Personal Data
NAME
DATE
ADDRESS
CITY/STATE
ZIP
PHONE #'S: HOME
CELL
WORK
DATE OF BIRTH
AGE
BLOOD TYPE
HEIGHT
CURRENT WEIGHT
IDEAL WEIGHT
OCCUPATION
EMPLOYER
MARITAL STATUS
EMAIL
HOW DID YOU HEAR OF US?
EMERGENCY CONTACT: NAME
RELATIONSHIP
PRIMARY CARE PHYSICIAN
PHONE #
SPECIALIST
PHONE #
SPECIALIST
PHONE #
SPECIALIST
PHONE #
PHONE #
Is there a possibility that you are pregnant? Yes/No
As your cell phone and email are not considered “secure” communication devices:
Is it acceptable for us to contact you with medical information via e-mail? Yes / No
Is it acceptable for us to leave messages on a voice mail / answering machine for you? Yes / No
PATIENT'S INITIALS ___________
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 1
What are your 3 primary health concerns/health goals in order of importance?
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
Have you received other treatment for these conditions? Yes/No
If yes, what, when?
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
What were the results of the treatment?
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
What are your hopes and expectations from treatment with Dr. Bethune?
_____________________________________________________________
Past Medical History
Please list any medical problems or illnesses you have had or currently have. Include any
infectious diseases, hospitalizations and accidents with approximate dates.
DATE
MEDICAL DIAGNOSIS, ILLNESS, OR ACCIDENT
Past Surgical History
DATE
SURGERY
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 2
Allergies
PLEASE LIST ALL PHARMACEUTICAL ALLERGIES WITH REACTIONS
PLEASE LIST ALL FOOD ALLERGIES WITH REACTIONS
Medications
PLEASE LIST ALL CURRENT PRESCRIPTION MEDICATIONS, INCLUDING HORMONES
PRESCRIPTION
DOSAGE
DOSING SCHEDULE
Supplements and Herbal Remedies
PRODUCT
DOSAGE
DOSING SCHEDULE
Medical Symptoms Questionnaire
Rate each of the following symptoms based upon your health profile for the past 30 days:
POINT SCALE:
1 = occasionally have it, effect is not severe
3 = frequently have it, effect is not severe
HEAD
___ Headaches
___ Faintness
___ Dizziness
___ Insomnia
_____ TOTAL
0 = never or almost never have the symptom
2 = occasionally have it, effect is severe
4 = frequently have it, effect is severe
DIGESTIVE SYSTEM
___ Nausea or vomiting
___ Diarrhea
___ Constipation
___ Belching, passing gas
___ Bloated feeling
___ Heartburn
______ TOTAL
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 3
EYES
___ Watery, itchy eyes
___ Swollen, reddened, or sticky eyelids
___ Dark circles under eyes
___ Blurred/tunnel vision
JOINTS / MUSCLES
___ Pain or aches in joints
___ Arthritis
___ Stiffness, limited movement
___ Pain, aches in muscles
___ Weakness or tiredness in joints
______ TOTAL
______ TOTAL
EARS
___ Itchy ears
___ Earaches, ear infection
___ Drainage from ear
___ Ringing in ears
___ Hearing loss
______ TOTAL
NOSE
----- Stuffy nose
----- Sinus problems
----- Hay fever
----- Sneezing attacks
----- Excessive mucus formation
WEIGHT
___ Binge eating/drinking
___ Craving certain foods
___ Excessive weight
___ Water retention
___ Underweight
___ Compulsive eating
______ TOTAL
ENERGY / ACTIVITY
___ Fatigue, sluggishness
___ Apathy, lethargy
___ Hyperactivity
___ Restlessness
----------- TOTAL
_____TOTAL
MOUTH / THROAT
___ Chronic coughing
___ Gagging, frequent need to clear throat
___ Sore throat, hoarse TOTAL
___ Swollen or discolored tongue, gums, or lips
___ Canker sores
______ TOTAL
SKIN
----- Acne
----- Hives, rashes, dry skin
----- Hair loss
----- Flushing, hot flashes
----- Excessive sweating
______ TOTAL
HEART
___ Skipped heartbeats
___ Rapid heartbeats
___ Chest pain
MIND
___ Poor memory
___ Confusion
___ Poor concentration
___ Poor coordination
___ Difficulty making decisions
___ Stuttering, stammering
___ Slurred speech
___ Learning disabilities
______ TOTAL
EMOTIONS
___ Mood swings
___ Anxiety, fear, nervousness
___ Anger, irritability
___ Depression
_____ TOTAL
______ TOTAL
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 4
LUNGS
___ Chest congestion
___ Asthma, bronchitis
___ Shortness of breath
___ Difficulty breathing
OTHER
___ Frequent illness
___ Frequent of urgent urination
______TOTAL
______TOTAL
Gynecological History
Please complete the following to the best of your knowledge
Date of last PAP smear?
