Still Quiet Place
885 Oak Grove Ave. #204
Menlo Park, CA 94025
Phone (650) 575-5780
Fax 650-326-1173
Email dramy@stillquietplace.com
Initial Visit: I look forward to your initial visit, and supporting you in the ongoing process of enhancing your health
and discovering true well-being.
Health History Form: The attached questions have been carefully chosen to address the many aspects of life that
affect health and well-being. Completing this questionnaire is the next step in caring For Your Self. Please find a
quiet, peaceful place where you will not be interrupted, and use this process to reflect on your health, habits,
circumstances, and intentions. Answer the questions as completely and truthfully as possible. All responses are part of
your medical record and strictly confidential. If there are responses you prefer not to put in writing, but would like to
discuss with me, please note that on the form. If a question does not apply to you leave it blank. Remember there are
no "right" answers, only what is true for you at this time.
To reserve your initial appointment please fax the first two pages with your consent for treatment, signature and
credit card information to 650-326-1173. Because of the length, and limited number of available appointments, a
credit card number is required to book an initial visit. Complete the questionnaire and save it as “your name. doc”
and email it to me at dramy@stillquietplace.com. Please return the completed questionnaire via email 48 hours
prior to your visit so that I may review it before we meet. We will go through the entire form together during your
initial visit. If you have not returned your form 48 hours before your initial visit, your appointment time will be
made available to another patient.
Medical Records: Please bring to your initial visit, or have your health care providers forward to me, copies of any
pertinent medical records- previous consultations, operative reports, laboratory tests, and x-ray reports. Usually this
information is sufficient, and it is not necessary to have your entire chart copied. A "Release of Medical Information"
form is attached on the last page of this packet.
Please be aware I offer specialty consultation in holistic medicine. I do not provide primary care, take call, or admit
patients to the hospital. I strongly encourage you to develop a relationship with a primary care physician for medical
emergencies and some routine care. If you wish, I will work in partnership with your primary care and specialty
physicians, and alternative medicine practitioners. If you do not currently have a primary care physician I can refer you
to physicians who support the use of holistic medicine and are willing to collaborate.
Payment: I offer care on a fee for service basis, and request payment at the time of service. I provide billing sheets for
you to submit to your insurance company. To date, all patients with PPO's have been reimbursed at their out-of-plan
rate. The initial appointment is 1 1/2 hours, and $450. Follow-up appointments are billed in 15 minute increments at
$300/hr. Payment may be made in cash, by personal check, VISA, or MasterCard. Often there are additional lab fees.
There is no charge for appointments cancelled 24 hours before the scheduled time (48 hours for the initial
appointment). Appointments missed or canceled with less than 24 hours notice will be billed at 100% of the cost
of the scheduled visit. I happily offer brief emails or phone calls at no charge, and email or phone consultation longer
than 15 minutes is billed at my hourly rate in 15 minute increments.
For most issues I am usually able to get someone on a maintenance plan with the initial visit and 1-3 follow-up visits.
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Consent to Treatment: The sciences of conventional and alternative medicine are evolving rapidly. With each
treatment recommendation we will discuss the available treatment options- conventional and alternative, the risks and
benefits of each option, and the current level of evidence supporting each option. It is impossible to list every
undesirable effect of any given treatment. It is possible that the condition for which a given treatment is recommended
may not be cured or significantly improved, and in rare cases may even become worse, or result in death. Please ask
all questions you have regarding your care. I make mistakes and misunderstandings may arise. It is important that we
deal with any concerns as soon as possible.
My signature below certifies that I have read this form and discussed it with Dr. Saltzman, and that I understand,
consent and agree to the conditions as described above. Completion and return of this form by email will be
considered consent to treatment.
Signature___________________
print name___________________
date __________
credit card number___________________ expiration date_______________
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Health History Form
Your name:
Male/ Female
Phone number:
Address:
Date of birth:
Home:
Age:
Work:
Email:
Primary care physician:
Phone number:
Address:
Date of last visit:
Date of 1ast Physical Exam:
Complementary/alternative medicine practitioner(s):
Name:
Modality:
Phone number:
Address:
Name:
Modality:
Phone number:
Address:
Were you referred here by your physician or health care practitioner?
Name of referring physician/practitioner:
May I contact them with follow-up information?
Yes/ No
Yes/ No
Objective(s): What would you most like to achieve regarding your health?
How committed are you to achieving this objective? (Please circle)
0
(Not very committed)
1
2
3
4
5
6
7
8
9
10
(Very committed)
3
Other
Sibling
Sibling
Grandpa
Grandma
Father
Mother
Self
Personal and Family
History.
Check all that apply to
you and your blood
relatives
High Blood Pressure
Heart Attack, Disease
Stroke
Asthma
Emphysema, COPD
Allergies, Hayfever
Frequent Infections
HIV, AIDS
Peptic Ulcer Disease
Colitis or Crohn's
Liver Disease, Hepatitis
Kidney Disease
Cancer or Tumors
Arthritis, Rheumatism
Mental Illness
Depression
Nervous Breakdown
Suicide (or attempted)
Alcoholism, Drug Use
Migraine Headache
Epilepsy, Seizures
Thyroid Disease
Obesity
Diabetes
Anemia
Bleeding Disorder
Psoriasis, Eczema
Glaucoma, Cataracts
Other:
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Review of Symptoms
Check and/or circle each item that to applies to you.
History of Head Injury
Loss of Memory
General Weakness or Loss of Energy
Dizzy Spells, Faintness, Blackouts
Frequent Headaches
Vision Disturbances, Glasses
Hearing Loss, Ringing in Ears
Ear Infections
Nosebleeds
Sinus Infections, Nasal Stuffiness
Frequent Sore Throats, Tonsillitis
Hoarseness
Swollen Glands
Shortness of Breath
Frequent Coughs, Wheezing
Palpitations, Chest Pains, Rapid Heartbeats
Anxious Feeling in Chest or Stomach
Poor Appetite
Indigestion
Abdominal Pain, Discomfort, Bloating
Constipation, Use of Laxatives
Diarrhea, Bloody Stools
Rectal Pain, Itching, Irritation
Hemorrhoids, Anal Fissures
Difficulty Urinating
Urinary Incontinence
Urinary Tract Infections (bladder or kidney)
Genital Warts
Men: Prostate Enlargement or Disease
Men: Penile or Testicular Problems
Women: Irregular or Painful Menses or Periods
Women: Premenstrual Tension, Irritability (PMS)
Women: Uterine or Ovarian Tumor or Cancer
Women: Menopausal Difficulties
Breast Cancer
Back Pain, Sciatica
Joint Pain, Swelling
Skin Rashes, Eczema, Psoriasis, Moles, Warts
Perspiration: Smelly, Profuse, Unusual; Night Sweats
Nightmares, Recurrent Dreams
Fears or Phobias (heights, dark, insects, etc.)
Anxiety, Nervousness; I Worry a Lot
Angry Irritable, Impatient, Critical
Sadness, Grief, Depression, Weeping
Perfectionist, Fastidious, Ambitious
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Symptoms/Issues: list those currently of concern to you (most important first) and circle their current severity.
(least severe)
1.
2.
3.
4.
5.
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
(most severe)
3
3
3
3
3
4
4
4
4
4
5
5
5
5
5
6
6
6
6
6
7
7
7
7
7
8
8
8
8
8
9
9
9
9
9
10
10
10
10
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Please list any other current symptoms/issues and provide any additional information regarding the above symptoms:
In the past year,
approximately how many days were you ill? ___
approximately how many days did you miss work/school? ___
how many times did you visit a medical doctor or health practitioner?___
how many times were you in the hospital?___
Hospitalizations: list diagnosis and date.
Surgical History: list any surgeries you have had and the dates (including cosmetic surgery).
Major Injuries or Accidents: list type of injury and date.
Psychotherapy: list any psychotherapy you are currently undergoing, or have had in the past; include the dates of any
psychiatric hospitalizations and the diagnosis.
Spiritual Counseling: list the most recent first; note the dates and spiritual tradition.
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Medications: list your current prescription and over-the-counter medications, including dose, frequency of use, and
conditions for which they were prescribed. List birth control pills if you use them.
Allergies to Medications: list the medications and the reaction that occurred.
Nutritional and Vitamin Supplements, Homeopathic and Herbal Remedies: list your current supplements and
remedies, including dose, frequency of use, and conditions under treatment.
Alternative/Complementary Medicine History: list all current and previous alternative/complementary medicine
therapies you have used. For each therapy, include the date or duration of use, the conditions for which it was used, and
how effective it was.
List any other alternative/complementary medicine therapies you are interested in pursuing.
Health Habits: Describe the foods you eat at each meal during a typical week. Note any special diet or restrictions.
Breakfast:
Lunch:
Dinner:
Snacks/ sweets (include number per day):
Foods you tend to crave:
Foods you dislike:
Food allergies:
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Have you ever had weight issues or been told you had an eating disorder? Yes /No
If yes, please describe:
Briefly describe your current exercise regimen, including the type and frequency.
Sleep: What time do you usually go to sleep? AM/PM
Wake up?
Describe any concerns regarding your sleep habits or quality of sleep.
AM/PM
Media use: Please describe your typical use of media—t.v., internet, cell phone, tablet, gaming.
For each of the following, list how much you consume and how often. If you quit using a particular substance, state
when and why you quit.
Coffee
Tea
Other caffeinated beverages
Cigarettes
Cigars
Other tobacco products
Beer
Wine
Other alcoholic beverages
Marijuana
Cocaine
LSD
Amphetamines
Heroin
Other drugs, including inhalants
Have you ever had a problem with alcohol or alcoholism? Yes/ No. If yes. please describe.
Have you ever had a problem with, or dependency on drugs? Yes/ No. If yes, please describe.
Briefly describe your current living space, or any other place where you spend a significant amount of time (workspace,
vacation home, etc.). Include any concerns you may have about these spaces.
Do you have any known exposures to toxic substances? Yes/ No. If yes, please describe.
What gives you joy?
What are you afraid of?
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Who or what angers, saddens, or disappoints you? And why
Life/Social History:
List and briefly describe the most significant events in your life.
Briefly describe the most significant relationships in your life.
Living arrangement:(circle all that apply): single, married, divorced, separated, remarried, widowed,
significant-other, co-habitating, or other (describe):
List the names and ages of your immediate “family” (e.g. spouse/partner & children) and any other people
who live with you.
Do you have concerns about parenting? Yes/ No. If yes, please describe:
"I am satisfied with my current relationships with my immediate “family”. (Circle your response.)
spouse/ partner:
strongly agree
agree
neutral
disagree
strongly disagree
child: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
child: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
child: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
"I am satisfied with my current relationships with friends."(Circle your response)
strongly agree
agree
neutral
disagree
strongly disagree
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"I am satisfied with my current relationships with my family of origin.” (Circle your response.)
mother:
strongly agree
agree
neutral
disagree
strongly disagree
father:
strongly agree
agree
neutral
disagree
strongly disagree
sibling: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
sibling: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
sibling: name ______________ age______________
strongly agree
agree
neutral
disagree
strongly disagree
Body Image/Sexuality. How do you feel about your body/body image?
I consider myself (circle whichever applies) heterosexual, homosexual, bisexual, transgender, other:
Sexual desire:
absent
Recent change? Yes/ No.
low
problematic
average
high
excessive
“I am satisfied with my current sexuality/sexual life”. (Circle your response.)
strongly agree
agree
neutral
disagree
strongly disagree
“My partner is satisfied with our current sexuality/sexual life.” (Circle your response.)
strongly agree
agree
neutral
disagree
strongly disagree
Is there any personal or family history of sexual abuse/assault? Yes/ No. If yes, please explain.
Briefly describe any additional aspects of your sexuality/reproductive history which you consider significant
(e.g. birth control/safe sex practices you currently use, or have used in the past, sexual orientation, gender
identity, infertility, previous abortions or miscarriages, etc.).
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Women Only: age at First Menses:
age at Menopause
Date of last PAP, pelvic, and breast exam:
Number of pregnancies:
live births:
Abnormal PAP: Yes/ No.
miscarriages:
abortions:
Education: Check the highest educational level you have completed:
_ high school
_college (2-year)
_college (4-year)
_post-graduate (one-year, e.g. Masters)
_ post-graduate (multi-year, e.g. PhD, MD, JD)
Career/Financial: describe your current job/occupation and any previous significant ones.
"I am satisfied with my current job/occupation.”
strongly agree
agree
neutral
(Circle your response.)
disagree
strongly disagree
How comfortable-are you with your current financial situation List any significant financial concerns.
Stress: Please list any additional stressors not mentioned above.
Spirituality What was your role in the family when you were growing up? Briefly describe your family dynamics. How
your related to your parents and siblings.
When you were growing up, how were you "supposed" to act and what was expected of you?
What values, myths, or mottoes were common in your family? (e.g. “work hard, play hard”, “ the grass is always
greener”, “big boys/girls don’t cry”).
If you were asked to describe the life ethic or principle that guides you, what would you say?
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What word, phrase, or image best describes your current spirituality?
If you have had any spiritual experiences that have influenced you, please describe them briefly.
Do you think your relationship something greater has anything to do with the quality of your
life and/or health? Yes/ No Please explain:
Have you ever belonged to an organized religious/spiritual group(s)? Yes/ No. If yes, please list, most current first.
Briefly describe the practices you find helpful in making your life more meaningful (e.g. spending time in nature,
organized worship services, meditation, prayer, art etc.).
"I am satisfied with my current spirituality/spiritual life." (Please circle your response.)
strongly agree
agree
neutral
disagree
strongly disagree
If there is anything that has not been adequately covered above, or if you would like to add a comment or question, please
include it here. Acknowledge yourself for devoting the time to caring For Your Self.
Blessings
Amy Saltzman M.D.
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If you have had an extensive diagnostic work-up in the past please sign the release below and send it to your current and
previous physicians.
Release of Medical Information
To:
Address:
City:
Phone:
State:
Fax:
Zip Code:
I hereby authorize and request that you release my medical records and any information regarding my health (consultation
notes, procedure notes, and lab/x-ray/biopsy results, etc.) to:
Dr. Amy Saltzman
Still Quiet Place
885 Oak Grove Ave. #204
Menlo Park, CA 94025
Phone 650-575-5780
Fax 650-326-1173
Print Name:
Date of Birth:
Date:
Signature:
Phone:
Address:
City:
State:
Zip Code:
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Driving Directions
From 280 and Sand Hill Road
Take Sand Hill East
Turn Left on Santa Cruz Avenue
Veer Right and remain on Santa Cruz
Right at the stop sign to stay on Santa Cruz
Just after the first light in downtown Menlo Park
Turn Left on University
Turn Right into the parking lot
Park behind the red brick building
885 Oak Grove Ave.
Suite #204
From 101 and Willow
Go West on Willow
Right on Middlefield
Left on Oak Grove
Cross El Camino
885 Oak Grove will be a red brick building on your left just before Oak Grove T-s
into University.
There is parking in the back of the building.
Suite #204
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