319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
___________________________________________________________________________________________
Date:________________________
Name:______________________________Birthdate:___________Age:_______________
Address:__________________________________________________________________
City, State, Zip:____________________________________________________________
Phone:____________________work:____________________cell:___________________
E-mail:____________________________________________________________________
Primary Care Provider’s Name______________________________________
Address (if known)__________________________________________________
City, State, Zip________________________________Phone:_______________
Referred by:_____________________________________________________________
Reason for today’s visit
Date problem(s) began
__________________________________________________________________________________
__________________________________________________________________________________
______
__________________________________________________________________________________
___
Height:__________________Weight:___________ Usual Weight:______________
Allergies to
Medication:________________________________________________________________________
Allergies to foods: ( please specify what type of allergy testing was
performed)_________________________________________________________________________
Education (Last grade completed or degree)____________________________________________
Sex and Ages of Siblings____________________________________________________________
Surgeries:_________________________________________________________________________
Accidents/Injuries:__________________________________________________________________
Hospitalizations:___________________________________________________________________
Current Medications:________________________________________________________________
Nutritional Supplements:_____________________________________________________________
Smoker? Yes_____ No______ If yes, how many years:________ # of packs per day_________
Drink Alcohol? Yes_______ No________ # of drinks per week or month___________________
Exercise Regimen__________________________________________________________________
Please circle or place a check mark next to any of the following. Please make comments as
needed.
FAMILY HISTORY
Hypertension
Obesity
Mental Illness
Migraine
Glaucoma
Asthma
Heart Disease
Tuberculosis
Renal Disease
Epilepsy
Lupus
Hay Fever
Cancer
Emphysema
Alcoholism
Jaundice
Arthritis
HIV
Diabetes
Birth Defects
Blood Disorders
Anemia
Strokes
Thyroid Disorders
GENERAL STATE OF HEALTH
Sweating
Fever
Night Sweats
Wake Often
Weakness
Chills
Bruise Easily
Dry Mouth
Fatigue
Malaise
Anemia
Bleeding Tendencies
Can’t Fall Asleep
Hot or Cold Spells
Sensitive to temp changes
HEAD, EYES, EARS, NOSE, AND THROAT
Wears glasses
Eye irritation
Ear infections
Hearing Problems
Thrush
Sores in Mouth
(describe)
Frequent Colds
Frequent sore throat
Post-Nasal Drip
Throat Clearing
Nose Bleeds
Stuffy Nose
Tonsil Infections
Breathe thru mouth
Dark circles under eyes
Itchy Throat
Bad breath
Dental Problems
Bleeding Gums
Ringing in Ears
Hearing Changes
Dizziness
Blurred Vision
Headaches
SKIN, NAILS, HAIR
Lesions
Psoriasis
Thinning Hair
Itching
Excessive Dryness
Crust behind ears
Yellow or Crusty Nails
Excessive Flakiness Itching of scalp
RESPIRATORY AND CARDIAC
Eczema
Brittle Nails
Oily Face
Chest Tightness
Bronchitis
Palpitations
Asthma
Chronic Cough
High Blood Pressure Low Blood Pressure
Mucus color:________ Edema or swelling
High Cholesterol
Chest Pain
Fainting
Rib Pain
GASTROINTESTINAL
Abdominal pain
Nausea
Diarrhea
Loss of appetite
Hemorrhoids
Heartburn
Bloating
Vomiting
Jaundice
Loose Stools
Constipation
Use of laxatives
Rectal Bleeding
Food Intolerances (please list)
Abdominal cramping
Excess Gas
# of stools per day_______
Blood in stool
Noisy digestion
GENITOURINARY
Dribbling of urine Frequency of urine Urgency
Blood in urine
Foul odor of urine Hesitancy
Itching
Wake to urinate
Prostate Problem
Discharge
Infertility/sterility
Impotence
Lack of sexual desire
Change in urine color
Painful Urination
Incontinence
Dribbling
Sexual Problems
MENSTRUAL / MENOPAUSAL
Age at onset________
Heavy Flow
Cramps
Date of last period_______
Length of Cycle_____
Duration of flow____
Menopause
Hot Flashes
Last Pap___________
# of pregnancies_____
Endometriosis
