Patient Health History - Madison, WI · 2016. 6. 14. · Fenske Holistic Healthcare Center 2 Patient Acceptance Policy (FM Wellness) SUBSEQUENT APPOINTMENTS: 7. If necessary, follow-up

608.836.8883 tel 608.836.8863 fax

[email protected] www.drfenske.com

7702 Terrace Ave. Ste 2 Middleton, WI 53562

To-Do List Functional Medicine (WELLNESS) patients

A SUMMARY OF THE FORMS YOU WILL NEED TO COMPLETE BEFORE YOUR INITIAL

FUNCTIONAL MEDICINE APPOINTMENT WITH DR. FENSKE, AND WHEN SHE WILL

NEED TO RECEIVE THEM IN ORDER TO FULLY PREPARE FOR YOUR APPOINTMENT.

FORM: DUE:

___ Patient Acceptance Form Within ONE WEEK of scheduling your initial appointment.

___ Patient Health History Within ONE WEEK of scheduling your initial appointment.

___ Diet Diary (3-Day) Within ONE WEEK of scheduling your initial appointment.

___ Health Goals Within ONE WEEK of scheduling your initial appointment.

___ Copy of Labs from Last 2 Years Within ONE WEEK of scheduling your initial appointment.

(download your labs from your My Chart account or request

directly from your healthcare provider using our Medical

Records Request , a separate download from our website)

(608) 836-8883

Patient Acceptance Policy Functional Medicine (WELLNESS) patients

Name (last, first) _________________________________________________________ Date: ____________

Address__________________________________________________________________________________

City, State, Zip____________________________________________________________________________

Phone (home) _________________ Phone (cell) _________________ Email __________________________

Sex ____ Age_____ Date of Birth____________ Spouse/Partner’s Name______________________________

Children (ages, names)___________________ Occupation_____________ Employer/School______________

Whom may we thank for referring you to our office? ______________________________________________ In order to best serve you, the Patient Acceptance Policy should be carefully reviewed. It is Dr. Fenske’s opinion that you should be well informed on our expectations and clinical procedures. To prevent any misunderstandings or confusion on what to expect, Dr. Fenske would appreciate that you read the below steps and provide your signature. This would simply imply that you have read the Patient Acceptance Policy and understand what is expected of you. PRIOR TO FIRST APPOINTMENT:

1. Completion of the following forms: Patient Acceptance Policy, Patient Health History, Diet and Lifestyle Diary (3-day), Health Goals. These forms were developed to gather important information about your body. They will help Dr. Fenske more quickly “zero” in on the probable causes of your health problems. It is VERY important for you to carefully and thoroughly complete all of these forms prior to your first consultation with Dr. Fenske.

2. Labs: If applicable please obtain lab reports from the last two years from all healthcare providers you have

seen. You may print them from My Chart or request lab results directly from your providers (using the Request for Records form available on our website). Please email, fax, or mail results to our office.

FIRST APPOINTMENT:

3. At your initial appointment Dr. Fenske will review your case with you. The cost for the 60-minute appointment as well as Dr. Fenske’s time for studying your forms / lab reports is $240.

4. Based on your medical history, available labs and initial consultation, it may be necessary to order

additional laboratory tests. You will be presented with detailed information on the specific tests recommended. The cost for your initial laboratory tests will be discussed at that time.

SECOND APPOINTMENT:

5. The time it takes to receive the results of your tests varies based on individual test processing time as well as on when you choose to initiate the test. When results are available our staff will call to schedule your second appointment. The fee for this second appointment is typically $120 to $240.00 for approximately 30 to 60 minutes. Dr. Fenske will present recommendations at this appointment. Your recommendations may consist of personalized dietary and lifestyle changes as well as nutritional supplements.

6. After this second appointment, you may meet with our patient educator to discuss implementation of

specific diet recommendations.

Fenske Holistic Healthcare Center 2 Patient Acceptance Policy (FM Wellness)

SUBSEQUENT APPOINTMENTS:

7. If necessary, follow-up consultations will be scheduled every 3, 6 or 12 weeks allowing you the opportunity to discuss your progress and any concerns with Dr. Fenske. Dr. Fenske will at this time determine what direction to take to help you continue your progress. Your cooperation in taking “personal responsibility” in your health care will go a long way in getting better. Consultations may be conducted either by phone or in person at our office. The fee for follow-up consultations is based on the time required for the appointment (typically $120.00 to $240).

