PERSONAL HEALTH QUESTIONNAIRE
All information will remain strictly confidential. Successful health care and preventative medicine address the whole person
on a physical, emotional and mental level. Your time, thoughtfulness and honesty will greatly aid me in assisting your
health needs. Thank you for your trust and patience.
Name: _____________________________________________________________ Date: ______________
Address: _______________________________________________________________________________
City: _______________________________________________ State: _____________ Zip: ____________
Telephone (home): __________________ (work): ____________________ (cell): ____________________
Email address: __________________________________________________________________________
Age: _______ Date of Birth: __________Place of Birth: _______________________Gender: Female / Male
Occupation:_______________________________ Hours/Week: _______
Marital Status:__________________________ Live with (circle): Spouse/Partner/Children/Friends/Alone
Children:_________________ Pets:____________________
How did you hear about this clinic? ________________________________________________________
Has any other family member already been a patient at this clinic? ______________________________
Emergency contact: __________________________________ Relationship: ______________
Phone: (W)__________________(C)____________________
Medical Doctor Information:________________________________________________________________
Pharmacy Information: _________________________________________ (P): ________________________
Would you like to receive our email newsletter for articles, news, events, and discounts? ___________
What method(s) can we use to contact you? cell phone ____ home phone ____ e-mail ____ mail _____
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
CONTEXT OF CARE REVIEW
What is your present level of commitment to address any underlying causes of your signs and symptoms that
relate to your lifestyle?
0%
0
1
2
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5
6
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9
10
100%
What behaviors or lifestyle habits do you currently engage in regularly that you believe support your
health?_________________________________________________________________________________________
_______________________________________________________________________________________________
What behaviors or lifestyle habits do you currently engage in regularly that you believe are selfdestructive?_____________________________________________________________________________________
_______________________________________________________________________________________________
Who do you know that will sincerely and consistently support you with the beneficial lifestyle changes you will be
making?________________________________________________________________________________________
_______________________________________________________________________________________________
What do you love to do (include main interests & hobbies)?______________________________________________
_______________________________________________________________________________________________
What specific events/trauma have impacted or changed your life?________________________________________
_______________________________________________________________________________________________
Are you currently receiving healthcare? Yes / No
If yes, where and from whom? ____________________________________________________________________
What is the reason? _____________________________________________________________________________
What are your most important health problems? List in order of importance.
1)____________________________________________________________________________________________
2)____________________________________________________________________________________________
3)____________________________________________________________________________________________
4)____________________________________________________________________________________________
Pain, Where?__________________________________________________________________________________
Do you have any known contagious diseases at this time? Yes / No. If yes, what? __________________________
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
FAMILY HISTORY
Do you or anyone in your family have a history of any of the following? (please circle & indicate who)
Cancer
Epilepsy Arthritis
Kidney disease
Asthma
Heart Disease
Glaucoma
Anemia
Hay fever
High Blood Pressure
Tuberculosis
Mental Illness
Hives
Diabetes
Stroke
Any other relevant family history? _______________________________________________________________
What is your family heritage? ___________________________________________________________________
CHILDHOOD HISTORY
Reactions to vaccinations: ___________________________________________________________________
Please circle whether you had any of the following as a child:
Measles
Chicken Pox
German Measles
Scarlet Fever
Mumps
Diptheria
Rheumatic Fever
Other:
HOSPITALIZATIONS/SURGERY/IMAGING
What hospitalizations, surgeries, x-rays, CAT scans, EEG, EKGs have you had?
_____________________ year __________
____________________ year __________
_____________________ year __________
____________________ year __________
ALLERGIES
Are you hypersensitive or allergic to:
Any drugs? _________________________________________________________________________________
Any foods? _________________________________________________________________________________
Any environmentals or chemicals? ______________________________________________________________
CURRENT MEDICATIONS
Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Have you ever had a drug overdose or a drug problem? __________________________________________
GENERAL
Height: ____________ Weight: ___________ Weight one year ago: _______________
Maximum Weight: ______________ When: ____________________________
Cosmetic Surgery:__________________________________________ Left/Right Handed:___________
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
When during the day is your energy the best? ____________ Worst? _____________
Exercise: Y / N If so, what kind and how often: ___________________________
FOR THE FOLLOWING, PLEASE CIRCLE:
Y=yes/condition you have now N=no/never had P= problem in the past S=sometimes a problem now
GENERAL
Do you sleep well?
YNPS
Hyperthyroid?
YNPS
Average 6-8 hours?
YNPS
Diabetes?
YNPS
Awake rested?
YNPS
Excessive hunger?
YNPS
Have a supportive relationship?
YNPS
Seasonal depression?
YNPS
Have a history of abuse?
YNPS
Difficulty exercising?
