRITIONAL SUPPLEMENTS (VITAMINS / MINERALS / HERBS / HOMEOPATHY)
SUPPLEMENT & BRAND
DOSE
FREQUENCY
START DATE (mo/yr)
REASON FOR USE
 
Have your medications or supplements ever caused you unusual side effects or problems?
Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin?
Have you had prolonged or regular use of Tylenol?
Have you had prolonged or regular use of Acid Blockers (Tagamet, Zantac, Prilosec, etc.) :
Frequent antibiotics (> 2 times/year):
Long term antibiotics:
Use of steroids (prednisone, nasal allergy inhalers) in the past:
Use of oral contraceptives:

NUTRITION HISTORY

Have you ever had a nutritional consultation?
Have you made any changes in your eating habits because of your health?
Do you currently follow a special diet or nutritional program?
Check all that apply:
Check all that apply:
Weight Fluctuations ( > 10 lbs.)
How often do you weigh yourself?
Do you avoid any particular foods?
Do you grocery shop?
Do you read food labels?
Do you cook?
How many meals do you eat out per week?
Check all the factors that apply to your current lifestyle and eating habits:

SMOKING

Currently Smoking?
Previously Smoking?

ALCOHOL INTAKE

How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, or 1.5 ounces spirits
Previous alcohol intake?
Untitled
Have you ever been told you should cut down your alcohol intake?
Do you ever feel guilty about your alcohol consumption?
Do you notice a tolerance to alcohol (can you “hold” more than others)?
Have you ever been unable to remember what you did during a drinking episode?
Do you get into arguments or physical fights when you have been drinking?
Have you ever been arrested or hospitalized because of drinking?
Have you ever thought about getting help to control or stop your drinking?

OTHER SUBSTANCES

Caffeine Intake:
Coffee cups/day:
Tea cups/day:
Caffeinated Sodas or Diet Sodas Intake:
12-ounce can/bottle:
Are you currently using any recreational drugs (marijuana, ecstasy, etc)?
Have you ever used IV recreational drugs?

EXERCISE

Current Exercise Program: (List type of activity, number of sessions/week, and duration)
Activity
Type
Frequency per Week
Duration in Minutes
 
Rate your level of motivation for including exercise in your life?
List problems that limit activity:

PSYCHOSOCIAL

Do you feel significantly less vital than you did a year ago?
Are you happy?
Do you feel your life has meaning and purpose?
Do you believe stress is presently reducing the quality of your life?
Do you like the work you do?
Have you ever experienced major losses in your life?
Do you spend the majority of your time and money to fulfill responsibilities and obligations?
Would you describe your experience as a child in your family as happy and secure?

STRESS/COPING

Have you ever sought counseling?
You currently in therapy?
Do you feel you have an excessive amount of stress in your life?
Do you feel you can easily handle the stress in your life?
Do you practice meditation or relaxation techniques?
Check all that apply:
Have you ever been abused, a victim of a crime, or experienced a significant trauma?

SLEEP / REST

Average number of hours you sleep per night:
Do you have trouble falling asleep?
Do you feel rested upon awakening?
Do you have problems with insomnia?
Do you snore?
Do you use sleeping aids?

ROLES / RELATIONSHIPS

Marital status:
Resources for emotional support?
Are you satisfied with your sex life?
List
How well have things been going for you?
Very Well
Fine
Poorly
Does Not Apply
 

ENVIRONMENTAL AND DETOXIFICATION ASSESSMENT

Do you have known adverse food reactions or sensitivities?
Do you have any food allergies or sensitivities?
Do you have an adverse reaction to caffeine?
When you drink caffeine do you feel:
Do you adversely react to any of the following?
In your work or home environment, are you exposed to:
Do you have a known history of significant exposure to any harmful chemicals such as the following:
Do you dry clean your clothes frequently?
Do you or have you lived or worked in a damp or moldy environment?
Do you have any pets or farm animals?

SYMPTOM REVIEW

Please check all symptoms experienced within the past 6 months to the present.

MOOD / NERVES
GENERAL
HEAD, EYES & EARS
EATING
DIGESTION
MUSCULOSKELETAL
SKIN & HAIR PROBLEMS
NAILS
ITCHING SKIN
RESPIRATORY
SKIN, DRYNESS OF
CARDIOVASCULAR
URINARY
MALE REPRODUCTIVE
FEMALE REPRODUCTIVE
LYMPH NODES

READINESS ASSESSMENT

Rate on a scale of 5 (very willing) to 1 (not willing):

In order to improve your health, how willing are you to:

Significantly modify your diet
Take several nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (e.g., work demands, sleep habits)
Practice a relaxation technique
Engage in regular exercise
Have periodic lab tests to assess your progress
Rate on a scale of 5 (very confident) to 1 (not confident at all):
How confident are you of your ability to organize and follow through on the above health related Activities?
Rate on a scale of 5 (very supportive) to 1 (very unsupportive):
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

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  • 674 Prospect Avenue, Hartford, CT 06105
  • dr.natalieibh@gmail.com
  • (860) 999-6099
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