Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Adult Patient Profile

Date ________________________________ Name _______________________________ Age __________ Birth date _______________ Sex _______________ Address ____________________________________________City, State & Zip____________________________ Telephone: Home______________________ Work_________________________ Cell______________________ May we leave a message at these numbers? __YES NO__ Which number is best? Home Work Cell (circle one) Email Address _________________________________________________ Occupation _____________________________________________________________________ Employer _____________________________________________________________________________________ Emergency Contact Name _____________________________ Telephone _________________________________ Is this your first visit to a Naturopathic Physician? ____________________________________________________

How did you hear about us? ________________________________________________________________ Medical History: Please complete this questionnaire as thoroughly as possible to aid us in an assessment and treatment. This is a confidential record of your medical history and will not be released except when you authorize us to do so. Thank you.

What positive health improvements would you like to see in order of their importance?

1. _________________________________________________________________________________ 2. _________________________________________________________________________________ 3. _________________________________________________________________________________ 4. _________________________________________________________________________________ 5. _________________________________________________________________________________ 6. _________________________________________________________________________________ What alternative medicines or therapies have you tried? ____________________________________________ _____________________________________________________________________________________

Medicines: Please list all prescription medicines, supplements, vitamins, minerals, herbs, or homeopathic remedies that you are currently taking on the form provided.

Allergies: List known allergies to the following:

Drugs ________________________________________________________________________________________ Food ________________________________________________________________________________________

Environmental (grasses, pollens, etc.) _________________________________________________________ Personal Habits: Check if you use: Tobacco_________ Caffeine__________ Alcohol___________ Recreational drugs___________ Do you follow any diet restrictions or regimens? _________ If yes, please describe:__________________________ _____________________________________________________________________________________________

Name: _______________________________________________________ Date: __________________________

History: For What When

Last complete physical exam: Month __________ Year ___________ by Dr.______________________________ For women: Last PAP smear: Month __________ Year ___________ by Dr._______________________________ Results were: Normal _____ Abnormal_______ Date of last menstrual cycle ______________ Duration of cycle _________________

List all other Physicians you are currently seeing and why ______________________________________ _____________________________________________________________________________________ Social History: Single ____ Married ____ Significant Other ____ Number of Children: ____ Ages ____________

Family History: Yes Who Comments

Hospitalizations

Accidents

Illness

Serious Illness

Allergies

Anemia

Arthritis

Auto Immune Disease

Asthma

Cancer

Diabetes

Epilepsy

Heart Disease

Hepatitis

High Blood Pressure

Kidney Disease

Mental Illness

Osteoporosis

Stroke

Thyroid: hypo/hyper

Tuberculosis

Other

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Symptom Survey Form (Restricted to Professional Use)

Patient: ____________________________ Age: _________ Physician: ________________Date:___________

INSTRUCTIONS: Check the boxes that apply to you. Please do not think about your answers; move through the survey as quickly as possible to provide us with your initial response to each symptom.

1 □ Acid foods upset 2 □ Get chilled, often 3 □ "Lump" in throat 4 □ Dry mouth-eyes-nose 5 □ Pulse speeds after meal 6 □ Keyed up - fail to calm 7 □ Cuts heal slowly

GROUP ONE 8 □ Gag easily 9 □ Unable to relax, startle easily 10 □ Extremities cold, clammy 11 □ Strong light irritates 12 □ Urine amount reduced 13 □ Heart pounds after retiring 14 □ "Nervous" stomach

15 □ Appetite reduced 16 □ Cold sweats often 17 □ Fever easily raised 18 □ Neuralgia-like pains 19 □ Staring, blinks little 20 □ Sour stomach frequent

21 □ Joint stiffness after arising 22 □ Muscle-leg-toe cramps at night 23 □ "Butterfly" stomach, cramps 24 □ Eyes or nose watery 25 □ Eyes blink often 26 □ Eyelids swollen, puffy 27 □ Indigestion soon after meals

GROUP TWO 28 □ Always seem hungry; feels "lightheaded" often 29 □ Digestion rapid 30 □ Vomiting frequent 31 □ Hoarseness frequent 32 □ Breathing irregular 33 □ Pulse slow; feels "irregular" 34 □ Gagging reflex slow 35 □ Difficulty swallowing

