1. No category

PLEASE COMPLETE ENTIRE FORM
(print Clearty)
E-MAIL
DATE
PATIENT NAME
SEX-AGE-BIRTHDATE
MARRIED tr
tr SINGLE tr
E]
ADDRESS
ztP
REFERRED BY
soc. sEc.
#
_t_t_
_t_/_
DIVORCEI)
REMABRIED
tr
WIDQWED
HOME PHONE
OCCUPATION
WOFIK PHONE
SPOUSE'S SOC. SEC. #
A MTNOR)
MERGENCY)
RELATIONBHIP
PHONE
DATES OF IMMUNIZATIONS AND SKINTESTS
HOSPTTALTZATTONS AND SURGERTES
ALLERGIES
sPECfl\L NOTES (OFF\CE LiSE ONLY)
Asthma Health Flistorv
Today's
ay's Date
Date
_J_/
Male Female
_JVlanied
_separirted
EdUCatiOn_
File#
Race D
Divorced
veats Elementary
Elemenfarv
years
_Widowed _single
rreorc High
fJicl e^L^^l
years
School
_
Social SQcurity or Medicare No.
FAMILY HISTORY: For
each member of your fbmily,
follow
o
the grey dr white line across the page and check the boxes for:
Family refers to blood or
natural rQlatives)
PRINT NAMES BELOW
write in age and
cause ofdeath.
Include fatal
accidents and
suicides.
Father:
Mother:
Brothers/SIsters:
Spouse:
child
child:
child
child;
Matemal r latives (in each box, write how many affected with).
Paternal re etives (in each box, write how many affected with).
Beein YO ,UR HEALTH HISTORY here. Have you had:
!
(.)
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0)
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(.)
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F
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Additiontil rllnesses or Problems: Mark
tr
!
eye infQctions
an
X in the box next to any of the following that you have now or ever have had.
pneumqnia
tr neuralgia or neuritis
fl
tr
scarlet fgver
mononqcleosis
tr thyroid Sisease
tr pancreafitis
E tension I anxiety
E
measles
tr
venerea{ disease
E eczema
tr liver disbase
tr depressi[n
E mumps
tr yellow jbundice
tr hives or rashes
tr divertic{losis
tr childhoQd hyperactivity
u pollo
tr tuberculpsis
tr bronchitis
LJ
I
tr
tr
nernla
chicken pox
rheumatirc fever
tr
tr
tr German
tr malaria
tr
fneasles
Have you eirer been turned down for life insurance, military service or employrnent because
of health problems?
Yes
No
MAJOR HOSPITALIZATIoNS: If you have
been hospitalize,d for any major mercical illness or operation, write in your most
.ever
recent hospitalizations below, Check this box
if you had -ore than four such hospitalizations. (Do not include normal pregnancies)
!
YEAR
OPERATION OR ILLNESS
NAME OF HOSPITAL
CITY AND STATE
I't Hospitalization
2no
Hospitalization
3'o
Hospitalization
4* Hospitalization
had. Enter the year when you last,were given the tests or,.shots.,,
tr
mdmmosram
tr
tr
tr
--;
Ll
Ilu lnrectlons
tr
tr
mrimps "shots"
gallbladder x-ravs
elebtrocardiosram
tr
TB test
me[sles "shots"
tr
tr
colon x-ravs
ty/hoid "s'hots"
-
sisinoidoscoov
Medic rnes:
taking:
allergic : tot
takingl
allergic to:
tr
tr
tr
antilbiotir
antib
E
aspirrin
aspir
''f
tr
tr penicillin
tr
tr diet pills
tr
E
sulfa
!
oplates/co$elne
El laxatives
tr
E
tr
diuretics/ulater pills
Ll colo
tr
n
-
sedatives
tr
!
n
Demerol
----------------tr
tr blood prelsure meds.
I
tr
-----t---
YOUR SIGNATURE
DATE
Symptom Chart
Began
Rate S
a Survival Program on
ns from I (worst) to 10
(best: normal)
I
c.l
s
I
O
c)
o
'50
I
c)
SYMPT( M
Shortness ofbreath
Wheezinl
Cough Cough
ry
'etlmucusy
Head con$estion (fullness)
Nasal con estion (stuffz nose)
Postnasal
np
Headache
Yellow/gr len mucus (from nose)
Yellow/gr
)en mucus (back
of throat)
Sneezing
Itching: n se, throat
Ear conger ;tion (ears plugged up)
Sore throa
Swollen glands (in neck)
Fatigue (ra te energy level)
Avg # of h[s sleep
Other Sym ptoms:
Medicatio: s: (Pharmaceutical Drugs) (use a "r/
if still taki g drug
"
F
rrl
O
0)
.o
F
-l
fr)
N
oo
c.)