Result?
Date of last mammogram?
Result?
Have you ever had an abnormal PAP smear?
If yes, what was the abnormality and what follow up did you have?
YES
NO
Have you ever had an abnormal mammogram?
If yes, what was the abnormality and what follow up did you have?
Have you ever had a breast biopsy?
Have you ever had a cervical biopsy?
Have you noticed breast skin or nipple changes?
Have you noticed any lumps in your breasts?
Are you using a birth control method? If yes, what kind?
Are you still having menstrual periods?
If yes, when was the first day of your last period?
Please describe any problems you have with your periods:
Periods are (were): □ regular □ irregular
□painful □ crampy
□heavy
□light
□other
Age periods began: _____ # days of bleeding _____ cycle length (days) _____
Did your periods stop because you had a hysterectomy? □Yes □No
If yes, what was the reason for the surgery? ______________________
Were the ovaries removed at the same time? □Yes □No □Not Sure
Do you have a history of any of the following cancers:
□Vulva □Ovary □ Other: ______________________________________
□Uterus □Fallopian Tube
□Vagina □Breast ______________________________________
□Cervix □Colon
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 5
Estrogens
Check which of these symptoms are troublesome and have persisted over time
Estrogen Deficiency
□Hot Flashes
□Night Sweats
□Vaginal Dryness
□Foggy Thinking
□Memory Lapses
□Urinary Incontinence
□Tearful
□Depressed
□Sleep Disturbances
□Heart Palpitations/Arrhythmia
□Bone Loss
□Headaches
Estrogen Excess / Progesterone Deficiency
□Mood Swings (PMS)
□Uterine Fibroids
□Cystic Ovaries
□Weight Gain – Hip Area
□Tender Breasts
□Bleeding Changes
□Heavy Menses
□Elevated Triglycerides
□Water Retention
□Breast Cancer
□Sugar Craving
□Low Libido
□Nervousness
□Irritable
□Anxious
□Fibrocystic Breast
□Headaches
□Cold Body Temperature
Androgens
Check which of these symptoms are troublesome and have persisted over time
Androgen Excess
□Increased Facial Hair
□Increased Body Hair
□Acne
□Oily Skin
□Nervous
□Irritable
□Anxious
□Breast Cancer
□Ovarian Cysts
□Elevated Triglycerides
□Sleep Disturbances
Androgen Deficiency
□Low Libido
□Heart Palpitations/Arrhythmia
□Vaginal Dryness □Headaches
□Fatigue
□Fibromyalgia
□Aches/Pains
□Irritable
□Memory Lapses □Thinning Skin
□Foggy Thinking □Bone Loss
□Urinary Incontinence
□Depressed
□Anxious
□Sleep Disturbances
□Apathy/Decreased Passion for Life
□Decreased Muscle Mass
Thyroid
Check which of these symptoms are troublesome and have persisted over time
Thyroid Excess
□Heat Intolerance
□Irritable
□Heart Palpitations/Arrhythmia
□Weight Loss
□Tremors/Shakiness
□Diarrhea
□Nervousness
□Anxious/Panic Attacks
□Insomnia
□Difficulty Conceiving/Infertility
Thyroid Deficiency
□Cold Intolerance
□Constipation
□Fatigued/Weakness
□Unexplained Weight Gain
□Inability to Lose Weight
□Stress
□Cold Body Temperature
□Coarse Dry Skin
□Lack of Motivation
□Voice has become hoarse
□Aches/Pains
□Hair Loss
□Muscle Weakness
□Muscle Cramps
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 6
Social History
Please remember that this information is strictly confidential.
