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1208 W. Drew
Houston, Texas 77006
USA

Adult Intake Form

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Home Phone
Home Phone
Work Phone
Work Phone
Cell Phone *
Cell Phone
Gender
How did you hear about us? *
Marital Status *
HEALTH CONCERNS (PLEASE LIST ALL OF YOUR HEALTH CONCERNS IN ORDER OF IMPORTANCE TO YOU; INDICATE WHEN IT STARTED)
general health history
How would you rate your energy on a scale from 1 to 10, with 10 being the most energy?
Do you have any trouble with sleep?
medical history
Please check the conditon(s) you have had or currently have:
allergies and sensitivities
Are you aware that you have ever been exposed to toxic substances such as chemicals pesticides, herbicides, solvents, or sprays.
Are you aware that you have been exposed to heavy metals such as lead, mercury, arsenic, or cadmium?
Have you ever had to lower the regular dose of prescription medication, over-the-counter medication or herbal supplemenation?
Do you avoid caffeine in the afternoon or altogether because it keeps you up at night?
Do you smell odors others cannot?
Do you have a sudden onset of symptoms (headaches, rashes, nausea, fatigue, shortness of breath, etc.) when exposed to chemicals?
medications/supplements
Do you currently take any medications or supplements, including prescription drugs, herbs, vitamins, minerals, homeopathics, or any other products?
please list all the medications and supplements you currently take. include name of medicine/supplement (include brand name), dosage (amount taking, and how often), for what, and how long?
which of the following have you used/currently use? please include amount, frequency and length of use. Use P to Indicate past use and c for current use.
How often have you take antibiotics in the past?
family history
please indicate any health conditions (e.g. Cancer, heart disease, arthritis, tb, diabetes, asthma, allergies, food sensitivities, digestive issues, celiac disease, crohn's/colitis, thyroid, autoimmune, kidney disease, depression/anxiety, anemia, stroke, seizures, high blood pressure, other) for the following family members:
food and digestion
Please list a typical day's diet below
Work and Lifestyle
Do you enjoy your work?
Are you currently in a relationship?
If so, are you happy with your relationship?
Do you have a supportive family or friends who are there when you need them?
Do you exercise?
Sexual health
Check all that apply
Excessive sexual desire?
Sexually Transmitted Disease?
Pain during intercourse?
Lack of sexual desire?
Sexual dysfunction?
Are you currently sexually active?
Male Reproductive system (if applicable)
Check all that apply
Prostate problems?
Difficulty getting an erection?
Painful erection?
Testicular pain?
Discharge from penis?
Premature ejaculation?
Infertility?
Other sexual difficulties (please specify below)?
Female reproductive system (if applicable)
Check all that apply
Breast pain/tenderness?
Breast lumps?
Nipple discharge?
Pelvic pain?
PMS?
Spotting/bleeding between periods?
Never/seldom orgasms?
Birth control pills?
Pain before menses?
Moodiness?
Sexual difficulties?
Cysts?
Painful intercourse?
Vaginal discharge?
Vaginal dryness?
Vaginal Itching/Burning?
Absent menstruation?
Abnormal PAP test?
Pain during menses?
Clots during menses?
Fluid retention?
Endometriosis?
Do you do regular self breast exams?
