Intake Health - Amber Wellness Group

Amber Wellness Group, PLLC 1944 NE 45th Ave. Portland, OR 97213

Lisa Dickinson, N.D. * Meghan Bennett, N.D. * Jade Wienbar, N.D. *Sumner Van Brunt, N.D.

971-319-0045 Office 833-962-2422 Fax

Print Name(Required)

Preferred Name

Cell Phone(Required)

Home Phone

Work Phone

Address(Required)

Street Address City State ZIP Code

Email(Required)

Age(Required)

Date of Birth(Required)

Height ft.(Required)

Height in.(Required)

Weight lbs(Required)

Gender assigned at birth(Required)

Marital Status(Required)

Pronoun(Required)

Employer:

Occupation:(Required)

Emergency Contact:(Required)

Phone

Relationship

How did you hear about us or who may we thank for referring you?(Required)

Name of your primary care physician?

Phone

Please list other practitioners that you have seen for your health concerns:

Name

Phone

Please list any prescriptions, supplements, or over the counter medications you are currently taking:

Medication or Supplement

For?

Dosage

Medication or Supplement

For?

Dosage

What is your primary health concern?(Required)

When did this problem begin?(Required)

What makes it better or worse?(Required)

Has this condition been evaluated by another physician?(Required)

If so, list any known diagnosis:

What prior treatments have you had for this condition and what were the results?

Does this impair your daily activities?(Required)

If so, how?

Please list any other health concerns that you wish to address:

Please provide complete information in the following pages related to your current and past health concerns.

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Please upload your current and past health concerns

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Allergies

Past

Present

Asthma

Past

Present

Blood Pressure

Past

Present

Bruise Easily

Past

Present

Cancer

Past

Present

Chicken Pox

Past

Present

Diabetes

Past

Present

Emphysema

Past

Present

Epilepsy

Past

Present

Glaucoma

Past

Present

Heart Disease

Past

Present

Hepatitis

Past

Present

Herpes Virus

Past

Present

High Fever

Past

Present

HIV

Past

Present

Jaundice

Past

Present

Lyme Disease

Past

Present

Measles

Past

Present

Meningitis

Past

Present

Mononucleosis

Past

Present

Multiple Sclerosis

Past

Present

Pneumonia

Past

Present

Rheumatic Fever

Past

Present

STI's

Past

Present

Thyroid Disorder

Past

Present

Tuberculosis

Past

Present

Other:

Past

Present

Please provide complete information in the following pages related to your Recent Medical Tests:

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Please upload your recent medical tests

Max. file size: 1 MB.

CBC / Ferritin

Date

Results

Complete Metabolic / Blood Sugar:

Date

Results

Thyroid: TSH, Free T4, Free T3

Date

Results

Cholesterol TC, HDL, LDL, TG

Date

Results

Vitamin D

Date

Results

Cancer Markers

Date

Results

Hormones (Prog, Est, Test)

Date

Results

Adrenal (cortisol, DHEA)

Date

Results

Prostate PSA

Date

Results

GI Testing

Date

Results

Mammogram

Date

Results

Physical

Date

Results

Pap Smear

Date

Results

STI testing

Date

Results

Ultrasounds

Date

Results

Pathology reports

Date

Results

Other testing / Imaging

Date

Results

List any prior surgeries and what they were for and the date or approximate date / year performed

Type

Reason

Date

FAMILY HISTORY

Please indicate family history of:(Required)

Please indicate any personal addictions to(Required)

Nicotine

Prescription Medications

Alcohol

Other

None

Describe other family history

Describe other personal addictions

HEALTH CONCERNS

Energy, Emotions, and Immunity(Required)

Stress Level ____/10

Number of hours of sleep per night:

Sleep(Required)

Cardiovascular:(Required)

Heart Disease

Chest Pain

Swelling of Ankles

Heart Murmurs

High Blood Pressure

Palpitations / Fluttering

Poor Circulation

Varicose Veins

None

Respiratory:(Required)

Cough

Shortness of Breath

Pneumonia

Pleurisy

Tobacco Use Current

Tobacco Use Past

Asthma

None

Skin(Required)

Rash

Eczema

Psoriasis

Itchy Skin

Dry Skin

Hives

Acne

Dandruff

None

Head, Eye, Ear, Nose, Throat:(Required)

Gastrointestinal:(Required)

Female Reproductive:(Required)

Genito-Urinary Tract(Required)

Musculoskeletal:(Required)

Endocrine:(Required)

Hypothyroid

Hypoglycemia

Diabetes Mellitus

Feel Hot

Feel Cold

Low Libido

Hair Loss

None

Neurological:(Required)

Vertigo / Dizziness

Numbness / Tingling

Loss of Balance

Paralysis

None

Please describe other pain

Please describe other Female Reproductive

Are you currently pregnant?

Please list due date:

Are you currently taking hormonal birth control?

Please list medication:

Are you interested in learning more about the various pelvic floor rehabilitation therapies that we offer (trigger point therapy, Holistic Pelvic Care ™, and THERMIva, MLT)?

*If you are seeing us for preconception counseling or infertility concerns, please make sure you fill out our separate questionnaire.

Click HERE to fill out the questionnaire.

