ESSENTIAL HEALTH WELLNESS
6818 South Route 83, Unit 300 • Darien, Illinois 60561
Phone 630.280.5316 • www.brainreplete.com • essentialhealth@comcast.net
Welcome to a healthier lifestyle…… Welcome to a healthier you Thank you for choosing our wellness center to assist you in achieving your personal wellness goals now and throughout your life. This form is a fillable PDF. Please tab through and fill out the provided paperwork and email it back to us at essentialhealth@comcast.net or if need be physically mail it to 5840 South Grant Street, Hinsdale, Illinois
60521. Once the paperwork is sent please allow us 2-3 days prior to scheduling your initial consultation so we can review your history. Consultation can be scheduled in person at our clinic or via phone which ever you are more comfortable with. If you have any questions please contact our office, Monday – Thursday 9:00 a.m. to 4:00 p.m. CST and/or visit our website. Again thank you for choosing Essential Health Wellness we look forward to assisting you. Dr. Shawn Juliano ©ESSENTIAL HEALTH, LLC 1 ESSENTIAL HEALTH WELLNESS
6818 South Route 83, Unit 300 • Darien, Illinois 60561
Phone 630.280.5316 • www.brainreplete.com • essentialhealth@comcast.net
New Client Paperwork
Please allow 2-3 days prior to scheduling your initial consultation so we can review your paperwork
DATE: NAME: LAST
FIRST ADDRESS: STREET CITY CONTACT: HOME: STATE ZIP CELL: EMAIL: AGE: ________ DATE OF BIRTH: ________________ MALE FEMALE HEIGHT: ________ WEIGHT: ________ MARITAL STATUS: SINGLE MARRIED WIDOWED
SEPERATED DIVORCED
CHILDREN LONG TERM RELATIONSHIP EMPLOYMENT INFO: STATUS:
FULL TIME PART TIME RETIRED ____________ DATE STUDENT: FULL TIME PART TIME OCCUPATION: ____________________________________________________________________________________________________________ NATURE OF WORK: WHAT DO YOU DO PHYSICALLY (DESK JOB, MANUAL LABOR, FACTORY WORKER) HOW DID YOU HEAR ABOUT OUR CLINIC: _____________________________________________________________________________ DO YOU HAVE A FAMILY MEMBER OR FRIEND ALREADY A CLIENT AT THE CLINIC: ____________________________
NAME WHO IS YOUR PRIMARY MEDICAL PHYSICIAN: ______________________________________________________________________
PRIMARY PHYSICIAN ADDRESS AND PHONE: _______________________________________________________________________
©ESSENTIAL HEALTH, LLC 2 Health History Questionnaire
Please complete the following Health History Questionnaire to the best of your ability. Your thoroughness and accuracy in answering all appropriate questions will help us evaluate the root cause of your health concerns and determine an effective program designed uniquely for you. Note that we are interested in so-­‐called minor symptoms as well as major problems. We know that in many doctor’s offices there is some tendency not to mention too many symptoms for fear that the doctor will take you for a hypochondriac. The rules in our office are different. We are interested in any odd or unusual message you are getting from your body, even though it may be considered irrelevant to “making a diagnosis” or it may seem to you to be of no consequence to your health. However every symptom is a message being sent from the body to alert you that some system is out of balance. Please include as much information as you can on this form. CURRENT HEALTH STATUS/CONCERNS Please list your chief symptoms and/or complaints in order of decreasing severity, starting with the worst one. Please note how long each issue has been present. Symptom 1.
e.g. Headaches Onset 10 / 2007 Frequency Severity 4 times per week Mild / moderate / severe 2.
3.
4.
5.
6.
7.
8.