36 □ Constipation, diarrhea alternating 37 □ "Slow starter" 38 □ Get "chilled" infrequently 39 □ Perspire easily 40 □ Circulation poor, sensitive to cold 41 □ Subject to colds, asthma, bronchitis

42 □ Eat when nervous 43 □ Excessive appetite 44 □ Hungry between meals 45 □ Irritable before meals 46 □ Get "shaky" if hungry 47 □ Fatigue, eating relieves 48 □ "Lightheaded" if meals delayed

GROUP THREE 49 □ Heart palpitates if meals missed or delayed 50 □ Afternoon headaches 51 □ Overeating sweets upsets 52 □ Awaken after few hours sleep - hard to get back to sleep

53 □ Crave candy or coffee in afternoons 54 □ Moods of depression - "blues" or melancholy 55 □ Abnormal craving for sweets or snacks

56 □ Hands and feet go to sleep easily, numbness 57 □ Sigh frequently, "air hunger" 58 □ Aware of "breathing heavily" 59 □ High altitude discomfort 60 □ Opens windows in closed room 61 □ Susceptible to colds and fevers 62 □ Afternoon "yawner"

GROUP FOUR 63 □ Get "drowsy" often 64 □ Swollen ankles worse at night 65 □ Muscle cramps, worse during exercise; get "charley horses" 66 □ Shortness of breath on exertion 67 □ Dull pain in chest or radiating into left arm, worse on exertion

68 □ Bruise easily, "black and blue" spots 69 □ Tendency to anemia 70 □ "Nose bleeds" frequent 71 □ Noises in head, or "ringing in ears" 72 □ Tension under the breastbone or feeling of "tightness", worse on exertion

Name: ________________________________________________ Date: ______________________________

Symptom Survey Form - Page 2

73 □ Dizziness 74 □ Dry skin 75 □ Burning feet 76 □ Blurred vision 77 □ Itching skin and feet 78 □ Excessive falling hair 79 □ Frequent skin rashes 80 □ Bitter, metallic taste in mouth in mornings 81 □ Bowel movements painful or difficult 82 □ Worrier, feels insecure

GROUP FIVE 83 □ Feeling queasy; headache over eyes 84 □ Greasy foods upset 85 □ Stools light-colored 86 □ Skin peels on foot soles 87 □ Pain between shoulder blades 88 □ Use laxatives 89 □ Stools alternate between soft to watery 90 □ History of gallbladder attacks or gallstones

91 □ Sneezing attacks 92 □ Dreaming, nightmare type bad dreams 93 □ Bad breath (halitosis) 94 □ Milk products cause distress 95 □ Sensitive to hot weather 96 □ Burning or itching anus 97 □ Crave sweets

98 □ Loss of taste for meat 99 □ Lower bowel gas several hours after eating 100 □ Burning stomach sensations, eating relieves

GROUP SIX 101 □ Coated tongue 102 □ Pass large amounts of foul- smelling gas 103 □ Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hours

104 □ Mucous colitis or "irritable bowel" 105 □ Gas shortly after eating 106 □ Stomach "bloating" after eating

(A) 107 □ Insomnia 108 □ Nervousness 109 □ Can't gain weight 110 □ Intolerance to heat 111 □ Highly emotional 112 □ Flush easily 113 □ Night sweats 114 □ Thin, moist skin 115 □ Inward trembling 116 □ Heart palpitates 117 □ Increased appetite without weight gain 118 □ Pulse fast at rest 119 □ Eyelids and face twitch 120 □ Irritable and restless 121 □ Can't work under pressure

(B) 122 □ Increase in weight 123 □ Decrease in appetite 124 □ Fatigue easily 125 □ Ringing in ears 126 □ Sleepy during day 127 □ Sensitive to cold 128 □ Dry or scaly skin 129 □ Constipation 130 □ Mental sluggishness 131 □ Hair coarse, falls out

GROUP SEVEN

(B) continued 132 □ Headaches upon arising wears off during day 133 □ Slow pulse, below 65 134 □ Frequency of urination 135 □ Impaired hearing 136 □ Reduced initiative

(C) 137 □ Failing memory 138 □ Low blood pressure 139 □ Increased sex drive 140 □ Headaches, "splitting or rendering" type 141 □ Decreased sugar tolerance

(D) 142 □ Abnormal thirst 143 □ Bloating of abdomen 144 □ Weight gain around hips or waist 145 □ Sex drive reduced or lacking 146 □ Tendency to ulcers, colitis 147 □ Increased sugar tolerance 148 □ Women: menstrual disorders 149 □ Young girls: lack of menstrual function

