general information · heart disease hypertension obesity diabetes stroke inflammatory arthritis...

Name First Middle Last

Preferred Name

Date of Birth

Age

Gender ☐ Male ☐ Female

Genetic Background ☐ African ☐ European ☐ Native American ☐ Mediterranean

☐ Asian ☐ Ashkenazi ☐ Middle Eastern ☐ _______________

Highest Education Level ☐ High School ☐ Under-Graduate ☐ Post-Graduate

Job Title

Nature of Business

Primary Address Number, Street

City State Zip

Home Phone Work Phone

Cell Phone Fax

E-mail

Emergency Contact Name Phone Number

Relationship Cell Phone

Address Work Number

City State Zip

Primary Care Physician Name Phone Number

Fax

Referred by ☐ Website ☐ LHHP Facebook Page ☐ Family or Friend (Name ________________________)

☐Physician or other practitioner (Name: ___________________________________) ☐ Other

GENERAL INFORMATION

**LHHP uses email and text messaging to communicate with out clients regarding appointment confirmations, office announcements (weather closings, etc.), and special offers. Please indicate your consent to contact you via:

Email: Y___ N___ Text Messaging: Y___ N___ **LHHP will never sell, lease, or otherwise disclose your email address/personal information.

Medication / Supplement / Food Reaction

What do you hope to achieve in your visit with us?______________________________________________________________

_______________________________________________________________________________________________________

If you had a magic wand and could erase three problems, what would they be?

1. _______________________________________________________________________________________________

2. _______________________________________________________________________________________________

3. ________________________________________________________________________________________________

When was the last time you felt well? ________________________________________________________________________

_______________________________________________________________________________________________________

Did something trigger your change in health? _________________________________________________________________

_______________________________________________________________________________________________________

What makes you feel worse? _______________________________________________________________________________

_______________________________________________________________________________________________________

What makes you feel better? _______________________________________________________________________________

_______________________________________________________________________________________________________

Please list current and ongoing problems in order of priority:

Describe Problem Mil

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Example: Post Nasal Drip X Elimination Diet X

ALLERGIES

COMPLAINTS AND CONCERNS

DISEASES/DIAGNOSIS/CONDITIONS Check appropriate box and provide date of onset

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GASTROINTESTINAL Pa

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GENITAL AND URINARY SYSTEM

☐ ☐ Irritable Bowel Syndrome_________________ ☐ ☐ Kidney Stones__________________________

☐ ☐ Inflammatory Bowel Disease______________ ☐ ☐ Gout__________________________________

☐ ☐ Crohn’s_______________________________ ☐ ☐ Interstitial Cystitis_______________________

☐ ☐ Ulcerative Colitis_______________________ ☐ ☐ Frequent Urinary Tract Infections___________

☐ ☐ Gastritis or Peptic Ulcer Disease___________ ☐ ☐ Frequent Yeast Infections_________________

☐ ☐ GERD (reflux)__________________________ ☐ ☐ Erectile Dysfunction_____________________

☐ ☐ Celiac Disease__________________________ Or Sexual Dysfunction

☐ ☐ Other _________________________________ ☐ ☐ Other ________________________________

CARDIOVASCULAR MUSCULOSKELETAL/PAIN

☐ ☐ Heart Attack___________________________ ☐ ☐ Osteoarthritis___________________________

☐ ☐ Other Heart Disease_____________________ ☐ ☐ Fibromyalgia___________________________

☐ ☐ Stroke________________________________ ☐ ☐ Chronic Pain___________________________

☐ ☐ Elevated Cholesterol_____________________ ☐ ☐ Other _________________________________

☐ ☐ Arrhythmia (irregular heart rate)____________ INFLAMMATORY/AUTOIMMUNE

☐ ☐ Hypertension (high blood pressure)_________ ☐ ☐ Chronic Fatigue Syndrome________________

☐ ☐ Rheumatic Fever________________________ ☐ ☐ Autoimmune Disease____________________

☐ ☐ Mitral Valve Prolapse____________________ ☐ ☐ Rheumatoid Arthritis_____________________

☐ ☐ Other _________________________________ ☐ ☐ Lupus SLE_____________________________

METABOLIC/ENDOCRINE ☐ ☐ Immune Deficiency Disease_______________

☐ ☐ Type 1 Diabetes_________________________ ☐ ☐ Herpes-Genital_________________________

☐ ☐ Type 2 Diabetes_________________________ ☐ ☐ Severe Infectious Disease_________________

☐ ☐ Hypoglycemia___________________________ ☐ ☐ Poor Immune Function___________________

☐ ☐ Metabolic Syndrome_____________________ (frequent infections)

(Insulin Resistance or Pre-Diabetes) ☐ ☐ Food Allergies__________________________

☐ ☐ Hypothyroidism (low thyroid)______________ ☐ ☐ Environmental Allergies__________________

☐ ☐ Hyperthyroidism (overactive thyroid)________ ☐ ☐ Multiple Chemical Sensitivities____________

☐ ☐ Endocrine Problems______________________ ☐ ☐ Latex Allergy__________________________

☐ ☐ Polycystic Ovarian Syndrome (PCOS)_______ ☐ ☐ Other _______________________________

☐ ☐ Infertility_______________________________ RESPIRATORY DISEASES

☐ ☐ Weight Gain____________________________ ☐ ☐ Asthma_______________________________

☐ ☐ Weight Loss____________________________ ☐ ☐ Chronic Sinusitis_______________________

☐ ☐ Frequent Weight Fluctuations______________ ☐ ☐ Bronchitis_____________________________

☐ ☐ Bulimia________________________________ ☐ ☐ Emphysema___________________________

☐ ☐ Anorexia_______________________________ ☐ ☐ Pneumonia____________________________

☐ ☐ Binge Eating Disorder____________________ ☐ ☐ Tuberculosis___________________________

☐ ☐ Night Eating Syndrome___________________ ☐ ☐ Sleep Apnea___________________________

☐ ☐ Eating Disorder (non-specific)______________ ☐ ☐ Other ________________________________

☐ ☐ Other _________________________________

CANCER SKIN DISEASES

☐ ☐ Lung Cancer____________________________ ☐ ☐ Eczema_______________________________

☐ ☐ Breast Cancer___________________________ ☐ ☐ Psoriasis______________________________

☐ ☐ Colon Cancer___________________________ ☐ ☐ Acne_________________________________

☐ ☐ Ovarian Cancer_________________________ ☐ ☐ Melanoma_____________________________

☐ ☐ Prostate Cancer_________________________ ☐ ☐ Skin Cancer____________________________

☐ ☐ Skin Cancer____________________________ ☐ ☐ Other ________________________________

☐ ☐ Other _________________________________

MEDICAL HISTORY

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☐ ☐ Depression____________________________ ☐ ☐ Mild Cognitive Impairment________________

☐ ☐ Anxiety_______________________________ ☐ ☐ Memory Problems_______________________

☐ ☐ Bipolar Disorder_______________________ ☐ ☐ Parkinson’s Disease_____________________

☐ ☐ Schizophrenia__________________________ ☐ ☐ Multiple Sclerosis_______________________

☐ ☐ Headaches____________________________ ☐ ☐ ALS__________________________________

☐ ☐ Migraines_____________________________ ☐ ☐ Seizures_______________________________

☐ ☐ ADD/ADHD__________________________ ☐ ☐ Other Neurological Problems______________

☐ ☐ Autism_______________________________

PREVENTIVE TESTS AND SURGERIES

DATE OF LAST TEST Check box if yes and provide date of surgery

Check box if yes and provide date ☐ Appendectomy______________________________

☐ Full Physical Exam__________________________ ☐ Hysterectomy +/- Ovaries_____________________

☐ Bone Density_______________________________ ☐ Gall Bladder_______________________________

☐ Colonoscopy_______________________________ ☐ Hernia____________________________________

☐ Cardiac Stress Test__________________________ ☐ Tonsillectomy______________________________

☐ EBT Heart Scan____________________________ ☐ Dental Surgery_____________________________

☐ EKG_____________________________________ ☐ Joint Replacement – Knee/Hip_________________

☐ Hemoccult Test-stool test for blood_____________ ☐ Heart Surgery - Bypass Valve_________________

☐ MRI_____________________________________ ☐ Angioplasty or Stent_________________________

☐ CT Scan__________________________________ ☐ Pacemaker_________________________________

☐ Upper Endoscopy___________________________ ☐ Other_____________________________________

☐ Upper GI Series____________________________ ☐ None

☐ Ultrasound_________________________________

INJURIES BLOOD TYPE:

☐ Back Injury ☐ Head Injury ☐ A ☐ B

☐ Neck Injury ☐ Broken Bones ☐ AB ☐ O

☐ Other_____________________________________ ☐ Rh+ ☐ Unknown

HOSPITALIZATION ☐ None

Date Reason

COMMENTS

MEDICAL HISTORY (continued)

OBSTETRIC HISTORY Check box if yes and provide number of

☐ Pregnancies___________ ☐ Caesarean____________ ☐ Vaginal Deliveries____________

☐ Miscarriage___________ ☐ Abortion_____________ ☐ Living Children______________

☐ Post-Partum Depression ☐ Toxemia ☐ Gestational Diabetes ☐ Baby Over 8 Pounds

☐ Breast Feeding for how long?____________

MENSTRUAL HISTORY

Age at First Period:______ Menses Frequency:_____ Length:_____ Pain: ☐Yes ☐No Clotting: ☐Yes ☐No

Has you period ever skipped? _____ For how long?___________

Last Menstrual Period:____________

Use of hormonal contraception such as: ☐ Birth Control Pills ☐ Patch ☐ Nuva Ring How long?____________

Do you use contraception? ☐Yes ☐No ☐ Condom ☐ Diaphragm ☐ IUD ☐ Partner Vasectomy

WOMEN’S DISORDERS/HORMONAL IMBALANCES

☐ Fibrocystic Breasts ☐ Endometriosis ☐ Fibroids ☐ Infertility

☐ Painful Periods ☐ Heavy Periods ☐ PMS

Last Mammogram:______________ ☐ Breast Biopsy/Date:_____________

Last PAP Test:______________ ☐ Normal ☐ Abnormal

Last Bone Density:______________ Results: ☐High ☐Low ☐Within Normal Range

Are you in Menopause? ☐Yes ☐No

Age at Menopause:____________

☐Hot Flashes ☐Mood Swings ☐Concentration/Memory Problems ☐Vaginal Dryness ☐Decreased Libido

☐Heavy Bleeding ☐Joint Pains ☐Headaches ☐Weight Gain ☐Loss of Control of Urine ☐Palpitations

☐Use of hormone replacement therapy How long?______________________

Have you had a PSA done? ☐Yes ☐No

PSA Level: ☐0-2 ☐2-4 ☐4-10 ☐> 10

☐ Prostate Enlargement ☐ Prostate Infection ☐ Change in Libido ☐ Impotence

☐ Difficulty Obtaining an Erection ☐ Difficulty Maintaining an Erection

☐ Nocturia (urination at night). How many times at night?____________

☐ Urgency/Hesitancy/Change in Urinary Stream ☐ Loss of Control of Urine

MEN’S HISTORY (for men only)

GYNECOLOGIC HISTORY (for women only)

Foreign Travel ☐Yes ☐ No Where?___________________________________________________________________

Wilderness Camping ☐Yes ☐ No Where?______________________________________________________________

Have you ever had severe: ☐ Gastroenteritis ☐ Diarrhea

Do you feel like you digest your food well? ☐Yes ☐ No

Do you feel bloated after meals? ☐Yes ☐ No

☐ Term ☐ Premature

Pregnancy Complications:__________________________________________________________________________________

Birth Complications:______________________________________________________________________________________

☐ Breast Fed How long?______________ ☐ Bottle Fed

Age at introduction of: Solid Foods:____________ Dairy:____________ Wheat:____________

Did you eat a lot of candy or sugar as a child? ☐Yes ☐ No

☐ Silver Mercury Fillings How many?____________

☐ Gold Fillings ☐ Root Canals ☐ Implants ☐ Tooth Pain ☐ Bleeding Gums

☐ Gingivitis ☐ Problems with Chewing

Do you floss regularly? ☐Yes ☐ No

GI HISTORY

PATIENT BIRTH HISTORY

DENTAL HISTORY

CURRENT MEDICATIONS

Medication Dose Frequency Start Date (month/year) Reason For Use

PREVIOUS MEDICATIONS (Last 10 years)

Medication Dose Frequency Start Date (month/year) Reason For Use

NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY)

Supplement & Brand Dose Frequency Start Date (month/year) Reason For Use

Have your medications or supplements ever caused you unusual side effects or problems? ☐Yes ☐ No

Describe:_____________________________________________________________________________________________

Have you had prolonged or regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Aspirin? ☐Yes ☐ No

Have you had prolonged use of Tylenol? ☐Yes ☐ No

Have you had prolonged or regular use of acid blocking drugs (Tagamet, Zantac, Prilosec, etc.) ☐Yes ☐ No

Frequent antibiotics ☐Yes ☐ No

Long term antibiotics ☐Yes ☐ No

Use of steroids (prednisone, nasal allergy inhalers) in the past ☐Yes ☐ No

Use of oral contraceptives ☐Yes ☐ No

MEDICATIONS

Check family members that apply

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Age (if still alive)

Age at death (if deceased)

Cancers

Colon Cancer

Breast or Ovarian Cancer

Heart Disease

Hypertension

Obesity

Diabetes

Stroke

Inflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing Spondylitis)

Inflammatory Bowel Disease

Multiple Sclerosis

Auto Immune Diseases (such as Lupus)

Irritable Bowel Syndrome

Celiac Disease

Asthma

Eczema / Psoriasis

Food Allergies, Sensitivities or Intolerances

Environmental Sensitivities

Dementia

Parkinson’s

ALS or other Motor Neuron Diseases

Genetic Disorders

Substance Abuse (such as alcoholism)

Psychiatric Disorders

Depression

Thyroid Problems

ADHD

Autism

Bipolar Disease

FAMILY HISTORY

NUTRITION HISTORY

Have you ever had a nutrition consultation? ☐Yes ☐ No

Have you made any changes in your eating habits because of your health? ☐Yes ☐ No Describe:_____________________

Do you currently follow a special diet or nutritional program? ☐Yes ☐ No

Check all that apply:

☐ Low Fat ☐ Low Carbohydrate ☐ High Protein ☐ Low Sodium ☐ Diabetic ☐ No Dairy ☐ No Wheat

☐ Gluten Restricted ☐ Vegetarian ☐ Vegan ☐ Low-Histamine

☐ Specific Program for Weight Loss/Maintenance Type:_______________________ ☐ Other_________________________

Height (feet/inches)_______________________________ Current Weight___________________________________

Usual Weight Range +/- 5 lbs_______________________ Desired Weight Range +/- 5 lbs______________________

Highest Adult Weight_____________________________ Lowest Adult Weight______________________________

Weight Fluctuations (>10 lbs) ☐Yes ☐ No Body Fat %______________________________________

How often do you weigh yourself? ☐ Daily ☐ Weekly ☐ Monthly ☐ Rarely ☐ Never

Have you ever had your metabolism (resting metabolic rate) checked? ☐Yes ☐ No If yes, what was it?________________

Do you avoid any particular foods? ☐Yes ☐ No If yes, types and reason_________________________________________

_______________________________________________________________________________________________________

If you could only eat a few foods a week, what would they be?_____________________________________________________

_______________________________________________________________________________________________________

Do you grocery shop? ☐Yes ☐ No If no, who does the shopping?______________________________________________

Do you read food labels? ☐Yes ☐ No

Do you cook? ☐Yes ☐ No If no, who does the cooking?_____________________________________________________

How many meals to you eat out per week? ☐ 0-1 ☐ 1-3 ☐ 3-5 ☐ > 5 meals per week

Check all the factors that apply to your current lifestyle and eating habits:

☐ Fast eater ☐ Significant other or family members have special

☐ Erratic eating pattern dietary needs or food preferences

☐ Eat too much ☐ Love to eat

☐ Late night eating ☐ Eat because I have to

☐ Dislike healthy food ☐ Have a negative relationship to food

☐ Time constraints ☐ Struggle with eating issues

☐ Eat more than 50% meals away from home ☐ Emotional eater (eat when sad, lonely, depressed,

☐ Travel frequently bored)

☐ Non-availability of healthy foods ☐ Eat too much under stress

☐ Do not plan meals or menus ☐ Eat too little under stress

☐ Reliance on convenience items ☐ Don’t care to cook

☐ Poor snack choices ☐ Eating in the middle of the night

☐ Significant other or family members don’t like healthy

foods☐ Confused about nutrition advice

The most important thing I should change about my diet to improve my health is:______________________________________

SOCIAL HISTORY

SMOKING

Currently Smoking? ☐Yes ☐ No If yes, how many years?_________ Packs per day:_________

Attempts to quit:____________

Previous Smoking: How many years?____________ Packs per day:____________

Second Hand Smoke Exposure?_________________

ALCOHOL INTAKE

How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits

☐ None ☐ 1-3 ☐ 4-6 ☐ 7-10 ☐ > 10 If none, skip to “Other Substances”

Previous alcohol intake? ☐ Yes (☐ Mild ☐ Moderate ☐High) ☐ None

Have you ever been told you should cut down your alcohol intake? ☐Yes ☐ No

Do you get annoyed when people ask you about your drinking? ☐Yes ☐ No

Do you ever feel guilty about your alcohol consumption? ☐Yes ☐ No

Do you ever take an eye-opener? ☐Yes ☐ No

Do you notice a tolerance to alcohol (can you ”hold” more than others)? ☐Yes ☐ No

Have you ever been unable to remember what you did during a drinking episode? ☐Yes ☐ No

Do you get into arguments or physical fights when you have been drinking? ☐Yes ☐ No

Have you ever thought about getting help to control or stop your drinking? ☐Yes ☐ No

OTHER SUBSTANCES

Caffeine Intake: ☐Yes ☐ No | Coffee cups/day: ☐ 1 ☐ 2-4 ☐ > 4 | Tea cups/day: ☐ 1 ☐ 2-4 ☐ > 4

Caffeinated Sodas or Diet Sodas Intake: ☐Yes ☐ No

12-ounce can/bottle: ☐ 1 ☐ 2-4 ☐ > 4

List favorite type (Ex. Diet Coke, Pepsi, etc.): __________________________________

Are you currently using any recreational drugs? ☐Yes ☐ No If yes, type:___________________________

Have you ever used IV or inhaled recreational drugs? ☐Yes ☐ No

EXERCISE

Current Exercise Program: (List type of activity, number of sessions/week, and duration)

Activity Type Frequency Per Week Duration in Minutes

Stretching

Cardio/Aerobics

Strength

Other (yoga, pilates, gyrotonics, etc.)

Sports or Leisure Activities

(golf, tennis, rollerblading, etc.)

Rate your level of motivation for including exercise in your life? ☐ Low ☐ Medium ☐ High

List problems that limit activity:_____________________________________________________________________________

_______________________________________________________________________________________________________

Do you feel unusually fatigued after exercise? ☐Yes ☐ No

If yes, please describe:_____________________________________________________________________________________

_______________________________________________________________________________________________________

Do you usually sweat when exercising? ☐Yes ☐ No

PSYCHOSOCIAL

Do you feel significantly less vital than you did a year ago? ☐Yes ☐ No

Are you happy? ☐Yes ☐ No

Do you feel your life has meaning and purpose? ☐Yes ☐ No

Do you believe stress is presently reducing the quality of your life? ☐Yes ☐ No

Do you like the work you do? ☐Yes ☐ No

Have you ever experienced major losses in your life? ☐Yes ☐ No

Do you spend the majority of your time and money to fulfill responsibilities and obligations? ☐Yes ☐ No

Would you describe your experience as a child in your family as happy and secure? ☐Yes ☐ No

STRESS/COPING

Have you ever sought counseling? ☐Yes ☐ No

Are you currently in therapy? ☐Yes ☐ No Describe:________________________________________________________

Do you feel you have an excessive amount of stress in your life? ☐Yes ☐ No

Do you feel you can easily handle the stress in your life? ☐Yes ☐ No

Daily Stressors: Rate on scale of 1-10

Work_____ Family_____ Social_____ Finances_____ Health_____ Other_____

Do you practice meditation or relaxation techniques? ☐Yes ☐ No How often?____________

Check all that apply: ☐ Yoga ☐ Meditation ☐ Imagery ☐ Breathing ☐ Tai Chi ☐ Prayer ☐ Other:_______________

Have you ever been abused, a victim of a crime, or experienced a significant trauma? ☐Yes ☐ No

SLEEP/REST

Average number of hours you sleep per night: ☐ > 10 ☐ 8-10 ☐ 6-8 ☐ < 6

Do you have trouble falling asleep? ☐Yes ☐ No

Do you feel rested upon awakening? ☐Yes ☐ No

Do you have problems with insomnia? ☐Yes ☐ No

Do you snore? ☐Yes ☐ No

Do you use sleeping aids? ☐Yes ☐ No Explain:____________________________________________________________

ROLES/RELATIONSHIP

Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Long term partnership ☐ Widow

List Children: Child’s Full Name Age Gender

Who is Living in Household? Number:________ Names:_______________________________________________________

Their Employement/Occupations:____________________________________________________________________________

Resources for emotional support?

Check all that apply: ☐ Spouse ☐ Family ☐ Friends ☐ Religious/Spiritual ☐ Pets ☐ Other:_____________________

Are you satisfied with your sex life? ☐Yes ☐ No

How well have things been going for you? Very Well Fine Poorly N/A

- Overall

- At school

- In your job

- In your social life

- With close friends

- With sex

- With your attitude

- With your boyfriend/girlfriend

- With your children

- With your parents

- With your spouse

Do you have known adverse food reactions or sensitivities? ☐Yes ☐ No If yes, describe symptoms:

_______________________________________________________________________________________________________

Do you have any food allergies or sensitivities? ☐Yes List all:________________________________________ ☐ No

Do you have an adverse reaction to caffeine? ☐Yes ☐ No

When you drink caffeine do you feel: ☐ Irritable or Wired ☐ Aches and Pains

Do you adversely react to (Check all that apply)

☐ Monosodium glutamate (MSG) ☐ Aspartame (NutraSweet) ☐ Caffeine ☐ Bananas ☐ Garlic ☐ Onion

☐ Cheese ☐ Citrus Foods ☐ Chocolate ☐ Alcohol ☐ Red Wine

☐ Sulfite Containing Foods (wine, dried fruit, salad bars) ☐ Preservatives (ex. Sodium Benzoate)

☐ Other:_______________________________________________________________________________________________

Which of these significantly affect you? (Check all that apply)

☐ Cigarette Smoke ☐ Perfumes/Colognes ☐ Auto Exhaust Fumes ☐ Other:_____________________________________

In your work or home environment, are you exposed to: ☐ Chemicals ☐ Electromagnetic Radiation ☐ Mold

Have you ever turned yellow (jaundiced)? ☐Yes ☐ No

Have you ever been told you have Gilbert’s Syndrome or a liver disorder? ☐Yes ☐ No

Explain:________________________________________________________________________________________________

Do you have a known history of significant exposure to any harmful chemicals such as the following:

☐ Herbicides ☐ Insecticides (frequent visits of exterminator) ☐ Pesticides ☐ Organic Solvents

☐ Heavy Metals ☐ Other_________________________________________________________________________________

Chemical Name, Date, Length of Exposure:____________________________________________________________________

Do you dry clean your clothes frequently? ☐Yes ☐ No

Do you or have you lived or worked in a damp or moldy environment or had other mold exposure? ☐Yes ☐ No

Do you have pets or farm animals? ☐Yes ☐ No

ENVIRONMENTAL AND DETOXIFICATION ASSESSMENT

Please check all current symptoms occurring or present in the past 6 months GENERAL DIGESTION

☐ Cold Hands & Feet ☐ Muscle Weakness ☐ Anal Spasms

☐ Cold Intolerance ☐ Tendonitis ☐ Bad Teeth

☐ Low Body Temperature ☐ Tension Headache ☐ Bleeding Gums

☐ Low Blood Pressure ☐ TMJ Problems ☐ Bloating of Lower Abdomen

☐ Daytime Sleepiness MOOD/NERVES ☐ Bloating of Whole Abdomen

☐ Difficulty Falling Asleep ☐ Agoraphobia ☐ Bloating After Meals

☐ Early Waking ☐ Anxiety ☐ Blood in Stools

☐ Fatigue ☐ Auditory Hallucinations ☐ Burping

☐ Fever ☐ Black-out ☐ Canker Sores

☐ Flushing ☐ Depression ☐ Cold Sores

☐ Heat Intolerance Difficulty ☐ Constipation

☐ Night Waking ☐ Concentrating ☐ Cracking at Corner of Lips

☐ Nightmares ☐ With Balance ☐ Cramps

☐ No Dream Recall ☐ With Thinking ☐ Dentures w/ Poor Chewing

HEAD, EYES & EARS ☐ With Judgment ☐ Diarrhea

☐ Conjunctivitis ☐ With Speech ☐ Alternating Diarrhea and

☐ Distorted Sense of Smell ☐ With Memory Constipation

☐ Distorted Taste ☐ Dizziness (Spinning) ☐ Difficulty Swallowing

☐ Ear Fullness ☐ Fainting ☐ Dry Mouth

☐ Ear Pain ☐ Fearfulness ☐ Excess Flatulence/Gas

☐ Ear Ringing/Buzzing ☐ Irritability ☐ Fissures

☐ Lid Margin Redness ☐ Light-headedness ☐ Food “Repeat” (Reflux)

☐ Eye Crusting ☐ Numbness ☐ Gas

☐ Eye Pain ☐ Other Phobias ☐ Heartburn

☐ Hearing Loss ☐ Panic Attacks ☐ Hemorrhoids

☐ Hearing Problems ☐ Paranoia ☐ Indigestion

☐ Headache ☐ Seizures ☐ Nausea

☐ Migraine ☐ Suicidal Thoughts ☐ Upper Abdominal Pain

☐ Sensitivity to Loud Noises ☐ Tingling ☐ Vomiting

☐ Vision Problems (other than glasses) ☐ Tremor/Trembling Intolerance to:

☐ Macular Degeneration ☐ Visual Hallucinations ☐ Lactose

☐ Vitreous Detachment EATING ☐ All Dairy Products

☐ Retinal Detachment ☐ Binge Eating ☐ Wheat

MUSCULOSKELETAL ☐ Bulimia ☐ Gluten (Wheat, Rye, Barley)

☐ Back Muscle Spasm ☐ Can’t Gain Weight ☐ Corn

☐ Calf Cramps ☐ Can’t Lose Weight ☐ Eggs

☐ Chest Tightness ☐ Can’t Maintain Healthy Weight ☐ Fatty Foods

☐ Foot Cramps ☐ Frequent Dieting ☐ Yeast

☐ Joint Deformity ☐ Poor Appetite ☐ Liver Disease/Jaundice

☐ Joint Pain ☐ Salt Cravings (yellow eyes/ skin)

☐ Joint Redness ☐ Carbohydrate Craving (breads, pasta) ☐ Abnormal Liver Function Tests

☐ Joint Stiffness ☐ Sweet Cravings (candy, cookies, cakes) ☐ Lower Abdominal Pain

☐ Muscle Pain ☐ Chocolate Cravings ☐ Mucus in Stools

☐ Muscle Spasms ☐ Caffeine Dependency ☐ Periodontal Disease

☐ Muscle Stiffness ☐ Sore Tongue

☐ Muscle Twitches – around eyes ☐ Strong Stool Odor

☐ Muscle Twitches – Arms or Legs ☐ Undigested Food in Stools

SYMPTOM REVIEW

SKIN PROBLEMS ☐ Hair Unmanageable? ☐ Heart Murmur

☐ Acne on Back ☐ Hands ☐ Irregular Pulse

☐ Acne on Chest ☐ Any Cracking? ☐ Palpitations

☐ Acne on Face ☐ Any Peeling? ☐ Phlebitis

☐ Acne on Shoulders ☐ Mouth/Throat ☐ Swollen Ankles/Feet

☐ Athlete’s Foot ☐ Scalp ☐ Varicose Veins

☐ Bumps on Back of Upper Arms ☐ Any Dandruff? URINARY

☐ Cellulite ☐ Skin in General ☐ Bed Wetting

☐ Dark Circles Under Eyes LYMPH NODES ☐ Hesitancy (trouble getting started)

☐ Ears Get Red ☐ Enlarged/neck ☐ Infection

☐ Easy Bruising ☐ Tender/neck ☐ Kidney Disease

☐ Lack of Sweating ☐ Other Enlarged/Tender ☐ Leaking/Incontinence

☐ Eczema ☐ Lymph Nodes ☐ Pain/Burning

☐ Hives NAILS ☐ Prostate Infection

☐ Jock Itch ☐ Bitten ☐ Urgency

☐ Lackluster Skin ☐ Brittle MALE REPRODUCTIVE

☐ Moles w/Color/Size Change ☐ Curve Up ☐ Discharge From Penis

☐ Oily Skin ☐ Frayed ☐ Ejaculation Problem

☐ Pale Skin ☐ Fungus-Fingers ☐ Genital Pain

☐ Patchy Dullness ☐ Fungus-Toes ☐ Impotence

☐ Rash ☐ Pitting ☐ Prostate or Urinary Infection

☐ Red Face ☐ Ragged Cuticles ☐ Lumps in Testicles

☐ Sensitivity to Bites ☐ Ridges ☐ Poor Libido (Sex Drive)

☐ Sensitivity to Poison Ivy/Oak ☐ Soft FEMALE REPRODUCTIVE

☐ Shingles ☐ Thickening of fingernails ☐ Breast Cysts

☐ Skin Darkening ☐ Thickening of toenails ☐ Breast Lumps

☐ Strong Body Odor ☐ White Spots/Lines ☐ Breast Tenderness

☐ Hair Loss RESPIRATORY ☐ Ovarian Cyst

☐ Vitiligo ☐ Bad Breath ☐ Poor Libido (Sex Drive)

ITCHING SKIN ☐ Bad Odor in Nose ☐ Vaginal Discharge

☐ Skin in General ☐ Cough-Dry ☐ Vaginal Odor

☐ Anus ☐ Cough-Productive ☐ Vaginal Itch

☐ Arms ☐ Hoarseness ☐ Vaginal Pain with Sex

☐ Ear Canals ☐ Sore Throat Premenstrual:

☐ Eyes Hay Fever ☐ Bloating Breast Tenderness

☐ Feet ☐ Spring ☐ Carbohydrate Cravings

☐ Hands ☐ Summer ☐ Chocolate Cravings

☐ Legs ☐ Fall ☐ Constipation

☐ Nipples ☐ Change of Season ☐ Decreased Sleep

☐ Nose ☐ Nasal Stuffiness ☐ Diarrhea

☐ Penis ☐ Nose Bleeds ☐ Fatigue

☐ Roof of Mouth ☐ Post Nasal Drip ☐ Increased Sleep

☐ Scalp ☐ Sinus Fullness ☐ Irritability

☐ Throat ☐ Sinus Infection Menstrual:

SKIN, DRYNESS OF ☐ Snoring ☐ Cramps

☐ Eyes ☐ Wheezing ☐ Heavy Periods

☐ Feet ☐ Winter Stuffiness ☐ Irregular Periods

☐ Any Cracking? CARDIOVASCULAR ☐ No Periods

☐ Any Peeling? ☐ Angina/chest pain ☐ Scanty Periods

☐ Hair ☐ Breathlessness ☐ Spotting Between

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

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

Significantly modify your diet……………………………………….☐5 ☐4 ☐3 ☐2 ☐1

Take several nutrition supplements each day…………………………☐5 ☐4 ☐3 ☐2 ☐1

Keep a record of everything you eat each day……………………… ☐5 ☐4 ☐3 ☐2 ☐1

Modify your lifestyle (e.g., work demands, sleep habits)……………☐5 ☐4 ☐3 ☐2 ☐1

Practice a relaxation technique……………………………………….☐5 ☐4 ☐3 ☐2 ☐1

Engage in regular exercise……………………………………………☐5 ☐4 ☐3 ☐2 ☐1

Have periodic lab tests to assess your progress………………………☐5 ☐4 ☐3 ☐2 ☐1

Comments______________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Rate on a scale of 5 (very confident) to 1 (not confident at all):

How confident are your of your ability to organize and follow through on the above health related activities?

☐5 ☐4 ☐3 ☐2 ☐1

If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in

the above activities?______________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Rate on a scale of 5 (very supportive) to 1 (very unsupportive):

At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

☐5 ☐4 ☐3 ☐2 ☐1

Comments______________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Rate on a scale of 5 (very frequent contact) to 1 (very infrequent contact):

How much on-going support and contact (e.g., telephone consults, e-mail correspondence) from our professional staff would be helpful to you

as you implement your personal health program? ☐5 ☐4 ☐3 ☐2 ☐1

Comments______________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

READINESS ASSESSMENT

It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please

complete this Diet Diary for 3 consecutive days including one weekend day.

• Describe the food or beverage as accurately as possible e.g., milk- what kind? (whole, 2%, nonfat); toast

(whole wheat, white, buttered); chicken (fried, baked, breaded); coffee (decaffeinated with sugar and ½ and ½).

• Record the amount of each food or beverage consumed using standard measurements such as 8 ounces, ½

cup, 1 teaspoon, etc.

• Include any added items. For example: tea with 1 teaspoon honey, potato with 2 teaspoons butter, etc.

• Record all beverages, including water, coffee, tea, sports drinks, sodas/diet sodas, etc.

• Include any additional comments about your eating habits on this form (ex. craving sweet, skipped meal and

why, when the meal was at a restaurant, etc.).

• Please note all bowel movements and their consistency (regular, loose, firm, etc.)

Name:____________________________________________________ Date:_______________________________________

Daily Exercise (Type of Activity / Time of Day / Duration): ______________________________________________________

_______________________________________________________________________________________________________

Daily Bowel Movements:__________________________________________________________________________________

TIME FOOD/ BEVERAGE / AMOUNT COMMENTS

3 DAY DIET DIARY INSTRUCTIONS

DIET DIARY – DAY 1

Name:____________________________________________________ Date:_______________________________________


_______________________________________________________________________________________________________



Name:____________________________________________________ Date:_______________________________________


_______________________________________________________________________________________________________





OTHER COMMENTS QUESTIONS OR CONCERNS:

Medical Symptoms Questionnaire (MSQ)

Name __________________________________________ Date _________________

Rate each of the following symptoms based upon your typical health profile for the past 30 days. Add and total the scores.

Point Scale 0 - Never or almost never have the symptom 3- Frequently have it, effect is not severe

1 - Occasionally have it, effect is not severe 4- Frequently have it, effect is severe

2 - Occasionally have it, effect is severe

________ Headaches

________ Faintness

________ Dizziness

________ Insomnia Total ________

________ Watery or itchy eyes

________ Swollen, reddened or sticky eyelids

________ Bags or dark circles under eyes

________ Blurred or tunnel vision

(does not include near or far-sightedness) Total ________

________ Itchy ears

________ Earaches, ear infections

________ Drainage from ear

________ Ringing in ears, hearing loss Total ________

________ Stuffy nose

________ Sinus problems

________ Hay fever

________ Sneezing attacks

________ Excessive mucus formation Total ________

________ Chronic coughing

________ Gagging, frequent need to clear throat

________ Sore throat, hoarseness, loss of voice

________ Swollen or discolored tongue, gums, lips

________ Canker sores Total ________

________ Acne

________ Hives, rashes, dry skin

________ Hair loss

________ Flushing, hot flashes

________ Excessive sweating Total ________

________ Irregular or skipped heartbeat

________ Rapid or pounding heartbeat

________ Chest pain Total ________

HEAD

EARS

NOSE

MOUTH/THROAT

SKIN

EYES

HEART

________ Chest congestion

________ Asthma, bronchitis

________ Shortness of breath

________ Difficulty breathing Total ________

________ Nausea, vomiting

________ Diarrhea

________ Constipation

________ Bloated feeling

________ Belching, passing gas

________ Heartburn

________ Intestinal/stomach pain Total ________

________ Pain or aches in joints

________ Arthritis

________ Stiffness or limitation of movement

________ Pain or aches in muscles

________ Feeling of weakness or tiredness Total ________

________ Binge eating/drinking

________ Craving certain foods

________ Excessive weight

________ Compulsive eating

________ Water retention

________ Underweight Total ________

________ Fatigue, sluggishness

________ Apathy, lethargy

________ Hyperactivity

________ Restlessness Total ________

________ Poor memory

________ Confusion, poor comprehension

________ Poor concentration

________ Poor physical coordination

________ Difficulty in making decisions

________ Stuttering or stammering

________ Slurred speech

________ Learning disabilities Total ________

________ Mood swings

________ Anxiety, fear, nervousness

________ Anger, irritability, aggressiveness

________ Depression Total ________

________ Frequent illness

________ Frequent or urgent urination

________ Genital itch or discharge

Total ________

GRAND TOTAL TOTAL _________

LUNGS

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

Loudoun Holistic Health Partners, 2019

LHHP Financial Policy Please read through carefully and sign the bottom to acknowledge understanding of our financial policies.