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What diagnosis or explanations have been given to you? ________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ When was the last time you felt well? ______________________________________________________________________________________ Did an event trigger your change in health? _______________________________________________________________________________ ©ESSENTIAL HEALTH, LLC 3 What makes you feel worse? _______________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ What makes you feel better? _______________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ MEDICAL & SURGICAL HISTORY P = Past Condition C = Current Condition GASTROINTESTINAL P C Crohn’s Disease P C Gastritis or Peptic Ulcer P C GERD (Reflux) P C Inflammatory Bowel Disease P C Irritable Bowel Syndrome P C Ulcerative Colitis P C Other:_____________________________________________ GENITAL AND URINARY SYSTEMS P C Kidney Stones P C Gout P C Interstitial Cystitis P C Frequent urinary Tract Infections P C Frequent Yeast Infections P C Erectile Dysfunction P C Other: _____________________________________ METABOLIC / ENDOCRINE P C Type 1 Diabetes P C Type 2 Diabetes P C Hypoglycemia P C Metabolic Syndrome (Insulin Resistance or Pre-­‐Diabetes) P C Hyperthyroidism (Over Active Thyroid) P C Hypothyroidism (Under Active Thyroid) P C Hyperadrenalism (Over Active Adrenals) P C Hypoadrenalism (Under Active Adrenals) P C Polycystic Ovarian Syndrome (PCOS) P C Fibrocystic Breasts P C Infertility P C Weight Gain P C Weight Loss P C Frequent Weight Fluctuations P C Bulimia P C Anorexia P C Binge Eating Disorder P C Other: _____________________________________________ AUTOIMMUNE P C Addison’s Disease P C Ankylosing Spondykitis P C Celiac Disease P C Chronic Fatigue Syndrome P C Graves Disease P C Hashimoto Thyroiditis P C Multiple Sclerosis P C Pernicious Anemia P C Rheumatoid Arthritis P C Sjogren Syndrome P C Systemic Lupus Erthematosus (SLE) P C Other: _____________________________________ ©ESSENTIAL HEALTH, LLC 4 IMMUNE P C Frequent Colds P C Frequent Infections P C Immune Deficient Disease P C Food Allergies P C Environmental Allergies P C Chemical Sensitivities P C Mononucleosis P C Other: _____________________________________ INFLAMMATION P C Fibromyalgia P C Chronic Pain P C Osteoarthritis P C Other:_____________________________________________ CARDIOVASCULAR P C Arrhythmia (Irregular Heart Beat) P C Heart Attack P C Stroke P C Mitral Valve Prolapse P C Rheumatic Fever P C Hypertension (High Blood Pressure) P C Elevated Cholesterol P C Other:_____________________________________________ NEUROLOGICAL P C Anxiety P C Depression P C Bipolar P C ADD /ADHD P C Headaches P C Migraines P C Autism P C Memory Problems P C Seizures P C Other: _____________________________________________ SURGERIES Appendectomy Hernia Hysterectomy Ovaries Removed Gallbladder Kidney Stones Kidney Removed Tonsillectomy Dental Root Canal Dental Implant Joint Replacement Heart Bypass Heart Valve Replacement Angioplasty or Stent Pacemaker Other: ____________________________________________________ ©ESSENTIAL HEALTH, LLC 5 RESPIRATORY P C Asthma P C Bronchitis P C Emphysema P C COPD P C Pneumonia P C Sleep Apnea P C Tuberculosis P C Other: _____________________________________ CANCER P C Breast P C Colon P C Leukemia P C Lung P C Ovarian P C Prostate P C Skin SKIN DISEASES P C Acne P C Eczema P C Melanoma P C Psoriasis P C Other: _____________________________________ Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: MEDICATIONS & SUPPLEMENTS How often have you taken antibiotics? Less than 5 times More than 5 times Comments More than 5 times Comments Infancy/Childhood Teen Adulthood How often have you taken oral steroids? Less than (e.g. Prednisone, Cortisone, etc) 5 times Infancy/Childhood Teen Adulthood List all medications. Include all over the counter non-­‐prescription drugs. Medication Name ©ESSENTIAL HEALTH, LLC Date started Date stopped 6 Dosage List all vitamins, minerals, and any nutritional supplements that you are taking now. Type Date Started Date Stopped Dosage Have your medications or supplements ever caused you unusual side effects or problems? Yes No If yes, please describe: _______________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ ©ESSENTIAL HEALTH, LLC 7 NUTRITIONAL ASSESSMENT QUESTIONNAIRE PART I Key: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section I 01. ____ Belching or gas within 1 hour after eating
02. ____ Heartburn or acid reflux
03. ____ Bloating within 1 hour after eating
04. ____ Vegan Diet (no dairy, meat, fish or eggs
(0 = No, 1 = Yes) 05. ____ Bad breath (Halitosis)
06. ____ Loss of taste for meat
07. ____ Sweat has a strong odor
08. ____ Stomach upset by taking vitamins
09. ____ Sense of excess fullness after meals
10.