Hormone
Therapy
Birth Control
# of births______
Miscarriages_____ Irregular periods
ENDOCRINE
High Blood Sugar Low Blood Sugar
Known or suspected thyroid disorder
Weight Change
Hot/Cold Spells
MUSCULOSKELETAL AND NEUROLOGICAL
Tenderness
Muscle Cramps
Decreased movement
Pain
Tremors
Convulsions
Balance or coordination problems
Joint Aches
Weakness
Arthritis
Use of anti-inflammatories
Loss of Consciousness
PSYCHOSOCIAL
Depression
Nightmares
Feeling fearful
Tense
Temper outbursts Feeling blue
Blaming yourself
Feeling lonely
Stressful job
Financial worries
Occupation________________________
Crying easily
Feeling trapped
Easily annoyed
Worried about things
Feeling hopeless
Trouble concentrating
Anxiety
Childhood Trauma
Stressful relationships
Recent personal loss
319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
___________________________________________________________
INFORMED CONSENT AND OFFICE POLICY
I make no representations, claims or guarantees that you will be helped with your medical problems or
conditions by undergoing treatment. However, I will do my best to help you accomplish your healthcare
and wellness goals.
I am a Master’s prepared Family Nurse Practitioner. Nurse Practitioners are licensed to perform physical
examinations, order laboratory tests and to prescribe medications. My Collaborating Physician’s name is
Dr. Muralidhar Reddy. He maintains a separate practice from mine, and is available to me for
consultation and collaboration when needed.
Some of your treatment plan may consist of nutritional supplements. I will recommend certain brands or
products based on research and past experience with these products. While I will provide you with
information on where you can purchase these supplements, you are free to purchase these products from
any source that you choose.
I require that all patients have a primary care provider. My services are to act as a compliment to your
primary healthcare. Thus, I will not be responsible for maintaining your routine screenings such as
yearly physicals, lab work, pap smears, mammograms, etc. If requested, I can recommend primary care
providers who share my philosophy about health and wellness.
Most health insurance plans today have clauses which limit coverage to “usual and customary” fees for
reasonable and necessary services. Because certain treatments used in complementary medicine are not
recognized by mainstream medicine, we can NOT guarantee the amount of availability of coverage for
our services, lab testing, and treatments under your healthcare policy. You are responsible for payment
when services are rendered without regard to insurance coverage.
My fee is $150 per hour. The first 2 visits are often longer than 1 hour due to the amount of information
gathering and teaching to be done during those visits. Payment for any ordered lab work is made directly
to the lab used for the testing. Specialty lab testing is sometimes NOT covered by insurance. Lab testing
will not usually exceed $500. There is a $20 charge for all returned checks 24 hours notice is required
for ALL cancellations. There will be a $50 fee for any cancellation without 24 hours notice.
319 Airport Road
Hackettstown, NJ 07840
Ph: 908-850-0888 / FAX: 908-850-1005
___________________________________________________________
INFORMED CONSENT AND OFFICE POLICY
I seek the medical and health care services of Elaine Hardy, MS, RN, APN, C. I understand that this
medical practice uses some diagnostic and treatment methods that are sometimes considered
complementary, alternative or holistic. Many of these methods have not yet been accepted by consensus
mainstream medicine.
I understand that Elaine Hardy, MS, RN, APN, C, makes no representations, claims or guarantees that I
will be helped with my medical problems or conditions.
I understand that my insurance may or may not cover the office visits and laboratory testing, and that
payment is due at time of service. I also understand that payment for any laboratory testing is to be
arranged with the laboratory used for the testing.
I have read, understand and agree to the Informed Consent and Office Policy. I acknowledge receipt of a
copy of the same. I have read and understand the cancellation policy.
PRINTED NAME OF PATIENT__________________________________
SIGNATURE__________________________________________________
RELATIONSHIP TO PATIENT____________________________________
DATE SIGNED_________________________________________________