Welcome to Freeze Naturopathic Care

Name: ------------------------Date: _Address: --------------------------~----------City: _Zip: _Tel: (H) (w) © _Age____ Date of Birth Gender: F or MMarital Status: Married Divorced Widowed~--- ------Single___ Partnership _

State:-------

Live with: -"-- _Occupation:,_________ Hours per week: _Employer:,__________ SSN# --,-__Work Address:--:-:- __ -:-:--:-:-_-:---:-- _Health Insurance NamelAddress/Tel; -----~~-----------Policy Holder's Name: Employer::...- _Policy/Group #: . ID# _How did you hear about the cIinic? _Has any other family member been a patient at our clinic? _Next of Kin or other toreach in an emergency?

Relationship: Phone: _Address: _

PLEASE FILL OUT BOTH SIDES OF EACH PAGE HEALTH HISTORYQUESTIONNAIRE. SUCCESSFUL HEALTH CARE AND PREVENTIVEMEDICINE ARE ONLY POSSIBLE WHEN THE PHYSICIAN HAS A COMPLETEUNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY ANDEMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS .THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARKANYTHING YOU DON'T UNDERSTAND WITH A QUESTIO~ MARK ..

Are you currently receiving healthcare? Y NIf'yes, where and from whom? _If no, when and where did you last receive medical or health care?

What was the reason?

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What health problems are bringing you into the doctor today? Please list inorder of importance.1) _2) _3) _4) _

Do you have any known contagious diseases at this time? Y NIf yes, what? -'-- _

FAMILY HISTORYFATHER MOTHER BROTHERS SISTERS CHILD

Health ( Gs=good P=poor )

Check U those if applicable:CancerDiabetesHeart DiseaseBlood PressureStrokeMental IllnessAllergiesAnemiaKidneyDzGlaucomaTuberculosisCause of Death

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*For all the following sections,Y = condition you have now N = never had P = condition in thepastChildhood IllnessesScarlet fever Y N Diphtheria YNMumps YN Measles YN

Rheumatic fever YNGerman measles Y N

Hospitalization and Surg~ryWhat hospitalizations or surgeries have you had?_________________ ye&:___________________ ye&: ______________ year:_

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How does your condition affect you?

What do you think is happening? And Why?

What do you feel needs to happen for,you to get better?

What do you enjoy most in life?

How much change are you willing to make at this time for improving yourhealth? COMPLETE MINIMAL SOME

Is there any information about your health you would like to add?

GENERALWeight lbs. Weight 1 yr ago lbs. Max Weight__ When __When during the day is your energy the best? worst? ---REVIEW OF SYSTEMSMENTAL! EMOTIONALTreated for emotional problems? Y P N Depression? Y P NMood Swings? Y P N Anxiety or nervousness? Y P NConsidered! Attempted suicide? Y P N Tension? Y P NPoor concentration? Y P N Memory problems? Y P NENDOCRINEHypothyroid? Y P NHypoglycemia? Y P NExcessive hunger? Y P N~IMUNEVaccinations? Y P NChronic Fatigue Syndrome? Y P NChronically swollen glands? Y P NNEUROLOGICSeizures'?Y PN Paralysis?Y PN Muscleweakness?Y PNNumbness or tingling?YP N Loss of memory?Y P N Easily stressed'IY P NVertigo or dizziness? Y P N Loss of balance? Y P NSKINRashes?YPNItching? Y P NLumps?YPN

Heat or cold intolerance? Y P NDiabetes? Y P N Excessive thirst? Y P 1'1Fatigue? Y P N Seasonal depression? YP N

Reactions to vaccinations? Y P NChronic infections? Y P NSlow wound healing? Y P N

Eczema, Hives? Y P NColor Change? Y P NNight Sweats? Y P N

Acne, Boils? Y P NPerpetual Hair Loss? Y P N

X-Rays and Special StudiesX-rays, CATscans, or other studies you have had:

ImmunizationsPolio Y N Pertussis YN Hepatitis B Y N Herpes Y NTetanus shot Y N Diphtheria Y N Chicken Pox Y NMeasles/Mumps/Rubella YN Other _--'- __

AllergiesAre you hypersensitive or allergic to...Any drugs? Any foods? _Any environmentals? ---!.