11.
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Section 2 20. ____ Pain between shoulder blades
21. ____ Stomach upset by greasy foods
22. ____ Greasy or shinny stools
23. ____ Nausea
24. ____ Motion sickness
25. ____ History of mourning sickness (0=no 1=yes) 26. ____ Light or clay colored stools
27. ____ Dry skin, itchy feet
28. ____ Headache over eyes
29. ____ Gallbladder attacks (0=never, 1=1 year ago,
2=within last year, 3=within past 3 months) 30. ____ Gallbladder removed (0=no 1=yes)
31. ____ Bitter taste in mouth, especially after meals 32. ____ Hemorrhoids or varicose veins
33. ____ Nutrasweet (aspartame) consumption
34. ____ Sensitive to Nutrasweet (aspartame)
35. ____ Easily hung over after drinking wine
(0 = No, 1 = Yes) 36. ____ Alcohol per week (0=<3, 1=<7, 2=<14,
3=>14) 37. ____ Recovering alcoholic (0=no 1=yes)
38. ____ History of drug or alcohol abuse
(0=no 1=yes) 39. ____ History of hepatitis (0=no 1=yes)
40. ____ Long term use of recreational drugs
(0=no 1=yes) 41. ____ Sensitive to chemicals (perfume, cleaning agents, etc.) 42. ____ Sensitive to tobacco smoke
43. ____ Exposure to diesel fumes
44. ____ Chronic fatigue or Fibromyalgia
45. ____ Pain under right side of rib cage
Section 3 46. ____ Food allergies
47. ____ Abdominal bloating 1 to 2 hours after
eating 48. ____ Specific foods make you tired or bloated
(0=no 1=yes) 49. ____ Pulse speeds after eating
50. ____ Airborne allergies
54. ____ Wheat or grain sensitivity
55. ____ Dairy sensitivity
56. ____ Are there foods you can not give up
(0=no 1=yes) 57. ____ Asthma
58. ____ Bizarre, vivid dreams, nightmares
59. ____ Use over the counter pain meds
©ESSENTIAL HEALTH, LLC 8 ____ Feel like skipping breakfast
____ Feel better if you don’t eat
____ Sleepy after meals
____ Fingernails chip, peel or break easily
____ Anemia unresponsive to iron
____ Stomach pains or cramps
____ Diarrhea shortly after meals
____ Diarrhea, chronic
____ Black or tarry colored stools
____ Undigested food in stools
51. ____ Experience hives
52. ____ Sinus congestion “stuffy head”
53. ____ Crave bread or noodles
60. ____ Feel spacey or unreal
61. ____ Alternating constipation / diarrhea
Key: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section 4 62. ____ Anus itches
63. ____ Coated tongue
64. ____ Feel worse in moldy or musty place
65. ____ Taken antibiotics for a total accumulated
time of (0=never, 1=<month, 2=<3 months, 3=>3months) 66. ____ Fungus or yeast infections
67. ____ Ring worm, jock itch, athletes foot, nail
fungus 68. ____ Yeast symptoms increase w/ sugar, starch
or alcohol 69. ____ History of parasites
Section 5 80. ____ History of carpal tunnel (0=no 1=yes)
81. ____ History of lower right abdominal pain
or ileocecal valve problems (0=no 1=yes) 82. ____ History of stress fracture
83. ____ Bone loss (reduced density on bone scan)
84. ____ Are you shorter than you used to be
(0=no 1=yes) 85. ____ Calf, foot or toe cramps at rest
86. ____ Cold sores, fever blisters, herpes lesions
87. ____ Frequent fevers
88. ____ Frequent skin rashes or hives
89. ____ Herniated disk (0=no 1=yes)
90. ____ Excessively flexible joints (double jointed)
91. ____ Joints pop or click
92. ____ Pain or swelling in joints
93. ____ Bursitis or tendonitis
70. ____ Stools have corners or edges
71. ____ Loose stools, not well formed
72. ____ Irritable bowel or mucus colitis
73. ____ Blood in stool
74. ____ Mucus in stool 75. ____ Excessive foul smelling bowel gas
76. ____ Stools hard or difficult to pass
77. ____ Less than 1 bowel movement / day
78. ____ Cramping in lower abdominal region
79. ____ Bad breath or strong body odor
94. ____ History of bone spurs (0=no 1=yes)
95. ____ Morning stiffness
96. ____ Nausea with vomiting 97. ____ Crave chocolate
98. ____ Feet have strong odor
99. ____ History of anemia
