Nutrition - New Patient Forms

PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC
NUTRITION NEW PATIENT FORMS
NUTRITION NEW PATIENTS:

Please bring the following with you to your appointment:
- A list of all the vitamins and mineral supplements you are currently taking (make sure it has the brand and dosage)
- A food/drink log in any form that includes two week days and one weekend day. Must be accessible on an app (if you choose to use an app) or a physical copy.
Thank you!
Welcome to HorizonView Health!

Thank you for scheduling an appointment at our office, we are happy you have found your way to us!

Please check-in 15 minutes prior to your scheduled appointment time with your paperwork, insurance card and ID. If you arrive late for your check-in time you may be asked to reschedule.

Our Address is: 1408 3rd St SE Suite 200 Puyallup, WA 98372          Ph: 253-268-3345 Fax: 253-881-1490
We are located across the street from Good Samaritan Hospital Emergency Room entrance and down one building. Covered/additional parking is available under the building for your convenience.

New patient forms are located on our website www.HorizonViewHealth.com, under patient information. Please print the Patient Intake Form, Patient Health Profile, No Show/Missed Appointment Policy, Medial Release of Information and optional Authorization to discuss with a relative/friend or family member.

Please bring with you:

·         Your picture ID

·         Current Insurance Card

·         Copayment (if you have one) due at the time of service

Note: We only accept debit/credit cards or checks

We are unable to accept cash. We apologize for this inconvenience.

If you are unable to keep your appointment, please call us at 253-268-3345

Sincerely,

HorizonView Health Staff

A map of our location is located on our website.
Patient Intake Form

Note: This form is HIPAA compliant and secure
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN*
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone *
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Email
example@example.com
Social Security #
Marital Status*

SingleMarriedDivorcedWidowedLife PartnerSignificant Other
Legal Gender*

MaleFemale
Preferred Pronoun

HeSheThey
Patient Race
Hispanic Ethnicity*

YesNo
Race*
Referring Physician
Primary Physician (if not establishing care with HorizonView Health)
Patient Employment
Patient Employment*

EmployedRetiredOther
Employer
Occupation/Title
Responsible Party
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Employer
Social Security Number
Date of Birth*

MonthDayYear
Date
Primary Insurance
Insurance Name/Type*
Subscriber Name*

First NameLast Name
Subscriber Phone*
Please enter a valid phone number.
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Employer
Relationship to Patient*
ID Number
Group Number
Secondary Insurance
Insurance Name/Type
Subscriber Name

First NameLast Name
Subscriber Phone
Please enter a valid phone number.
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Employer
Relationship to Patient
ID Number
Group Number
Emergency Contacts
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Notify on Hospital Admission*

YesNo
Secondary Emergency Contact (if applicable)
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Notify on Hospital Admission

YesNo
Patient Health Profile
Patient's Legal Name

First NameLast Name
Spouse's Name or Parent's Name (if minor)

First NameLast Name
Doctors that you regularly consult:
Name Reason
Phone Area Code Phone Number
Doctors that you regularly consult:
Name Reason
Phone Area Code Phone Number
Medications
Name, strength, dose (Please bring your medicine with you if this is easier)*
Allergies (Medications, food, other)
Preferred Pharmacy*
Social History
Do you have children? If so, please list birth year, sex and health problems*
Occupation*
Employment Status

Full TimePart TimeRetired
Do you exercise*

YesNo
Amount of exercise per week
Type of exercise
Smoking*

Current Every dayCurrent Some daysFormer/Year QuitNever
If Smoking - Current Some days (what amount per day?)
Amount per day
Alcohol*

NeverOccasionalModeratelyDailyQuit
Amount per day/week (Alcohol)
If quit, what year?
Illicit Drug Usage*

YesNoPast use
If yes, type/frequency
Previously, but quit/year (if applicable)
THC Usage*

YesNoPast use
If yes, frequency of use:
Previously, but quit/year (if applicable)
Past Medical History
Past Surgeries & Approximate Date*
Past Hospitalizations & Approximate Date*
Major Medical Problems*
Immunizations

Please list approximate dates (if you have these immunizations) if not, leave blank
Tetanus (Last Given)

MonthDayYear
Date
Pneumonia Shot

MonthDayYear
Date
Shingles Vaccine

MonthDayYear
Date
If over age 50: Last Colonoscopy

MonthDayYear
Date
Males: Last PSA Test

MonthDayYear
Date
Females Only:
Last Mammogram

MonthDayYear
Date
NormalAbnormal
Last Pap

MonthDayYear
Date
NormalAbnormal
Age of first Menstrual Period
Date of last Menstrual Period

MonthDayYear
Date
Number of Pregnancies
Miscarriages
Birth Control

YesNo
Type
Family History

Please indicate which family member has the health problem:

	Mom	Dad	Sibling	Mom's mom	Mom's dad	Dad's dad	Dad's Mom
High Blood Pressure
High Cholesterol
Coronary Artery Disease
Diabetes
Breast Cancer
Colon Cancer
Prostate Cancer
Alcoholism
Mental Illness

