New Patient Intake Forms

Client Intake Form

Name:

Age:

Birth date : 

Address:

City  State/Zip:

Email:

Home Phone:

Work Phone:

Cell Phone:

Occupation 

Employer 

Marital Status 

Name of Spouse/Partner

How Long Have Both of You Been Together? 

Religion/Spiritual Practice 

If Client is a Minor, Name of Responsible Adult    

Reason for Visit: _____________________________________________________

___________________________________________________________________

What have you tried to help this problem: ___________________________________________________________________

What works_______________________________________________________

What makes it worse:_______________________________________________

Do You Smoke? How Much? Do You Drink?

How Much per week?__________________________________________________

Do You Take Drugs? If yes, what kind? 

How often per week? ___________________________________________________

Date of Last Medical Examination and Reason:

Are You Now Under a Doctor’s Care?

If yes, Doctor’s name:

Reason for Doctor’s Care: 

Are You Taking Any Medication?

If yes, please list?

 

Reason for Medication(s):

 

Supplements taking: ________________________________________________________

Reason: _____________________________________________________________________

 

Have You Ever Been Hospitalized for a Physical Illness?

Describe: ________________________________________________________________

 

Surgeries (including tonsil removal) ___________________________________________

_________________________________________________________________________

Have you ever been hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc?  Describe:

________________________________________________________________________

Exercise? _________________________

How often? ________________________________

Diet (breakfast, lunch, dinner and snacks) B________________________________________________________________________

L _________________________________________________________________________

D _________________________________________________________________________

S _________________________________________________________________________

Fluids _____________________________________________________________________

Water _____________________________________________________________ oz/day

Please indicate if any of the following conditions below currently affect you (X) or if you have experienced them in the past year:

____ High Blood Pressure ____ Blood Clots ____ Heart Attack/Stroke

____ Low Blood Pressure ______Anemia ______Heart/circulation problems

____ Vision Problems ____Contact Lenses _____ Dizziness

____ Low Back Pain _______Muscle pain ___________Joint Pain

____ Tendonitis ____ Arthritis ____ Bursitis _______ Sprains/Strains

_____ Broken bones ______Osteoporosis _____Scoliosis

_____Weakness ____ Headaches ____ Diabetes ____ Hypo or Hyperglycemia

______Bruise easy

____ Contagious Conditions ____ Skin Infections/Problems ______Varicose Veins

____ Pregnant, ______ mo. along

____ Sinus Problems ______Chronic colds/bronchitis

____ Cancer/ Tumors

____ Depression ____ Sleep Difficulties ____ Dizziness

_____ Cloudy thinking _______Fatigue/low energy

____ Seizures/Epilepsy ____ Allergies

____ Numbness/Stabbing Pains ____ Sensitive to Touch/Pressure ____Radiating Pain

____ Digestive Disturbances: (Circle: Constipation, diarrhea, diverticulosis, gas, bloating)

How many times do you have a bowel movement per week ______________

_______Urinary Tract Infections __________Bladder Infections

Women: ________PMS ________Irregular or painful periods _______Irregular PAP Smear

_______Pelvic Pain __________Heavy flow __________Problems conceiving

________Hysterectomy __________D&C _________C-Sections

Men: ________BPH ________High PSA ________Irregular DRE

Medical Diagnoses: __________________________________________________________

_________________________________________________________________________

Your goal for this visit: ______________________________________________________

Your long-term health goal: _________________________________________________

 

Consent Form

 

I request that Sarah LoBisco, ND do a nutritional evaluation and to set-up a diet, nutritional supplements and lifestyle changes for the purpose of reducing stress and enhancing my life. I authorize Dr. LoBisco, ND to discuss and/or provide information about my case to any referring practitioner or to any other health care referral that I agree to consult with. This is in order to provide me with a more integrative approach to my wellness. If at any time, I decide that I would not like my information shared, it is my responsibility to inform Dr. LoBisco of this choice. I understand that due to the research, work and time Dr. LoBisco puts into my individualized treatment plans, there is a $25 cancellation fee for missed appointments or cancellations less than 24 hours notice. Clients will be charged the full consult fee for cancellations or now shows unless an emergency.

Disclosure Form

 

I understand that Dr. ­­­­­­­­­­­­­Sarah LoBisco has a degree in naturopathic medicine from the University of Bridgeport, College of Naturopathic Medicine, a federally accredited school in CT. I understand she/he has 8 years experience with natural healing modalities and 1300 clinical internship hours of training, but is not a licensed naturopathic doctor in the state of NY due to NYS laws. I understand she holds her license from Vermont .

 

Disclaimer

 

I understand that naturopathic medicine is not intended as diagnosis, treatment, prescription or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care in the state of  NY. I realize that I am a willing participant responsible for my health care and acknowledge that Dr. LoBisco, ND is a partner of my wellness team.

ARTICLE IX, U.S. CONSTITUTION

“The enumeration in the constitution, of certain rights, shall not be construed to deny or disparage others retained by the People.”

Under the Ninth Amendment to the Constitution of the United States of America, I retain the right to freedom of choice in health care. This includes the right to choose my diet, and to obtain, purchase and use any therapy, regimen, modality, remedy or product recommended by the doctor of my choice.

The enumeration in this declaration of these rights shall not be construed to dney or disparage other rights retained by me, or my right to amend this declaration at any time.

Constructive Notice

 

Notice is hereby given to any person who receives a copy of this Declaration and who, acting under the color of the law, intentionally interferes with the free exercise of the rights retained by me under the Ninth Amendment, as enumerated in this declaration, that they may be in violation of my civil and constitutional rights, Title 42, U.S.C 1983 et seq. and Title 18, Section 241.

Date: ­­­­­­­­­­­­______________                      Signed: ___________________________________

 

Supplementation Purchase Policy of Dr. LoBisco, ND

As part of my nutritional and lifestyle consulting, I understand that Dr. Sarah LoBisco, ND, may suggest the use of supplementation in order to enhance my wellness. These supplements may or may not contain animal products or gelatin. It is my responsibility to inform Dr. LoBisco of any nutritional restrictions or allergies during my consultation.

 

It is Dr. LoBisco’s practice to evaluate each case on an individual basis and to special order each supplement from her suppliers (Standard Process & Moss Nutrition) and Young Living Essential Oils. I realize that Dr. LoBisco chooses not to have a supplement inventory on hand in order to make available in her selection the best fit for my nutritional and health concerns at the time of the consultation.

 

Due to the fact that each order is individually placed and priced, and that Dr. LoBisco chooses to not keep an inventory of products, I realize that supplements are either paid for upfront by me to Dr. LoBisco, in order for her to purchase the products, and are non-refundable, or, paid directly by me through my credit card for essential oils and USP grade nutraceuticals which require a personal account through Dr. LoBisco’s referral.

 

I understand that Dr. LoBisco will only place my order for supplements when payment is received.

 

Date:__________________   Signed_________________________________________

 

Print name ____________________________________________________

 

Five Brain Systems checklist

Please read this list of behaviors and rate yourself (or the person you are evaluating) on each behavior listed. Use the following scale and place the appropriate number next to the item. Five or more symptoms marked 3 or 4 or a total of 20 or higher indicate a high likelihood of weakness with that brain system. A total between 10 and 20 indicates a possibility of an imbalance.

0= never

1= rarely

2= occasionally

3= frequently

4= very frequently

 

Deep Limbic

1. Feelings of sadness/crying

2. Moodiness/negativity

3. Low energy

4. Irritability

5. Decreased interest in others

6. Feelings of hopelessness about the future

7. Feelings of helplessness or powerlessness

8. Feeling dissatisfied or bored

9. Excessive guilt/low self esteem

10. Suicidal feelings

11. Lowered interest in things usually considered fun

12. Sleep changes (too much or too little)

13. Appetite changes (too much or too little)

14. Decreased interest in sex

15. Negative sensitivity to smells/odors

16. Poor concentration/forgetfulness

Total_____

 

Basal Ganglia

1. Feelings of nervousness or anxiety

2. Panic attacks or tics/ Avoidance of public places for fear of having an anxiety attack

3. Symptoms of heightened muscle tension (headaches, sore muscles, hand tremor)

4. Periods of heart pounding, rapid heart rate, or chest pain

5. Periods of trouble breathing or feeling smothered

6. Periods of feeling dizzy, faint, or unsteady on your feet

7. Periods of nausea or abdominal upset

8. Periods of sweating, hot or cold flashes, cold hands

9. Tendency to predict the worst/ Conflict avoidance

10. Fear of dying or doing something crazy

11.Excessive fear of being judged or scrutinized by others, worry about what others think

12. Persistent phobias/ Shyness or timidity

13. Low motivation/ Excessive motivation

14. Poor handwriting

15. Quick startle reaction/ Low threshold of embarrassment

16. Tendency to freeze in anxiety-provoking situations

Total_____

 

Prefrontal Cortex

1. Inability to give close attention to details or avoid careless mistakes

2. Trouble sustaining attention in routine situations (home work, chores, paperwork, etc.)

3. Trouble listening/ Distractibility

4. Poor organization of time or space/ Inability to finish things, poor follow-through

5. Lack of clear goals or forward thinking

6. Difficulty expressing feelings or empathy

7. Excessive daydreaming or talking too little

8. Apathy or lack of motivation, boredom

9. A feeling of spaciness or being “in a fog”

10. Restlessness or trouble sitting still, talking too much

11. Difficulty remaining seated in situations where remaining seated is expected

12. Conflict seeking

13. Blurting out of answers before questions have been completed, difficulty awaiting turn

14. Interruption of or intrusion on others (e.g., butting into conversations or games)

15. Impulsivity (saying or doing things without thinking first)

16. Trouble learning from experience; tendency to make repetitive mistakes

Total_____

 

Cingulate System

1. Excessive or senseless worrying

2. Being upset when things do not go your way

3. Being upset when things are out of place

4. Tendency to be oppositional or argumentative

5. Tendency to have repetitive negative thoughts

6. Tendency toward compulsive behaviors

7. Intense dislike of change

8. Tendency to hold grudges

9. Trouble shifting attention from subject to subject

10. Difficulties seeing options in situations

11. Tendency to hold on to own opinion and not listen to others

12. Tendency to get locked into a course of action, whether or not it is good

13. Being very upset unless things are done in a certain way

14. Perception by others that you worry too much

15. Tendency to say no without first thinking about questions

16. Tendency to predict negative outcomes

Total_____

 

Temporal Lobe

1. Short fuse or periods of extreme irritability

2. Periods of rage with little provocation

3. Frequent misinterpretation of comments as negative when they are not

4. Irritability that tends to build, then explodes, then recedes; person often feels tired after a rage

5. Periods of spaciness or confusion

6. Periods of panic and/or fear for no specific reason

7. Visual or auditory changes, such as seeing shadows or hearing muffled sounds

8. Frequent periods of deja vu (feelings of being somewhere you have never been) or jamais vu (not recalling a familiar place or person)

9. Sensitivity or mild paranoia

10. Headaches or abdominal pain of uncertain origin

11. History of a head injury or family history of violence or explosiveness

12. Dark thoughts, such as suicidal or homicidal thoughts

13. Periods of forgetfulness

14. Memory problems

15. Reading comprehension problems

16. Preoccupation with moral or religious ideas

Total_____

 

Comprehensive Total:_________

*Adapted from and inspired by the work of Dr. Daniel Amen and his book Change Your Brain, Change Your Life.

Download for Symptom-Questionnaire