Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, Kingston, NY 12401

Patient Information

Name ______Date ______

Age______Date of birth ______Sex: Male Female MTF FTM Other: ______
Address ______City ______State ____ Zip ______
After writing in your phone number, please circle which number (if any) is okay to leave confidential messages on.

Telephone (Home) ______(Work) ______(Cell)______

Email ______

Would you like to receive Blue Stone Natural Health updates via email? (Circle one)YesNo

Emergency Contact ______Relationship ______

Telephone (Home) ______(Work) ______(Cell)______

How did you hear about Dr. Morales? ______

NOTE: Holistic and preventative healthcare is enhanced dramatically when the practitioner has a complete picture of the patient physically, mentally, emotionally and spiritually. I ask for your cooperation and patience as you complete this health history questionnaire. You may find that some of the information is difficult to recall. I only ask that you do your best. The more information you provide, the better I will be able to serve your needs.

Thank you for your cooperation and thoroughness. I look forward to working with you.

Health History

When, where and by whom did you last receive medical care? ______
______

In your opinion, what are your most important physical, emotional, or mental health problems? Indicate which is/are of the most immediate concern to you.

1. ______

2. ______

3. ______

4. ______

5. ______

How do you rate your overall health? Excellent Good Fair Poor

What are your expectations for your first visit? ______

What are your expectations for our work together in general? ______

______

HOSPITALIZATION
What hospitalizations or surgeries have you had? When did they occur? ______

HEALTH STUDIES

When was your last blood test? ______What type of test? ______

What is your blood type?______

Any other tests recently? ______

MEDICATIONS

List all drugs, vitamins, herbs being taken at present with dosage: ______

Are you allergic to any medications or other substances? Y N
If yes, please list ______
______

What happens when you have an "allergy attack"? ______

CHILDHOOD ILLNESSES

Rubella (German Measles ) ___ Measles ___ Mumps ___ Chickenpox ___ Roseola ___

Whooping cough ___ Polio ___ Rheumatic Fever ___ Scarlet Fever ___ Diphtheria ___

Frequent ear infections or colds as a child? ______Asthma ___ Eczema ___

Any difficulties with your birth or your mother’s pregnancy with you?______

IMMUNIZATIONS

Polio Y N Pertussis Y N

Tetanus Y N Diphtheria Y N

Measles/Mumps/Rubella Y N Other ______

FAMILY HISTORY

Please list ages, any major health problems, and if deceased, what they died from and at what age.
Mother ______

Father ______Sisters ______

Brothers ______

Mother's Side:

Grandfather ______

Grandmother ______

Father's Side:

Grandfather ______

Grandmother ______

SOCIAL HISTORY
Occupation ______Work hours______

Are you: Married ___ Separated ___ Divorced ___ Single ___ Widowed ___ Partner ___

With whom do live: Spouse ___ Parents ___ Relatives ___ Friends ___ Alone ___ Other ___

Do you have the support of family and friends to make positive changes in your life? ______

Have you traveled outside the U.S? ______Where and when? ______
Military Status: When did you serve? ______Where? ______

Do you have a religious or spiritual practice? ______

In what areas of your life do you experience stress? Work Family Life Social Life Financial

Please list the most significant stressful events of your life (remember to include childhood):

______
______
______
______
______

HEALTH HABITS
Do you drink alcohol? ____ If so, what: Wine ____ Beer ____ Other alcohol______
Do you use tobacco or have you in the past? _____ If so, how much? ______

Total number of years smoking? _____ Total number of years since stopped smoking? ______

Do you now or have in the past used marijuana or other drugs? ____ If yes, which drugs, how often and for how long? ______

List any longterm health problems that have resulted from taking these drugs ______

Do you exercise? _____
How often? (Hours/day and days/week) ______

Circle any of the following that you do on a regular basis: Jog Swim Walk Bicycle Garden

