Elaine A by zhangyun


									                          319 Airport Road
                       Hackettstown, NJ 07840
               Ph: 908-850-0888 / FAX: 908-850-1005



Mother’s Name______________________ Father’s Name__________________________


City, State, Zip:____________________________________________________________



Primary Care Provider’s Name______________________________________
Address (if known)__________________________________________________
City, State, Zip________________________________Phone:_______________

Referred by:_____________________________________________________________

Reason for today’s visit                 Date problem(s) began

Height:__________________Weight:___________ Usual Weight:______________

Allergies to

Allergies to foods or environment ( please specify what type of allergy testing was

Education (Last grade completed or degree)____________________________________________

Sex and Ages of Siblings____________________________________________________________



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                                  ______________________________________
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

                          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

                          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__________________________________


RELATIONSHIP TO PATIENT____________________________________

DATE SIGNED_________________________________________________

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