8. Abnormal laboratory tests will need to be re-evaluated. The success of your treatment will not only be

measured on the reduction or elimination of your physical symptoms, but on abnormal laboratory tests returning to a normal status. Laboratory fees can vary depending on what needs to be re-tested.

Our goal at Fenske Holistic Healthcare Center is to provide high quality, personal service that is responsive to the healthcare needs of our patients. We require payment for services at the time they are provided. Insurance companies do not cover Functional Medicine consultations, nutritional supplements, or preventative lab services. Any specific questions you may have about coverage for our services should be directed to your insurance provider. Note: prices are subject to change without notice, the duration of each visit is approximate, and 24-hour notice is required to cancel an appointment without incurring a charge. Prices not only reflect the time spent with each patient but also the time studying your case between visits and the advanced training, expertise, and effort required to treat complex health conditions. We accept payment by cash, check, or credit card (Mastercard and Visa).

I have read and fully understand the Patient Acceptance Policy.

_________________________ _________________ Patient (Parent/Guardian) Signature Date

(The signature of Parent/Guardian hereby authorizes Dr. Nicole Fenske to provide care for the minor child listed as Patient).

(608) 836-8883

Patient Health History Functional Medicine (WELLNESS) patients

Name___________________________________________ Date________________

Date of Birth ___________ Age ______ Height ______ Weight ______ Blood Type ______

Occupation _____________________________________

Race/Ethnicity(circle one): White/Caucasian Black/African Amer. Asian Hispanic/Spanish Native Hawaiian Amer. Indian

What brings you to our office?_______________________________________________________

List your major health problem/concern:

1. _______________________________________________________________________________

_________________________________________________________________________________

Describe the causes of this concern (if known or suspected): _____________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Have you had the same (or similar) problem before (circle one)? Y / N

What activities aggravate your problem(s)? _____________________________________________

________________________________________________________________________________

What activities improve your problem(s)? ______________________________________________

_________________________________________________________________________________

Are your problems getting progressively worse? Y / N

Are your problems interfering with (check all that apply):

Work Daily Routine Sleep Other ____________

If your condition involves pain please characterize type:

Ache Sharp Radiating Constant Intermittent

Please rate the amount of pain you are generally experiencing:

(circle one) mild 1 2 3 4 5 6 7 8 9 10 severe

Please use the diagram to the right to indicate areas of involvement

(mark: P for pain, T for tightness, N for numbness).

Previous Treatment for Health Problems

Were you previously treated for the above problems? Y / N (if no, skip to Health Maintenance Update section below)

Fenske Holistic Healthcare Center 2 Patient Health History (FM Wellness)

Previous Treatment (Continued)

Name of practitioner ___________________________________________________________

Date first seen__________________________ Date last seen___________________________

Condition or diagnosis___________________________________________________________

How was the condition treated_____________________________________________________

Results of treatment: Good Fair Poor

Please list below other practitioners seen for this condition: (or check here for none ____ )

Name Date (approx.) Testing/Treatment

1. _____________________________________________________________________________

2. _____________________________________________________________________________

Current primary care physician _____________________________________________________

Health Maintenance Update

Please indicate approximate dates and results of last:

Physical exam __________________________________________________________________

Spinal exam _____________________________________________________________________

Dental exam ___________________________________________________________________

Cholesterol profile ________________________________________________________________

Other blood tests _________________________________________________________________

Chest X-ray _____________________________________________________________________

Spinal X-ray _____________________________________________________________________

Bone density (DEXA) scan ________________________________________________________

Mammogram ____________________________________________________________________

Eye exam _______________________________________________________________________

Colonoscopy or flexible sigmoidoscopy _______________________________________________

Other __________________________________________________________________________

List all medications you are currently using, or have used recently. Include all over-the-counter

medications. List dosages and approximate length of time you have used each medication:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

List (include name, brand, dosage) all vitamins, minerals, herbs, and other natural products you are

currently using:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Fenske Holistic Healthcare Center 3 Patient Health History (FM Wellness)

List medication/supplement/environmental allergies or intolerances and associated reactions:

____________________________________________________________________

____________________________________________________________________

List past or present exposure to harmful chemicals:

____________________________________________________________________

Surgical History

Please list all major and minor surgeries you have undergone with approximate dates:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Serious Accidents and Falls

Have you ever been in an auto accident? Y / N Date(s) _____________

Describe _________________________________________________________________________

Have you had any significant sports injuries? Y / N Date(s) _____________

Describe _________________________________________________________________________

Have you had any work accidents? Y / N Date(s) _____________

Describe _________________________________________________________________________