1. In order to provide comprehensive care and extended office visits, we do not participate with insurance.We are happy to provide the receipt necessary for you to file the claim for reimbursement but submission ofthe claim is the patient’s responsibility. It should be pointed out that we cannot assure a patient that anyinsurance company will reimburse for our services. Caseload demands do not allow time for this office torespond to insurance company requests for information. We will provide you a copy of medical records thatyou can forward to your insurance company. We are not obligated to take action on your behalf against aninsurance carrier for collection of negotiating your insurance claim. We will not contact your insurancecompany unless there has been an error by this office.2. Please note the following LHHP policies:

A) Unless included as part of Concierge Membership benefits package, payment for any LHHP service is dueat the time of service.B) In-Office and phone consults are billed in 15-minute increments (rounded up to next increment).C) Fees for laboratory testing vary depending on cost of panel selected. Please consult with your insurancecompany regarding your lab testing benefits. (See LHHP Lab Testing Policy for more info.)D) In-house labs (i.e. urinalysis, strep) are charged to patient at time of visit.E) Kindly provide 48-hours notice if you are not able to make your scheduled appointment.F) Appointments for IV Infusion Services must be canceled at least 24 hours prior to appointmentOR WILL BE CHARGED AT FULL PRICE.

3. We accept all major credit cards (a 3.5% processing fee will be added), cash, or check. A $35 fee will becollected for any failed credit card payment (for any reason).

4. Payment is expected in full at time of visit.

5. Phone consults are charged to the credit card on file after the consultation is finished. We will then mail youthe receipt and treatment plan that Dr. Stewart makes for you. If you have any questions please feel free tocontact our front office staff.

6. We accept ACH payments. A $35 fee will be collected for any failed ACH payment (for any reason).

7. Accounts are considered past due after the date of service. After 90 days, past due accounts willautomatically be turned over for collection. Please be aware that in the event that your account is referred toan attorney for collection, you will be responsible for and must pay our bill, all court costs, private processingfees, and other costs of collection, as well as attorney’s fees in the amount of 33 1/3% of the bill, which sumyou agree is reasonable. We also reserve the right to charge interest (up to 18%) on past due accounts.8. Opened supplements cannot be refunded or exchanged.

I acknowledge that I have read the financial policy and I agree to abide by its terms.

___________________________ _________________________ Signature Name (printed)

__________________ Date

Patient Acknowledgment of LHHP Privacy Policy

I understand that, under the Health Insurance Portability & Accountability Act (HIPPA), I have certain rights to privacy regarding my protected health information.

I have been informed by you of your Notice of Privacy Practices (Copy attached). I have been given the right to review such Notice of Privacy Practices prior to signing this consent form. I understand this practice has the

right to change its Notice of Privacy Practices from time to time and that I may contact this practice at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to

my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name:__________________________________________________________________

Signature:_____________________________________________________________________

Relationship to Patient:___________________________________________________________

Date:_________________________________________________________________________

I authorize the staff of Loudoun Holistic Health Partners to disclose medical information (i.e. lab results) by phone and/or in person to the following people (please provide names and phone number).

1.____________________________________________________________________________

2. ____________________________________________________________________________

3.____________________________________________________________________________



LHHP Medical Information Release Form

PLEASE NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to any person except when you have authorized our office to do so.

Please sign below if you would like LHHP to obtain medical records from a previous doctor(s) and hospital(s) in order to provide more complete care. You may also choose to have LHHP send copies of your office visit notes

to other providers that care for you.

AUTHORIZATION FOR MEDICAL INFORMATION (Release TO LHHP)

I,________________________________________________________, authorize (your full name and date of birth)

__________________________________________________________, to furnish David Stewart, MD or Anne Stewart, MD or their representative, any and all information in regard to any manner of treatment rendered to me, including blood tests, X-rays, findings, and diagnoses.

Date______________________________ Signature___________________________

AUTHORIZATION FOR MEDICAL INFORMATION (Release FROM LHHP)

This will authorize David Stewart, MD or Anne Stewart, MD of Loudoun Holistic Health Partners to furnish

______________________________________________________________________

______________________________________________________________________ (doctor/hospital name, address, phone number)

office visit notes, blood tests, X-rays, and any other pertinent information.

Name___________________________________ Date of Birth___________________

Date___________________ Signature_______________________________________

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Office Etiquette for LHHP Patients

Everyone at LHHP strives to ensure that your visit with us is as productive and effective as it can possibly be. For that reason, it is important for you, as well as for other patients visiting at the same time you are, to adhere to the following policies.

1. Silence ALL electronic devices while in our office.a. If you must take a call, please notify the receptionist and step out of the office.

2. Please leave your children at home, unless they are the scheduled patient.a. They may distract you and/or your LHHP provider and make your visit less productive.b. If you must bring them to the office:

i. They must not be left unattended. An adult must be present with them at all times.ii. If your children must be left unattended, LHHP reserves the right to reschedule your appointment.

iii. If your children are left unattended, LHHP will hold you responsible for any damages they cause to the officefurniture, equipment, etc.

3. Please do not ask the receptionist or the nurse questions about your medical care.a. They are NOT (except in certain circumstances) authorized to give medical advice of ANY kind.b. They are not aware of your care plan. This may lead to misinformation which may cause harm.

4. Please do not wear any perfumes, colognes, or other scented cosmetics or skincare products.a. Many LHHP patients have multiple sensitivities to odors.

5. LHHP will not provide medical advice to ANY person who is not an established LHHP patient.a. It is illegal for us to do so. It is unsafe for us to do so because we do not know the entire case.b. This includes your family members, best friends, etc.

6. LHHP expects its staff and its patients to extend the utmost respect and patience to one another.a. From Dr. Dave and Dr. Anne:

i. We, and our staff, will provide you with the best care possible. However, we are not perfect. We promiseto extend to you the utmost grace and patience possible (in accordance with our established officepolicies). In return, we expect the same from you. We will not tolerate rudeness or disrespectful behavior(including taking anangry/disrespectful tone or using disrespectful language) to our staff under ANY circumstance. Also, wepromise not to tolerate rudeness from our staff to you under ANY circumstance.

ii. It will be at the discretion of the LHHP Officers (David Stewart, MD, Anne Stewart, MD, and other LHHPAdministrators) to determine if any behavior is inappropriate. Violations of this policy will be handled asfollows:

1. First violation: A warning will be issued both verbally and in writing (by certified mail).2. Second violation: Immediate dismissal from LHHP. Notification will be provided both verbally and

in writing (by certified mail).iii. If you feel you have been treated inappropriately by anyone at LHHP, please contact David Stewart, MD to

discuss the matter.

I acknowledge that I have read the office policy and I agree to abide by its terms.

________________________________________ Print Name

________________________________________ Signature

__________________ Date


Dear esteemed LHHP patients,

As you know we continue to offer more services at Loudoun Holistic Health Partners. We are so pleased that our services are helping to achieve wellness!

Having more on-site services requires a higher level of attention to patients using those services. Our goal is to provide a safe and efficient experience for those patients. Some of the services we offer, such as IV infusion services, require the focused attention of our expert nursing staff to ensure each patient’s comfort and safety. Also, as more patients check in and out for these services, they occupy the dedicated attention of our caring reception staff.

To effectively meet the needs of our on-site patients, we may turn the office phones to voicemail from time to time. Rest assured that we will retrieve the voice messages frequently (at least on the hour) and return calls promptly. We will use the following policy for responding to voice messages:

• Urgent medical calls will be returned as soon as possible on the same business dayo If you have a medical emergency, call 911. DO NOT LEAVE A VOICE MESSAGE

• Non-urgent medical calls may be returned the next business dayo Examples include prescription refill requests, questions for the provider of a non-acute medical

nature, etc.

• Non-medical calls may be returned within two business dayso Examples include billing questions, appointment scheduling issues, requests for forms, etc.

We believe this policy will ultimately improve care for all LHHP patients. As described above, it allows our staff to provide the necessary care and attention to our patients receiving on-site services. At the same time it allows our staff to respond to telephone calls more effectively by granting time for us to prepare an effective response to your specific need.

Thank you for being our patients. We look forward to continuing to serve you.

Sincerely,

David Stewart, MD

I hereby acknowledge this Loudoun Holistic Health Partners policy.

____________________________________ __________________________________ Signature of patient or guardian Date

Relationship to patient: _________________________________________________________

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY - THIS IS YOUR COPY - KEEP FOR YOUR RECORDS

If you have any questions about this Notice, please contact our Privacy Officer at

209 Old Waterford Rd, NW Leesburg, VA 20176 or (703) 779-2801

1. Purpose.

We understand that medical information about you and your health is personal and we are committed to protecting that information. We create a record of the care and services you receive at Loudoun Holistic Health Partners, in order to provide you with quality care and to comply with certain legal requirements.

This Notice of Privacy Practices describes how we may use and disclose medical information about you, including demographic information, that may identify you and your related health care services to carry out your treatment, obtain payment for our services, to perform the daily health care operations of this practice and for other purposes that are permitted or required by law. This notice also describes your rights to access and control your medical information. For the purpose of this document, "you" refers to the patient.

We are required to abide by the terms of this Notice of Privacy Practices.

2. Written Acknowledgement.

You will be asked to sign a written statement acknowledging that you have received and reviewed a copy of this notice. The acknowledgement only serves to create a record that you have received a copy of the notice.

3. Changes 1D this Notice.

We may change the terms of our Notice, at any time. The new Notice will be effective for all medical information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. To request a revised copy, you may call our office and request that a' revised copy be sent to you in the mail or you may ask for one at the time of your next appointment.

4. How We May Use and Disclose MedicallnfOl'IDation about You.

The following categories describe the different ways that Loudoun Holistic Health Partners may use and disclose your medical information and a few examples of what we mean. These examples are not meant to describe every circumstance, but to give you an idea of the types of uses and disclosures that may be made by our office. Other uses and disclosures of your medical information that are not listed or described below will be made only with your written anthorization. You may revoke this authorimtion, at any time, in writing, but it will not apply to any actions we have already taken.

Please keep in mind that these examples pertain to medical information for your child, or yourself, if you are a patient who is of legal age.

✓ For your Treatment: Your medical informationmay be used and disclosed by us for the purpose of providing medical treatment to you or for another health care provider providing medical treatment toyou. For example, a nurse obtains treatment

information about you and documents it in your medical reoord and the physician has access to that information. .In addition, your medical information may be provided to a physician to whom you have been referred or are otherwise seeing to ensure that the physician has the necessary information to diagnose or treat you.

✓ For your Emergency Treatment: Your medical and certain demographic information may be used in order for us to provide emergency treatment to you. This information may be transmitted via pager, cell phone, or email. For example, if you need to speak tothe physician on-call at night, your natne, phonenumber, and nature of the emergency may becommunicated to the doctor via an alpha-numeric pager. This will allow for the quickest response toyour emergencies.

✓ To Obtain Payment for onr Services: Your medical information ritay be used and disclosed by us to obtain payment for your health care bills or to assist another health care provider in obtaining pll)'ffiCIII for their health care bills. For example, we may submit requests for payment to your health insurance company for the medical services that you received. We may also disclose your medical information as required byyour health insurance plan before it approves or paysfor the health care services we recommend for you.

✓ For our Health Care Operations: Your medicalinformation may be used and disclosed by us to support our daily operations. These health careoperation activities include, but are not limited to, quality assessment activities, employee rei,;iew activities, training of medical students, licensing, fundraising activities, and conducting or arranging forother business activities. For example, we maydisclose your medical information to medical school students that see patients at our office. We may also use the medical information we have to determine where we can make improvements in the services and care we offilr.

✓ For the Health Care Operation• of Other HealthCare Providers: We may also use your medical information to assist another health care provider treating you with its quality improvement activities, evaluation of the health care professionals or for ftaud and abuse detection or compliance. For exatnple, we may disclose your medical information to another physician to assist in its efforts to make sure it iscomplying with all rules related to o�ting a medical Pract!ce.

✓ For Appointment Reminders and Scheduling: We may use or disclose your medical information to contact you to remind you of your appointment, by mail, telephone, or email. Our message will include the. name of our practice or the name of our physician as well as the date and time for your appointment or areminder that an appointment needs to be scheduled.

✓ For Lah Result Notification: We may use or disclose your medical information to contact youregarding lab test results, by mail, telephone, or email. Our message will include the name of our practice or

the name of our physician as well as whether the lab test was positive or negative.

✓ For Referral Notification: We may leave youinformation regarding referral appointments/testing and referral numbers via mail, telephone, or email.

✓ To Provide you with Treatment Alternatives: Wemay use or disclose your medical information to provide you with information about treatment alternatives or other health-related benefits and services that may be ofinterest to you. For example, we may contact several home health agencies or physical therapy providers to discuss the services they provide when we have a patient who needs those services.

✓ To our Bnsiness Associates: We will share yourmedical information with third party "businessassociates" that perform various activities (e.g., billing,transcription services) for the practice. Whenever anarrangement between our office and a business associate involves the use or disclosure of your medical information, we will have a written agreement that contains terms that will protect the privacy of your medical information. For example, Loudoun HolisticHealth Partners may hire a billing company to submitclaims to your health care insurer. Your medicalinformation will be disclosed to this billing company,but a written agreement between our office and thebilling company will prohibit the billing company fromusing your medical information in any way other thanwhat we allow.

✓ For Education/Networking/FundraisingActivities: We may use or disclose your demographicinformation and the dates that you received treatmentfrom us in order to contact you regarding educational orfundraising opportunities supported by our office. Anexample of this would l!e inviting patients diagnosedwith fibromyalgia to a presentation on that topic. If you do not want to receive these materials, please contactthe Privacy Officer and request that these fundraisingmaterials not be sent to you.