Father
Alive

YesNo
Birth Year
Passed? blanks if yes, Year: blank
Mother
Alive

YesNo
Birth Year
Passed? blanks if yes, Year: blank
Brothers
Alive

YesNoN/A
Birth Year
Passed? blanks if yes, Year: blank
Sisters
Alive

YesNoN/A
Birth Year
Passed? blanks if yes, Year: blank

Please select any health conditions you have had or currently are having*

	Current condition	Past Condition	No/Never
Weight loss/Weight gain
Anxiety
Headache
Stroke
Tingling Location
Tremors
Memory Loss
Fainting Spells/Dizziness
Head Injury
Localized weakness/numbness
Hay Fever
Allergies
Hoarseness
Double Vision
Eye Problems
Ear Infections
Glasses/contacts
Hearing Loss
Frequent nose bleeds
Ringing in Ears
Sinus Infections
Swollen glands
Chest Pain
Heart Murmurs
Leg Cramps while walking
Ankle Swelling
Awakening at night short of breath
Cold hands/feet
Heart Attacks
Heart failure
High/low blood pressure
Irregular heart rate
Palpitations
Varicose Veins
Wheezing
Asthma
Prolonged cough
Cough with exercise
Emphysema/COPD
Shortness of Breath
Pneumonia
Bronchitis
Acne
Hives
Dry Skin
Rashes
Psoriasis
Lumps
Nail Problems
Moles - irregular
Moles - Changed or New
Skin Tags
Problems Urinating
Dribbling after Urination
Painful Urination
Involuntary Urination/ Incontinence
Weak Flow
Urinating Frequently day/night
Kidney Disease
Frequent Bladder Infections
Painful Intercourse
Sexually Transmitted Diseases
Diabetes
Abnormal Body Hair
Cold Intolerance
Heat Intolerance
Increased Hair Loss
Thyroid Disease
Join pain/swelling
Muscle weakness
Morning Stiffness
Constipation
Diarrhea
Gallstones
Heartburn day/night
Problems Swallowing
Hemorrhoids
Blood in stool

Males Only:

Please select any health conditions you have had or are currently having

	Current condition	Past condition	No/Never
Hernia
Penile Discharge
Lump on Testicle
Unable to Complete Intercourse
Problems maintaining erection
Prostate Disease
Decreased Urine Stream

Females Only:

Please select any health conditions you have had or are currently having

	Current condition	Past Condition	Never
Hot Flashes
D & C
Bleeding between cycles
PMS
Heavy Bleeding during cycles
Discharge from breasts
Pelvic Inflammatory Disease
Vaginal Discharge
Vaginal Dryness

Medical Forms
Please select any of the following forms you have completed and wish to bring copies to our office to have on record (if any selected please bring copy to appointment)

Advance Directive for Health Care (ADHC)Durable Power of Attorney (DPA) for healthcare decisionsLiving WillPOLST (Physician's Orders for Life-Sustaining Therapy)
Nutrition Questionnaire
1. Are you currently taking any dietary vitamins or supplements? If YES, please provide the vitamin/supplement, amount and dosage (i.e. Nature Made Iron 65mg, 2x/day)
2. Do you have any food allergies?
3. Do you have any religious or cultural food preferences?
4. Are you currently following a specific dietary preference (i.e. Atkins, Keto, Gluten-free, ect.) or have a dietary preference (i.e. Vegetarian)?
5. Do you have any gastrointestinal issues? if YES, when did it start and how often? (i.e. constipation, bloating, IBS, Crohn's disease, delayed gastric motility, ect.)
6. Do you have any current or previous nutritional deficiencies? (i.e. iron deficiency anemia, vitamin D deficiency, ect.)
7. Do you have a previous history or current eating disorders/behaviors? If YES, please select all that apply:

AnorexiaBulimiaBingingPurgingOrthorexiaOther
If Other selected: (Please list disorder)
If YES to any of the above disorders please indicate which one, for how long and if you received treatment:
Do you eat for any of the following reasons? If YES, please indicate how often below:

StressEmotionalBoredomComfortRewardWake up to eat
if YES to any of the above, please indicate how often:
9. What has been the most helpful in previous diets? What do you feel you need for successful weight management?
Consent for Treatment
CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.
Signature*

Clear
Date*

MonthDayYear
Date
Telehealth Consent Form
A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

I understand that:
- I can decline the Telehealth service at any time without affecting my right to future care or treatment.
- If I decline the Telehealth services, the alternative option would be in-person services.
- The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
- I will have access to all medical information resulting from the Telehealth service as provided by law.
- The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
- I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover.
- By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
- I have read this document carefully, and my questions have been answered to my satisfaction.
- I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.
Signature*

Clear
Date*

MonthDayYear
Date
Notice of Privacy Practices Acknowledgement
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.
Signature*

Clear
Date*

MonthDayYear
Date
NO SHOW/MISSED APPOINTMENT POLICY
We, at HorizonView Health, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible. We require at least 24-hour notice when canceling your scheduled appointment. You can cancel appointments by calling us at 253-268-3345.

To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder call is attempted two (2) business days prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.

Please review the following policy:

1. Please cancel your appointment with at least 24 hours' notice so your appointment time can be
offered to other patients.
2. If less than 24-hour notice is given, this will be documented as a late cancellation.
3. If you do not show up to your scheduled appointment, this will be documented as a no show.
4. Behavioral Health patients will be charged a $75 fee per no show/late cancellation.

5. All other patients will be charged a $40 fee per no show/late cancellation.
6. If you have three (3) or more no shows/late cancellations, a warning letter will be sent.

7. Patients with continuous no shows/late cancellations will be discharged from HorizonView Health at our discretion.

I have read and understand HorizonView Health's no show/late cancellation policy and understand my responsibility to plan appointments accordingly and notify HorizonView Health appropriately if I have difficulty keeping my scheduled appointments.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

NUTRITION NEW PATIENT FORMS

Patient Intake Form

Patient Employment

Responsible Party

Primary Insurance

Secondary Insurance

Emergency Contacts

Secondary Emergency Contact (if applicable)

Patient Health Profile

Medications

Social History

Past Medical History

Immunizations

Females Only:

Family History

Father

Mother

Brothers

Sisters

Males Only:

Females Only:

Medical Forms

Nutrition Questionnaire

Consent for Treatment

Telehealth Consent Form

Notice of Privacy Practices Acknowledgement

NO SHOW/MISSED APPOINTMENT POLICY