Naturopathic Wellness Center

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Naturopathic Wellness Center Ashley G. Lewin, N.D. Erica Waters, ND Mychael Seubert, ND Pediatric Intake Birth to 3 years Name Sex Date of Birth / / Age Parent(s)/Guardian(s) Address City/State/Zip Telephone (home) (work) (cell) What are the most important health concerns/problems with this child? 1. 2. 3. ------------------------------------------------------Medications--------------------------------------------------------------------- Now Past Now Past Now Past aspirin antibiotics decongestants Tylenol Ibuprofen anti-histamines inhalers asthma meds topical steroids other Any other food, environmental or medication allergies? Please list ----------------------------------------------------------Medical History--------------------------------------------------------------- Has this child ever had any of the following: chicken pox scarlet fever bronchitis tonsillitis # times measles pneumonia rubella ear infxn # times croup mumps eczema frequent colds asthma ------------ 548 Roanoke Avenue, Riverhead NY 11901-Phone(631)722-2246-Fax(631)727-8112

Imaging and Special Studies when where results Electroencephalogram (EEG) X-ray hearing evaluation speech/language behavior assessment Injuries/Surgeries/Hospitalizations Please describe: Immunizations measles polio MMR small pox diphtheria mumps DPT tetanus influenza hep B other Any adverse reactions? Please specify: Family History ------------ Has any one in the immediate family had any of the following: heart disease diabetes birth defects cancer mental illness hypertension arthritis tuberculosis allergies hayfever Previous pregnancies by birth mother, miscarriages or complications? Mother s age at child s birth Mother s health during pregnancy : bleeding hypertension illness cigarette, alcohol, drug use nausea thyroid problems diabetes physical/emotional trauma

Birth History Term: full premature late weight at birth length of labor complications: Has this child ever had: jaundice diarrhea birth defects rashes colic seizures allergies birth injury fever other Feeding: breast fed how long formula milk/soy Age began: solid foods sitting crawling first words Child s sleep pattern first year Symptoms Please circle: ( Y = condition the child has now N = never had P = has had in the past ) hives Y N P burning urine Y N P bloody urine Y N P eczema Y N P frequent urination Y N P cries easily Y N P bleeding gums Y N P heart murmur Y N P nervous Y N P nose bleeds Y N P anemia Y N P night sweats Y N P acne Y N P stomachaches Y N P sensitive to light Y N P high fevers Y N P jaundice Y N P body/breath odor Y N P chronic rash Y N P bruises easily Y N P motion/car sick Y N P hearing loss Y N P flat feet Y N P no appetite Y N P diarrhea Y N P constipation Y N P nightmares Y N P sore throat Y N P gas Y N P canker sores Y N P frequent colds Y N P joint pains Y N P unusual fears Y N P wheezing Y N P dizzy spells Y N P excessive fatigue Y N P Any other condition not previously mentioned : ---------------------------------------------------------------Diet------------------------------------------------------------------------- Please describe your child s typical daily diet: Breakfast: Lunch: Dinner: Snacks: Any known food allergies/intolerances?

Naturopathic Wellness Center, Inc. 548 Roanoke Ave Suite 1, Riverhead, NY 11901 P h o n e ( 6 3 1 ) 7 2 2-2 2 4 6 F a x ( 6 3 1 ) 7 2 7-8 1 1 2 N P I # 1 3 7 6 9 7 8 0 1 5 office@naturopathic-wellnesscenter.com Please read carefully and sign below: I understand that the Naturopathic Doctors at Naturopathic Wellness Centers have graduated from a federally accredited four-year naturopathic medical school, and that they attained the degree of Naturopathic Doctor (ND). I understand that the state of New York does not recognize or license qualified naturopathic doctors, and therefore the doctors at NWC do not practice medicine, and do not diagnose or treat disease or medical conditions in the state of New York. I understand that the doctors @ NWC function solely as health consultants and focus their recommendation & advice on the enhancement of health and that nothing that is said or done during any visit/consultation/phone call or in any other setting, is meant for the diagnosis and/or treatment of any medical condition(s) or disease. I further understand that the services at NWC are not meant to replace or be a substitute for those of a licensed physician. Furthermore, NWC requires all clients that seek professional consultation be under the concurrent care of a licensed N.Y. State health provider. I recognize, however, that as a side effect of the health improvement I may experience through working with any/all of the doctors of NWC, that the signs and/or symptoms of any medical condition, which I may have, may diminish or disappear. I have read and fully understand this document. Signed on (Date) Parent/Guardian (If client is under 18 years old) Please print name:

Naturopathic Wellness Center, Inc. 548 Roanoke Ave Suite 1, Riverhead, NY 11901 P h o n e ( 6 3 1 ) 7 2 2-2 2 4 6 F a x ( 6 3 1 ) 7 2 7-8 1 1 2 N P I # 1 3 7 6 9 7 8 0 1 5 office@naturopathic-wellnesscenter.com SUMMARY - NOTICE OF PRIVACY PRACTICES THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. A FULL VERSION OF THE NOTICE IS AVAILABLE FOR YOUR REVIEW IN OUR NOTICE OF PRIVACY PRACTICE IN OUR WAITING AREA. Our Pledge to Protect your Privacy: The staff of Naturopathic Wellness Center. NPI#1376978015, 548 Roanoke Ave Suite I are committed to protecting the privacy of your medical information. So that we can best meet your needs, we share your medical information with all the healthcare providers involved in your care. Only to the extent necessary, we also use and share your information to conduct our business operation, to collect payment for the services we provide to you and to comply with the laws that govern healthcare. We will not use or disclose your information for any other purpose without your permission. You have the following rights to access and control your health information: To inspect and obtain a copy of your medical and billing records, subject to some special requirements for substance and alcohol abuse, genetic, mental health and HIV-related data; To request restrictions on certain uses or disclosures of your medical information; To request an accounting of our disclosures of your medical information; To add an addendum to your medical record; To request that we communicate with you in a certain way or at a certain location; To receive a copy of the full version of our Notice of Privacy Practices. Examples of how we may use and disclose your health information: To provide you with medical treatment and services; To bill and receive payment for the treatment and services you receive; For functions necessary to run our Practice and to assure that our patients receive quality care; To provide only demographic information for studies in which patients remain anonymous; For worker's compensation or similar programs; For required public health activities (e.g., reporting abuse or adverse reactions to medications); For healthcare oversight (e.g., to a State Department of Health); For law enforcement in certain limited circumstances; To a coroner, medical examiner or funeral director as required by law; For organ procurement or transplantation, if you are a potential donor. For further information about the full Notice, reference our PRIVACY MANUAL in our waiting area.

Naturopathic Wellness Center, Inc. 548 Roanoke Ave Suite 1, Riverhead, NY 11901 Phone (631) 722-2246 Fax (631) 727-8112 NPI #1376978015 NOTICE OF RECEIPT OF PRIVACY PRACTICES INFORMATION Patient Name Address City State Zip Telephone Date of Birth I have received a copy of this Practice's Privacy Practices Information, or such information has been made available for me to read, and I acknowledge and accept its provisions. Consent Form for all Patients at Naturopathic Wellness Centers I acknowledge and agree that Naturopathic Wellness Centers (NWC) located at 548 Roanoke Ave. in Riverhead, New York is not responsible for the judgment or conduct of any health professional who provides a service to me, but rather each professional is an independent contractor who is self-employed and is not the agent, servant or employee of the clinic. I further understand that other health professionals may be called upon to provide care, either directly as consultants or indirectly through professional services. These health professionals are also independent contractors who are self-employed and are not agents, servants or employees of the clinic. You may be referred to other health professionals outside this clinic, however NWC is not responsible for their judgment or conduct as they are independent of this clinic in every way. Patient s Signature Date

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