100. ____ Whites of eyes (sclera) blue tinted 101. ____ Hoarseness 102. ____ Difficulty swallowing 103. ____ Lump in throat 104. ____ Dry mouth, eyes, or nose 105. ____ Gag easily 105. ____ White spots on fingernails 106. ____ Cuts heal slowly and/or scar easily 107. ____ Decreased sense or taste or smell Section 6 108. ____ Muscles become easily fatigued 109. ____ Feel exhausted or sore after exercise 110. ____ Vulnerable to insect bites 111. ____ Loss of muscle tone, heaviness in arms/legs 112. ____ Enlarged heart or congestive heart failure 113. ____ Ringing in the ears (Tinnitus) 117. ____ Night sweats 118. ____ Cracks at corner of mouth 119. ____ Fragile skin, easily chaffed 120. ____ Polyps or warts 121. ____ MSG sensitivity 122. ____ Small bumps on back of arms ©ESSENTIAL HEALTH, LLC 9 114. ____ Numbness, tingling in hands/feet 115. ____ Whole body or limb jerk as falling asleep 116. ____ Restless leg syndrome 123. ____ Strong lights at night irritates eyes 124. ____ Nose bleeds / bruise easily 125. ____ Bleeding gums especially brushing teeth Key: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section 126. ____ Crave fatty or greasy foods 127. ____ Low or reduced fat diet (0=never, 1=years ago, 2=within past year 3=currently) 128. ____ Tension headache at base of skull 129. ____ Headaches when in hot sun 130. ____ Sunburn easily or sun poisoning 131. ____ Muscles easily fatigued 132. ____ Dry flaky skin or dandruff Section 8 133. ____ Aware of heavy or irregular breathing 134. ____ Discomfort at high altitudes 135. ____ “Air hunger” or sigh frequently 136. ____ Compelled to open windows in closed room 137. ____ Shortness of breath w/ moderate exertion 138. ____ Ankles swell especially at end of day 139. ____ Cough at night 140. ____ Blush or face turns red for no reason 141. ____ Dull pain or tightness in chest and/or radiate into right arm, worse w/exertion 142. ____ Muscle cramps w/exertion Section 9 143. ____ Pain in mid back region 144. ____ Puffy around the eyes, dark circles under eyes 145. ____ Cloudy, bloody or darkened urine 146. ____ Urine has strong odor 147. ____ History of kidney stones (0=no 1=yes) Section 10 148. ____ Runny or drippy nose 149. ____ Catch colds at beginning of winter 150. ____ Mucus producing cough 151. ____ Frequent colds or flu (0=1< per year, 1=2-­‐3 per year, 2=4-­‐5 per year, 3=6> per year) 152. ____ Other infections (sinus, ear, lung, skin bladder, kidney, etc, (0=1< per year, 1=2-­‐3 per year, 2=4-­‐5 per year, 3=6> per year) Section 11 157. ____ Awaken a few hours after falling asleep, hard to get back to sleep 158. ____ Crave sweets 159. ____ Binge or uncontrolled eating 160. ____ Excessive appetite 161. ____ Crave coffee or sugar in the afternoon 162. ____ Fatigue that is relieved by eating 163. ____ Irritable before meals ©ESSENTIAL HEALTH, LLC 153. ____ Acne (adult) 154. ____ Itchy skin (dermatitis) 155. ____ Cysts, boils, rashes 156. ____ History of Epstein Bar, Mono, Herpes, Shingles, or other chronic viral condition (0=no, 1=yes in the past, 2=currently mild condition, 3=severe) 164. ____ Headache if meals are skipped or delayed 165. ____ Shaky if meals delayed 166. ____ Family members w/ diabetes (0=none, 1=1, 2=2, 3=3 or more) 167. ____ Frequent thirst 168. ____ Frequent urination 10 Key: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section 12 169. ____ Difficulty gaining weight 170. ____ Difficulty losing weight 171. ____ Nervous, emotional, can’t work under pressure 172. ____ Fast pulse at rest 173. ____ Intolerance to high temperatures 174. ____ Sensitive to cold, poor circulation (cold hands and feet) Section 13 181. ____ Difficulty falling asleep 182. ____ Slow starter in morning 183. ____ Low energy periods during the day 184. ____ Tend to be a night person 185. ____ Heart palpitations 186. ____ Headaches 187. ____ Feeling wired or jittery after caffeine 188. ____ Frequently get irritable 189. ____ Need caffeine for a pick me up during during the day 199. ____ Depressed 200. ____ Worrier, apprehensive, anxious 201. ____ Nervous or agitated 202. ____ Feeling of insecurity 203. ____ Tend to be keyed up, trouble calming