CrossroadsHealing Arts

X4 e. cl i, t' i. rt, e N c.t. tt,t r ct I Ly

1004 Parkway Avenue, Suite CElkhart, lN 46516

Phone: 574-294-1883Fax', 574-295-1749

www,crossroadshealin garts,com

Hello and Welcome to Crossroads Healing Arts!

Enclosed you will find all of your paperwork for your first visit. Please complete theforms in full, sign and bring with you to your appointment. Please also bring yourinsurance cards.

It is very imporlant that we have correct information on the medications that vou arecurrently taking.to vour appointment.

lf you have had any recent lab work done (past 12 months), it would be helpful foryou to bring these copies with you so that we do not duplicate any testing.

lf vou are female and your visit is regarding possible hormone related issues, weask for a copy of your recent pap and mammogram prior to prescribing hormonetherapy.

results prior to your visit, this would most certainly expedite your treatment,Please bring these with you or ask that they are faxed to us at 574-295-1749 priorto your appointment,

Please note; we do not file any insurance. However, we will give you all thenecessary information for you to submit an insurance claim on your behalf,

Finally, if you could arrive here 10-15 minutes early prior to your appointment, that willgive our staff a little extra time to get all of your paper work processed.

We look forward to meeting you very soon!

Crossroads fteaLLwq Ats

Checklist on what to bring to your first appointment:

1. Insurance Card – although we do not file to insurance, we keep one in your chart for blood draws or other orders that may require your insurance.

2. Copies of recent blood work or labs/consultations that would pertain to the reason of your visit. You may bring the copies with you or have them faxed to: (574) 295-1749 Attn: New Patient Records. **Please note – in some cases, if you do not have these and we are not able to obtain them promptly, your appointment may need to be rescheduled.**

3. For females, if wanting Bioidentical Hormone Replacement Therapy, we will need your most recent pap results and/or pelvic exam provider notes. If you are 40 or older we also need your most recent mammogram or thermogram results. Please note: Kelly Boyer N.P. can perform pap and pelvic exams. We can also do thermograms in office in case you are overdue and need to schedule one.

CrossroadsHealing Arts

M e cl ir:i rr.e N n.tu. r'cr,I11,,

1004 Parkway Avenue, Suite CElkhart, lN 46516

Phone: 574-294-1883Fax: 574-295-1749

www.orossroadsheal ingarts. com

Patient Registration

Legal First Name

Nick Name:

Middle lnitial

Birthdate:

Last Name

Sex: Male Female

State: _Zip:

Patient:

Address:

Phone:

City:

Cell:

Preferred # to contact you (please circle one): Home cell other:

Preferred way for appointment reminders (please circle one): Voicemail Text Email

Marital Status: S M D W EmailAddress:

Employer: Address: Phone:

Spouse/Parent: Living in Household?

Phone:Employer:

Yes No

Responsible

Address:

Address;

Phone:

Party: Phone:

EmergencyContact: Relationship:

Office PolicyCrossroads Healing Arts does not file any insurance claims, A copy of your itemized bill will be grven at the

r insurance company if you so desire. we are not a member of anyMedicare or Medicaid, lf you have any questions about coverage,or specific details. Payment is expected at the time of servicewe do accept Discover, Masteroard and VlsA, check or cash.

I understand and agree to the above office policies and the above information I have provided is correet andtrue to the best of my knowledge. I authorize the release of medical information to my insurance carriershould I decide to file charges incurred.

Patient Signature:

Parent Signature(lf Patient is a Minor):

Date:

Date:

How did you hear about our clinic? W Radio Referral Friend Other:

Patient Name: DATE OF BIRTH:

Allergies (to medications, latex, testing dyes, state ,,none" if none are known):

Goncern (Please rank by priority)Example: Headaches

1.

Onset Frequency Severity

2.

3.

what do you hope to achieve with Integrative and Functional Medicine?

Past Medical History:Examples: High blood pressure, high cholesterol, thyroid dysfunction, asthma, headaches, lBS, depression, obesity

1.

3

5.

7.

9,

2.

4.

6.

8.

10.

Past Surgical History:

Type of surgery:Example: Jan. 2000

Date of surgery:

Major Injuries:Example: Car accident-head injury 2000

Type of injury:1.

Date of injury:1.

2,

4.

2.?

4.