Do you smoke cigarettes now or have you in the past?
YES
If yes, how many packs are you currently smoking per day?
How many total years did you smoke?
Do you drink alcohol?
YES
Have you used any illicit drugs within the last 24 hours
YES
If yes, what illicit drug?
NO
NO
NO
Family History
Mother
Father
Brothers
Sisters
Children
Age (if living)
Health
G=good
P=poor
Age at death
(if deceased)
Check any of the following conditions that apply to members of your family
Cancer
Diabetes
Heart Disease
High blood
pressure
Stroke
Mental illness
Is there anything else you feel it is important for us to know?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 7
INFORMED CONSENT FOR NATUROPATHIC TREATMENT AND CARE
I hereby request and consent to the performance of Naturopathic Medicine treatments and other
complementary medicine procedures on me (or on the patient named below, for whom I whom I am
legally responsible) by Dr. Stephanie Bethune, Doctor of Naturopathic Medicine.
I understand that methods of treatment may include, but are not limited to, acupuncture, applied
kinesiology, detoxification, homeopathy, herbal medicine, massage, nutritional counseling, physical
examination, reiki, vitamin and mineral therapy.
I will discuss with Stephanie Bethune, ND, any questions or concerns that I have with my Naturopathic
Medicine treatments.
The goals of Naturopathic Medicine treatments are to normalize physiological functions, to modify the
perception of pain, and to treat certain diseases and dysfunctions of the body. The herbs and nutritional
supplements (which are from plant, animal and mineral sources) that have been recommended are
considered safe in the practice of Naturopathic Medicine. I understand that some herbs may be
inappropriate during pregnancy. If I experience any gastrointestinal upset or allergic reactions to the
herbs, I will inform Dr. Stephanie Bethune.
I do not expect the doctor to be able to anticipate and explain all risks and complications.
I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor
feels at the time, based upon the facts then known, is in my best interest.
I understand my records will be kept confidential and will not be released without my written consent.
I have read, or have had read to me, the above consent. If I have any questions, I will ask. By signing
below, I agree to the above named procedures. 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.
Patient’s Name: ____________________________________________
Signature ____________________________________________
Date: ____________________________________________
Are you or could you be pregnant? __________________________________________
Office: Light Body Natural Health
188 Norwich Ave, Suite C5
Colchester, CT 06415
Name of Naturopathic Doctor: Stephanie Bethune, ND
To be completed by the patient’s representative, if necessary, e.g., if the patient is a minor or is
physically or legally incapacitated:
Patient’s Name: ____________________________________________
Patient’s Representative: ________________Relationship to Authority: _____________
Witness: ____________________________________________
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 8
Light Body Natural Health
Naturopathic care *herbal medicine *nutrition *detox *homeopathy * acupuncture
FINANCIAL POLICIES FOR TREATMENT AND CARE
If you need to change, reschedule, or cancel, we greatly appreciate your calling Light Body Natural
Health as soon as you can and at least two days, or 48 HOURS, before your appointment.
Your appointment time is reserved for you. We prefer 48 hours notice. We understand that unexpected
circumstances may arise occasionally.
For consideration of the physician's time, as well as other patients waiting to be
seen, a $50 charge will be applied If LESS THAN 24 HOURS notice is given to
Light Body Natural Health.
If you have purchased a treatment package, one treatment will be deducted.
For your convenience, we have an answering machine available after hours and on weekends. This
policy must exist for us to be here for you. Thank you for your cooperation.