Yoga Stretch Weight lift Hike Other ______

Do you make time for rest, relaxation during the day and/or before bed? ____ How often? _____
How do you relax? ______
What are your primary interests or hobbies? ______

DIET
Number of meals eaten per day: 1 2 3 more than 3

How is your appetite? ______
Where do you usually buy your food? ______Who cooks the food you eat? ______

List the primary foods included in your diet. ______
______
List the foods excluded from your diet. ______
______

List any of the following (and relative amounts) eaten regularly by you: Coffee, caffeinated teas, highly seasoned foods, processed foods, preservatives, refined foods or foods you suspect may be harmful to your health:______

List any of the foods you crave, regardless of their nutritional value (including sweets, chocolate, salty, sour, bread, rich/fatty foods, etc.): ______
Are you satisfied with your diet as it is now? ____ If not, why not? ______
______

SLEEP

Do you have trouble falling asleep? ____ If yes, what keeps you up? ______
Do you sleep straight through the night? ____ If not, what time do you usually wake? ______

Average number of hours you sleep ______Do you wake refreshed? ____

Do you have recurring dreams or nightmares ? ____ If yes, what is the theme? ______
What position do you usually sleep in? ______

Is there a position you cannot sleep in? ____ If yes, which one? ______
How many pillows do you sleep on? _____ Nights sweats? ______

HOME ENVIRONMENT AND OTHER ENVIRONMENTAL EXPOSURES
Circle any of the following you routinely use at home:

Gas heat Oil heat Electric heat Wood stove Air conditioning Electric blanket T.V.

Distilled / Filtered / Spring / Well / Tap water

Is your home and work environment well ventilated? ______
Is your home or work environment excessively damp or moist? ______

Please circle any of the following you feel most bothered by:

Sunshine Lack of sunshine Dampness Dryness Cold Heat Dust/Mold Cat/Dog hair

Car fumes Poor air/ventilation Fluorescent lighting Chemicals Perfumes

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, Kingston, NY 12401

FEMALE REPRODUCTIVE HEALTH
Have you ever used birth control pills? ____ For how long? ______What kind? ______

Have you ever used an I.U.D.? ______For how long? ______What kind? ______

Hormone replacement therapy? ______For how long? ______What kind? ______
Are you currently sexually active? _____ Have you been sexually active in the past? _____

Current form/s of contraception ______

Age when menstrual periods began ______Did you have a normal puberty? ______

Period every ______days. Regular: Yes No

Periods usually last ______days (average) Date of last period ______

Quality of blood? (i.e. dark red, bright red, clots) ______

Amount of flow (i.e. # of pads or tampons/day) ______

Pain or cramping? ______PMS? ______

Date of last PAP smear ______Have you ever had an abnormal PAP? ______

Do you currently, or have had in the past, problems with infertility _____ if yes, explain ______
______

Number of: pregnancies _____ births _____ miscarriages _____ abortions _____

Any complications of pregnancy? ______If yes, explain ______

Sexual desire: 0 1 2 3 4 5 6 7 8 9 10 (please circle one, 0 = none)
Any sexual problems? ______Have you had any of the following concerning your breasts: Pain Lumps Infection Nipple discharge

MALE REPRODUCTIVE HEALTH
Are you currently sexually active? _____ Have you been sexually active in the past? ______
Type of contraception used? ______

Have you had any of the following: Testicular pain Prostate problems Hernia Discharges Sores

Have you had a prostate exam? ______If so, when? ______

Sexual desire: 0 1 2 3 4 5 6 7 8 9 10 (please circle one, 0 = none)
Any sexual problems? ______

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, Kingston, NY 12401

MEDICAL HISTORY

Please circle:

O= occasionally Y = condition you have now N = never had this problem P= conditon you have had in the past