MedicationsDo you take or use?Laxatives Y N Pain relievers YN Tranquilizers Y N Antacids Y NCortisone Y N Sleeping pills Y N Antibiotics Y N Thyroidmeds Y NAppetite suppressants Y NPlease list any prescription medications, over the counter medications,vitamins or other supplements you aretaking? . _

HabitsMain interests and hobbies?__ :---:-_~ -:-- ,__Do you exercise? Y N If yes, what form? _Howoften?~--~-~ - ___:_~--~-------~-----Average 6-8 hrs. sleep? YN '.Enjoy your work? YN Sleep well? YNTake vacations? Y N Awake rested? Y N .Spend time outside? YNHave a supportive relationship? Y N Have a history of abuse? Y NAny major traumas? Y P N Use recreational drugs? Y P NTreated for alcoholism? YP N Been treated for drug dependence? Y P NSmoked previously? Y P N Alcoholic beverages? YP N Tobacco? Y P NPacks per day? how many years? _Do you eat three meals a day? Y N Do you eat out often? Y NDo you go on diets often? Y N How many times/wk? __Do you drink coffee? Y P N Do you drink tea? Y P NDo you drink cola or other sodas? Y P N? Do you drink water? Y}>NDo you eat refined sugar? Y PN . Do you add salt? Y P NDo you have a religious or spiritual practice? Y NIf yes, what? _

HEADHeadaches? Y P NNfigrBines? Y P NEYES & EARSSpots in Eyes? Y P N Cataracts? Y.PN Impaired vision? Y P NGlasses or contacts? Y P N Blurriness? Y P N Eye pain/strain? Y PNColor blindness? Y P N Tearing or dryness? Y P N Double Vision? Y P NGlaucoma? Y P N Impaired bearing? Y P N . Ringing? Y P NEaraches? Y P N Dizziness? Y P NNOSE AND SINUSESFrequent colds? Y P N Nose Bleeds? Y PNHayfever? Y P N Sinus problems? Y PNMOUTH&THROAT&NECKFrequent sore throat? Y P NTeeth grinding? Y P NGum problems? Y P NSwollen glands? Y P NRESPIRATORYCough?YPN Sputum?YPNWheezing Y P N Asthma? Y P NPneumonia? Y P N Pleurisy? Y P NDifficulty breathing? Y P NShortness of breath? Y P NCARDIOVASCULARHeart disease? Y P N Angina? Y P N HighlLow Blood Pressure?Y P NMurmurs? Y P N Blood clots? Y P N Fainting? Y P NPhlebitis? Y P N PalpitationslFluttering? Y P N Rheumatic Fever? Y P NChest pain? Y P N Swelling in ankles? Y P NGASTROINTESTINALTrouble swallowing? Y P N Heartburn? Y PN Change in thirst? Y P NChange in appetite? Y P N Nausea? Y P N Vomiting? Y P NVomiting blood? YP N Bowel Movements: Number per day _Is this a change Y N Blood in stool? Y P N Pain or cramps? Y P NConstipation? Y P N Belching or passing gas? Y P N Diarrhea? Y J>NBlack stools? Y P N Gall Bladder disease? Y P NJaundice (yellow skin)?Y P N Ulcer? Y P N Liver Disease? Y lPNURINARYPain on urination? Y P NFrequency at night? Y P NFrequent infections? Y P N

Head Injury? Y P NJaw/TMJ problems Y P N

Stuffiness? Y P NLoss of smell? Y P N

Copious saliva? Y P NSore tongue/lips? Y P N

Hoarseness? Y P N Lumps? Y P NGoiter? Y P N Pain or stiffness? Y P N

Spitting up blood? Y P NBronchitis? Y P NEmphysema? Y P NPain on breathing? Y P N .Shortness of breath at night? Y P N

Increased frequency? Y P NInability to hold urine? Y P NKidney stones? Y P N

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MALE REPRODUCTIONHernias? Y PN Testicular masses? Y P N Testicular pain? Y P NProstate disease? Y P N Discharge or sores? Y P NAre you sexually active? Y N Chlamydia? Y P NSexual orientation: Gonorrhea? Y P NImpotence? Y P N Condyloma? Y P N Premature ejaculation? Y P NHerpes? Y P N Birth control? Y N Type? Syphilis? Y P NFEMALE REPRODUCTION/BREASTSAge of first menses? Age of last menses? __Are cycles regular? Y N Length of cycle? daysBleeding between cycles? Y P N Duration of menses? daysPain during intercourse? Y P N Painful menses? Y P NClotting? Y P N Heavy or excessive flow? Y P N Discharge? Y P NPMS? Y P N If yes, what are your symptoms _Birth control? Y P N . What Type? Number of years? ----Number of pregnancies? .Number of live births? ----Number of miscarriages? Number of Abortions