Please describe any other accidents, falls, or injuries (include dates):

____________________________________________________________________ Please list all fractures you have sustained and when they occurred:

____________________________________________________________________

Early Health History

List any known problems your mother had during her pregnancy with you (illness, stress,

medication, smoking, alcohol, traumatic delivery):

____________________________________________________________________

____________________________________________________________________

Were you breast fed? Y / N. If yes, please indicate duration if known _________________ Was your home life as a child loving/supportive? Y / N

If there were significant stresses please describe _____________________________

______________________________________________________________

Please check if you had any of the following childhood illnesses:

Frequent ear infections Colic Eczema Recurrent colds Bronchitis

Pneumonia Meningitis Other _____________________

As a child were you on frequent or prolonged antibiotic therapy? Y / N

Did you receive immunizations? Y / N

Did you experience any adverse reactions to immunizations? Y / N / NA

If yes, please describe ________________________________________________________

Fenske Holistic Healthcare Center 4 Patient Health History (FM Wellness)

Please check all of the following conditions that you have experienced:

Alcohol/drug addiction

Allergies

Anemia

Anxiety, reoccurring

Asthma

Blood fats, high (cholesterol,

triglycerides)

Blood pressure, high

Blood pressure, low

Bone loss

Cancer

Depression

Diabetes

Emphysema

Environmental sensitivities

Epilepsy

Fatigue, chronic

Gallstones

Headaches, reoccurring

Heart attack

Heart disease

Heart palpitations

Insomnia

Kidney disease

Mental health problems

Pneumonia

Sexually transmitted infection

Sinus congestion, chronic

Skin problems

Thyroid disorder

Ulcer

Urination problems

Other (please describe):

____________________

____________________

Female Health History

Age at first period ____ Date of last period ___________

Number of pregnancies ____ Number of live births ____

Date of last Pap test _____________ History of abnormal Pap tests? Y / N

History of irregular periods? Y / N Menstrual cycle length: ____ days.

Duration of menstrual period: ____ days.

Do you experience significant menstrual cramping? Y / N

Is heavy bleeding a problem? Y / N

Do you have a history of endometriosis? Y / N

Do you have a history of yeast infections? Y / N

Do you have a history of infertility? Y / N

Do you have excessive unwanted hair growth? Y / N

Do you have a tendency toward premenstrual syndrome? Y / N

If yes, please describe symptoms: ______________________________________________

Do you have a family history of (check all that apply): breast cancer ovarian cancer osteoporosis

Describe any current menstrual or menopausal symptoms or concerns:

____________________________________________________________________

Describe any current breast problems: __________________________________________

Did you breast feed? Y / N If yes, please indicate duration for each child: ___________________

Digestive Function

Describe any food intolerances you have: _______________________________________________

_____________________________________________________________________

Describe any digestive problems: ______________________________________________

_____________________________________________________________________ Your usual bowel movement frequency is (check one):

>2 times daily 1 time daily 1time every 2 days <1 time every 2 days.

Do you usually have to strain to have a bowel movement? Y / N

Are your bowel movements chronically loose? Y / N

Fenske Holistic Healthcare Center 5 Patient Health History (FM Wellness)

Digestive Function (Continued)

Do you ever have blood with bowel movements? Y / N

Are your stools ever black or tarry? Y / N

When was the last time you received antibiotics? ________________________

Family Health History

Review the conditions below. Indicate if a family member has ever had a condition with an ‘X’ in

the appropriate space. Leave blank any spaces that do not apply.

CONDITION Father Mother Spouse Brother(s) Sister(s) Children

Age ___ Age ___ Age ___ Age(s)____

___________ Age(s)____

___________ Age(s)____

___________

Acne

Alcoholism/addiction

Allergies/hay fever

Alzheimer’s Disease

Arthritis

Asthma

Bedwetting

Cancer (specify type _____________)

Depression

Diabetes

Digestive problems

Ear infections

Female problems

Headaches

Heart disease

High blood pressure

Insomnia

Kidney problems

Liver disease

Mental health problems

Migraine

Muscle pain/cramps

Osteoporosis

Spinal curve

Thyroid problems

Other (specify __________________)

Other (specify __________________)

If any of the above family members

are deceased, please list their age at

death and specify cause of death.

Other pertinent family history:

Fenske Holistic Healthcare Center 6 Patient Health History (FM Wellness)

Stress Factors

Please indicate if any of the major stresses listed below apply to you (check all that apply):

Job New retirement New baby Change of marital status Health problems

Family stress Financial concerns Abusive relationship Other: _____________.

