To-Do List Functional Medicine (COMPREHENSIVE) patients UNDER 10 YEARS OLD
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1 To-Do List Functional Medicine (COMPREHENSIVE) patients UNDER 10 YEARS OLD A SUMMARY OF THE FORMS YOU WILL NEED TO COMPLETE BEFORE YOUR INITIAL FUNCTIONAL MEDICINE APPOINTMENT WITH DR. FENSKE, AND WHEN SHE WILL NEED TO RECEIVE THEM IN ORDER TO FULLY PREPARE FOR YOUR APPOINTMENT. FORM: DUE: Medical Record Request (separate download from other forms) Patient Acceptance Form Within TWO DAYS of scheduling your initial appointment. Within ONE WEEK of scheduling your initial appointment. Weekly Symptom Checklist Within ONE WEEK of scheduling your initial appointment. Nutritional Assessment Questionnaire Within ONE WEEK of scheduling your initial appointment. Diet Diary Within ONE WEEK of scheduling your initial appointment. Health Goals Within ONE WEEK of scheduling your initial appointment tel fax Info@DrFenske.com Terrace Ave. Ste 2 Middleton, WI 53562
2 Patient Acceptance Policy Functional Medicine (COMPREHENSIVE) patients (608) Name (last, first) Date: Address City, State, Zip Phone (home) Phone (cell) Sex Age Date of Birth Spouse/Partner s Name Children (ages, names) Occupation Employer/School Whom may we thank for referring you to our office? In order to best serve you, the Patient Acceptance Policy should be carefully reviewed. It is Dr. Fenske s opinion that you should be well informed on our expectations and clinical procedures. To prevent any misunderstandings or confusion on what to expect, Dr. Fenske would appreciate that you read the below steps and provide your signature. This would simply imply that you have read the Patient Acceptance Policy and understand what is expected of you. PRIOR TO FIRST APPOINTMENT: 1. Completion of the following forms: Patient Acceptance Policy, Patient Health History, Nutritional Assessment Questionnaire, Diet and Lifestyle Diary, Health Goals, Request for Records. These forms were developed to gather important information about your body. They will help Dr. Fenske more quickly zero in on the probable causes of your health problems. It is VERY important for you to carefully and thoroughly complete all of these forms and questionnaires prior to your first consultation with Dr. Fenske. 2. Medical Records and Lab Reports (see Request for Records form) Obtain medical records and lab reports from all physicians since you were first diagnosed with your health condition. We MUST receive these prior to your initial appointment. FIRST APPOINTMENT: 3. At your initial appointment Dr. Fenske will review your case with you and provide a detailed written report based on the information you have provided. The cost for the 60 to 75 minute appointment as well as Dr. Fenske s time for studying your forms / medical records is $ Based on your initial appointment and review of all your medical information Dr. Fenske may recommend various labs. These labs help uncover underlying weaknesses in the body that may result in disease. You will be presented with detailed information on the specific tests recommended. Because it varies case by case, the cost for your initial laboratory tests will be discussed at that time. SECOND APPOINTMENT: 5. The time it takes to receive the results of your tests varies based on individual test processing time as well as on when you choose to initiate the test. When results are available our staff will call to schedule your second appointment. This appointment usually takes approximately one hour. You will be presented with the possible causes of your health problem and the recommended treatment protocol. The fee for this second appointment is typically $120 to $ for approximately 30 to 60 minutes.
3 6. Your recommendations may consist of personalized dietary and lifestyle changes as well as nutritional supplements. 7. After this second appointment, you may meet with our patient educator to discuss implementation of specific recommendations. SUBSEQUENT APPOINTMENTS: 8. Follow-up consultations will be scheduled every 3, 6 or 12 weeks allowing you the opportunity to discuss your progress and any concerns with Dr. Fenske. Dr. Fenske will at this time determine what direction to take to help you continue your progress. Your cooperation in taking personal responsibility in your health care will go a long way in getting better. Consultations may be conducted either by phone or in person at our office. The fee for follow-up consultations is based on the time required for the appointment (typically $ to $240). 9. Abnormal laboratory tests will need to be re-evaluated. The success of your treatment will not only be measured on the reduction or elimination of your physical symptoms, but on abnormal laboratory tests returning to a normal status. Laboratory fees can vary depending on what needs to be re-tested. Our goal at Fenske Holistic Healthcare Center is to provide high quality, personal service that is responsive to the healthcare needs of our patients. We require payment for services at the time they are provided. Insurance companies do not cover Functional Medicine consultations, nutritional supplements, or preventative lab services. Any specific questions you may have about coverage for our services should be directed to your insurance provider. Note: prices are subject to change without notice, the duration of each visit is approximate, and 24-hour notice is required to cancel an appointment without incurring a charge. Prices not only reflect the time spent with each patient but also the time studying your case between visits and the advanced training, expertise, and effort required to treat complex health conditions. We accept payment by cash, check, or credit card (Mastercard and Visa). I have read and fully understand the Patient Acceptance Policy. Patient (Parent/Guardian) Signature Date (The signature of Parent/Guardian hereby authorizes Dr. Nicole Fenske to provide care for the minor child listed as Patient). Fenske Holistic Healthcare Center 2 Patient Acceptance Policy (FM Comprehensive)
4 Fenske Holistic Healthcare Center WEEKLY SYMPTOM CHECKLIST FOR CHILDREN Name Date Date of Birth Age Height Weight Blood Type Rate each of the following symptoms based on your child s current health profile Point Scale 0 - Never or almost never has the symptom 1 - Occasionally has symptoms 2 - Frequently has symptoms HEAD Headaches Difficulty falling asleep Wakes up during the night Total EYES Watery or itchy eyes Dark circles under eyes Bags under eyes Swollen eyelids Total EARS Reddening of ears Itchy ears Earaches/Ear infections (circle which apply) Drainage from ear Hearing loss Frequent pulling on ears Total NOSE Runny nose Stuffy nose Sneezing Allergic Salute (rubs, itches, wipes nose frequently with hands) Total MOUTH/THROAT Swollen or red lips Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or sore or discolored tongue Swollen or sore gums or lips Canker sores Total SKIN Easy bruising Hives Rash Dry or flaky skin Flushing Cold hands or feet Eczema Total
5 LUNGS Coughing Sneezing Difficulty breathing Wheezing Total DIGESTIVE TRACT Nausea Vomiting Diarrhea Constipation Bloated feeling Belching Passing gas (flatulence) Heartburn Tummy ache Poor appetite Refusal to eat Total JOINTS/MUSCLE Coordination problems Pain in muscles (e.g., leg ache) Pain in joints ( e.g., knee ache) Total ENERGY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Sleeping problems Total MIND/EMOTIONS Inattentiveness or poor concentration Mood swings Anxiety, nervousness Fear Anger Irritability Aggressiveness (e.g. hitting, kicking, biting) Crying or weepiness Tantrums Hyperactivity Total OTHER Frequent urination Itching of anus or genitals Bed wetting Wetting or soiling of clothes Total GRAND TOTAL TOTAL Fenske Holistic Healthcare Center 2 Weekly Symptom Checklist
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12 Establishing Your Health Goals Functional Medicine (COMPREHENSIVE) patients (608) Name Date: Personal Message Before You Begin Before you begin our journey together, I would like to discuss something very important that will have a major impact on your ability to recover and achieve maximum improvement. After many years in private practice, I have had the opportunity to work with thousands of patients and have seen many patients achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and why others fail. This questionnaire is about much more than eliminating your symptoms it s about living a life of vibrant health. I ve discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality, a discussion of how you have lived your life up to this point and how you will live it in the future. Therefore, to help you make significant changes in your present health, I want to ask you a few very important questions. I want you to be honest with yourself and really dig deep inside yourself for the answers. 1. Have you made the decision to change? To do what it takes to get well? Yes No I have read something interesting: The definition of insanity is to keep doing the same thing and expecting different results. If you keep following the same course of treatment you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to reach your destination. Most people I ask tell me they have made the decision to change. But how many people have truly decided to change? Very few! Why? Because there is a big difference between deciding something and having reasons to actually do it. When you have made a decision to make a change and you know your reasons, you create an internal power that can propel you to achieve health and wellness. So now I ask: 2. List up to 5 things that you have been unable to do as a result of your present symptoms. Please be specific. (Use extra pages if necessary)
13 3. List up to 5 things that you plan to do once you are feeling better. Please be specific. (Use extra pages if necessary) 4. Please check off the following that you would like to achieve with my help: o Increase energy o Sleep better o Have better digestion o Be able to eat more foods o Get rid of my allergies o Have a better immune system (i.e. less colds /coughs) o Not be dependent on laxatives or stool softeners o Be able to work out again o Have better muscle tone o Be in less pain o No longer use pain medication o No longer use allergy medication o No longer use sleep medication o To feel less sleepy in the afternoon o Lose weight o Increase my sex drive o Increase my metabolism to burn more fat o Increase my flexibility o Reduce my stress o Improve my memory o Improve my focus o Improve my mood o Reduce my risk of developing a chronic disease o I want to work on an anti-aging program o I want to detoxify my body o I want to improve my diet o I want to clear up my skin 5. Are there any other health goals you want to achieve? Fenske Holistic Healthcare Center 2 Health Goals (FM Comprehensive)
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