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Endometriosis? Y P N Ovarian cysts? Y P N Difficulty conceiving? v P NMenopausal symptoms? Y P N If yes, what? _Cervical Dysplasia? YP N . Abnormal PAP? Y P NSexual difficulties? Y P N .Chlamydia? Y P N Gonorrhea? Y P N.Condyloma? Y P N Herpes? Y P N Syphilis? Y P NAre you sexually active? Y N Sexual orientation:' ----Do you do breast self exams? Y P N Breast lumps? Y P NBreast pain/tenderness? Y P N Nipple discharge? Y P NMUSCULOSKELETAL . .Joint pain or stiffness? Y P N .Arthritis? Y P N Broken bones? Y P NWeakness? Y P N Muscle spasms or cramps? Y P N Sciatica? Y P NBLOOD/PERIPHERAL VASCULAREasy bleeding or bruising? Y P N Anemia?Y P N Deep leg pain? Y P NCold hands/feet? YPN Varicose veins? yP N Swelling in the legs? YPN

Welcome! We look forward to helping you reach optimalhealth and wellness in your life!

If you have any questions, please do not hesitate to ask!

Freeze Naturopathic Carewww.karenfreeze.com

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Freeze Naturopathic Care

Terms of Agreement

Patient Name: last _ First _

Age: DOB: _ Social Security Number: __ -__ -__

Welcome to the Freeze Naturopathic Care and thank you for selecting us for your healthcare needs.We look forward to helping you along the way to great health.

Office Hours: Please note our office hours will vary, as will the days during the month that we are

available in the office. However the days we are not in the office, we will be available by phone or/and

ernail, on normal business days.

Cancellation: Please give at least 24 hour notice to reschedule an appointment. Failure to cancel an

appointment without giving the clinic a 24-hour notice will result in a full charge of your appointment.

Fees & Financial Policy: Payment of fees is the direct responsibility of the patient. We shall collect

payment for services and products at the time of visit. We accept cash, check, Visa, MasterCard and

Discover as forms of payment.

Insurance Billing: We do not bill insurance and fees are due at visit.

Medicinarv: To pick up refills of your medicinary items, please call the center 24hrs in advance so that

any waiting time can be minimized. We will ship supplements to you. A charge of $5.00 will be applied

or shipping. Please note orders of $75.00 or more will not have a shipping fee.

Terms: All of our fees are subject to change without prior notice. Past due balances are subject t 0 a 2%

per month (18% per annum) service charge, plus a monthly billing charge of $10.00.

Statement: I have read and understand the above policies of Freeze Naturopathic Center PllC and agree

with them. I consent to the treatment with Dr. Karen Freeze, N.M.D and accept full responsibility for all

expenses incurred by or on the account of the patient. In the event of non-payment, I will bear the cost

of collection and/or all court costs and legal fees should it be required. I authorize the release of any

medical information necessary to process an insurance claim and authorize payment directly to the

signed physician. Due to the new privacy policies, this form must be signed to disclose your private

health information.

Signature if Patient and/or Guardian Date:

Freeze Naturopathic Care

9221 W. San Pablo Drive

Goodyear, AZ 85338

Tel: 623.824.9600

www.drkarenfreeze.com

SUMMARY OF NOTIVE OF PRIVACYPRACTICES

We strongly believe in maintaining the confidentiality of the personal information we possess and/orreceive about you and are committed to protecting your privacy. We do not disclose any non-publicinformation about you to anyone, except as permitted or required by law. We do not sell or otherwisedisclose your personal information to anyone for purposes unrelated to our health practice. Wemaintain physical and procedural safeguards that comply with federal and state regulations to protectinformation about you from unauthorized disclosure. We may disclose any information we believenecessary to conduct our business as is legally required. You have the right to access, review and correctall personal information collected. You may also request the Privacy Policies of other entities whoprovide information to our office. We will provide phone numbers and addresses.

Please take a moment to sign the Acknowledgement of Receipt of Privacy Practices Summary.

ACKNOWlDGEMENT OF RECIEPTOF NOTIVE OF PRIVACY PRACTIVES SUMMARY

This document is to be signed by a person legally responsible for the patient's medical decisions relativeto the treatment situation.

I, , hereby acknowledge that The Freeze Naturopathic Care has providedme with a copy of its Notice of Privacy Practices Summary that summarizes how medical informationabout me may be used and disclosed.

I understand that fi I have questions I may contact: Dr. Karen Freeze Tel: 623.824.9600.

I also understand that I am entitled to receive updates upon request if the clinic amends or changes itsNotice of Privacy Practices in a material way. Privacy Practices Policy effective July 1, 2012.

Signature of Patient and/or Guardian Date:

Relationship to Patient, if signed by someone other than patient.