FAMILY HISTORY:Relationship Living Deceased

(aqe of death)Cause of death Medical problems

Father

Mother

Sibling

Sibling

Sibling

Sibling

Children

Children

Children

Children

I

Patient Name: DATE OF BIRTH:

Personal Background:1' Do you feel that your health has gotten worse over the past two years? No _ yes _2. Have you lost orgained morethan 10 percent of your bodyweight overthe pastfive years, even

though you were not intentionally dieting? No _ yes _3. Do you have trouble going to sleep or staying asleep? No _ yes _4. Does pain in your joints or muscles limit your physical activity or mobility? No _ yes _5. Do you commonly feel fatigued for no apparent reason? No _ yes __6, Are you frequently depressed or anxious? No _ yes _7. Do you have problems with memory? No _ yes _-8, ls there a consistent ringing in your ears? No _ yes _9. Do you feel that you are losing your strength? No _ yes _10, Do you take more than two prescription medications? No _ yes _11' How about over{he-counter medications? Do you commonly take any of these?

a, Anti-inflammatories No _ yes _b, Antacids No _ yes _c, Analgesics No _ yes _d. Sleeping remedies No _ yes _

12. Do you suffer from allergies? No _ yes _13' Do you occasionally have episodes of poor concentration or confusion? No _ yes _14. Do you commonly suffer from shortness of breath or feel winded? No _ yes _1 5. Have you lost any of your sense of taste or smell over the past few years? No _ yes _16. Do you feel you have lost significant amount of muscle mass over the past few years? No _ yes _17. Have you heard from a doctor that you have any of the following?

a, Elevated blood pressure No _ yes _b. Elevated blood cholesterol No _ yes _c, Elevated blood glucose No _ yes

1 8. Has your dentist told you that you have gum or periodontal disease? No _ yes _1 9' Do you frequently alternate constipation and diarrhea or feel pain or discomfort in your digestive area?No_Yes_20. Have you been told that you have chronic bad breath? No _ yes _21. Are you shofier than you used to be, or have you any evidence of calcium deposits? No _ yes22. Do you catch every cold and flu that,s going around? No yes

Patient Name; DATE OF BIRTH:

Social History:Occupation:

Single: Married: Widowed: Divorced:current tobacco use: No Yes _, packs per day number of years

Current drug abuse (alcohol, marijuana, cocaine, heroin, etc):History of drug abuse (alcohol, marijuana, cocaine, heroin, etc:

Diet History:How many cups of coffee do you drink daily?How many cups of caffeinated tea do you drink daily?How many sodas do you drink daily?How much alcohol do you drink daily?How often do you eat processed food?How much water do you drink a day?

REVIEW oF SYMPTOMS (check ail that appry to you currenily or in recent past):

Constitutional:! Fevers I Chills tr Weight LossEars, Nose, Mouth. Throat:! Earache ! Ringing in ears ! Difficulty hearing ! Sinusitis ! Sore throatsRespiratorv:! Cough I Sputum production ! Coughing up bloodGastrointestinal:D Nausea or vomiting ! Diarrhea ! Constipation E Liver problemsGenitourinary:! Burning with urination ! Frequent urinary infections ! Prostate problems! Blood in urine D Urinary incontinence (inability to hold urine)Musculskeletal:! Afthritis ! Muscle cramosNeuroloqical:! Seizures tr Fainting spells ! Loss of consciousnessSkin:! Rashes ! Skin ulcersEmoth ional/Psvch iatric :

! Depression ! Anxiety ! psychiatric problemsEndocrine:! Enlarges thyroid ! Sweating ! Diabetes ! Feeling unusually hot or coldHematoloqical/Lvmphatic Oncoloqic:! Anemia ! lron deficiency ! CancerAllerqic/lmmunoloqic:! Hay fever ! Seasonal Allergies

Patient Name:

Symptoms of Hormonal lmbalance (Women Only):When was your last menstrual period?When was your last mammogram per-formed?

When was your last pap performed?

Do you have fibrocystic breasts (many smallDo you have anxiousness, irritability or foggy

DATE OF BIRTH:

Are your periods regular?Where?

Where?

* To expedite your treatment, please bring a copy of your last mammogramand pap/pelvic results to your appointment.