Additional Information
Informed consent
I would like to take this opportunity to welcome you to the services of Sakura Natural Health. This practice utilizes the principles of Naturopathic Medicine to assist the body's own ability to heal and thrive. Naturopathic Medicine is the treatment and prevention of disease by natural means. Naturopathic Doctors assess the whole person, taking into consideration physical, mental, emotional and spiritual aspects of the individual. Gentle, non-evasive techniques are generally used in order to stimulate the body’s inherent healing capacity. A Naturopathic Doctor (ND) is trained as a primary care provider and is a board-certified physician in states where licensure is applicable. Currently licensure for naturopathic doctors is not available in the State of Texas. Therefore, Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA., the naturopathic consultants employed by Sakura Natural Health, do not practice medicine, and do not diagnose or treat diseases or medical conditions in the State of Texas. Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. focus on the enhancement of health. Erica Campbell’s, ND* and Fi Connors, ISHOM.RN.MA. services are not meant to substitute or replace those of a Texas- licensed medical professional(s) and/or specialist(s) and clients seeking their consultations are advised to be under the care of a Texas- licensed medical professional. During your visit, Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. will take a thorough case history and may, when indicated, suggest outside laboratory assessments independent of Sakura Natural Health. A number of different approaches may be used throughout the course of health counseling. Health counseling modalities include diet modification, lifestyle counseling, clinical nutrition, botanicals, homeopathy, and hydrotherapy. I hereby authorize Erica Campbell, ND and Fi Connors, ISHOM.RN.MA. of Sakura Natural Health, to act in the following capacity as complementary healthcare consultants, utilizing one or more of the following treatment modalities as necessary: Individual diets and nutritional supplements are recommended to address deficiencies, treat disease processes, and promote health. The benefits may include increased energy, increased gastrointestinal function, improved immunity, and general well-being. Botanical medicine is a plant based medicine that involves the use of herbal teas, tinctures, capsules, and other forms of herbal preparations to assist in the recovery of well being. Homeopathy is a form of medicine based on the Law of Similars- that is, the use of tiny doses of the very things that causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the body’s ability to heal itself. Homeopathy is a powerful tool that effects healing on a physical and emotional level. Hydrotherapy refers to the use of hot and cold water applications to improve circulation and stimulate the immune system. Lifestyle counseling involves identifying risk factors and making recommendations to help optimize one’s physical, mental, and emotional environment. It is very important that you inform Erica Campbell, ND* and/or Fi Connors, ISHOM.RN.MA. immediately of any disease process that you are suffering from as well as any medications (prescription or over-the-counter) that you are taking. If you are pregnant, breast-feeding, taking anti-coagulant drugs (coumadin), have a severe bleeding disorder (hemophilia), heart condition, diabetes, circulatory problems, blood clots, cancer/malignancies, bone disorders (osteoporosis, Paget’s disease, Multiple Myeloma), metal implants or have a pacemaker, you should make that information known to Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. prior to treatment. Special notice to pregnant women: Any female patient must alert Erica Campbell, ND as well as your Texas-licensed medical professional(s) and/or specialist(s) if or when you know or suspect that you are pregnant as one or more of the treatment modalities may present a risk to the pregnancy. Potential health risks associated with Naturopathic Medicine include but are not limited to: • Aggravation of pre-existing symptoms during the healing process. • Allergic reactions to herbs and supplements. • Interaction between herbs/supplements and pharmaceutical medications. • Inconvenience of lifestyle changes. Acknowledgement Agreement I understand that, at this time, Texas does not offer licensing in the field of naturopathic medicine and the services provided by Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. to me may only serve as an integrative and/or complementary care consultation. Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. are not licensed to practice medicine or act in this capacity in the state of Texas as this time, as well as for the immediate and foreseeable future. Erica Campbell’s, ND* and Fi Connors’, ISHOM.RN.MA. services that you consent to are intended to be used in concert with and while you are under the care of Texas-licensed medical professional(s) and/or specialist(s). I understand that Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. will answer any questions that I have to the best of their ability. I understand that the results are not guaranteed. I do not expect that Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to diagnostic and therapeutic procedures mentioned above, except for (please list any exceptions): Any treatment or advice provided to me by Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. as a patient is not mutually exclusive from any treatment or advice that I may now be receiving or may in the future from a Texas- licensed medical professional(s) and/or specialist(s). The treatment and therapies rendered or recommended by Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. of Sakura Natural Health may be different than those usually offered by a medical doctor or other licensed health care provider. No independent contractor, agent, student or anyone else under Erica Campbell’s, ND* of Sakura Natural Health’s direction or control is suggesting or advising me to refrain from seeking or following the directions of a Texas-licensed medical professional(s) and/or specialist(s). I am at liberty to seek or continue medical care from a medical professional or specialist or other health care provider qualified to practice in Texas. I understand that it is my responsibility to seek and receive concurrent primary and specialty healthcare from a Texas-licensed medical professional(s) and/or specialist(s). I understand and agree that I will not make any changes to my current pharmaceutical regimen, as prescribed by my Texas-licensed medical professional(s) and/or specialist(s) without the consent and guidance of the prescribing Texas-licensed medical professional(s) and/or specialists(s). Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. may not advise me in this capacity and it is my responsibility to maintain active communication with my primary Texas-licensed medical professional(s) and/or specialist(s). Any change in my health status must always be directly communicated in person and/or in writing to my primary Texas-licensed medical professional(s) and/or specialist(s). I understand that a record will be kept of the health services provided to me by Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. of Sakura Natural Health. This record will be kept confidential and will not be released to others without my consent, unless required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee. *Erica Campbell, ND graduated with a doctoral degree from the Southwest College of Naturopathic Medicine located in Tempe, Arizona. Southwest College of Naturopathic Medicine is one of only four nationally-accredited naturopathic medical schools. Erica Campbell, ND has passed the required national professional board exams and fulfilled all requirements for Naturopathic Physician licensure from the Office of Professional Regulation in the state of Arizona. *Fi connors, ISHOM.RN.MA is a registered general nurse graduating from St Vincents University hospital , Dublin Ireland. She is educated to a masters degree level and has continually worked in general medicine for the past twenty years. Fi graduated as a homeopathic clinician in 2005 and completed a years homeopathic post graduate in chronic disease. She then grew a busy green medicine practice in Dublin, before recently relocating to Sakura natural health. I have read and understand the above-stated policies and information. I intend this consent form to cover the entire course of treatment for my present condition, realizing that no guarantees have been given to me by Erica Campbell, ND* and Fi Connors, ISHOM.RN.MA. of Sakura Natural Health or any of her and/ or the clinic’s agents and/or independent contractors regarding cure or improvement of my condition. I understand that I am free to withdraw my consent to discontinue participation in these procedures at any time.
