Dr. Frank L. Aieta                                                               Naturopathic Physician                                             301 North Main Street, West Hartford, CT 06117                                                   Tel: (860) 232-9662  Fax: (860) 206-6160 Dear Patient: Please PRINT and FILL OUT this questionnaire and bring it with you for your appointment on: ________________at______AM/PM.                                                    PATIENT INFORMATION FORM Name__________________________________  Date of First Visit_____________________________________ Address____________________________________________________________________________________ City_______________________________State__________________Zip Code_________________________ Telephone # (home)______________________(work)______________________(Cell)_____________________ E-Mail address_______________________________________________________________________________ Age__________Date of Birth____________________        Sex: Female_________Male_________ Social Security Number________________________________________________________________________ Married_____Separated_____Divorced______Widowed______Single______Partnership______ Live with: Spouse____Partner____Parents____Children____Friends____Alone_____ Student Status:  ____Non-student____Part-time____Full-Time____ School Name_________________________________________________________________________________ Occupation_______________________________________________Hrs per week__________Retired_________ Employer______________________________Work address__________________________________________ How did you hear about our clinic?_______________________________________________________________ Has any other family member already been a patient at the clinic?_______________________________________ In case of emergency contact___________________________________________________________________ Relationship______________________________________Phone#______________________________________ Address_____________________________________________________________________________________
			HEALTH HISTORY QUESTIONNAIRE Have you ever received naturopathic care, if yes with whom and when? ___________________________________________________________________________________________ Please List Specific Health Concerns in Order of Importance to you: 1._________________________________________________________________________________________ Date Began________________ What makes it better?_______________________________Worse?___________________________________ Have you seen other health care providers for this (y/n)________ If yes, what medications or treatments were given_________________________________________________ _________________________________________________________________________________________ 2._______________________________________________________________________________________ Date Began________________ What makes it better?_______________________________Worse?__________________________________ Have you seen other health care providers for this (y/n)________ If yes, what medications or treatments were given_________________________________________________ __________________________________________________________________________________________ 3.________________________________________________________________________________________ Date Began________________ What makes it better?_______________________________Worse?__________________________________ Have you seen other health care providers for this (y/n)________ If yes, what medications or treatments were given_________________________________________________ __________________________________________________________________________________________ Do you have any opinions regarding what may have caused your health concerns? __________________________________________________________________________________________ __________________________________________________________________________________________ How much effort are you willing to put into getting better?  NONE  0       1        2        3        4        5        6       7        8       9       10        WHATEVER IT TAKES
		Do you have any known contagious diseases at this time? (y/n) If yes, what?________________________________________________________________________________ Allergies (Medicine, Food, Environmental)________________________________________________________ __________________________________________________________________________________________ Please list any hospitalizations or surgeries with dates:____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please indicate:   SELF or a RELATIVE have experienced any of the following:                             YES     WHO                                                                      YES        WHO Alcoholism         ___________________                               Hemophelia            _______________________ Allergies             ___________________                                High Blood         Anemia               ___________________                                Pressure               _______________________ Arthritis              ___________________                                High Cholesterol    _______________________ Asthma               ___________________                                 Mental Health Auto immune                                                                        Condition            ______________________ Disorder             __________________                                 Migraines              ______________________ Cancer                __________________                                Obesity                ______________________ Depression         __________________                                 Osteoporosis        _______________________ Diabetes             __________________                                 Other Addiction  ________________________ Eczema              ___________________                               Psoriasis             _______________________ Glaucoma          __________________                                  Seizures              _______________________ Gout                  __________________                                 Fibrocystic breast_______________________ Hay fever          __________________                                  Stroke                ________________________ Heart Attack     __________________                                   Suicide Attempt _________________________ Heart Disease    __________________                                  Thyroid Disorder_________________________ CURRENT MEDICATIONS Do you take or use? Laxatives____Pain relievers____Antacids____Cortisone____Appetite suppressants____ Antibiotics______ Tranquilizers____Thyroid medication____Sleeping pills____ Please list ANY prescription, over the counter medications, vitamins or other supplements you are taking:      1.___________________________________  5._____________________________________      2.___________________________________  6._____________________________________      3.___________________________________  7._____________________________________      4.___________________________________  8._____________________________________
				Please indicate any of the following: Smoke________How long___________________Number/Day___________________________ Alcohol_______Type_______________________How often:____________________________ Caffeine_______What drink_________________How often:_____________________________ Sugar_________How much_________________How often:_____________________________ Artificial Sweetener_____Type______________________How often:_____________________________ Exercise______ Type______________________How often:_____________________________ Food Cravings______ What_____________________How often:_____________________________ Sleep Problems______ Type_____________________How often:_____________________________ Weight Changes_______ Gain/Loss________________When:_________________________________ Diet Restrictions_____________________________What:_________________________________ Which of the following treatments are you interested in specifically: Homeopathy_____  Spinal Manipulation____  Acupuncture____  Nutritional Counseling____ No preference_____ If one of your health concerns was fatigue you may want to read Dr. Aieta's article on fatigue and fill out, print and bring with you to your first visit a fatigue questionnaire. Click here to read the article:  WHY AM I SO TIRED? Click here to print out a fatigue questionnaire:  ADRENAL FATIGUE QUESTIONNAIRE I hereby allow my health insurance company to reimburse Dr. Frank Aieta directly for services rendered by this office.  I understand and agree to pay, in a timely manner, any fees not covered or denied by my insurance company, including co-payments and annual deductibles. SIGNATURE_______________________________________________DATE_____________
	OFFICE POLICIES Regarding insurance: Our office accepts Anthem Blue Cross/Care and Connecticare insurance plans. All individuals with other insurance must pay for services at the time they are rendered. If you have a private insurance plan (non-HMO), then your insurance company will be responsible for providing some type of out-of-network coverage. Please contact your insurance directly for their out-of-network policy. Out of pocket fee schedule is as follows: Initial visit  $275 2nd visit  $125 Subsequent visits $85 Regarding payment: Payment is required at the time of services rendered. We accept cash payments, credit card (Visa, Mastercard, Discover) or personal checks.  Cancellation/Rescheduling policy: Please be aware there is a 24-hour cancellation policy. Appointments cancelled with less than 24 hours notice will be charged a fee of $25 added to their next rescheduled visit. If an emergency occurs and you cannot make an appointment this policy will not be in effect the first occurrence. Patients who need to reschedule or cancel appointments continually will have invoices mailed directly to their home address. Questions for the doctor: We encourage patients to call with questions regarding their treatment plan. If there is need for longer discussion regarding new symptoms or new concerns then we recommend you schedule an additional follow-up appointment. Questions that require longer than 5-minute responses fit this scenario. Additionally, if it has been longer than 6 weeks since your last appointment then we also recommend that you schedule a time to come in for further evaluation. Office hours are as follows: Office visits are by appointment only Monday, Tuesday, Thursday: 9:00am - 5:00pm Wednesday: 9:00am – 1:00pm Alternating Wed: 9:00am - 5:00pm Friday: closed Office hours are subject to change: please listen to office phone message for any changes
DIRECTIONS TO OFFICE:
			Take Route 84 to Exit 43 (Park Road Exit).  Take a LEFT at the end of the exit ramp. At your second stop light take a RIGHT onto South Main Street.  Stay on this road for exactly 2 miles, South Main Street will turn into North Main Street.  Look for Pioneer Drive on the left.  Take a left onto Pioneer Drive and pull into the first driveway on the LEFT. The office is a Tan Ranch Style house that is located on the corner of Pioneer Drive and North Main Street.  The office address is 301 North Main Street.                                 Park in the driveway and walk up the walkway to the front entrance