0)
F
(a
frl
o
,O
frl
al
Trl
q)
.()
F
L<
frl
you ever been diagnosed by
Yes
No
a
physician as having asthma?
For example, was it a pulmonary.function test, a doctor listening to
per year?
ids (prednisone, medrol)
_
or
antibiotics
have
6.Inthdpastye3r,howmanyacuteflare-upsorasthmaattackshaveyouhad-;arrdhowmturyof
cQurses
7, P
oforal steroids
or antibiotics have you taken during this year?
list all of the things you're
presently doing to treat your asthma. Irrclude medications/inhalers,
'uIizer, nasal inigation, vitamins, supplements, etc. Also estimate how long you've been using each
THERAPY
8.
H:OW LONG
ed in #8, has your r;ondition gotten better, stayed the
ale o:f 1-10,
with 1C)being optimal energy?
ician for nasal allergies/hay fever, sinus
a infection? If so, when were you treated, who is (or
vyoD/ JUur prrysrurau, anq wnar were tne results of the
treatment?
AGNOSIS
11. Are
DATE/PHYSICIAN
RESULTiS
presently taking anlthing for the conditions described in #10
If yes, what?
Yes
Most of the following questions have yes or lrio answers.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Has Jrour sense of smell or taste changed lately?
Do ypu ever have sneezing spells?
Does your nose ever bleed for no reason at all?
Do ypu have than two to three colds per year?
FIas jour voice ever been hoarse when you didn,t have a cold?
Are jou sweating more than usual or having night sweats?
Have you been bothered by a thumping or racing heart?
_.
Are you using more pillows to help you breathe at night?
Do ypu have trouble with swollen feet or ankles?
Are you getting cramps in yoru legs at night or upon walking?
Have you ever been told that you have a heart murmur?
Are >{our bowel movements ever black or bloody?
Do yQu suffer pains when you move your bowels?
14.
15.
16.
17.
18.
Do ydu have a constant feeling that you have to urinate?
No
For Men Only:
your urine stream very weak and slow?
Has a doctor ever told you that you have prostate trouble,/
Havp you had any buming or discharge from your penis?
Are there any swellings or lumps on your testicles?
Do 1'our testicles get painful?
19. Is
20.
2r.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
JZ.
aa
JJ.
34.
35.
36.
a3t.
38.
39.
40.
41.
Fpr Women Only:
Whlt was the date of your last menstrual period?
Are you past your menopause, or have you had a hysterectomy?
If ygs to #25: Have you noticed any vaginal bleeding since?
Waq your last menstrual period abnormal?
D
h your periods?
H
yourperiods?
D
intercourse?
Do liou examine your breasts less than once a month?
Havp you ever noticed any lumps or pain in your breasts?
Have you had any complications with any type of birth control?
Havp you ever taken any birth control pills?
Wrife in the month and year of your tait fap test_
Nunlber of pregnancies _
Nurriber of children born alive
Nur4ber of premature births _
Nunlber of miscarriages _
Number of stillbirths
Hav$ you ever had an abortion?
42. Are jyou troubled with
_
stiff or painful muscles or joints?
Are jzour joints ever swollen?
Are you tloubled by pains in th-eback or shoulder?
Are ;'our feet often painful?
Are you handicapped in any way? _
H
ring worm, jock itch, or other chronic funLgus infections of the skin or nails?
D
D
g-.u* r-ull cut from bleedinLg?
50, Do you ever faint or feel faint?
51. Is anp parl of your body always numb?
52. Have you ever had any seizures or convulsions?
53. Has your handwriting changed lately?
54. Do you have tendency to shake or tremble?
55. Havqi you, at any time in your life, taken antibiotics for rer;piratory, urinary, skin (acne), ol other infections
for two months or longer or in shorter courses four or more times in a. one-year period?
56. Havq you taken predisone, Decaron, or other cortisone-type drugs, orall.g or by injection orr inhalation, for
orie week or more?