(E) 150 □ Dizziness 151 □ Headaches 152 □ Hot flashes 153 □ Increased blood pressure 154 □ Hair growth on face or body (females) 155 □ Sugar in urine (not diabetes) 156 □ Masculine tendencies (female)

(F) 157 □ Weakness, dizziness 158 □ Chronic fatigue 159 □ Low blood pressure 160 □ Nails, weak, ridged 161 □ Tendency to hives 162 □ Arthritic tendencies 163 □ Perspiration increase 164 □ Bowel disorders 165 □ Poor circulation 166 □ Swollen ankles 167 □ Crave salt 168 □ Brown spots or bronzing of skin 169 □ Allergies - tendency to asthma 170 □ Weakness after colds, influenza 171 □ Exhaustion - muscular and nervous 172 □ Respiratory disorders

Name: __________________________________________________ Date: ____________________________

Symptom Survey Form - Page 3

173 □ Very easily fatigued 174 □ Premenstrual tension 175 □ Painful menses 176 □ Depressed feelings before menstruation

FEMALE ONLY 177 □ Menstruation excessive and prolonged 178 □ Painful breasts 179 □ Menstruate too frequently 180 □ Vaginal discharge

181 □ Hysterectomy/ovaries removed 182 □ Menopausal hot flashes 183 □ Menses scanty or missed 184 □ Acne, worse at menses 185 □ Depression of long standing

186 □ Prostate trouble 187 □ Urination difficult or dribbling 188 □ Night urination frequent 189 □ Depression

MALE ONLY 190 □ Pain on inside of legs or heels 191 □ Feeling of incomplete bowel evacuation 192 □ Lack of energy 193 □ Migrating aches and pains

194 □ Tire too easily 195 □ Avoids activity 196 □ Leg nervousness at night 197 □ Diminished sex drive

198 □ Apprehension 199 □ Irritability 200 □ Morbid fears 201 □ Never seems to get well 202 □ Forgetfulness 203 □ Indigestion 204 □ Poor Appetite 205 □ Craving for sweets 206 □ Muscular soreness

GROUP EIGHT 207 □ Depression; feelings of dread 208 □ Noise sensitivity 209 □ Acoustic hallucinations 210 □ Tendency to cry without reason 211 □ Hair is coarse and/or thinning 212 □ Weakness 213 □ Fatigue 214 □ Skin sensitive to touch 215 □ Tendency toward hives 216 □ Nervousness

217 □ Headache 218 □ Insomnia 219 □ Anxiety 220 □ Anorexia 221 □ Inability to concentrate; confusion 222 □ Frequent stuffy nose; sinus infections 223 □ Allergy to some foods 224 □ Loose joints

IMPORTANT TO THE PATIENT: Please list below the six main physical complaints you have in order of their importance.

1. _________________________________________ 2.__________________________________________

3. _________________________________________ 4. _________________________________________

5. _________________________________________ 6.__________________________________________

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Supplement and Medication List

Patient Name: Date: Date

StartedDate

DiscontinuedSupplement Dosage Attending

Physician

Date Started

Date Discontinued

Prescription Medication

Dosage Attending Physician

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Patient Consent Form

I, ______________________________, do hereby consent to be treated by a Naturopathic Physician at The Center of Naturopathy. I understand that Jennifer Ball, naturopathic physician was trained at an accredited university both didactically and clinically and is licensed by the Vermont State Board of Health as a Naturopathic Physician. I also understand that Ohio does not offer licensing to fully trained Naturopathic Physicians at this time.

I, _____________________________, take full responsibility for my choice of health care and completely understand that I am choosing to be treated by a physician who is unable by Ohio law to hold a license in the State of Ohio.

_________________________________________ _____________________________ Signature Date

Primary Care Physician Primary Care Physician____________________________________________________________________ Address_____________________________________________________________________ Phone______________________________Fax______________________________________ Any other physicians and their specialty you are seeing in relation to medical history: ________________________________________________________________________________________________________________________________________________________ In the case that you do not have a Primary Care Physician, read and sign below. I understand that Jennifer Ball, naturopathic physician requests that I have a Primary Care Physician in addition to care at the Center of Naturopathy. I understand if I do not currently have or choose not to have an Ohio Licensed Primary Care Physician, it may limit the ability to obtain certain diagnostic tests, medicines or procedures normally prescribed by a Naturopathic Physician in states which license Naturopathic Physicians as Primary Care Physicians.

