OFFICE: 413-637-8921 • CELL: 413-446-3205
42 Summer Street • Suite 308 • Pittsfield, MA 01201 •
Patient Name: ________________________________________________________________ Nickname: _____________________________ Birth Date: _________________________________ Social Security No._________________________________ Address Information:
Street: ______________________________________________________________________________________________________________ City: _____________________________________________________________ State: _____________ Zip: __________________________ Telephone: (Home) _______________________________________ (Other, eg, work/cel) ________________________________________ May we leave a detailed message at either of these numbers? o No o Yes at: _____________________________________________ Email: ______________________________________________________________________________________________________________ Insurance Information: (You can bring your card instead of filling this out.)
Primary care doctor: _____________________________________ Insurance Company Name: __________________________________ Your ID Number: ________________________________________ Group Number: ____________________________________________ Subscriber/Primary Insured Name: _______________________________________________________________ Second Insurance Company Name: ______________________________________________________________ Some insurance plans require a referral to pay for nutrition services. It is your responsibility to check with your insurer to determine whether a referral is required and to ask your health care provider to issue the referral if it is.
Our Financial Policy
Our practice participates with many insurance plans. It is your
the terms of our contract with the insurance company.
responsibility to provide us with a current copy of your insur-
ance card. Failure to provide accurate insurance information can
You agree that if either a medically necessary or elective service is result in a denial of your services by your insurance carrier, and rendered, and your insurance carrier denies or refuses to pay for while you may have insurance, under the law, you are still per- any service for whatever reason, that upon receipt of a bill from sonally responsible for payment for any and all services rendered.
us, you will pay the total amount due within thirty (30) calendar days. If you fail to pay any amount due within this time, you It is also your responsibility to pay any and all co-pays or deduct- agree to pay any rebilling or late fees, and, if your account is ibles that may be due at the time of your visit. If you do not
referred to collections, all collection fees, and that these amounts have your co-payment with you on the day of service, we can will be in addition to any amount that was originally due. You refuse to treat you, and may reschedule your appointment. understand that a fee is charged for all first visits, examinations, procedures, and copies of medical records/reports.
With most insurances, we will file a claim with your insurance carrier on your behalf as a courtesy. If our practice has con- I have read the above policy. I understand and agree to these tracted with your insurance carrier, we will accept any payments terms, and also understand that if I fail to adhere to the terms made on your behalf for all services rendered in accordance with above, I may be released as a patient by the practice.
_______________________________________________________________________ Please rank current and ongoing problems by priority and fill in the other boxes as completely as possible:
1. With whom do you live? (Include children, parents, relatives, and/or friends. Please include ages.)
Example: Wendy, age 7, sister __________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 2. Do you have any pets or farm animals?
If yes, where do they live? o indoors o outdoors o both indoors and outdoors 3. Have you lived or traveled outside of the United States? o Yes o No
If so, when and where? _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ 4. Have you or your family recently experienced any major life changes?
If yes, please comment: _______________________________________________________________________________________ ____________________________________________________________________________________________________________________ 5. Have you experienced any major losses in life? o Yes o No
If so, please comment: ______________________________________________________________________________________ __________________________________________________________________________________________________________________ 6. How important is religion (or spirituality) for you and your family’s life?
7. How much time have you lost from work or school in the past year?
8. Past Medical and Surgical History:
High blood fats (cholesterol, triglycerides) INJURIES
9. Hospitalizations:
10. How often have you have taken antibiotics?
11. How often have you have taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
12. What medications are you taking now? Include non-prescription drugs.
Are you allergic to any medications?
If yes, please list: _____________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 13. List all vitamins, minerals, and other nutritional supplements that you are taking now. Indicate whether
mg or IU and the form (e.g., calcium carbonate vs. calcium lactate), when possible.