If you have read and fully understand the informed consent, please electronically sign below.
Name *
Name
Date *
Date
Practitioner guidelines and financial agreement
Erica Campbell, ND and Fi Connors, ISHOM.RN.MA. see clients at her office in Houston, Texas. Erica Campbell and Fi Connors do not provide a primary care service. A Naturopathic Doctor (ND) is trained as a primary care provider and is a board-certified physician in states where licensure is applicable. Erica Campbell is a Naturopathic Physician licensed in the State of Arizona. Currently licensure for naturopathic doctors is not available in the State of Texas. Erica Campbell, ND does not practice medicine, and does not diagnose or treat diseases or medical conditions in the State of Texas. Therefore, the focus of the practice on the enhancement of health. The first office visit commonly lasts 90-120 minutes and return office visits between 30-85 minutes. Office visits include a thorough health history intake, appropriate physical examination, naturopathic medical assessment and consultation concerning advisable testing and therapies. Erica Campbell, ND will answer brief questions for established clients over the phone and via email. Longer consultations will be charged at a rate of $50 for 15 minutes, or $85 per 30 minutes. Erica Campbell, N.D. may request that the patient schedule an office visit to address their concerns. Appointments: We consider an appointment to be an agreement between you and our office. When you schedule an appointment, we reserve that time exclusively for you. We are responsible to be here and provide our services, or to inform you otherwise. You are responsible for keeping the appointment or giving us 24 hours notice. Unavoidable emergencies will be considered reasonable exceptions. Cancellation charge for missed appointments: • If a circumstance arises that causes you to change your scheduled appointment time, please call with a minimum of a 24 hour notice. • A $50 deposit is taken at time of booking initial appointment. This will be applied at time of check out to full total of transaction. If appointment is not cancelled 24 hours or earlier of time of appointment, the $50 deposit will be non-refundable. • Any no-show or late cancellations are subject to a cancellation fee that must be paid prior to scheduling another appointment. The cancellation fee is $50 for all appointments. Payment: In order for us to keep our services available to our patients, it is necessary to require payment at the time of your visit. We are not contracted with health insurance companies. Payment for services, supplements, and/or products is expected at the time of each visit. Please pay for all supplements at the time that you pick them up, unless other specific arrangements have been made. Cash, check, money order and credit cards are accepted. There is a $35.00 NSF fee on all returned checks. Two occurrances of NSF checks will prohibit any additional checks written to the practice and only cash or money orders will be accepted. Please make your check out to Sakura Natural Health Any outstanding balance remaining 30 days after the date of service will be assessed an additional fee of 15% annual interest. Balances older than 60 days are subject to additional billing fees of $20 per statement. If you would like to apply for a special payment plan due to financial hardship, please discuss this with our office manager before your appointment is scheduled. I have read, understand and agree with the above guidelines and financial terms. I understand that I am responsible for all fees and charges and agree to pay for all services. I understand that fees for laboratory work and supplements are not included in the office visit fees. I understand the costs for office visits and services are subject to change and that I will be notified about office visit and service fee changes prior to my appointment. I may not necessarily be informed of changes in the price of herbal supplements and laboratory tests prior to an appointment.
If you have read and fully understand our practitioner guidelines and financial agreement, please electronically sign below.
Name *
Name
Date *
Date