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There are many ways to improve patient intake procedures. One of the ways has been recently in the news. It was created with Salesforce. com’s Force. com enterprise application development platform. It is run on staff members AppleIphones. This replaces a manual process. It has cut the admission process from 18 hours to sometimes less than 1 hour. Having this done on the AppleIphone keeps the protection on health information. When putting this procedure on the AppleIphone it saves time for both the staff and patient. You, as a staff member have to realize that each patient is an individual.

Each patient has unique healthcare needs. There are four steps to be taken to hae a quick and efficient patient intake experience. Step 1: The first thing that has to be done is to have the diagnosis from your doctor that you need this procedure. Step 2: Download, print and fill out forms at home at your leisure. When you come in for your appointment, bring or e-mail the completed forms. This will expedite the intake process. If there are any questions about the forms, fixing the details, is easier than completing the whole form at the provider’s office.

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Step 3: Call to speak to your billing specialist if you have any questions or concerns about the cost of this procedure. This would be the time to ask any questions that are insurance related, or any questions about the patient intake procedure or forms. Step 4: Call to make your first appointment, and to schedule your procedure. When you are at home and fill out the patient intake forms at your own pace. It can make the intake procedure quicker and go a whole lot smoother. When the office has little, if any, questions, it can expedite the paperwork procedure.

The patient can download the papers and print them off, or you are able to complete the forms on the computer, and e-mail them to your doctor’s office, or you can do things the old fashioned way, and put pen to paper to fill out the form and bring it to your first appointment. One of the main forms, that is being used to complete the patient intake process, is the basic patient intake form. This seven page form can be taken from the office, or downloaded off the computer, filled out and brought back to your first appointment.

This procedure will leave little if any questions needed to be answered in the office on your first appointment. PATIENT INTAKE FORM Date: Name: Date of Birth: Address: Home phone: Work phone: Cell phone: Email: How did you hear about our practice: “X” all that apply: Is it o. k. to leave a phone/mail message regarding your care at: home work cell phone email Emergency Contact Information: Name: Relationship: Phone Number: Name and phone number of primary care physician: ____________________________________________________________ _ Please list your health concerns in order of priority: 1. 2.

3. 4. 5. What do you believe is causing your most important health concerns? Please list any medications and supplements you are currently taking, along with doses and the reason you are taking them: Medications:| Reason:| Date began:| Dose:| Helps? Yes or no| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Supplements:| Reason:| Date began:| Dose:| Helps? Yes or no| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | PLEASE CHECK AND DESCRIBE ANY PROBLEMS OR CHANGE IN FUNCTION IN THE PAST OR PRESENT IN ANY OF THESE AREAS (the notes in parentheses are examples.

Please don’t limit your responses to these). ___ Headaches ___ Weight ___ Vision ___ Nose/sinuses (example: allergies, sinus infections) ___ Throat (example: recent or recurrent infections) ___ Digestive tract problems (example: bowel problems, hemorrhoids, hernias, diarrhea, bloating) How often do you have a bowel movement? ___ Energy ___ Body temperature ___ Other eye problems (infections, sties) ___ Mouth/teeth/gums (including dental procedures) ___ Skin (eczema, infections, rashes) ___ Heart disease (rheumatic fever, shortness of breath, palpitations) ___ Stomach (ulcers, reflux, etc)

___ Musculoskeletal concerns (arthritis, joint problems, Osteoporosis, muscle pain, weakness):___ ___ Other:_________ WOMEN: Are you currently experiencing any gynecological symptoms or problems? ______ Are you currently sexually active? _____ Partner(s) is/are __Male __Female If sexually active, do you perform safe sex practices? ___________________________________ Any problems related to sexual function? ____________________________________________ History of sexually transmitted diseases? _____________________ Genital worts? ___________ Number of pregnancies? ____ Births?

____ Abortions? ____ Miscarriages? ____ Date of last Pap Smear? ____________ Abnormal Pap? _________________________________ How frequent do you have a gyn exam/ pap smears? ___________________________________ Any cervical cancer history? _____________if yes, when:________________________ Any ovarian cancer history? _____________if yes, when:________________________ Do you perform regular breast self exams? _____yes ____no If menopausal or perimenopausal: List symptoms and concerns:_____________ ____________________________________________________________ _______________

Any personal history of breast cancer? ______________________________________________ FOR WOMEN WHO ARE OF MENSTRUATING AGE: Onset of first menses was age___. Periods generally last ___ days and occur every ___ days. Date of last period ____________ Bleeding is __Heavy __Moderate __Light Do you experience PMS symptoms? _____ List:_______________________________________ MEN: Are you currently sexually active? _____ Partner(s) is/are __Male __Female History of sexually transmitted diseases? _____________________ Genital worts? ___________ Date of last prostate exam? ____________ Trouble with urination?