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, Kingston, NY 12401

GENERAL

Weight ______

Weight one year ago______

Maximum weight ______

When?______

Height ______

Last physical exam? ______

ENERGY

FatigueOYNP

SKIN

RashesOYNP

Eczema, hivesOYNP

ItchingOYNP

Color changeOYNP

LumpsOYNP

HEAD

Head achesOYNP

Head injuryOYNP

EYES

Impaired visionOYNP

Eye painOYNP

Tearing/drynessOYNP

Double visionOYNP

GlaucomaOYNP

CataractsOYNP

EARS

Impaired hearingOYNP

RingingOYNP

EaracheOYNP

NOSE and SINUSES

Frequent coldsOYNP

Nose bleedsOYNP

StuffinessOYNP

Hay feverOYNP

Sinus problemsOYNP

MOUTH and THROAT

Frequent sore throatOYNP

Sore TongueOYNP

Gum problemsOYNP

HoarsenessOYNP

Dental cavitiesOYNP Last dental exam? ______

RESPIRATORY

CoughOYNP

SputumOYNP

Spitting up bloodOYNP

WheezingOYNP

AsthmaOYNP

BronchitisOYNP

PneumoniaOYNP

PleurisyOYNP

EmphysemaOYNP

Trouble breathingOYNP

Pain on breathingOYNP

Short of breathOYNP

At nightOYNP

Lying downOYNP

TuberculosisOYNP

CARDIOVASCULAR
Heart diseaseOYNP

AnginaOYNP

HypertensionOYNP

MurmursOYNP

Rheumatic feverOYNP

Chest painOYNP

Swelling in anklesOYNP

PalpitationsOYNP

URINARY

Pain on urinationOYNP

Increased frequencyOYNP

Frequency at nightOYNP

Unable to hold urineOYNP

Frequent infectionsOYNP

Kidney stonesOYNP

EXTREMITIES

Deep leg painOYNP

Cold hands/feetOYNP

Varicose veinsOYNP

ThrombophebitisOYNP

Nail FungusOYNP

Restless legsOYNP

EMOTIONAL

Anxiety, panicOYNP

Depressed, hopelessOYNP

Mood swingsOYN P

WeepingOYNP

CompulsionsOYNP

Excessive angerOYNP

Restless, boredOYNP

GASTROINTESTINAL

Belching/gasOYNP

Gall bladder OYNP

HeartburnOYNP

IndigestionOYNP

Liver problemsOYNP

JaundiceOYNP

VomitingOYNP

Vomiting bloodOYNP

Blood in stoolOYNP

Change in thirstOYNP

Change in appetiteOYNP

Binge eatingOYNP

Abdominal crampsOYNP

HemorrhoidsOYNP

ConstipationOYNP

DiarrheaOYNP

MUSCULOSKELELTAL

Joint pain, stiffnessOYNP

ArthritisOYNP

Broken bonesOYNP

Muscle spasmsOYNP

WeaknessOYNP

NECK

LumpsOYNP

Swollen glandsOYNP

GoiterOYNP

BLOOD

Easy bruisingOYNP

AnemiaOYNP

ENDOCRINE

HypothyroidOYNP

HyperthyroidOYNP

Low blood sugarOYNP

DiabetesY NP

NEUROLOGICAL

FaintingOYNP

SeizuresOYNP

ParalysisOYNP

Numbness/tinglingOYNP

Memory lossOYNP

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, NY 12498

Informed Consent and Services

Informed Consent and Additional Information About Dr. Morales’ Services:

Eli Morales ND graduated from a four-year Naturopathic Medical Program at an accredited Naturopathic Medical School, The National College of Natural Medicine in Portland, Oregon. There he attained a doctorate degree as a Doctor of Naturopathic Medicine. In the state of Vermont Dr. Morales is an actively licensed Naturopathic Physician. He is licensed to diagnose, treat, perform physical exams, and order labs or imaging in that state.Dr. Morales ND does not provide after hour services and in case of an emergency I understand I should contact the appropriate licensed health care provider.

