Judith Boice N.D., L.Ac., FABNO
Seven Winds Institute, Inc.
586 SW 4th St.
Madras, OR 97741
541.475.2131
drjudith@drjudithboice.com
Welcome to the clinic! We have been looking forward to your visit. We offer the following information to help orient you to our clinic procedures. Please ask Dr. Boice if you have any questions.
Appointment scheduling: Our commitment is to assist you in fulfilling your vision of health. Your visit will include an extensive health history, a review of your current health, and lab tests (if necessary). During the first visit we will clarify your vision of health and then determine where you are now in relationship to your vision. At the end of the evaluation, you and Dr. Boice will decide on a course of care that usually includes a combination of educational materials, specific therapies, consultations, and then subsequent reevaluation.
These reassessments and re-examinations are crucial to evaluate your response to the prescribed program. The reassessments help Dr. Boice determine whether you need to make changes in your treatment plan to fulfill your vision of health. Remember that symptoms may resolve long before the underlying causes of disease have been completely eliminated. Instead of merely eliminating symptoms, our aim is to support you in creating health.
Appointment changes: We require a minimum of 24 hours notice to reschedule an appointment. For patients who neglect to reschedule 24 hours in advance, we charge 50% of the office visit fee.
Fees: Fees are due the day the service is provided. Payment can be made with credit card, check, or PayPal. Please see the attached financial policy agreement. Your cooperation is appreciated. We have found this policy to be most effective for both patients and providers. Outstanding balances can cause embarrassment and communication breakdowns, and potentially decrease adherence to the prescribed treatment program. If you foresee any financial challenges, be sure to address them with Dr. Boice prior to your initial consultation.
I understand the office policies as stated above, and I agree to fulfill my responsibilities as a patient as stated herein.
_____________________________________ _______________________________
Patient’s signature Date
Greetings, and welcome to the clinic! Please read the following important information, and then sign your name to confirm your understanding. Please ask Dr. Boice if you have any questions.
- Anything you discuss in the office will remain in the office. Test results are also confidential. The only exception is if you sign a consent form giving Dr. Boice permission to discuss your health and/or test results with another health care practitioner, family member, or friend.
- Boice charges $200.00 per hour (divided in 15-minute increments).
- For a listing of Dr. Boice’s educational and professional background, please see the attached vitae.
- You are free at any time to seek a second opinion or terminate your care with Dr. Boice.
- Boice maintains the following licenses and certifications:
- Acupuncture (NCCAOM, Oregon and Alaska state)
- Chinese Herbology (NCCAOM)
- Naturopathic Medicine (Oregon and Alaska state licensure), including nutrition, exercise therapeutics, botanical medicine, homeopathy, hydrotherapy, physical medicine.
- Fellow of the American Board of Naturopathic Oncology (FABNO, advanced clinical experience, training and passage of board exam in integrative oncology)
- International Board of Hypnotherapy
Dr. Boice works with a variety of treatment modalities including (but not limited to):
- Acupuncture
- Bio-identical hormones
- Bowen work
- Chinese and western herbs
- Clinical hypnotherapy
- Color therapy (Dinshah)
- Essential oils
- Flower essences
- Homeopathy
- Hydrotherapy
- Mindfulness training
- Nutritional supplements
- Qigong (Soaring Crane Qigong, Essence Qigong, Awakening Light Gong)
- Trigger point therapy
- Tuning fork therapy
I have read the information presented here.
________________________________________ _____________________________
(Signature) (Date)
FINANCIAL POLICY FOR PAYMENTS
Our goal is to provide professional, quality care at a reasonable cost to our patients. To help us minimize costs and pass those savings on to you, we need you to be aware of the following policies.
Payment is due at the time of service. We have several ways of helping you meet this requirement:
- We accept checks (received before the time of the phone consultation).
- We accept Visa, Master Card, and Discover
- We accept cash
____________________________________ _______________________________
Patient Date
BIOGRAPHY: Judith L Boice. N.D.. LAc., FABNO
Dr. Judith Boice is a naturopathic physician, acupuncturist, Fellow of the American Board of Naturopathic Oncology (FABNO), award-winning author, and international teacher. Her mission is to help people know what being healthy is for them so they can focus on what is most important, whether that is riding bikes with their grandchildren, running three Iron Man competitions a year, or overcoming cancer. Dr. Boice consults with private patients, writes books, and offers trainings that teach people with chronic illness how to increase their energy, reduce symptoms and reverse disease by restoring their health with natural medicines. She believes the health of Earth, body and spirit are completely interdependent.