down 204. ____ Chronic low back pain 205. ____ Low blood pressure 206. ____ ”Second wind” at bedtime 207. ____ Suffer from chronic pain 208. ____ Insomnia 209. ____ Low blood sugar or hypoglycemia 175. ____ Enlarged tongue 176. ____ Mentally sluggish, reduced initiative 177. ____ Constipation, chronic 178. ____ Excessive hair loss, coarse hair 179. ____ Loss of lateral 1/3 of eyebrow 180. ____ Morning headaches, wear off during day 190. ____ Frequent low body temperatures <98° F. 191. ____ Poor memory or concentration 192. ____ Frequent or chronic infections 193. ____ Dry, thinning skin 194. ____ Bruise easily, wounds heal slowly 195. ____ Unexplained hair loss 196. ____ Skip meals 197. ____ Exercise >1 / week 198. ____ Thyroid problems 210. ____ Chronic or recurrent inflammation 211. ____ Light headed when sitting up or standing up 212. ____ Weakness or dizziness 213. ____ Crave salty food 214. ____ Perspire easily 215. ____ Tendency to need sunglasses 216. ____ Allergies, or hives 217. ____ Asthma, wheezing, difficulty breathing 218. ____ Symptoms of PMS (breast tenderness, abdominal cramping, heavy periods, mood swings) NOTE: If you have insomnia answer questions 219 – 236 This section only 0=no 1=yes 219. ____ Mind racing when trying to go to sleep 229. ____ Depressed when weather is cloudy or 220. ____ More than 20 minutes to fall asleep overcast 221. ____ Trouble staying asleep 230. ____ Take sleeping pills natural or prescription 222. ____ Wake more than once per night 231. ____ Do you snore 223. ____ Frequently waken between 2-­‐3 AM 232. ____ Diagnosed with sleep apnea 224. ____ Restless legs when trying to sleep 233. ____ Eat carbohydrate snakes before bed 225. ____ Recall your dreams 234. ____ Drink alcohol at night ©ESSENTIAL HEALTH, LLC 11 226. ____ Vivid or disturbing nightmares 227. ____ Groggy or sleeping upon awakening 228. ____ Work third shift (night shift) 235. ____ Sinus problems, allergies or asthma worse at night 236. ____ Ever blacked out Key: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section 14 Pre or Peri Menopausal Woman Only 237. ____ Depression during periods 238. ____ Mood swings associated w/ periods 239. ____ Crave chocolate, sugar around periods 240. ____ Breast tenderness associated w/cycle 241. ____ Excessive menstrual flow 243. ____ Scanty blood flow during periods 244. ____ Occasional skipped periods 245. ____ Variations in menstrual cycles 246. ____ Endometriosis 247. ____ Uterine fibroids Section 15 Post Menopausal Woman Only 257. ____ Hot flashes 258. ____ Night sweats 259. ____ Gain weight around hips, thighs, buttocks 260. ____ Anxiety or panic attacks 261. ____ Excess facial or body hair Section 16 Men Only 266. ____ Prostate problems 267. ____ Difficulty with urination, dribbling 268. ____ Difficult to start & stop urine stream 269. ____ Pain or burning with urination 270. ____ Waking to urinate at night ©ESSENTIAL HEALTH, LLC 248. ____ Brest fibroids, benign masses 249. ____ Painful intercourse 250. ____ Vaginal discharge 251. ____ Vaginal Dryness, itching, thinning 252. ____ Severe abdominal cramping 253. ____ Anxiety or panic attacks 254. ____ Bloating water retention around period 255. ____ Headaches, migraines around period 256. ____ Trouble getting pregnant or miscarriage (0=no 1=yes) 262. ____ Vaginal discharge 293. ____ Vaginal Dryness, itching, thinning 264. ____ Do you notice a reduced libido 265. ____ Are you concerned for osteoporosis or hip/spinal fractures 271. ____ Interruption of stream during urination 272. ____ Pain on inside of legs or heels 273. ____ Feeling of incomplete bowel evacuation 274. ____ Decreased sexual function 275. ____ Erectile dysfunction 12 FEMALE MEDICAL HISTORY (For women only) GYNECOLOGICAL HISTORY Menses: Average number of days? ___________ Length of cycle? __________ Are cycles regular? Yes No Painful: Yes No Clotting: Yes No Type: Normal Heavy Light PMS Symptoms: None Mild Moderate Severe Even if you are not currently using contraception, but have used hormonal birth control in the past, please indicate which type and for how long. ___________________________ Are you: Pre or Peri Menopausal Yes Menopausal Yes If yes, age of menopause: _____________ Had a Hysterectomy Yes If yes, age of hysterectomy: ______________ Do you currently take hormone replacement? Yes No Synthetic Natural If yes, what type and for how long? Date of last bone density ________________ Results: High Low Within normal range DENTAL HISTORY Have you had sore gums (gingivitis) often over the years? Yes No Do you have a lot of bad breath (halitosis) or white tongue (thrush)? Yes No Do you have problems chewing? Yes No How many amalgam fillings have you had? ________________ Do you have any now? Yes No List the approximate age and the type of MAJOR dental work done (crowns, bridges, etc.): Age Describe Dental Work ©ESSENTIAL HEALTH, LLC Health Problems following dental work? (describe) 13 LIFESTYLE HISTORY TOBACCO HISTORY Have you ever used tobacco? Yes No If yes, what type? Cigarette Smokeless Cigar Pipe Patch/Gum How much? ____________ Number of Years? ______________ If not a current user, year quit? ________________ ALCOHOL INTAKE Have you ever used alcohol? Yes No If yes, how often do you now drink alcohol? No longer drink alcohol Rare occasions Average 1-­‐3 drinks per week Average 4-­‐6 drinks per week Average 7-­‐10 drinks per week Average > 10 drinks per week Type of beverage? White Wine Red Wine Hard Liquor Beer Do you notice a tolerance to alcohol (can you “hold” more than others)? Yes No Have you ever had a problem with alcohol? Yes No If yes, indicate time period (month/year) From _________ / __________ To ___________ /____________ OTHER SUBSTANCES Do you currently or have you previously used recreational drugs? Yes No If yes, what type(s) and method? (IV, inhaled, smoked, etc) ______________________________________________________________ __________________________________________________________________________________________________________________________________ SLEEP & REST HISTORY Average number of hours that you sleep at night? More than 10 8-­‐10 6-­‐8 Less than 6 VACCINATIONS Flu Date of last shot __________ / __________
Tetnus Date of last shot ___________ / ___________
Shingles Date of last shot __________ /___________ ©ESSENTIAL HEALTH, LLC 14 EXERCISE HISTORY Do you exercise regularly? Yes No If yes, please indicate: Type of exercise Times/week 1x 2x 3x Length of session 4x/+ ≤15 16-­‐30 31-­‐45 >45 min min min min Jogging/Walking Aerobics Strength Training Pilates/Yoga/Tai Chi Sports (tennis, golf, water sports, etc) Other: If no, please indicate what problems limit your activity (e.g., lack of motivation, fatigue after exercising, etc) PERSONAL DESCRIPTIVE INFORMATION Do you have any pets or farm animals? Yes No If yes where do they live? Indoors
Outdoors Both indoors & Outdoors Do you work with toxins or chemicals in the workplace? Yes No If so, please comment: _______________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Do you live or have lived in an area where pesticides / herbicides are commonly sprayed? Yes No Have you ever lived or travelled outside the United States? Yes No If so where and when and how long? ______________________________________________________________________________________ _________________________________________________________________________________________________________________________________ Have you or your family recently experienced any major life changes? Yes No If so, please comment: _______________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ How much time have you lost from work or school in the past year? 0-­‐2 days 3 –14 days > 15 days ©ESSENTIAL HEALTH, LLC 15 ESSENTIAL HEALTH WELLNESS
6818 South Route 83, Unit 300 • Darien, Illinois 60561
Phone 630.280.5316• www.brainreplete.com • essentialhealth@comcast.net
Policies
Consultation Fees:
Initial Consultation: $265.00 (45 min.)
Initial Consultation for Couples $325.00 (1 Hr.)
Follow Up Consultations:
1 Hour:
$280.00
45 Min:
$210.00
30 Min:
$140.00
15 Min:
$ 70.00
Nutritional Consultations:
30 Min.
$ 85.00
Payment:
•
•
•
Payment is due at the time of the consultation
The length of a follow up consultation is billed only by the amount of time used
We accept Mastercard, Visa, AMEX or check (only for in office visits)
Phone Consults:
•
•
•
•
We keep a tight schedule to stay on time. You will be contacted at the number you have provided at
the specified time. Please be aware of the time and have your line available.
If there is no answer we will attempt to contact you one more time 5 minutes later
A credit card MUST be on file for all phone consults
You will receive notification of your appointment with an e-mail and a text message as a reminder
Appointments:
•
•
•
Follow up appointments may be scheduled in 60, 45, 30 or 15 minute blocks of time
We encourage you to book appointments 1 week in advance
Two business days is required for cancellations or rescheduling. We have a three strike policy as we
understand emergencies may arise, after that the cost of the consultation may be charged
©ESSENTIAL HEALTH, LLC 16 Neutraceuticals or Supplements:
•
•
The supplements we use are sold to practitioners only because they are the purest pharmaceutical
grade and the potency is guaranteed. These products have been lab tested for their effectiveness.
This is why we do not recommend you substitute for local health food store brands. This way we can
be assured of consistent results.
PRE-APPROVAL is required on ALL RETURNS.
Refrigerated items, Special Order Items, Liquid Supplements CANNOT be returned
15% restock fee of purchase price less shipping and handling may be refunded on unopened items
No supplement returns will be accepted after 30 days on all regularly stocked items
Any authorized return will be issued as a credit only. No refunds are available.
Disclaimer:
•
•
•
Dr. Juliano, DN, ND, CNC is not an MD or DO (medical physician). If you are seeking a medical
diagnosis to a specific disease or illness you need to see an MD.
If this is a medical emergency you need to call 911 or go to your local emergency room or see your
primary physician. We do not handle medical emergencies.
Dr Juliano, DN, ND, CNC cannot advise on changes or discontinuation of prescribed
pharmaceuticals by your primary MD or DO
I (please print name here)________________________________________ have read and
understand the above policies of Essential Health Wellness.
Date: ______________
Signature: ____________________________________
*Electronic signatures are legal and binding*
©ESSENTIAL HEALTH, LLC 17 ESSENTIAL HEALTH WELLNESS
6818 South Route 83 Unit 300 • Darien, Illinois 60561
Phone 630.468.2266 • www.brainreplete.com • essentialhealth@comcast.net
Effective Date: July 6, 2008
HIPAA Privacy Policy
Notice of Privacy Practices This notice describes how medical information about you may be used and
disclosed and how you can get access to that information. Please review this notice carefully.
Essential Health Wellness is committed to maintaining the privacy of your protected health information
("PHI"), which includes information about your health condition and the care and treatment you receive from
the Clinic. The creation of a record detailing the care and services you receive helps this office to provide
you with quality health care. We do not disclose your personal or medical information to any outside
parties. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details
your rights regarding your PHI.
No Consent Required
The Practice may use and/or disclose your PHI for the purposes of:
• Treatment - In order to provide you with the health care you require, the Practice will provide your PHI
to those health care professionals, whether on the Practice's staff or not, directly involved in your care
so that they may understand your health condition and needs.
• Health Care Operations – We can use and share your health information to run our practice, improve
your care and contact you when necessary and to e-mail or text you to schedule an appointment.
• Research – We can use or share your information for health research. Under no circumstances will
we include your name or any information that would identify you in any way.
• Comply with the law – We will share information about you if state or federal laws require it. Including
with the Department of Health and Human Services if it wants to see that we are complying with
federal privacy law.
• Respond to lawsuits and legal actions – We can share health information about you in response to a
court of administrative order, or in response to a subpoena.