57. Havo you gained or lost more than ten pounds in the last six months?
58. Havq you lost interest in eating lately?
59. .Are j,ou always hungry?
60. Are 1[ou more thirsty than usual lately?
61. Are tfrere any swellings in yorn armpits or groin?
62. .Do ypu have difficulty either falling asleep or staying asleep?
43.
44.
45.
46.
47.
48.
49.
63. Are you a regular user of sleeping pills, tranquilizers, or painkillers?
64. Do
sical
rn three timeia week?
65. Do
, cigars,
66. Do
alcoholi
67. Do 1|ou drink more than two cups of coffee or tea a day?
68. Havb you ever used cocaine, heroin, LSD or another hallircinogen?
you
1'ou
you
69.
70.
71.
72.
___
act
___
Do /ou drive a motor vehicle more than 25,000 miles ayear?
Do lrou frequently not use seat belts when riding in carsi
List any countries outside the U.S. you have visited in the past six months?
Are there any personally challenging physical feats that you have ever considered domgltn-d if
so, what are
_
they?
73.
WhaJ changes would you
to see with respect to your body, ailments, and your environment?
Most of the following questions have yes or,No answers.
1.
2.
3.
4.
5.
6.
8.
9.
10.
11.
12.
13.
t4.
15.
16.
t7.
18.
19.
20.
21.
22.
Are irou very nervous around strangers?
Do you find it hard to make decisions?
Has your memory diminished significantly? _
Do /ou
Do 5/ou
Do y'ou
Do y'ou tend to see the cup half-empty rather than half-full?
Do you have difficulty relaxing? _
Do you a tendency to womy a lot?
Are you troubled by frightening dreams or thoughts? __
Do you have a tendency to be shy or sensitive?
Do you have a strong dislike for criticism?
Do you lose your temper often?
Do little things often annoy you?
Do you often feel time pressure (not enough time)?
HavQ you ever considered committing suicide?
Havg you ever been in counseling or seen a psychotherapist?
lf thE answer to #16 is "yes", when did the counseling take place, and how long did it last?
on a scale of 1 to 10, with 10 being the peak of enjoyment, how much do you like your job?
.How long have you held your curent job?
Whai was your previous job, and ho*long did you have irl?
Wha{ are your career and financial goals?
__
23.
What is the highest level of education that you have attairred and from what schools did ygu receive your
academic degrees?
24.
Ho
I
much vacation time do you have each year?
25.
26.
27.
_
HoW do you usually spend your vacations?
What do you do to relax on a regular basis?
Wtiat are your hobbies and special interests outside of work?
Please answer the following questions in the space provided.
3.
4.
Are you presently married or in a committed relationship?
If sq, how long have you been in this relationship?
Havp you been married previously?
lf sQ, how many times and what was the duration of each relationship?
5.
Ple4se describe your present relationship with your spouse or partner.
1.
2.
6.
Pledse describe your present relationship with your parents and how often you communicate with them,
are still living. If not, what was it like when they were alive?
if thpy
Whdt was your childhood like?
If you have children, please describe yoru present relationship with thern.
9.
10.
Do you have any close friends?
On 4 scale of 1 to 10, with 10 being the most intimate, how connected ilo you feel to the people closest to
YPU?
On d typical day, do you usually experience some degree of human touoh, either a hug, a sfi:oke, or some
fdrm of physical affection?
T2, Do j'ou belong to any social group, club, or organization that meets regularly?
13. Do J'ou ofter feel alone, isolated, or detached from others?
14. On 4 scale of 1 to 10, with 1 being an almost paralyzingfear, what is your general level o:flfbar or anxiety?
11.
-
15.
WnE situutions, practices, or people make you feel less fearful?
16. What
was your religious upbringing like, and what impact do you think
it has on your present state of
being?
17.
Plealse describe your present spiritual
that you engage in on a regular basis.
focusing on your concept of God and any spiritual practices
Candida Questionnaire and Score Sheet
Name:
This questi
stionnaire
for adults; the scoring system ruu
---'- is
isn'tL eyyrvyrr4rw
----'o
r
appropr:iate rv+
-- designed
for vurrurvlr.
children. rL
It IIJLD
lists I<IvLUIJ
factors III
in
your me{ical history that promote the growth of Candida albicans (Section A), and symptoms commonly found
in individuals with yeast-connected illness (sections B and C).
qugstion in Section A has a numerical score. If your answer to the question is Yes, write or type the
Pu:h
indicate{ number in the shaded area next to the score. This is a protected form-field document, so if
typing' ;iou can just tab to the next field. Total your answers, then move on to sections B and C and score as
directed. Filling out and scoring the questionnaire should help you and your doctor evaluate the possible role of
candida ip contributing to your health problems. Yet, it will not provide an automatic "Yes" or "No" answer.