Symptoms of Low Estrogen (Women Only):Do you have any hot flashes or night sweats? No _ yesDo you have foggy brain or inability to think clearly? No YesDo you have sleep disturbance (either inability to fall asleep or stay asleep)? NoDo you feel tearful easily? No _ yes _Do you have vaginal dryness? No YesDo you have urinary incontinence (inability to hold your urine)? No _ yes _Do you have frequent bladder infections? No yes

Yes

Symptoms of Low Progesterone (Women Only):Do you have heavy bleeding or uterine fibroids? No _Do you have breast tenderness? No _ yes _Do you have weight gain around the middle? No _ yesDo you have water retention (swollen, ankles, legs, fingers,Have you had any miscarriages? No YesHave you had problems with inferlility? No Yes

Yes

or face)? No _ Yes

lumps that can be felt)? Nobrain? No Yes

Yes

Do you have insomnia? No Yes

Symptoms of Low Testosterone (Men Only):Do you have morning erections? No _ yes _Do you have a noticeable decrease in muscle mass? No _ yesDo you have decreased sex drive? No yesDo you have decreased quality of erection or decreased sexual performance? No _ yesDo you have decrease mental ability, decrease memory, or foggy brain? No _ yes _Do you have decreased stamina for exercise or sexual activity? No yesDo you have low motivation or depression? No yesDo you wake up at night to urinate? No yesHave you ever had an elevated pSA or prostate cancer? No Yes

PatienUGuardian S ignature Date

/^/,ru Crossroads

H ea lin g ArtsM etd ic: it,r L: N utu rnll.l;

1-004 Parkway Avenue, Suite C

Elkhart, lN 46516Phone: 574-294-1883

Fax: 574-295-1749www,CrossroadsHea lingArts,com

Dear Patients and Friends,

The Providers of Crossroads Healing Arts are always striving to bring you the best in preventive care.Therefore, we would like to remind you that cedain health examinations and screenings are recommended ona regular basis, Review the recommendations below and then speak to your provider about which ones areright for you.

BEQO M M EN p E p p ER I o p! a LLEALTH EXAMINAIIQ rrLS Fo R Ap!! rTq :

RECOMMENDEDMen and WomenlByears&above

35 years & above(or earlier if risk factors)

Blood pressure, height, weight

Lipid Profile, Blood Chemistry Profile,Complete Blood Count, & Thyroid profile

Periodically or as needed,

Yearly or more if abnormal orat high risk.

50 years & above Stool for microscopic bloodSigmoidoscopy or Colonoscopy

YearlyEvery 5-'10 years

Women

25 years & above(younger it sexually active)

Pap, Pelvic, Breast exam Yearly, especially if taking hormones

Self Breast Exam Monthly

40 years & above(or at age 35 if strong

family history ol breastcancer)

Mammogram and/or Thermography Every 1-2yearsYearly if taking any hormones

45-50 years & aboveOr earlier if menopausalOr family history

Bone Density measurement Every 1-2 years

Men

50 years & above PSA Blood TestProstate ExamBone Density measurement

YearlyYearly

Every 1-2 years

I have read and understand the Preventive Healthcare Recommendations. I will take the appropriate actionto make arrangements for the necessary exams, (Note: these are just recommendations, not required.By signing says we have informed you of your options.) Thank you!

Signature: Witness Signature:Printed Name:Printed Name:

Date: Date:

Hormone Replacement Therapy Information Bio-identical Hormone Replacement Therapy (BHRT) is the therapeutic use of hormones that are identical to the hormones made naturally by the body. There are many different types but the ones used predominantly include: testosterone, progesterone, estradiol (E2), estriol (E3), DHEA, cortisol, and thyroid. These hormones are typically used to treat symptoms ofperimenopause, menopause, andropause (male menopause), thyroid dysfunction and adrenal fatigue, although other symptoms may be treated as well.

Potential RisksSafety of any of these hormones during pregnancy cannot be guaranteed. Notify your Provider if you are pregnant, suspect that you are pregnant, or are planning to become pregnant during this therapy.

Estrogen Therapy: Bio-identical estrogens are available in various forms including troches, and topical creams. Adverse reactions may include bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, death (e.g.-from blood clots or cancer) and mood swings. High potency synthetic conjugated estrogens (e.g. Premarin) have been associated with an increased risk of breast cancer and blood clots (the latter especially in smokers). Bioidentical estrogen, however, has the same cancer risk as the estrogen produced in your own body. Estriol may carry a lower risk of breast cancer and may even protect against breast cancer. Research is ongoing. It is not recommended to take estrogen if you have had breast cancer.