Have you completed and submitted the questionnaire?(Required)

Male Reproductive:

Prostate Problems

Testicular Pain / Swelling

Sexual Difficulties

Penile Discharge

None

Habits / Lifestyle:

Exercise: times/week(Required)

Excercise(Required)

Mild

Moderate

Intense

Nome

Hobbies:(Required)

Work

Work Activity(Required)

Sitting

Standing

Computer

Work hours/week(Required)

Do you enjoy your work?(Required)

Alcohol:(Required)

Alcohol days/ week?

Caffeine(Required)

Water: Cups/day:(Required)

Stress Level:(Required)

Tobacco(Required)

Spiritual Practice(Required)

Television(Required)

Reading(Required)

Have you experienced any major traumas?(Required)

Please Explain:

Typical Daily Food Menu:(Required)

Breakfast:

Lunch:

Dinner:

Snacks:

Beverages:

List any food allergies, sensitivities, or intolerances and your reaction:(Required)

List any allergies related to medications or supplements and your reaction:(Required)

Generalized Anxiety Disorder 7-item (GAD-7) scale

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

Not at all sure

Several days

Over half the days

Nearly every day

2. Not being able to stop or control worrying

Not at all sure

Several days

Over half the days

Nearly every day

3. Worrying too much about different things

Not at all sure

Several days

Over half the days

Nearly every day

4. Trouble relaxing

Not at all sure

Several days

Over half the days

Nearly every day

5. Being so restless that it's hard to sit still

Not at all sure

Several days

Over half the days

Nearly every day

6. Becoming easily annoyed or irritable

Not at all sure

Several days

Over half the days

Nearly every day

7. Feeling afraid as if something awful might happen

Not at all sure

Several days

Over half the days

Nearly every day

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Patient Health Questionnaire-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following

1. Little interest or pleasure in doing things

Not at all sure

Several days

Over half the days

Nearly every day

2. Feeling down, depressed, or hopeless

Not at all sure

Several days

Over half the days

Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

Not at all sure

Several days

Over half the days

Nearly every day

4. Feeling tired or having little energy

Not at all sure

Several days

Over half the days

Nearly every day

5. Poor appetite or overeating

Not at all sure

Several days

Over half the days

Nearly every day

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Not at all sure

Several days

Over half the days

Nearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all sure

Several days

Over half the days

Nearly every day

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Not at all sure

Several days

Over half the days

Nearly every day

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all sure

Several days

Over half the days

Nearly every day

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Policies and Consents

By voluntarily signing this document, I show that I have been provided the clinic policies and consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Initial each section below

HIPAA Notice of Privacy Practices(Required)

I acknowledge that I received a copy of Amber Wellness Group clinic policies, as well as, HIPAA privacy laws and I agree to the use of my medical information for my treatment.

Financial Responsibility(Required)

I understand that I am responsible for full payment of services and supplements at the time of service. If you do not have insurance or your provider is out of network with your insurance, we offer you a 20% discount on the office visit charge. (We encourage you to bill your own insurance, please ask us how we can help).

Insurance Billing(Required)

I understand that I am responsible for completing the insurance verification form and know that I am responsible for payment for any non-covered services denied by my insurance company. If you request us to bill your out of network insurance you agree to pay for the entirety of the charges billed and not covered by your insurance and you will not be granted the 20% discount that is offered at time of service.

Roles and Responsibilities for Provider and Patient(Required)

I understand that my provider will only prescribe medications that they believe are in my best interest and it is my responsibility to keep them informed of any changes or updates in my health or outside medications.

Labs Review(Required)

I accept that any labs ordered by my provider requires a follow up appointment for review and interpretation to establish an appropriate treatment plan.

Prescription Refill Policy(Required)

I accept responsibility to call my pharmacy when I need a refill on my pharmaceutical medications, even if I am out of refills. The clinic will respond to all refills within 48 hours of receiving notice from the pharmacy.

Supplements(Required)

I understand that refills on my supplements should go through the front office to verify availability, or I can use the clinic’s online dispensary through Fullscript. Supplements purchased from the clinic are non-refundable.

Cancellation Policy(Required)

I understand that it is my responsibility to know when my appointment is and that reminders from the clinic are a courtesy. Failure to notify the clinic 48 hours prior to my appointment, for either a cancellation or rescheduling, or missing my appointment entirely will result in a $140 fee.

E-consult Policy(Required)

I understand that the patient portal is where my provider will communicate with me as it is the most secure platform. Any messages that I send that go beyond simple clarification may be subject to an e-consult fee.

By signing below:

I acknowledge that I have been provided ample opportunity to read the HIPAA Notice of Privacy Practices provided by the clinic or that it has been read to me.
I understand all of the above and give my oral and written consent to evaluation and treatment. I intend this as a consent form to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.
I agree that I will consult the consent form or call the office for clarification when I have concerns regarding my care at Amber Wellness Group.

Printed Name of Patient/Guardian(Required)

Signature of Patient/ Parent/ Guardian(Required)

Date(Required)

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Amber Wellness Group, PLLC 1944 NE 45th Ave. Portland, OR 97213

Generalized Anxiety Disorder 7-item (GAD-7) scale

Patient Health Questionnaire-9 (PHQ-9)

Policies and Consents

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