• Personal Representative - To a person who, under applicable law, has the authority to represent you
in making decisions related to your health care. We may also give information to someone who helps
pay for your care.
Your Choices
• For certain health information, you can tell us your choices about what we share. If you choose we
will share information with a family member or close friend or others involved in your care.
©ESSENTIAL HEALTH, LLC 18 Your Rights
• Copy of Information - You can ask to see or get an electronic or paper copy of your medical
information and other health information we have about you. We will provide a copy or a summary of
your health information, usually within 30 days of your written request. We may charge a reasonable
fee for this service.
• Inspect Health Information - You can ask us to correct health information about you that you may
think is incorrect or incomplete, we may say “no” to your request but we will tell you why in writing.
• Accounting of Disclosures - You can ask for an accounting of the times we have shared your health
information. The request should be made in writing. We will provide the first accounting list within a
12 month period for free. For additional lists we may charge you for the costs of providing the list.
• Request Restrictions - You can ask us not to share certain health information for treatment, payment
or our operations. We may not agree to your request, and we may say no if it would affect your care.
• Copy of Notice - You can ask for a paper copy of this notice at any time.
• Complaints – If you believe your privacy rights have been violated you may file a complaint with the
clinic or with the U.S. Department of Health and Human Services Office. To file a complaint with the
clinic call us 630.468.2266. All complaints must be in writing. We will not penalize you for filing a
complaint.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security
of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you
change your mind. You understand that we are unable to take back any disclosures we have already
made with your permission, and that we are required to retain our records of the care that we
provided to you.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office and on our website.
PLEASE RETAIN A COPY OF THIS NOTICE
©ESSENTIAL HEALTH, LLC 19 ESSENTIAL HEALTH WELLNESS
6818 South Route 83, Unit 300 • Darien, Illinois 60561
Phone 630.280.5316 • www.brainreplete.com • essentialhealth@comcast.net
THIS FORM IS REQUIRED BY LAW AND SERVES TO
PROTECT YOUR RIGHT TO PRIVACY
Essential Health, LLC protects the privacy of your personal and health information. Personal and health
information includes both medical information and individually identifiable information, such as your name,
address or telephone number. We will not disclose this information without your authorization except as
permitted by law.
Our Notice of Privacy Practices (HIPPA) provides information about how your protected health information
may be used or disclosed. You have the right to request that we restrict how protected health information
about you is used or disclosed. Please review the Notice of Privacy Practices before signing this consent.
By signing this form, you consent to our use and disclosure of your protected health information as indicated
in the Notice of Privacy Practices. Please note that your personal information is not shared with third parties
such as marketing companies, financial institutions, or credit companies. Use id restricted to procedures
that are relevant to your care.
You have the right to revoke this consent, in writing, except where we have already made disclosures in
reliance on your prior consent.
Print Name
Signature
Date
*Electronic Signatures Are Legal and Binding*
©ESSENTIAL HEALTH, LLC 20 ESSENTIAL HEALTH WELLNESS
6818 South Route 83 Unit 300 • Darien, Illinois 60561
Phone 630.280.5316 • www.brainreplete.com • essentialhealth@comcast.net
PAYMENT AUTHORIZATION I, (print name) __________________________________________________________________ authorize Dr. Juliano, DN, ND, CNC located at 6818 South Route 83, Darien, Il, to bill my credit card as listed below. Name on Credit Card _________________________________________________________ Credit Card Holder’s Billing Address (Where your statement is mailed) Address: ___________________________________________________ City: ___________________________________________ State: ____________________________ Zip Code: _____________________ Credit Card Details Type of credit card (please check one): Visa Master Card American Express Card #: _____________________________________________ Exp Date: _____________________ Last 3 digits (4 for Amex on front) on back of card: _________________ Patient Information: Name: ______________________________________________________ Address: ___________________________________________________
City: ___________________________________________ State: __________________________ Zip code: ______________________ Authorization: _______________________________________________________ Cardholder’s Signature (Electronic Signatures are binding) ________________ Today’s Date _______________________________________________________ ________________ Patient’s Signature Today’s Date (Electronic Signatures are binding) This authorization may be revoked at any time when the following stipulations have been performed. 1. Patient has already made new financial agreement that has been signed and dated or card
holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated). 2. Patient’s account is paid in full.
©ESSENTIAL HEALTH, LLC 21