Name_____________________________________________________________Date______

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Financial Policy and Cancellations

To ensure that there are no verbal miscommunications please read and sign the information below.

Office fees:

First Office call:

Regardless of time spent in the office, this visit costs $250 for Jennifer Ball. Sometimes the actual office visit is shorter and sometimes longer than two hours depending on the individual case. The physician spends time outside of the office visit in research, lab work and locating necessary resources for your unique case.

Lab Work:

If any lab work is required it is billed separately or paid directly to the lab. The physician only does necessary lab work to obtain information not contained in the history or clinical trials. This minimizes lab expenses.

Copies of Lab Work and Information Packets:

It is necessary for the Physician to see previous medical records that are pertinent to your case. If we need to make copies of those records and they exceed 3 sheets you will be assessed a copying fee of 10 cents per copy. If packets of information need to be copied for your treatment plan and they exceed 3 sheets the same fees will apply (our cost of copying).

First Follow-up appointment for Treatment Plan:

Depending on the complexity of the case this visit lasts anywhere from 45 to 90 minutes and costs $90 -$180 accordingly. The patient is billed $30 per quarter hour. Please let reception or the physician know if you have time restraints which need to be addressed.

Follow-up appointments thereafter:

Time allotment for follow-up appointments is based on the patient’s need and whether it is on the same condition or a new one. The patient is billed $30 per quarter hour for Jennifer Ball but this visit generally runs 30 minutes to one hour. Again, it is your responsibility to notify reception or the physician of any time restraints.

Initials__________

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Cancellation Policy:

Please understand that we do not book overlapping appointments for your convenience. If you cancel your appointment without proper notice, we are unable to book that space for someone else. As such, we found it necessary to implement a cancellation policy.

If you must cancel, please do so 48 HOURS before your scheduled appointment or the following fees will apply.

No Shows:

If no one calls to cancel or patient does not show up for a scheduled appointment, payment in full for that visit will be charged and billed directly to the patient.

Cancellations:

All cancellations or reschedules made at least 48 hours prior to scheduled appointments will not incur a charge. All cancellations or reschedules made in less than 48 hours will be charged as follows:

• Cancel or reschedule in less than 48 hours: $40. fee • Cancel or reschedule in less than 24 hours: $60. fee • No call, No show: Full fee for time scheduled.

If you do not specify a time, appointment time defaults to an hour.

Wait Time:

We do everything possible to run on schedule so that your wait time is minimal. While we usually stay on time, the nature of medicine does have unexpected presentations which may cause an appointment to last longer than it was scheduled. We hope that you will understand that if you need this time it will be given to you, as it may be given to someone ahead of you.

We thank you for your consideration of other patients and our medical staff. It is our desire to serve you in health and be considerate of your time and investment.

Thank you and be well,

Jennifer Ball, naturopathic physician

I have read and understood the above.

________________________________________________ __________________ Name Date

Center of Naturopathy Jennifer Ball ND

2700 E. Main Street, Suite 109 Columbus, OH 43209

(614) 397-6878

Driving Directions and Parking

The Center of Naturopathy is located in Bexley, a suburb just to the east of downtown Columbus, Ohio. Located at 2700 East Main Street, the office is between S. Roosevelt Avenue and S. Gould Road. While you can not park on E. Main Street, there is convenient, free parking along the building’s sides and at the back of the building. When you arrive, there’s no need to knock — just come on in to the waiting room for Suite 109, make yourself comfortable and Dr. Ball will be with you very soon.

If You Are Driving East on E. Main Street: The Center of Naturopathy is located on your Left side, 5 blocks east of S. Drexel Avenue (Route 40).

The downtown Columbus, Ohio area will be behind you, and the office building will be on your Left, about 1/2 block east of the E. Main Street and S. Roosevelt Avenue intersection. There is a large green sign with the street address near the sidewalk at the front of the building.

If You Are Driving West on E. Main Street: The Center of Naturopathy is located on your Right side, 6 blocks west of S. James Road.

The office building will be on your Right side, about 1/2 block west of the E. Main Street and S. Gould Road intersection. There is a large green sign with the street address near the sidewalk at the front of the building.