New Patient Intake Form

Judith Boice N.D., L.Ac., FABNO

Seven Winds Institute, Inc.

586 SW 4th St.

Madras, OR 97741



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)





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:

  1. We accept checks (received before the time of the phone consultation).


  1. We accept Visa, Master Card, and Discover


  1. 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:





Name                                                                                     Date                               

Age                          Date of Birth                                         Gender   F       M           


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                                                                                                         




What are your most important health problems that you are seeking treatment for?

List as many as you can in order of importance.











NAME_________________________________________________DATE  ____________________________


What is your major concern? ________­­__________________________________________________________



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.


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:
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
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
muscle wasting
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



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

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




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: