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319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
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Date:________________________
Name:______________________________Birthdate:___________Age:_______________
Mother’s Name______________________ Father’s Name__________________________
Address:__________________________________________________________________
City, State, Zip:____________________________________________________________
Phone:____________________work:____________________cell:___________________
E-mail:____________________________________________________________________
Primary Care Provider’s Name______________________________________
Address (if known)__________________________________________________
City, State, Zip________________________________Phone:_______________
Referred by:_____________________________________________________________
Reason for today’s visit Date problem(s) began
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Height:__________________Weight:___________ Usual Weight:______________
Allergies to
Medication:________________________________________________________________________
Allergies to foods or environment ( please specify what type of allergy testing was
performed)_________________________________________________________________________
Education (Last grade completed or degree)____________________________________________
Sex and Ages of Siblings____________________________________________________________
Surgeries:_________________________________________________________________________
Accidents/Injuries:__________________________________________________________________
Hospitalizations:___________________________________________________________________
Current Medications:________________________________________________________________
Nutritional Supplements:_____________________________________________________________
Medical History (circle if applicable, and comment if necessary)
Eyes Skin
Crosses or wandering eyes Eczema
Vision problems Psoriasis
Eye irritation Dry skin or other rash
Wears glasses Yellow or crusty nails
Ears, Nose, Mouth, Throat Slow healing bruises
Frequent Ear infections Crust behind the ears
Hearing Problems Cradle Cap or scaly scalp
Difficulty talking Neurological
Stuttering Dizzy or fainting
Thrush Periods of confusion
Sores in mouth /gums Seizures/convulsions
Frequent colds or sore throat Tics or tremors
Post nasal drip Headaches
Throat clearing Gastrointestinal
Nose Bleeds History of worms
Stuffy nose Loss of appetite
Tonsil Infections Constipation
Breathes thru mouth Use of laxatives
Dark circles under eyes Abdominal bloating
Bad breath Noisy digestion
Itchy throat Excessive burping or belching
Seasonal allergies More than 3 BM’s per day
Cardiovascular Loose bowels or diarrhea
Shortness of breath Nausea or vomiting
Needs to squat when playing Painful bowel movements
Respiratory Rectal bleeding
Chronic or frequent cough Blood in stool
Asthma or wheezing Abdominal pain or cramping
Shortness of breath Excess gas
Bronchitis Psychosocial
Pneumonia Nightmares
Genitourinary Trouble falling/staying asleep
Urination problems Irritable
Painful, burning urination Tantrums
Blood in urine Spinning/flapping
Unusual odor to urine Usually disobedient
Persistent diaper rash Problems at school or with friends
Bedwetting problems Suicide attempts
Discharge from vagina or penis Extreme mood swings
Itching of vaginal/penile area Sensitivity to odors
Redness around rectum Sensitivity to fabrics
Is patient potty trained? Y or N Sensitivity to smells
Musculoskeletal Sensitivity to noises
Painful or swollen joints Aggression towards self
Frequent complaints of aches or pains Aggression towards others
Posture problems Overly affectionate / not affectionate
Muscle coordination problems Difficulty organizing tasks
Strength problems Easily distracted
Psychosocial (continued) Maternal Information During This Pregnancy
Poor focus Vaginal yeast infections
Poor listening skills Gestational Diabetes
Doesn’t stay on task Vaginal or C-Section, pre or full term
Easily forgetful Antibiotic Use during pregnancy
Overly talkative Infant Health History
Finger/foot tapping or leg restlessness Breast fed ____ months
Engages in physically daring activities Bottle fed: type of formula______________
Always on the go did baby tolerate formula Y or N
Impulsive excessive fussiness or colic
Bothers or is annoying to others Development
Interrupts others was growth and development normal?