✓ Others Involved in your Health Care: Unless youobject, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your medical information that directly relates to that person's involvement in your health care. If you areunable to agree or object to such a disclosure, we maydisclose such information as necessary if we determine that it is in your best interest based on our professionaljudgment We may use or disclose your medical information to notify a family member or any otherperson that is responsible for your care of your location and general health condition. Finally, we may use or disclose your medical information to an authorm:d public or private entity to assist in (I) disaster reliefefforts and (2) to coorljinate uses and disclosures tofamily or other individuals involved in your health care.

✓ A. Required by Law: We may use or disclose your medical information to the extent that the use or disclosure is required by law. The use or disclosure willbe made in compliance with the law and will be

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limited to the relevant requirements of the.laws. You will be notified, as required by law, of any such uses or disclosures.

✓ For Public Health Activities: We may discloseyour medical information for public health activitiesand purposes to a public health authority that is permitted by law to collect or receive the information.The disclosure will be made for the purpose ofcontrolling disease, injury or disability. We may alsodisclose your medical information, if directed by thepublic health authority, to any other governmentagency that is collaborating with the public healthauthority.

✓ As Required by the Food and DrugAdministration: We may disclose your medicalinformation to a person or company required by the

• Food and Drug Administration to report adverseevents, product defects or problems, biologic product deviations, or to track products; to enable product recalls; to make repairs or replacements; or to conduct post marketing surveillance, as required.

✓ For Communicable Disease Exposure: We maydisclose your medical Information, If authorized bylaw, to a person who may have been exposed to acommunicable disease or may otherwise be at risk ofcontracting or spreading the disease or condition.

✓ To your Employer: We may disclose yourmedical information concerning a work related injuryor illness to your employer if you are covered underyour employer's policy in order to conduct anevaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-relatedinjury, in accordance with the law.

✓ For Abuse or Neglect:· We may disclose your.medical information to a public health authority that isauthorized by law to receive reports of child or adultabuse or neglect In addition, we may disclose yourmedical information if we believe that you have been avictim of abuse, neglect or domestic violence as maybe required or permitted by Virginia and/or federallaw.

✓ For Health Oversight: We may disclose yourmedical information to a health oversight agency foractivities authorized by law. Oversight agenciesseeking this information include government agenciesthat oversee the health care system, government benefitprograms (such as Medicare or Medicaid), othergovernment regulatory programs, and civil rights laws.

✓ In Legal Proceedings: We may disclose yourmedical information in the course of any judicial oradministrative proceeding, in response to an order of acourt or administrative tribunal (to the extent suchdisclosure is expressly authorized), and in certainconditions in response to a subpoena or other lawfulrequest.

✓ For'l,aw Enforcement: We may also discloseyour medical information, so long as all legalrequirements are met, for law enforcement purposes.Examples of these law enforcement purposes include(I) information requests for identification and locationpurposes, (2) pertaining to victims of a crime, (3)suspicion that death has occurred as a result of criminalconduct, (4) in the event that a crime occurs on thepremises of the Practice, and (S) in a medicalemergency where it is likely that a crime has occurred.

✓ To Coroners, to Fuueral Directors, aud forOrgan Donation: We may disclose your medicalinformation to a coroner or medical examiner foridentification purposes, determining cause of death orfor the coroner or medical examiner to perform otherduties authorized by law. We may also disclose

medical information to a funeral director in order to permit the fimeral director to carry out its duties. We may disclose such information in reasonable anticipation of death. Your medical information may be used and disclosed for cadaveric organ, eye, or tissue donation purpose.

✓ For Research: We may disclose your medicalinformation to researchcfs when their research hasbeen established as required by federal and state law.

✓ Due to Criminal Activity: Consistent withapplicable federal and state laws, we may disclose yourmedical information if we believe that the use ordisclosure is necessary to prevent or lessen a seriousand imminent threat to the health or safety of a personor the public. We may also disclose your medicalinformation if it is necessary for law enforcementauthorities to identify or apprehend an individual.

✓ For Military Activity and National Security:When the appropriate conditions apply, we may use ordisclose medical information of individuals who areArmed Forces personnel (I) for activities deemednecessary by appropriate military commandauthorities; (2) for 1he purpose of a determination bythe Department of Veterans Affairs of your eligibilityfor benefits; or (3) to foreign military authority if youare a member of that foreign military services. Wemay also disclose your medical inrormation toauthorized federal officials for conducting nationalsecurity and intelligence activities, including for theprovision of protective services to the President orothers legally authorized.

✓ For Workers' Compensation: Your medicalinfomtation may be disclosed by us as authorized tocomply with workers' compensation laws and othersimilar legally established programs.

✓ Regarding Inmates: We may use or disclose yourmedical information if you are an inmate of acorrectional facility and your physician created orreceived your medical information in the course ofproviding care to you.

✓ For Required Uses and Disclosures: Under thelaw, we must make disclosures to you and, whenrequired by the Secretary of the Department of healthand Hmnan Services, to investigate or determine ourcompliance with the requirements of the HealthInsurance Portability and Accountability Act and itsregulations.

5. Your Rights.

Following is a statement of your rights with respect to your medical information and a brief description of how you may exercise these rights.

You have the right to inspect and ropy your medical informatio1L You may inspect and obtain a copy of your medical information that we maintain. The information may contain medical and billing records and any other records that we use for making decisions about you. However, under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled related to a civi� crlmlnal, or administrative action; and medical information that is subject to law that prohibits access to medical information in certain circumstances. We may deny your request to inspect your medical information. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

You have the right to request a restriction of your medleal Information. This means you may ask us not to use or disclose any part of your medical information

for the purposes of treatment, payment or health care operations. You may also request that any part of your medical information not be disclosed to family members or friends wbo may be involved in your care. Your request must state the specific restriction requested and to whom you want the restriction to apply.

We are not required to agree to your request. If we agree to the requested restriction, we may not use or disclose your medical information in violation of that restriction unless it is needed to provide emergency treatment or Wlless we otherwise notify you that we can no longer honor your request. With lhis in mind, please discuss any restriction you with to request.with you physician. Please request all restrictions in writing to our Privacy Officer.

You have the right to request that we acrommodate you in communicating roofidentlal medical information. We will accommodate reasonable requests, but we may condition this accommodation by asking you for information as to how payment will be handled or other information necessary to honor your request. Please make this request in writing to our Privacy Officer.

You may have the right to ask us to amend your medical information. You may request an amendment of your medical information as long as we maintain this information. In certain cases, we may deny your request for amendment If we deny your request for an amendment, you have the right to file a disagreement with us and we may respond in writing to you. Please contact our Privacy Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures we have made, if any, of your medical informatio1L This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made pursuant to your authorization (permission), made directly to you, to family members or friends involved in your care, or for appointment notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2006. You may request a shorter time ftame. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper ropy of this notice from us. If you would like a paper copy of this notice, please request one from our Privacy Officer or request one when you are in our offices.

6. Complaints.

You may complain to us if yon believe your privacy rights have been violated by us. To file a complaint, please contact our Privacy Officer who will be happy to assist you. You may file a complaint with us by notifying our Privacy Officer of your complaint We will not retaliate against you for filing a complaint. If you do not wish to file a complaint with us, you may contact the Secretary of Health and Human Services.

7. Privacy Contact.

If you have any questions about this Notice or require additionfll information, please contact our Privacy Officer, at (703) 779-2801 or at 209 Old Waterford Rd, NW,Leesburg, Virginia 20176. Our Privacy Officer is available during normal business hours to discuss your privacy questions, concerns or complaints.

8. Effective Date. This notice was published andbecomes effective on April 14, 2006.

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