Practicing Location: Good Life Medicine Center

Dr. Stephanie Farrell

Stephanie K Farrell, ND LLC

Practicing Location: Good Life Medicine Center

827 NE Alberta St

Portland, Oregon, 97211

Phone: (503) 477-6670

Name ______Date of First Visit ______

Address______

City ______State______Zip Code ______

Telephone # (home)______(work) ______

(cell)______Is it ok to leave a message?______

Age ______Date of Birth ______Social Security Number______

Gender______Sex ______

Single Married Partnership Separated Divorced Widowed

Live with: Spouse Partner Parents Children Friends Alone

Occupation ______Hours per week ______Retired ______

How did you hear about our clinic? ______

Has any other family member already been a patient at the clinic? ______

Emergency Contact ______

Relationship ______Phone ______

Address ______

Are you currently receiving healthcare? Y N

If yes, where and from whom?______

______

If no, when and where did you last receive medical or health care?

______

What was the reason?______

How familiar are you with Naturopathic Medicine? ______

What role do you expect me to play in your healthcare?

□Primary Care Physician□Adjunctive Care□Acupuncture Only

What are your most important health problems? List as many as you can in order of importance.

1)______

2) ______

3) ______

4) ______

5) ______

6) ______

General

Weight______lbs. Weight one year ago______lbs.

Maximum Weight______lbs. When?______

Height______

Any major Traumas?______

______

Do you watch television?______Hours per day/week?______/______

Family History

For all of the following sections:

Y = a condition you have now N = never had P = a condition you had previously

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

1)______2)______

3)______4)______

5)______6)______

7)______8)______

Allergies

Are you hypersensitive to:

Any drugs?______

Any foods?______

Any environmentals?______

Hospitalization and Surgery

What hospitalizations or surgeries have you had?

______year:______year:______

______year:______year:______

Major Past Illnesses

What significant illnesses have you had?

______year:______year:______

______year:______year:______

X-rays and Special Studies

X-rays, CAT scans, or other studies you have had:

______

Electrocardiogram Y N Electroencephalogram Y N

Bone Density Scan Y N Mammogram Y N

How does your condition affect you? ______

______

______

What do you think is happening? ______

______

______

How would your life be different if you weren’t suffering from your symptoms? ______

______

______

______

Is there any information about your health you would like to add? ______

______
______

______

Welcome! We’re happy to serve you. If you have any questions, please ask!
Insurance Information Form

If you have insurance coverage for your office visits, please fill out this form.

Your Name:______DOB:______Today’s Date:______

Have you called your insurance company to see if visits are covered?

 Yes, I have called and visits are covered.

 No, I haven’t called but the doctor is on my provider list.

 No I haven’t called and have no idea if visits are covered or not.

Insurance company/plan name ______

Member ID number: ______

Group number (not all plans have one): ______

Insurance phone number: ______

If you do not know the following information, you can leave it blank. Please fill in what you do know.

Co-pay:______

Deductible:______

Yearly max for ND services:______

Coverage for preventive services (annual exams, PAP’s, PE’s, well-child exams): Y N

Coverage for mental/ emotional services (anxiety, stress, depression, other): Y N

If you have insurance through someone else (your spouse, parent, other)and your name is not on the insurance card, please fill out the following for the main person on the policy:

Name:______Birthdate:______

Address (if different from yours):______

______

Employer:______

Please read, sign, and date:

Stephanie K Farrell, ND LLC has a policy of offering a discount for services paid at the time of the visit. If your insurance allows you to submit for reimbursement, you have the option of paying the discounted fee at the time of your visit. Our office will provide you with the codes needed for you to request reimbursement from your insurance company. This is usually the most beneficial for patients who may not meet their deductible for the year. Please ask us for clarification if you think that the discount for payment at the time of services may benefit you.

Please be aware that some tests or services may be needed for your treatment that are not covered by your insurance policy. Your doctor will discuss these labs and services with you ahead of time whenever possible. By signing below, you are agreeing to pay for any testing or services that are not covered by your insurance policy.

______

Signature Date

Terms and Conditions of Treatment

HIPAA Notice of Privacy Practices and Consent: I hereby consent to the use and disclosure of my protected health information by Stephanie K Farrell, ND LLC for the purposes of treatment, paymentandhealthcare operations, or as otherwise required by law.

______

Signature of patient or patient’s responsible partyDate