Impatient if not, please describe any concerns:
Unpredictable behavior
Hot and explosive temper
Endocrine Current Eating Habits
Hormone problem please list food cravings:
Diabetes please list any foods that your child cannot
Excessive thirst or urination tolerate and the reason:
Heat or cold intolerance
Hair loss Please Circle Previous Diagnoses
Recent weight loss/gain Learning disability
Hematologic ADHD
slow to heal after cuts PDD / Autism spectrum
excessive bleeding Oppositional Defiant Disorder
anemia Asperger’s
bruising tendency Autism
Immunological Speech Delay or Disorder
Is your child immunized? Y or N Tourette’s Syndrome
Fevers Obsessive Compulsive Disorder
Fatigue Eating Disorder
Family History (please indicate what family member) Anxiety
Birth Defects Depression
Genetic Defects
Mental Retardation
Allergies Please List any other Pertinent Information
Lung Disease
Asthma ______________________________________
Celiac Disease
Other Food Allergies ______________________________________
Rheumatoid Arthritis
Heart Disease ______________________________________
Skin Disease
Eye or Ear Disorders ______________________________________
Cancer
Diabetes ______________________________________
Thyroid Disease
Blood Disorders
Kidney Disease
Epilepsy ______________________________________
Mental Disorder Signature of Parent or Guardian
319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
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INFORMED CONSENT AND OFFICE POLICY
I make no representations, claims or guarantees that you will be helped with your medical problems or
conditions by undergoing treatment. However, I will do my best to help you accomplish your healthcare
and wellness goals.
I am a Master’s prepared Family Nurse Practitioner. Nurse Practitioners are licensed to perform physical
examinations, order laboratory tests and to prescribe medications. My Collaborating Physician’s name is
Dr. Muralidhar Reddy. He maintains a separate practice from mine, and is available to me for
consultation and collaboration when needed.
Some of your treatment plan may consist of nutritional supplements. I will recommend certain brands or
products based on research and past experience with these products. While I will provide you with
information on where you can purchase these supplements, you are free to purchase these products from
any source that you choose.
I require that all patients have a primary care provider. My services are to act as a compliment to your
primary healthcare. Thus, I will not be responsible for maintaining your routine screenings such as
yearly physicals, lab work, pap smears, mammograms, etc. If requested, I can recommend primary care
providers who share my philosophy about health and wellness.
Most health insurance plans today have clauses which limit coverage to “usual and customary” fees for
reasonable and necessary services. Because certain treatments used in complementary medicine are not
recognized by mainstream medicine, we can NOT guarantee the amount of availability of coverage for
our services, lab testing, and treatments under your healthcare policy. You are responsible for payment
when services are rendered without regard to insurance coverage.
My fee is $150 per hour. The first 2 visits are often longer than 1 hour due to the amount of information
gathering and teaching to be done during those visits. Payment for any ordered lab work is made directly
to the lab used for the testing. Specialty lab testing is sometimes NOT covered by insurance. Lab testing
will not usually exceed $500. There is a $20 charge for all returned checks 24 hours notice is required
for ALL cancellations. There will be a $50 fee for any cancellation without 24 hours notice.
319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
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INFORMED CONSENT AND OFFICE POLICY
I seek the medical and health care services of Elaine Hardy, MS, RN, APN, C. I understand that this
medical practice uses some diagnostic and treatment methods that are sometimes considered
complementary, alternative or holistic. Many of these methods have not yet been accepted by consensus
mainstream medicine.
I understand that Elaine Hardy, MS, RN, APN, C, makes no representations, claims or guarantees that I
will be helped with my medical problems or conditions.
I understand that my insurance may or may not cover the office visits and laboratory testing, and that
payment is due at time of service. I also understand that payment for any laboratory testing is to be
arranged with the laboratory used for the testing.
I have read, understand and agree to the Informed Consent and Office Policy. I acknowledge receipt of a
copy of the same. I have read and understand the cancellation policy.
PRINTED NAME OF PATIENT__________________________________
SIGNATURE__________________________________________________
RELATIONSHIP TO PATIENT____________________________________
DATE SIGNED_________________________________________________