New York State does not currently license Naturopathic Physicians to practice medicine. The practice of the profession of medicine is defined as diagnosing, treating, operating or prescribing for any human disease, pain, injury, deformity or physical condition. Dr. Morales ND is not an MD/DO and does not practice medicine in the state of New York. Furthermore, his services are not meant to replace or to be a substitute for those of a licensed medical practitioner or physician. Patients seeking his consultation are advised to also be under the care of a licensed New York state physician.

In New York State Dr. Morales functions as a health consultant, and focuses his practice on the enhancement of health. He uses his education and experience to give you suggestions. We may discuss substances that have and/or have not been subject to double blind clinical studies or FDA approval or regulation. You assume the responsibility for the decision to follow any recommendations. These may include dietary changes, lifestyle modification, vitamin or mineral recommendations, botanical or homeopathic remedies, hydrotherapy (application of hot/cold water), counseling, and education. He will discuss expected benefits and side-effects of any recommendations, and always allow you the opportunity to ask questions. If you feel you are having any adverse reaction then stop all aforementioned recommendations immediately. If you are pregnant or nursing, confirm the safety of any recommendations with your obstetrician or pediatrician.

* * *

I agree to the physical contact necessary for assessment of my case and that I will make informed decisions about whether to follow his guidelines. I recognize that, as an effect of the suggestions provided by EliMorales ND, the signs and symptoms of my medical condition(s) may diminish or disappear.

I herby request and consent to a naturopathic consultation, herbal and nutritional supplement suggestions for me (or for the client named below, for which I am legally responsible) by Eli Morales ND.

I understand that all my records will be kept confidential and will not be released without my written consent.

I understand it may be necessary for Eli Morales ND to contact another one of my health care providers in order to discuss any emergency situation. My signature gives Eli Morales ND permission to release my medical records for the reason listed above.

I have been informed that I have the right to refuse any suggestions given by Eli Morales ND. I have read, or have had read to me, the above consent. I intend this consent form to cover all the suggestions EliMorales ND will provide me for my present condition and for any future condition(s) for which I seek assistance with. I have also had an opportunity to ask questions about this consent, and by signing below I agree to the above.

I have read and understand the information provided, and have received a copy for my records.

Signature: ______Relationship: ______Date: ______

HIPAA Notice of Privacy Practices and Consent

I hereby consent to the use and disclosure of my protected health information by Eli Morales ND for the purposes of health consulting, payment and healthcare operations, or as otherwise required by law. New York State law provides additional protection for information regarding HIV/AIDS. Dr. Morales will continue to follow New York State law with respect to such information. By signing below you are agreeing that you have been informed about your protected health information and how to obtain a personal copy of the privacy policy.

I have the right to request restrictions to the usage and disclosure of my protected health information.

I have the right to request an alternative to the standard method of communication of my protected health information.

I have the right to refuse disclosure of care/services to health plans regarding care/services that I have paid out of pocket for.

I have the right to request my personal health information in writing and understand that it could take up to 60 days to receive that information.

I have the right to access my electronic medical record through the patient portal, Patient Fusion, at no cost at any time and my email address is required to do so.

I have the right to contact Eli MoralesND through unsecured email, text, phone, or online, however, I understand those are not HIPAA-compliant forms of communication and that Eli MoralesND provides other secure options.

I am aware that EliMoralesND reserves the right to change the terms of this Notice of Privacy Practices and to make new Notice of Privacy Practices provisions effective for all protected health information maintained. In the event of amendments, Eli Morales ND will make available a revised Notice of Privacy Practice for my review.

I have the right to revoke this consent, in writing, at any time. Revocations will be honored as of the date they are received by Eli Morales ND at the address below.

I have read and understand the information provided, and have received a copy for my records.

Signature: ______Relationship: ______Date: ______

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, NY 12498

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, NY 12498

Blue Stone Natural Health , LLC

Eli Morales, Naturopathic Doctor| 325 Albany Ave, NY 12498