Progesterone Therapy: Bio-identical progesterone is available in various forms including oral capsules, troches, and topical creams. Oral Progesterone therapy may be sedating, so it is recommended to take at bedtime. Adverse reactions may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, sedation, and depression.

Testosterone Therapy: Bio-identical testosterone therapy is available in various forms including topical creams, and injection. Side effects may include acne, change in libido, hirsutism (facial hair growth) and scalp hair loss, and possible clitoral engorgement.

Bioidentical vs. Synthetic: Synthetic hormones such as Progestins, and bioidentical hormones such as progesterone have different effects on the body. Bioidentical hormones can be used and metabolized as our body was designed to do, thus potentially minimizing side effects. Compounded bioidentical hormone dosages can be fine tuned to your specific needs. Many European studies suggest that bioidentical hormones are safer than synthetic hormones. However, that doesn’t mean that bioidentical hormones are perfect. Although the use of bio-identical hormone replacement therapy has been shown in many studies to be safer than synthetic hormone replacement therapy, the risk of cancer-related side effects is still possible.

Getting Started: Baseline hormone levels are ordered at your initial visit. You will then be given an individualized prescription of BHRT based on your symptoms and test results. Symptom resolution is not usually immediate. While many patients feel better in the first 2 weeks, sometimes it can take anywhere from 2-4 months until patients feel like they have the perfect fit. There are many different preparations of BHRT, and some women respond to one form better than another. Sometimes additional lab draws are needed for hormone adjustment. A current pap smear and mammogram are required to start hormone therapy. Pap smears or a pelvic exam and mammograms (or thermograms) are required yearly to continue BHRT. All of which can be performed or ordered from our office. If you want to obtain those elsewhere, it is required that you supply us a copy for our records. Hormones are generally not prescribed or renewed unless these records are up to date. You will still however, be required to be seen in our office yearly with hormone labs to continue therapy.

Hormone Replacement Therapy Consent(Please initial each statement, indicating understanding and agreement)

_______ I request and consent to the administration of hormones and oral supplements and authorize that these will be prescribed by the healthcare providers at Crossroads Healing Arts.

_______ I acknowledge that there are no guarantees or assurances made with respect to the benefit of hormone replacement therapy prescribed for me.

_______ I acknowledge that there are certain potential risks involved in hormone replacement therapy that may require referral to a specialist for further evaluation and treatment.

_______ I agree to report to the healthcare provider any adverse reaction or problems that might be related to my hormone therapy.

_______ I understand that I will be in charge of administering the hormones and supplements prescribed to me. I will conform and comply with the recommended doses and methods of administration.

_______ I understand that initial blood and/or saliva tests will be performed to establish my baseline hormone levels. I agree to comply with requests for ongoing testing to assure proper monitoring of my hormone levels.

_______ I have been given a copy of the Hormone Replacement Therapy informational sheet and understand all requirements and risks involved with therapy.

I have read and understand all of the above consent. I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages. I have been given the opportunity to ask any questions about hormone replacement therapy, potential complications, required testing, and costs and have had them answered to my satisfaction. I fully understand what I am signing andhereby request and consent to treatment using hormone replacement therapy.

Patient Printed Name _________________________________________________Date _______________

Patient Signature _____________________________________________________Date _______________

MD/NP Signature _____________________________________________________Date _______________

Crossroads Healing ArtsPatient Supplement List

Patient Name: Date of Birlh:

Date Supplement Directions Reason for Use

Prescription MedicationsPatient Name: Date of Birth:Medication Allergies:

Pharmacy

Date/Provider Medication Dose/lnstructions Date # Refills Initial

Faxeo,

Phoned or

Written

Date Discontinued

or Changed

Date Preferred Pharmacy Fax # Phone Number City

Allergies Alert:

CrossroadsH ea lin g ArtsMedicine I{aturally

1004 Parkway Ave,, Suite CElkha rt, lN 46 5 t 6

Phone: 57 4-294-1883Fax.574-2951749

www.crossroadsheal i n ga rts.com

CANCELLATION/M ISSED APPO I NTM ENT POLICY

our goal is to provide quality medical care in a timely manner. In order to do so, we have had toimplement an appointment/cancellation policy, This policy enables us to better utilize availableappointments for our patients in need of medical care,

Cancel lation of Appointment:

In order to be respectful of the medical needs of other patients, please be courteous and callCrossroads Healing Arts promptly if you are unable to attend an appointment. This time will bereallocated to someone who is in urgent need of treatment. lf it is necessary to cancel yourscheduled appointment, we require that you call at least24 hours in advance, and calling early in theday is appreciated. Appointments are in high demand, and your early cancellation will give anotherperson the possibility to have access to timely medical care, Any appointment that is not cancelledat least 24 hours before the appointment time will result in a fee of $50 billed to the patient's account,

No-Show Policy:

A "no-show" is someone who misses an appointment without cancelling it in an adequate manner."No-shows" inconvenience those individuals who need access to medical care in a timely manner, Afailure to be present at the time of a scheduled appointment will be recorded in the patient's chaft asa "no-show", Any "no-show" will result in a fee of $50 billed to the patient's account,

I have read the above policy, and will comply accordingly.

Patient Name (printed)

Date:

Patient's Signature

Crossroads Healing Arts RELEASE RECORDS

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Patient Name: __________________________________________________ Soc. Sec. # __________________________

Telephone: ____________________________ Cell #: ____________________________ DOB: ______________________

Patient Address: ______________________________________________________________________________________

Send information to :

NAME: _____________________________________________ ATTENTION: ________________________

ADDRESS: ___________________________________________________________________________________

TELEPHONE: ________________________________

Request information from: Crossroads Healing Arts, 1004 Parkway Ave., Suite C, Elkhart, IN 46516 Phone: 574-294-1883

Purpose of Release (Example: continued care, personal ,etc.) __________________________________________________

Specific items or dates needed: __________________________________________________________________________

___ Cardiovascular Reports ___ EKG Reports ___ Lab Results ___ Pathology Reports

___ Radiology Reports ___ History & Physical ___ Operative Reports ___ Discharge Summary

___ Emergency Room ___ Other: _______________________________________________________

Needed for Doctor’s appointment on: _____________________________________________

This authorization is for release of medical records and information including diagnosis, treatment, and/or examination related to mental health (psychiatry or psychology) and/or alcohol abuse, HIV testing/AIDS and sexually transmittable diseases.

As required by State and Federal Law, Crossroads Healing Arts may not use or disclose your health information, except as provided in our Notice of Privacy Practices, without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of the protected health information described on this form.

I understand that State Law prohibits the re-disclosure of the information disclosed to the person/entities listed above without my further authorization, but that Crossroads Healing Arts cannot guarantee that the recipient of the information will not re-disclose this information contrary to such prohibition.

I understand that this authorization will remain in effect for one (1) year or until I revoke it in writing. I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing to Crossroads Healing Arts at the location listed above. I further understand that any such revocation does not apply to information already released in response to this authorization.

I understand that I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment will not depend in any way on whether I sign this authorization.

I understand that I have a right to inspect and to obtain a copy of any information disclosed. I hereby release Crossroads Healing Arts and its employees from any and all liability that may arise from the release of information as I have directed.

I understand that I may be charged a fee for every page copied. This fee is waived for copies provided to a health care provider for continuing medical care. I understand this fee is within the limits allowable under Indiana Law.

I hereby authorize the Provider listed above to release health information as described above. Patient Signature: ______________________________________________ Date: _____________________ Signature of parent or guardian: ___________________________________ Date: ______________________ Relationship to Patient: __________________________________________

After completing this release, please return it to the Provider listed above.

Crossroads Healing Arts, LLC

RECEIPT OF NOTICE OF PRIVACY PRACTICESWRITTEN ACKNOWLED GEMENT FORM

I, have read and been offered a copy of(Patient's Name)

Crossroads Healing Afts' Notice of Privacy Practices,

|..,giveCrossroadsHea|ingArts,LLC,permissiontodiscuss my medical status, laboratory results, appointment time(s), and alt other medical carewith the following person(s) effective immediately, This authorization will remain in effect until I

notify Crossroads Healing Arts' office manager of any change in writing,

Patient's Signature DOB Date

Witness Signature

NAME RELATIONSHIP

Blending the Best of rraditional and preventive Medicine1004 Park | 2gl-174g