SECTIC NA:
(1)
HISTORY POINT SCORE:
Ha, /e you taken tetracyclines (SumycinrM, PanmycinrM, Vibramycinrvr,
Mir rocinrM, etc.) or other antibiotics for acne for one month or
longer?
(2)
Zs
Har /e you, at any time in your life, taken other "broad spectrum" antibiotics*
for respiratory, urinary, or other infections for 2 months or longer or in
sho rter courses 4 or more times in a l-year
20
period?
course'/
(3)
Har /e you taken a broad spectrum antibiotic*----even in a single
(4)
Har /e you, at any time in your life, been bothered by persistent prostatitis,
vaginitis, or other problems affecting your reproductive
(5)
Har /e you been pregnant2 or more
organs?
times?
I ti:ne?
(6)
(7)
Har /e you taken birth control pills for more than2 years?
For 6 months to 2 years?
Har /e you taken prednisone, Decadron or other cortisone-type drugs, by
inje ction or inhalation for more than2 weeks?
For 2 weeks or less?
(8)
Dor )s exposure to perfumes, insecticides, fabric shop odors and other
che micals provoke moderate to severe symptoms?
Mil d sl. nPtoms?
6
25
5
3
15
8
15
6
20
5
(9) Are your symptoms worse on damp, muggy days or in moldy places? 20
(10) Har /e you had athlete's foot, ringworm, jock itch or other chronic fungus
inf :ctions of the skin or nails? Have such infections been:
Sev ere or persistent?
20
Mil d to moderate?
10
(11) Do 1 'ou crave sugar?
10
(12) Do 1 'ou crave breads?
10
(13) Do 1 'ou crave alcoholic beverages?
10
(14) Doer r tobacco smoke reallv bother vou?
10
TOTAL SCORE, SECTION A:
*Includiilg ampicillin, amoxicillin, Augmentin, Keflex, ceclor, Bactrim,
septra,
Levaquirf, Zitlromax, and many others. Such antibiotics kill off "good gernrs"
while th$y are killing off those which cause infection.
SECTION B: HISTORY
For each of your symptoms, enter the appropriate figure in the point score column:
Not at all:0 points
Occasiodal or mild: 3 points
Frequenf andlor moderately severe: 6 points
Severe aldlor disabling:9 points
Add totaf score and record it in the box at the end of this section.
POINT
RE:
F atigue or lethargy
Bloating
F eeling of being "drained"
Troublesome vaginal discharge
P oor
memory or concentration
F oeling "spacey"
or'tffeal"
Persistent vaginal burning or itching
Prostatitis
D epression
Impotence
N umbness, burning, or tingling
Loss of sexual desire
N luscle aches
Endometriosis or irrfertility
N luscle weakness or paralysis
Cramps andlor othr:r menstrual
irresularities
P ein and/or
swelling in joints
A bdominal pain
Premenstrual tension
C onstipation
Spots in front of the eyes
D iarrhea
Erratic vision
S ubtotal
Subtotal
MPTOMS
Not at alf
:0
, enter the appropriate figure in the point score column:
points
Occasio4al or
mild:
1
point
:2
points
points
t in the box at the end of this section.
y severe
D]rowsiness
I{ritability
Rash or blisters in mouth
or jitteriness
Bad breath
Iircoordination
Joint swelling or arthritis
Iilability to concentrate
Nasal congestion o,r discharge
Postnasal drip
Nasal itching
Sore or dry throat
Pfessure above ears, feeling ofhead
swelling and tingling
Itching
Other rashes
Heartburn
hidigestion
Belching and intestinal gas
Mucus in stools
Cough
Pain or tightness irr chest
Wheezing or shortness of breath
Urinary rugency or frequency
Burning on urination
Failing vision
Burning or tearing of eyes
Recurrent infectiorrs or fluid in ears
flemonhoids
Dry mouth
Ear pain or deafness
Subtotal
Subtotal
TOTAL SCORE, SECTION B:
GRAND SCORE:
The Gtqld Total Score will help you and your doctor decide if your health problems are yeast-connected.