14. Childhood:
Comment ________________________________________ Comment ________________________________________ Comment ________________________________________ Comment ________________________________________ As a child did you eat a lot of sugar and/or candy? Comment ________________________________________ 15. As a child, were there any foods that you had to avoid because they gave you symptoms?
If yes, please: name the food and symptom (Example: milk - gas and diarrhea) _______________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 16. Place a check mark next to the food/drink that applies to your current diet.
17. How much of the following do you consume each week?
Candy ___________________________________________________ Diet sodas _____________________________________________ Cheese __________________________________________________ Ice cream ______________________________________________ Chocolate ________________________________________________ Salty foods _____________________________________________ Cups of coffee containing caffeine ___________________________ Slices of white bread (rolls/bagels) _________________________ Cups of decaffeinated coffee or tea __________________________ Sodas with caffeine _____________________________________ Cups of hot chocolate _____________________________________ Sodas without caffeine __________________________________ Cups of tea containing caffeine _____________________________ 18. Are you on a special diet? o Yes o No
o other (describe): _________________________________ 19. Is there anything special about your diet that we should know? o Yes o No
If yes, please explain: ________________________________________________________________________________________________ 20. a. Do you have symptoms immediately after eating,
such as belching, bloating, sneezing, hives, etc.?
o Yes o No
If yes, are these symptoms associated with any particular food or supplement(s)? o Yes o No Please name the food or supplement and symptom(s). Example: Milk = gas and diarrhea.
____________________________________________________________________________________________________________________ 21. Do you feel you have delayed symptoms after eating certain foods (symptoms may
not be evident for 24 hours or more), such as fatigue, muscle aches, sinus congestion, etc.?
o Yes o No
22. Do you feel much worse when you eat a lot of :
o other ___________________________________________ 23. Do you feel much better when you eat a lot of :
o other ___________________________________________ 24. Does skipping a meal greatly affect your symptoms? o Yes o No
25. Have you ever had a food that you craved or really “binged” on over a period of time? o Yes o No
Food craving may be an indicator that you may be allergic to that food.
If yes, what food(s)? ________________________________________________________________________________________________ 26. Do you have an aversion to certain foods? o Yes o No
If yes, what foods? _________________________________________________________________________________________________ 27. Please fill in the chart below with information about your bowel movements:
o Alternating between hard and loose/watery 28. Intestinal gas: o Daily o Present with pain o Occasionally o Foul smelling o Excessive o Little odor
29. Have you ever used alcohol? o Yes o No
If yes, how often do you now drink alcohol? o No longer drinking alcohol o Average -3 drinks per week o Average 4- drinks per week o Average 7-0 drinks per week o Average >0 drinks per week Have you ever had a problem with alcohol? o Yes o No If yes, please indicate time period (month/year): from __________________________ to __________________________ 30. Have you ever used recreational drugs? o Yes o No
31. Have you ever used tobacco? o Yes o No
If yes, number of years as a nicotine user _______________ Amount per day _______________ Year quit _______________ If yes, what type of nicotine have you used? o Cigarette o Smokeless o Cigar o Pipe o Patch/Gum 32. Are you exposed to second hand smoke regularly? o Yes o No
33. Do you have mercury amalgam fillings? o Yes o No
34. Do you have any artificial joints or implants? o Yes o No
35. Do you feel worse at certain times of the year? o Yes o No
If yes, when? o spring o fall o summer o winter 36. Have you, to your knowledge, been exposed to toxic metals in your job or at home? o Yes o No
If yes, which one(s)? o lead o cadmium o arsenic o mercury o aluminum 37. Do odors affect you? o Yes o No
38. Do you exercise regularly? o Yes o No
If so, how many times a week? o x o x o 3x o 4x or more When you exercise, how long is each session? o <5 min o -30 min o 3-45 min o > 45 min What type of exercise is it? o jogging/walking o tennis o basketball o water sports o home aerobics o other ________________________________________________________________ Copyright The Institute for Functional Medicine


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