Dr. Boice has traveled around the U.S. conducting over 1000 trainings and public lectures to educate about women’s health, bio-identical hormones, thyroid, oncology, qigong, and natural medicines (herbs, essential oils, homeopathy and flower essences).
Dr. Boice has been in practice for over 23 years. She was honored to work for 3.5 years with late stage cancer patients at the Southwestern Regional Medical Center of Cancer Treatment Centers of America. For over a decade she served 5000 patients on Colorado’s western slope. Currently she lives and works in Madras, Oregon.
Dr. Boice is the author of several magazine articles and ten books, including The Green Medicine Chest: Healthy Treasures for the Whole Family. Dr. Boice is listed in Who’s Who in America. A Phi Beta Kappa graduate of Oberlin College, she has lived and traveled around the world, fostering an understanding and respect for many cultures and traditions.
You can find more information about Dr. Boice, her books, naturopathic medicine and acupuncture on her website: www.drjudithboice.com.
Name Date
Age Date of Birth Gender F M
Address
City State Zip Code
Telephone # Home # Work # Cell
Privacy: May we leave messages on your voice mail? Yes No
If yes, which phones?
Email Address
Do want to receive E-letters (health tips and updates about the clinic?) Yes No
Occupation Employer
Hours worked per week Retired Y N Date
Single Married Partnership Separated Divorced Widowed
Live with: Alone Spouse Partner Parents Children Friends
Source of Referral
PLEASE FILL OUT EACH PAGE
What are your most important health problems that you are seeking treatment for?
List as many as you can in order of importance.
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SYMPTOM SURVEY
NAME_________________________________________________DATE ____________________________
What is your major concern? __________________________________________________________________
__________________________________________________________________________________________
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This survey will help us to evaluate you more completely. Please place a check mark next to those symptoms which you NOW experience or have experienced in the PAST. Include all the complaints which are familiar to you. If there are one or more words in a line which describe your specific issue you may want to circle those words.
| Now | Past | GENERAL SYMPTOMS | Now | Past | EYES | |
| tired, weak, lack of energy | nearsightedness or farsightedness | |||||
| depression, melancholy, moodiness | blurred or failing vision | |||||
| worry, anxiety, irritability | dry, burning or itching eyes | |||||
| sleeplessness or sleep too much | eyes water excessively | |||||
| frequent colds or other illness | eyes sensitive to light | |||||
| headaches | night blindness | |||||
| don’t sweat enough | bloodshot or puffy eyes | |||||
| sweat too much | Other: | |||||
| night sweats | ||||||
| dizziness, fainting, convulsions | EARS | |||||
| loss or gain of weight | earaches | |||||
| Other: | noises or ringing in ears | |||||
| ear discharges | ||||||
| SKIN AND HAIR | loss of hearing | |||||
| acne or pimples | lots of wax | |||||
| skin rashes | Other: | |||||
| hives | ||||||
| stretch marks | NOSE AND THROAT | |||||
| skin ulcers or sores | hay fever, sinusitis, runny nose | |||||
| dryness, roughness or scaling skin, | dry mouth or nose | |||||
| scalp, elbows, knees, feet, | nosebleeds | |||||
| around nose, ears, eyebrows, etc. | cracks in corners of mouth | |||||
| hair loss or thinning | dry or chapped lips | |||||
| dry, coarse hair or split ends | sore throats or tonsillitis | |||||
| bruise easily | clear throat a lot | |||||
| nails weak, ridged or split easily | sore, red or cracked tongue | |||||
| brown spots or bronzing or skin | cold sores or herpes | |||||
| moles, warts or skin tags | inability to smell or taste | |||||
| sun burn easily | lots of cavities | |||||
| cuts heal slowly or scar badly | bleeding gums | |||||
| flush easily | hoarseness | |||||
| hands or feet numb or tingling | Other: | |||||
| feet burn | ||||||
| athletes foot | ||||||
| Other: | ||||||
| Now | Past | RESPIRATORY | Now | Past | MUSCULO-SKELETAL | |
| cough frequently | muscle pain or stiffness | |||||
| spitting up mucus or blood | Where? | |||||