Payment: In an attempt to keep health care costs low, payment is required at the time of your service.
Preferred payment methods are cash, check, Visa, Master Card.
Reduced Fee Treatment Packages For Private-Pay Patients: are available to (1) make check-out easier,
(2) lower the price, and (3) make a commitment between practitioner and patient to help you complete
your treatment goals. Treatment Packages are not refundable and can only be used for the services
purchased.
Treatment Packages are good for a one year time period from the date of purchase.
Your credit card number is kept on file for payment of any missed or cancelled appointments and for
guarantying personal checks. Your credit card information is kept private, confidential, and secure.
The following information is required to receive treatments:
Visa/MC ____________________________________ _______/______
Credit Card Number,
Month/year,
_____________
3 digit code on back
I _________________________________ have read, I understand, and I agree to the above information:
___________________________________ ___________________________ ___________
Signature
Printed Name
Date
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 9
STEPHANIE BETHUNE, ND, LIGHT BODY NATURAL HEALTH
188 NORWICH AVE #C5 COLCHESTER, CT 06415
PATIENT NOTICE OF PRIVACY POLICY
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN
ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Patient Rights and Uses and Disclosures of Health Information and PERSONAL HEALTH INFORMATION DISCLOSURE: In the
course of your care as a patient at Light Body Natural Health, we may use or disclose personal or health related information
about you in the following ways:
1. Your personal health information, including your clinical records, may be disclosed to another health care provider or
hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records, as well as your billing records, may be disclosed to another party, such as an insurance carrier, an
HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services.
3. Your name and address, phone number, and your health care records may be used to contact you regarding appointment
reminders, information about alternatives to your present care, Light Body Natural Health newsletters, or other health related
information that may be of interest to you. If you are not home to receive an appointment reminder, a message may be left on
your answering machine or voicemail. Further, you have the right to refuse to provide authorization for this office to contact
you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you, or the
reimbursement avenues associated with your care.
UNDER federal law, we are also permitted or required to use or disclose your health information without your consent or
authorization in these following circumstances:
1. If we are providing health care services to you based on the orders of another health care provider.
2. If we provide health care services to you in an emergency.
3. If there are substantial barriers to communicating with you, but in our professional judgment believe that you intend for us
to provide care.
4. If we are ordered by the courts or another appropriate agency. ANY USE OR DISCLOSURE OF YOUR PROTECTED HEALTH
INFORMATION, OTHER THAN OUTLINED ABOVE, WILL ONLY BE MADE WITH YOUR WRITTEN AUTHORIZATION
We normally provide information about your health in person at the time you receive services or care from us. We also may
mail or email information to you regarding your health care, or about the status of your account. If you would like to receive
this information at an address other than your home or, if you would like the information in a different form, please advise us in
writing as to your preferences.
You have the right to inspect and/or copy your health information for seven years from the date that the record was created or
as long as the information remains in our files. In addition, you have the right to request an amendment to your health
information. Requests to inspect, copy or amend your health related information should be provided to us in writing
PRACTIONER LEGAL DUTIES: We are required by state and federal law to maintain the privacy of your patient file and the
protected health information herein. We are also required to provide you with this notice of our privacy practices with respect
to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend
the terms of this privacy notice. If changes are made to our privacy notice, we will notify you in writing as soon as possible
following the changes. Any change in our privacy notice will apply for all of your health information in our files.
Information we use or disclose based on this privacy notice may be subject to redisclosure by the person to whom we provide
the information and may no longer be protected by the federal privacy rules.
COMPLAINTS & QUESTIONS: If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our
privacy activities, you should direct your questions to Stephanie Bethune, ND.860.537.1007
This notice is effective immediately. This notice, and any alternation or amendments made hereto, will expire seven (7) years
after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice.
__________________________________ __________________________________________________
Patient Name (printed)
Signature
DATE
All information within this document is considered private patient/provider communication by Dr. Stephanie Bethune is held as
CONFIDENTIAL INFORMATION in accordance with federal HIPAA regulations.
Page 10