YNPS
Use recreational drugs?
YNPS
IMMUNE
Use alcoholic beverages?
YNPS
Chronically swollen glands?
YNPS
Use tobacco?
YNPS
Slow wound healing?
YNPS
If in the past, how many years? ________
Chronic fatigue syndrome?
YNPS
How many packs per day? ____________
Chronic infections?
YNPS
Do you enjoy your work?
YNPS
Night sweats?
YNPS
Take vacations?
YNPS
EARS
Spend time outside?
YNPS
Impaired hearing?
YNPS
Do you go on diets often?
YNPS
Ringing in ears?
YNPS
Do you add salt to your food?
YNPS
Dizziness?
YNPS
Low libido
YNPS
Ear aches?
YNPS
NEUROLOGIC
EYES
Seizures?
YNPS
Impaired vision?
YNPS
Muscle weakness?
YNPS
Cataracts?
YNPS
Loss of memory?
YNPS
Glaucoma?
YNPS
Vertigo or dizziness?
YNPS
Spots in vision?
YNPS
Paralysis?
YNPS
Color blindness?
YNPS
Numbness or tingling?
YNPS
Tearing or dryness?
YNPS
Easily stressed?
YNPS
Eye pain or strain?
YNPS
Loss of balance?
YNPS
HEAD/NECK/THROAT
ENDOCRINE
Headaches?
YNPS
Hypothyroid?
YNPS
Migraines?
YNPS
Hypoglycemia?
YNPS
Head injury?
YNPS
Excessive thirst?
YNPS
Jaw or TMJ problems?
YNPS
Fatigue?
YNPS
Frequent colds?
YNPS
Heat or cold intolerance?
YNPS
Sinus problems?
YNPS
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
Nose bleeds?
Hayfever?
Loss of smell?
Lumps in neck?
Goiter?
Difficulty swallowing?
Pain or stiffness in neck?
Frequent sore throat?
Hoarseness?
Jaw clicks?
Teeth grinding?
Gum problems?
Dental cavities?
SKIN
Rashes?
Acne/boils?
Change in skin color?
Lumps or bumps on skin?
Eczema or hives?
Itching?
Perpetual hair loss?
RESPIRATORY
Cough?
Sputum?
Asthma?
Wheezing?
Bronchitis?
Coughing up blood?
Shortness of breath?
Shortness of breath when lying down?
Pain in breathing?
Emphysema?
Tuberculosis?
GASTROINTESTINAL
Trouble swallowing?
Change in thirst?
Change in appetite?
Nausea/vomiting?
Ulcer?
Jaundice?
Gall bladder disease?
Liver disease?
Hemorrhoids?
YNPS
YNPS
YNPS
YNPS
YNPS
YNPS
YNPS
YNPS
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Pancreatitis?
YNPS
Heartburn?
YNPS
Abdominal pain or cramps?
YNPS
Belching or passing gas?
YNPS
Constipation?
YNPS
Bowel movements: how often? ________
Is this a change?_______________
Black stools?
YNPS
Blood in stools?
YNPS
URINARY
Increased frequency of urination?
YNPS
Inability to hold urine?
YNPS
Pain in urination?
YNPS
Frequency at night?
YNPS
Frequent UTI’s?
YNPS
Kidney stones?
YNPS
MUSCULOSKELETAL
Joint pain or stiffness?
YNPS
Arthritis?
YNPS
Broken bones?
YNPS
Weakness?
YNPS
Muscle spasms or cramps?
YNPS
Carpal Tunnel?
YNPS
BLOOD
Anemia?
YNPS
Easy bleeding or bruising?
YNPS
Deep leg pain?
YNPS
Varicose veins?
YNPS
FEMALE REPRODUCTIVE
Age of first menses:_______
Age of last menses (if menopausal):______
Length of cycle:_______________ days
Duration of menses:____________ days
Are your cycles regular?
YNPS
Painful menses?
YNPS
Heavy or excessive flow?
YNPS
PMS?
YNPS
Symptoms:_______________________
Bleeding between cycles?
YNPS
Clots?
YNPS
Endometriosis?
YNPS
Ovarian cysts?
YNPS
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
Vaginal odor? Y N P S Discharge?
YNPS
Date of last pap smear:_______________
Abnormal PAP?
YNPS
Are you sexually active?
YNPS
Sexual orientation:________________
Birth control? Type:_______________
Do you do self breast exams?
YNPS
Breast pain/tenderness?
YNPS
Breast lumps?
YNPS
Nipple discharge?
YNPS
Menopausal symptoms?
YNPS
Birth control? Type:_____________________
Emotional state during pregnancy:___________
State of partner during pregnancy:___________
Pain during intercourse?