| difficulty breathing | swollen, painful or stiff joints | |||||
| shortness of breath on exertion | bone pains | |||||
| chest pain | painful feet, ankles or calves | |||||
| Other: | tremors or twitches | |||||
| loss of strength | ||||||
| hernia | ||||||
| muscle wasting | ||||||
| Other: | ||||||
| Now | Past | GASTROINTESTINAL | Now | Past | CARDIOVASCULAR | |
| loss of appetite | heart beats fast or irregularly | |||||
| gagging | tightness in chest | |||||
| difficulty swallowing | discomfort at high altitude | |||||
| nausea or vomiting | dizzy or weak when stand up | |||||
| bad breath | swollen feet, ankles or legs | |||||
| metallic or bitter taste in mouth | cold hands or feet | |||||
| food cravings or strong desires | hands or feet turn blue | |||||
| can’t eat fats | blue fingernails | |||||
| heartburn | leg pains when walking | |||||
| indigestion or distress | varicose veins | |||||
| heaviness after eating | tendency to anemia | |||||
| gas or belching | high blood pressure | |||||
| bloating | low blood pressure | |||||
| stomach or abdomen tender or painful | Other: | |||||
| symptoms relieved by eating | ||||||
| symptoms worse after eating | URINARY | |||||
| avoid certain foods | difficulty urinating | |||||
| headache, dizziness or irritability | urinate frequently at night | |||||
| if skip meals | bedwetting | |||||
| diarrhea or loose stools | incomplete urination or dribbling | |||||
| constipation | pain when urinating | |||||
| change in bowel movements | bladder infections | |||||
| light colored or greasy stools | kidney infections | |||||
| dark stools | kidney stones | |||||
| blood in stool | lower back pain | |||||
| feeling of incomplete evacuation | Other: | |||||
| undigested food in stool | ||||||
| foul odor of stool or gas | MALE | |||||
| hemorrhoids | prostate problems | |||||
| Other: | difficult or unusual urination | |||||
| discomfort or pain in genital area | ||||||
| diminished or excessive sexual desire | ||||||
| difficulty maintaining an erection | ||||||
| Other: | ||||||
| Now | Past | FEMALE | Now | Past | FEMALE |
| irregular menstruation | difficulty having orgasm | ||||
| pain prior to or with periods | inability to conceive | ||||
| depressed, tense or irritable around periods | pain, discomfort or itching in genital area | ||||
| painful or swollen breasts | miscarriages or abortions | ||||
| lumps in breasts | vaginal discharge | ||||
| discharge from breasts | hot flashes | ||||
| symptoms occur in monthly pattern | Other: | ||||
| diminished or excessive sexual desire |
Date of last period_______________ #days___________ length of cycle_________________________
Date of last PAP smear_______________ Was it normal?_______________________________________
Type of birth control____________________________________________________________________
Have you ever used birth control pills or an IUD?_____________________________________________
What type and for how long______________________________________________________________
# Pregnancies______________ #Births_____________________________________________________
| Do you use any of the following? | Do you get regular exercise?
what how often |
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| cigarettes or tobacco | packs per day | ||||||||
| coffee or black tea | cups per day | ||||||||
| alcohol | drinks per week | ||||||||
| marijuana or other drugs | times per week | ||||||||
| Are you allergic to anything? Include food, medications, plants, pollens, insects, MSG, chemicals, etc. | |||||||||
| vitamins (please list below) | |||||||||
| herbs or food supplements (please list below) | |||||||||
| over the counter medications (list below) | Have you had the following vaccinations? | ||||||||
| diptheria | measles | ||||||||
| whooping cough | tetanus | ||||||||
| prescription medications (please list below) | typhoid | polio | |||||||
| typhus | smallpox | ||||||||
| mumps | other: | ||||||||
Have you ever been hospitalized or had a serious illness or accident?
what when where
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Have you or any of your family members had any of the problems in this chart? Please indicate who’s had which by checking the appropriate space.
Thank you for taking the time to fill out this questionnaire. For additional comments use the space below:
