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?
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________