Please describe the quality of major relationships in your life: ___________________________

____________________________________________________________________________.

Indicate job satisfaction (if applicable): Excellent Good Fair Poor

Have you experienced physical, emotional, sexual, or verbal abuse? Y / N

Lifestyle Habits

Describe your sleep pattern: Time arise _________ Time retire _________ Naps? Y / N

Your quality of sleep is: Well-rested Tired upon awakening Awaken during night

Do you: Sleep in total darkness Sleep near electric clock, outlet, or other electronic device

Your typical sleep position is: Side Back Stomach Is your mattress firm? Y / N

Pillow type (check all that apply): Firm Soft Thick Thin Feather Synthetic Orthopedic

What is the frequency of your vacations: ____ times / year.

How frequently do you travel: Annually Semi-annually Monthly Weekly

Do you live/work in a damp or moldy home/office? Y / N

Do you exercise? Y / N

If yes… Type: ________________ Frequency: ____ times per week/month (circle one).

How do you relax or relieve stress? ____________________________________________________

_________________________________________________________________________________

Do you use tobacco? Y / N If yes, list amount you smoke/chew per day and week _____________

Years using tobacco ______, if you no longer use it, when did you quit ________________

Do you use recreational drugs? Y / N If yes, list type and frequency ________________________

Did you formerly use recreational drugs? Y / N If yes, specify ______________________

Diet History

How frequently do you dine out: Daily Weekly Monthly Rarely/never

How frequently do you eat fast food: Daily Weekly Monthly Rarely/never

How much water do you drink daily: < 1 qt. 1 qt. 2 qt. > 2qt.

Is it filtered water? Y / N

Foods you avoid and why (i.e. allergies, diet, dislike): _____________________________________

Foods you crave: __________________________________________________________________

Do you have (or have you had) an eating disorder? Y / N

Do you drink coffee? Y / N if yes, how many cups daily of decaf ______ and caffeinated ______

Do you drink tea? Y / N if yes, what kind _________ and how many cups do you drink daily ____

Do you drink soda? Y / N if yes, what kind ___________ and how many do you drink daily _____

Do you drink alcohol? Y / N if yes, list type and amount per day and week ___________________

Do you have (or have you had) a problem with alcohol overuse? Y / N

(608) 836-8883

Establishing Your Health Goals Functional Medicine (WELLNESS) patients

Name ___________________________________________ Date: ____________

Personal Message Before You Begin

Before you begin our journey together, I would like to discuss something very important that will have a major impact on

your ability to recover and achieve maximum improvement. After many years in private practice, I have had the

opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others

have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why

some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms – it’s

about living a life of vibrant health.

I’ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality, a discussion of

how you have lived your life up to this point and how you will live it in the future.

Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions.

I want you to be honest with yourself and really dig deep inside yourself for the answers.

1. Have you made the decision to change? To do what it takes to get well? Yes ____ No _____

I have read something interesting: “The definition of insanity is to keep doing the same thing and expecting different

results.” If you keep following the same course of treatment you have been following will your results really change?

Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and

improved road to reach your destination.

Most people I ask tell me they have made the decision to change. But how many people have truly decided to change?

Very few! Why? Because there is a big difference between deciding something and having “reasons” to actually do it.

When you have made a decision to make a change and you know your reasons, you create an internal power that can

propel you to achieve health and wellness. So now I ask:

2. List up to 5 things that you plan to do once you are feeling better. Please be specific. (Use extra pages if

necessary)

_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

Fenske Holistic Healthcare Center 2 Health Goals (FM Wellness)

3. Please check off the following that you would like to achieve with my help:

o Increase energy

o Sleep better

o Have better digestion

o Be able to eat more foods

o Get rid of my allergies

o Have a better immune system (i.e. less colds /coughs)

o Not be dependent on laxatives or stool softeners

o Be able to work out again

o Have better muscle tone

o Be in less pain

o No longer use pain medication

o No longer use allergy medication

o No longer use sleep medication

o To feel less sleepy in the afternoon

o Lose weight

o Increase my sex drive

o Increase my metabolism to burn more fat

o Increase my flexibility

o Reduce my stress

o Improve my memory

o Improve my focus

o Improve my mood

o Reduce my risk of developing a chronic disease

o I want to work on an anti-aging program

o I want to detoxify my body

o I want to improve my diet

o I want to clear up my skin

4. Are there any other health goals you want to achieve?

_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________