(frequency, hesitancy, pain, dribbling)___________________________ Trouble with sexual function/libido? __ __ If yes, explain: PLEASE DESCRIBE YOUR FAMILY’S HEALTH: (be sure to include current age or age of death, major illness history, including diabetes, heart disease, osteoporosis, cancer, allergies, etc. ) Member| Living? /Age| Major illness or chronic conditions| Mother| | | Father| | | Siblings| | | | | | | | | Mat. Grandmother| | | Mat. Grandfather| | | Pat. Grandmother| | | Pat. Grandfather| | | SURGERIES: Age:| Description:| | | | | | | | | DIET: Please describe a typical days diet for you

Breakfast| Lunch| Dinner| Snacks (what hour)| | | | | | | | | | | | | | | | | | | | | Sources and amounts of: Caffeine:_____________________ Alcohol:_______________ Smoking history and amount:________ WEIGHT and HEIGHT: | Current| Past year| Past 5 years| Weight| | | | Height| | | | ALLERGIES: please list any life threatening or severe allergies to drugs or foods that you know of: 1. 2. 3. LIFESTYLE: What are your primary sources of stress? 1. 2. 3. How much do you think they impact you life? __________ Occupation? ________________________ Do you like your work? ______________ How many hours do you work per week?

______Number of play/relaxation hours? _______ What do you do in order to manage stress and take care of yourself? : ____________ What is your exercise routine? : ____ CURRENT MEDICAL STATUS: Date of last full physical? __________ if abnormal, explain:__________ Date of last dermatology checkup? _______ if abnormal, explain:________ Any personal history of skin cancer? ____yes _____no If over age 50, have you had a colonoscopy? ____yes _____no Dates of colonoscopy? _____________________________ Any positive findings on colonoscopy? ___yes___no, if yes, explain:__________ Date of last visual acuity exam?

______if abnormal, explain: ____________ Date of last ophthalmologic exam? _________ if abnormal, explain: _________ Do you visit the dentist regularly? ___yes ____no If yes, how frequent? __ Do you have dental problems, gum inflammation or gingivitis? Circle which and explain: ___ What do you believe is your greatest challenge? What do you think you need to do in order for you vision of health to happen? Thank you for your time and for filling this form out as completely as possible. Please remember all information given is strictly confidential. Dr. Clara Barnett ND, LAc New York Acupuncture License Number: 3021

Patient Introduction and Informed Consent Naturopathic doctors obtain a doctorate in naturopathic medicine after graduating from an accredited naturopathic medical institution. Naturopathic doctors complete training in the study of biological sciences and conventional medical diagnosis and treatment. In addition, naturopathic doctors receive extensive training in clinical nutrition, homeopathy, botanical medicine, physical medicine and counseling. Naturopathic doctors concentrate on whole-patient wellness. Recommendations are specific to each patient and emphasize prevention and self-care.

Naturopathic doctors focus on the underlying cause of the patient’s illness rather than focusing solely on symptoms. Naturopathic therapies may require more time to be effective, yet often provide long-lasting health improvements. A Naturopathic Doctor (ND) is trained as a primary care provider and is a board-certified physician in states where licensure is applicable. Dr. Clara Barnett is a licensed naturopathic physician in the state of Washington and a licensed acupuncturist in the states of Washington and New York. Currently licensure for naturopathic doctors is not available in New York State.

Therefore, Dr. Clara Barnett does not practice medicine, and does not diagnose or treat diseases or medical conditions in the state of New York. Dr. Clara Barnett focuses her practice on the enhancement of health. Dr. Clara Barnett’s services are not meant to substitute or replace those of a licensed physician and clients seeking her consultation are advised to be under the care of a licensed NY state physician. Acupuncture is a healing therapy which involves inserting fine needles into specific points, along meridians, on the body. It can reestablish and unblock the flow of qi, or energy.

In addition to the use of needles, the scope of acupuncture includes use of electrical, mechanical or magnetic devices to stimulate acupuncture points, moxibustion, acupressure, cupping and/or infra-red therapy. All therapies, including the naturopathic/acupuncture modalities described above have the potential to create both desirable and undesirable effects. Of the latter, such effects can include the following: allergic reactions/sensitivities/adverse effects to recommendations of natural supplements and adjustments to making lifestyle modifications.

Acupuncture side effects may include some pain following treatment in the insertion area, minor bruising, infection, needle sickness (fainting) and broken needle. If you are pregnant, 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 Dr. Clara Barnett ND, LAc prior to treatment.

I have read and the understood the information on this consent form. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Dr. Clara Barnett ND, LAc, regarding cure or improvement of my condition. I understand that I am free to withdraw this consent and discontinue participation of these procedures at any time. Date _____/_____/20___ Name ___________________ Signature _________________ Dr. Clara Barnett ND, LAc Doctor of Naturopathic Medicine Licensed Acupuncturist.

Release of Information All information provided herein is true and correct. I hereby consent to treatment. I give permission to my provider and staff to release information, verbal and written, contained in my medical record and other related information to related health care providers, assignees and/or beneficiaries and other related persons. I have read and understood this release. X__________________________________ Date_________________ Payment Policy Payment of all services rendered is due at the time of service to Dr. Clara Barnett ND, LAc.

I have read and understood this policy. X__________________________________ Date_________________ Appointment Cancellation Policy I understand that 48 hours notice is required when canceling an appointment. I also understand that the full cost of the visit will be charged if I do not cancel 48 hours prior to the appointment. X__________________________________ Date_________________ This is a typical patient intake form, that you can download and complete in your home or on the computer. References: Medical Insurance www. Patient intake forms. pdf.

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