YNPS
Gonorrhea? Y N P S
Herpes? Y N P S
Chlamydia? Y N P S
Syphilis? Y N P S
Genital warts?
YNPS
Difficulty conceiving?
YNPS
Number of: pregnancies_____ live births_____
MALE REPRODUCTIVE
Are you sexually active?
YNPS
Sexual orientation:_______________________
Premature ejaculation?
YNPS
Discharge or sores?
YNPS
Gonorrhea? Y N P S Herpes? Y N P S
Chlamydia? Y N P S Syphilis? Y N P S
Genital warts? Y N P S Hernias? Y N P S
Testicular masses?
YNPS
Testicular pain?
YNPS
Prostate disease?
YNPS
Impotence?
YNP S
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
CONSENT FOR TREATMENT
I hereby request and consent to the performance of naturopathic treatments and/or naturopathic
procedures, including various modes of physical therapy and diagnostic procedures, on me (or on the
patient named below, for whom I am legally responsible) by Jennifer Abercrombie, doctor of
naturopathy and/or Hillary Martin, doctor of naturopathy, and/or Mikinzie Smoot, doctor of
naturopathy and/or Adam Sandford, doctor of naturopathy.
Type of care: I have had an opportunity to discuss with Jennifer Abercrombie, ND and/or Hillary
Martin, ND, and/or Mikinzie Smoot, doctor of naturopathy, and/orAdam Sanford, ND the nature and
purpose of naturopathic care and procedures. Employed general diagnostic procedures including but
not limited to venipuncture, pap smears, radiology, blood and urine tests, and physical exams.
Employed psychology, lifestyle, nutritional, and exercise counseling. Employed herbal and natural
medicine including but not limited to botanicals, minerals, and animal materials given in the form of
teas, tinctures, homeopathy, pills, powders, creams, pastes, plasters, vitamin injections, and
suppositories. Employed hydrotherapy and soft tissue/osseous manipulation including massage,
structural integration, muscle energy technique, grade 1-4 manipulation, and visceral work. Employed
cervical escharotic treatments.
Supplements Sales Disclosure: Supplement sold though this practice are sold at a discounted
price to patients to address the conflict of interest between acting as a provider and making retail
profits. Supplements are sold through the office because Jennifer Abercrombie, ND, Hillary Martin,
ND, and Adam Sandford, ND can guarantee the quality of supplements that you are ingesting. You can
commonly find high quality supplements at stores such as Santa Monica Homeopathic Pharmacy,
Pharmaca, or online through Emerson Ecologics. You are not obligated to purchase the supplements
from the office of Jennifer Abercrombie, ND, Hillary Martin, ND, Mikinzie Smoot, ND, or Adam
Sandford, ND.
Notice to Pregnant Women: All female patients must alert the doctor if they
know or suspect that they are pregnant. Some supplements and treatments
may interfere with pregnancy. Labor-stimulating techniques will not be used unless the
treatment is specifically for the induction of labor. A treatment intended to induce labor requires a
letter from a primary care provider authorizing or recommending such a treatment.
Recital of Risks: I understand and am informed that, as in the practice of medicine, in the practice
of naturopathy, there are some risks to treatment, including, but no limited to: venipuncture causing
local and systemic inflammation and infection, local pain and swelling at areas that received osseous
manipulation, burning and scarring from the escharotic treatment, and allergic reactions to any
medications administered. I understand that I am to contact Jennifer Abercrombie, ND, Hillary Martin,
ND, or Adam Sandford, ND immediately if there is any reaction to any type of procedure performed.
I wish to rely on the doctor to exercise judgment during the course of procedures and treatments which
the doctor feels at the time, based upon the facts then known, is in my best interests.
____________________________________________________________________
____/____/____
Patient Name (Please Print. Include parent/guardian name if patient is a minor.)
Date
____________________________________________________________________
____/____/____
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
Patient Signature
(Parent/guardian signature if minor)
Date
NOTICE OF PRIVACY PRACTICES
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain
privacy rights concerning your health care information. It is important that you understand that your
information can be used and shared in the following ways:
• For your treatment and care coordination. Multiple health care providers may be involved in your
treatment directly and indirectly.
• To protect the public’s health, such as reporting when the flu is in your area.
• To make required reports to the police.
• Obtain payment from third party payers.
I understand that a record will be kept of the health services provided to me, which will be kept
confidential and will not be released to others unless so directed by me or my representative or
otherwise permitted or required by law. I understand that I have the right to review my record and
obtain a copy of my record upon request. Obtaining a copy of my record may require a fee of payment.
In order to provide you with service that best meets your privacy needs, you will have an opportunity on
the New Patient Info packet to tell us how best to contact you. The policy at the Naturopathic Wellness
Center is to leave a message either to remind you of an appointment or inform you to call the office.
____________________________________________________________________
____/____/____
Patient Name (Please Print. Include parent/guardian name if patient is a minor.)
Date
____________________________________________________________________
Patient Signature
(Parent/guardian signature if minor)
____/____/____
Date
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
FINANCIAL POLICIES
Welcome to the Naturopathic Wellness Center. I look forward to providing for your health care
needs. I encourage your questions and participation in all aspects of your care. Please read the
following statements and the financial policies carefully.
Service
Time in Office
Fees for Service
First Visit
Pediatric First Visit (<12 years old)
Return Visit
Missed visit without 48 hour
cancellation notice
Lab work (some labs may be covered
under your insurance plan)
Acute Office Call (for cold, flu, urinary
tract infection).
Sports/Occupational Physical Exam
only
Annual Gynecological Exam
60-75 minutes
45-60 minutes
45 minutes
$250 - $275
$180
$150
$100
Escharotic Treatments
Vitamin injections
Phone consultations
Varies per plan and lab
30 min.
35 minutes
1 hour
$100 – established client
$150 – New client
$120
$165 for an established patient
$275 for a new patient (90 minutes)
$65 per session at 10 sessions
Varies per treatment
$25-$150
30 min.
15 min.
Up to 1 hour billed in 15 min.
increments
Home Visits
Same as first and return visits
$250 or $120 plus gas mileage
• Payment for all services and supplements is due at the time of the visit. Accepted forms of
payment include cash, check, Visa, MasterCard, and debit card. Returned checks will incur a $30
fee.
• Your health care provider may prescribe supplements. Most insurance companies do not cover
the
pharmacy items that we prescribe and dispense.
• Please call if you cannot make an appointment. There is a charge for missed appointments. You
time is valuable to me. Please be courteous, if you can’t make an appointment give me 48 hours’
notice. If you cancel within the 48 hours prior to your appointment, you will be charged $100.
Thank you.
I have read and understand the above-stated policies of the Naturopathic Wellness Center and will
comply with them in all respects. I understand the cancellation policy and that full payment is due
at the time of service for all fees. If my insurance company requires release of my medical records, I
hereby give my permission by signing this form.
____________________________________________________________________
____/____/____
Patient Name (Please Print. Include parent/guardian name if patient is a minor.)
Date
____________________________________________________________________
____/____/____
Patient Signature
(Parent/guardian signature if minor)
Date
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot
INFORMED CONSENT FOR INTRAVENOUS (IV) THERAPY
I, the undersigned, hereby authorize the doctors at Naturopathic Wellness Center to administer
intravenous therapy. I have recounted a complete history of all known allergies that I may have. I
understand that this treatment involves inserting a needle and injecting a standardized formula into my
veins or muscles. I realize that there may be some discomfort at the site of treatment and that it is my
responsibility to inform the attending physician of any burning, pain, or negative reactions that I may
be experiencing. During intravenous treatment, it is possible for the injection fluid to leak out of the
vein into the surrounding tissue. I understand that although the infiltrated fluid may cause pain, it is not
dangerous to my health and my body will absorb the fluid. I realize that during and after my treatment,
I may experience temporary discomfort at the site of treatment.
Advantages of IV Therapy:




Not affected by stomach or intestinal disease
Total amount given is available to tissues requiring the constituents
Force nutrients into the cells by means of a high concentration gradient, despite low energy due
to illness
Give doses of nutrients higher than those possible by mouth without intestinal irritation
Disadvantages of IV Therapy:



Pain, bruising or infection at the injection site
Inflammation of vein used for infusion, phlebitis
Severe allergic reaction or anaphylaxis, resulting in cardiac arrest, possibly death
Alternatives to IV Therapy:


Oral supplementation
Lifestyle and dietary changes
I understand that there is no implied nor stated guarantee of success or effectiveness of any specific
treatment. I understand that I am free to withdraw my consent and to discontinue participation in
these treatments at any time. I understand that, except in emergencies, I must give 24 hours notice of
intent to cancel or reschedule my appointment. Without 2 hours notice, I understand that I will incur a
fee of $25 for wasted materials, in addition to any applicable late-cancellation fee.
_____________________________________________________________________
Patient Name (Please Print. Include parent/guardian name if patient is a minor.)
____/____/____
Date
_____________________________________________________________________ ____/____/____
Patient Signature
(Parent/guardian signature if minor)
Date
390 N Sepulveda Blvd, Suite 1140, El Segundo, CA 90245
P: 310.926.4415 | F: 310.693.5492 | E: info@nawellness.com
Dr. Jennifer Abercrombie | Dr. Hillary Martin | Dr. Adam Sandford | Dr. Mikinzie Smoot