Scores inlwomen will run higher as 7 items in the questionnaire apply exclusively to women, whLile only 2 apply
exclusiveilv to men.
IF YOUR SCORE IS: SYMPTOMS ARE:
Women
180 or
hilgher: almost certainly yeast-connected
- IW: probably yeast-connected
60 - 19 : possibly yeast-connected
Less thari 60 : probably not yeast-connected
120
1
Men
140 or
higher: almost certainly
- 139 : probably yeast-connected
40 - 79 : possitily yeast-connected
80
<40 = probably.not yeast-connected
If after filling out this form on the computer you wish to e-maill it to Dr. Ivker, please re-name the
file like this: Lastname-Firstlnitial Cand-quest. Thank you.
Please nbte:
FAM HOLISTIC HEALTH QUESTIONNAIRE
tal your score. Each response will be a number
d within the paren.theses (e.g. "2 to 3x/wk',) when
le, "Do you maintain a healthy diet." However,
lon (most of the Mind and Spirit g;estions) - for
ponse is more sub.jective and less exact, ancl you
, such as ofien or dailg, but not to the numbered
SS)
4 = Regularty (4 to 6 times/week)
5 = Daily (every day)
BODY: Physical and Environmental Health
1. Do ygu maintain a healthy diet (low fat, low sugar, fresh fruits, grains
2.
3.
and vegetables)?
_
adequate (at least % oz.llb. of trody weighl.; 160 lbs. = BO oz.;,or 10 gtnl41A
r".nt
of your ideal body weight?
_
4. Do ybu feel physically attractive? _
5. Do ybu fall asleep easily and sleep soundly?
6. Do ybu awaken in the morning feeling well-rested? __
7. Do Ygu have more than enough energr to meet your daily responsibilities? _
8. Are ypur frve senses acute? _
9. Do ypu take time to experience
sensual pleasure?
10. Do 5iou schedule regular massage or deep-tissue body work? __
1 1. Doeb yout: sexual relationship feel gratifying?
12. Do Siou engage in regular physical workouts (lasting; at least 20 rninutes)? __
13. Do 51ou have good endurance or aerobic capacity? ___
14. Do 5iou breathe abdominally for at least a few minutes?
15. Do y'pu maintain physically challenging goals? _
16. Are you physically strong? _
17 . Do Siou do some stretching exercises? _
18. Are you free of chronic aches, pains, ailments, and diseases? ___
19. Do 54ou have regular effortless bowel movements?
20. Do 51ou understand the causes of your chronic physrical problems?_
2L Are you free ofany drug or alcohol dependency? _
t with. respect to clean air, water, eund indoclr
?
eciation for your brody, your home,
ehvironment? _
25. Do you have an awareness of life-energr or qi? _
Total BODY Score = _
aLnd
you.r
MIND: Mental and Emotional Health
1. Do yoi.r have specific goa-ls in your personal and professional life?__
2. Do ypu have the ability to concentrate for extended periods of time? _
3. Do yPu use visualization or mental imagery to help you attain yorur goals or enhance your
pprformance?
4. Do you believe it is- possible to change? _
5. Can you meet your financial needs and desires?
6.
Is yoiur outlook basically optimistic? _
7 . Do you give yourself more supportive messages than critical messages?
_
8. Doeg your job utlLize all of your greatest ta,lents?
9. Is your job enjoyable and fulfilling? _
10. Are you willing to take risks or make mistakes in order to succeed?
to adjust beliefs and attitudes as a result of learnin.g from painful e.xtrleriences?
1 1' lt" ifou_able
12. Do 5tou have a sense of humor?
13. Do 51ou maintain peace of mind and tranquility? _
14. Are you free from a strong need for control or the need to be rigkrt? _
15. Are you able to fully experience (feel) your painful fe:elings such as fear, anger, sadness, and.
hopelessness? _
16. Are jyou aware of and able to safely express fear? __
17 . Are you awa-re of and able to safely express anger? __
18. Are prou aware of and able to safely express sadness or cry? ___
19. Are you accepting of all your feelings? _
20. Do 51ou engage in meditation, contemplation, or psychotherapy to better understand your
feelings? _
21. Is your sleep free from disturbing dreams?
22. Do $ou explore the symbolism and emotional content of your dreams? _23, Do you take the time to let down and relax, or make time for activities that constitute the
abandon or absorption of play? _
24. Do liou experience feelings of exhilaration?
25. Do 51ou enjoy high self-esteem? _
Total MIND Score = _
_
SPIRIT: Spiritual and Social Health
1. Do ypu actively commit time to your spiritual life? __
2. Do ybu take time for pr
n? _
3. Do y0u listen and act u
4. Are oreative activities a
f.ime?
5. Do ypu take risks? _
6. Do you have faith in God, spirit guides, or angels?
7 . Are y'ou free from anger toward God? _
8. Are 5{ou grateful for the blessings in your life?
9. Do you take walks, garden, or have contact with nature?
10. Are you able to let go of your attachment to specific outcomes a-rrd embrace uncertainty? _
11. Do 51ou observe a day of rest completely away from work, dedical.ed to nurturing yourself and
your family? _
12. Can you let go of self-interest in deciding the best course of acl-ion for a given sitruertion? ____
13. Do you feel a sense of purpose? _
14. Do you make time to connect with young children, either your own or someone else's? __
15. Are blayfulness and humor important to you in your daily life? __
16. Do yiou have the ability to forgive yourself and others? _
17. Havg you demonstrated the willingness to commit to a marriage or comparable long-term
reilationship? _
18. Do )iou experience intimacy, besides sex, in your committed relationships? _
19. Do yiou confrde in or speak openly with one or more close frienrlsr? _
20. Do yiou or did you feel close with your parents? _
21.If yop have experienced the loss of a loved one, have you fully grieved that toss? ____
22. Has your experience of pain enabled you to grow spiritually? __
23. Do ]4ou go out of your way or give your time to help others? _
24. Do 54ou feel a sense of belonging to a group or comffrunity? _
25. Do yiou experience unconditional love? _
Total SPIRIT Score =
Total BpDY, MIND, SPIRIT Score = _
HEALTII SCALE:
325 - 375 Optimal Health: THRIVING
275 - 324 Excellent Health
225 - 274 Good Health
L75 - 224 Fair Health
L25 - IT4 Below Average Health
75 - L24 Poor Health
Less th4n 75 Extremely Unhealthy: SURVIVING
FULLY ALIVE MEDICINE (FAM)
FAM TREATMENT OUTCOME QUES'TIONNAIRE
1.
flow long
2.
How many physicians have you seen for treatment of this condition, and what was their diagnosis?
have you had the primary condition for which you're seetrdng treatment at FAM?
Since you've been treating this condition, is there anything you've done or taken that has made a
si gnifi cant improvement?
Alpproximately how many days of work do you miss per year as a result of this condition?
pproximately how much do you spend per year (out-of-pocket) on your medical treatment, including
ice visits, diagnostic tests, procedures, and medications?
(This figure is over and above
insurance coverage. Do you have health insurance? ___-)
are your most uncomfortable or debilitating symptoms? Please rate them
from 1 to 10 (1 is
inimal and 10 is the most uncomfortable and incapacitating).
What would you consider to be a successful treatment outcome folllowing a minimum of a 3-month
cbmmitment to the FAM Treatment Program? Please be as specific a.s possible.
Acknowledgment of Privacy Practices
Fully Alive Medicine
(303)404-2232
3000 Center Green Dr. #130
Boulder, CO 80301
Datei
The undbrsigned acknowledges receipt of a copy of the currently etfective Notice of Privacy Fractices for Fully
Alive MQdicine (FAM). A copy of this signed, dated Acknowledgement shall be as effective as the original. lf
you woUld llke a copy of Prlvacy Practices to keep please ask tlre receptionist.
By providing your email address
to Fully Alive Medicine you are consenting to recelve emall reminders of
appointfients and occasional FAM e-newsletters (of which you can opt-out). You may receive a reminder
phone cfllfrom our office before each appointment, Please see page 11.1of the Privacy Practices'Request
Alternatlve Communicatlons' for more information.
PLEASE |IIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTI.ICARE INFORMATION: (ThIs
includes step parents, grandparents and any care takers who can have accerss to this patient's records):
Name!
Relationship;
lPhone:
Relationship:-
Phone:
Phone:
Cancellation Policy:
Half of the treatment amount may be charged for cancellations with less than 24 hours notice.
Please
S!& your name