IHS - NEW CANCER Patient Intake Form

This form will time-out after an extended period of time. Please dedicate the time to finish this form when you decide to start it.

Please answer ALL questions to the best of your ability.

The more information IHS has for your file, the better.
IHS New CANCER Patient Questionnaire

At IHS we get to the root cause of illnesses!
Date

MonthDayYear
Submit Your Photo

Upload a File
Patient's Photo Cancelof
Patient's Full Name*

First NameMiddle NameLast Name
Prefferred Name
Birth Date*

MonthDayYear
Place of Birth*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent / Guardian's Name

First NameLast Name
Primary Contact Person (if different from the patient or patient is under 18):

First NameLast Name
USPS Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
UPS / FedEX Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Billing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you have an alternate address for Summer/Winter seasons?

YesNo
If Yes, please provide our office with the additional address and the timeframe to send products to this location:
Date(s) to send
Seasonal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Please understand that Integrated Health Solutions, LLC communicates extensively through email. Keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed.
Email*
Be sure that the email address you are providing is one you check regularly.

Mark clientservices@ihsvt.com and quickbooks@notification.intuit.com as "Safe Senders". You will receive office documentation and correspondance, recommended supplement schedules, as well as account invoices or statements to the email address provided.
Please select your preferred communication method (if you have one): (this will not eliminate emails with invoices or documentation as mentioned above)

EmailPhone CallText"Snail" MailOther
Primary Physician
Name
Office
Primary Dr. Office
Referred By
Existing Patient's Name(s)
Related To
Existing Patient's Name(s)
Oncology Information:

Tell us a bit about your diagnosis
When was your cancer diagnosed?

MonthDayYear
Type of Cancer:
Location of Cancer:
Have you had surgery as a result of your cancer diagnosis?

YesNo
Please describe

Do you have a history of any of the following?

	Black Fan	Falcone	Pernicious	Other	N/A
Select all that apply

Please Describe "Other":
Have you had a stem cell transplant?

YesNoOther
Do you have dietary restrictions?

YesNo
Please describe
Dietary Restrictions - Cancer
Have you had seizures as a result from cancer?

YesNo
Did you have seizures prior to your cancer diagnosis?

YesNoN/A
Top 3 Complaints:
#1*
Please describe complaint #1 as best you can:
How many months have you been experiencing this?
Duration in Months
#2
Please describe complaint #2 as best you can:
How many months have you been experiencing this?
Duration in Months
#3
Please describe complaint #3 as best you can:
How many months have you been experiencing this?
Duration in Months
Do you have other health issues/concerns that you would like Dr. Debbie to address?
Additional Health Concerns
Typically, Integrated Health Solutions, LLC likes to inform patients that for every 12 Months that one has a specific health issue, it could take up to 6 Months (if not longer) to start making significant progress against the said health issue. The body does not like change.

If you have multiple health issues currently, it could take a considerable amount of time to balance your body to achieve proper function. Please stay patient, and continue to Pray.
Can you recall the last time you really felt well?
Previous lab results, bloodwork, CT scans, MRI's... etc... are helpful to have in your file. Please scan/email to clientservices@ihsvt.com, fax (1-802-433-4260), or upload the documents here.
Lab Reports / Blood Work / Medication List(s) / Medical Reports

Upload a File
OR send them via email Cancelof
If you are unable to upload a list, please provide a list of current medications, supplements, OTC, etc... that you are taking.
It is our belief that genetics play a role in health.

We encourage all of our patients to purchase a $99 "Ancestry Kit" from www.23andme.com

Dr. Debbie will gladly profile out your genes, and provide you with health implications as well as recommended supplements which will help bypass specific gene defects.
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(Additional charges will apply to this service)
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Are you interested in Genetic Profiling? (additional fees will apply)
Bio-Feedback Information
Height*
Weight*
Personal Stress Level (1=No Stress, 10=Stressed to the MAX)*
Pick a number 1-10
Additional information regarding stress:
Additional Information
How many organs have you had removed?*
Which organs & when?
Organ & Date of Removal
Are you a smoker?*

YesNoN/A
If Yes... How many a day?
Daily Cigarettes
Do you have silver fillings?*

YesNoN/A
If Yes... How many?
# of Silver Fillings
Known allergies (food, drug, environment, etc...)
Known Allergies
Lifestyle
What is your primary occupation?

I am unable to work at this time [due to my age]I am unable to work at this time [due to my health issues]Other
Occupation (cont.)
Please describe your work-hours, your personal work ethic, any work-related stressors...etc
Do you have any restrictions on your diet?

YesNo
If Yes, please describe:
Diet Restrictions (religion, health, etc...)
Please note any additional comments about your nutrition/eating habits:
Additional Information
How many sugary products do you eat each day? (desserts, snacks, candy, etc...)
Quantity & Product(s)

Please let us know when you typically eat

	Snack	Small Meal	Large Meal	Grazing
4AM-8AM
8AM-10AM
10AM-2PM
2PM-4PM
4PM-8PM
8PM-4AM

Please indicate your water or juice consumption and frequency

	# per Day	# per Week	# per Month	# per Year
Water
Juice
Other

Do you exercise?*

YesNoN/A

Please indicate the type of exercise you are currently engaging in

	# Days per Week	Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other

Note any problems that may limit your physical activity:
Do you drink alcohol?*

YesNoN/A

Please indicate the type of alcohol consumption and frequency

	# per Day	# per Week	# per Month	# per Year
Beer
Cider
Wine
Spirits
Other

Do you consume caffeine?*

YesNoN/A

Please indicate your caffeine consumption and frequency

	# per Day	# per Week	# per Month	# per Year
Coffee
Tea
Soda
Energy Drinks
Chocolate
Decaf
Other

In the last year have you had any of the following procedures?*

	X-Ray	MRI	CT Scan	PET Scan	Surgery	Other	N/A
Select all that apply

Please Describe "Other":

In the last year have you been exposed to: ?*

	Chemicals	Insecticides	Other	N/A
Select all that apply

Please Describe "Other":

Have you had any major injuries in the past?*

	Broken Bones	Car Accident	Serious Fall	Dislocation of Joints	Tendon/Ligament Tears	Other	N/A
Select all that apply

Please Describe "Other":

Have you had any major infections in the past?*

	Staff	MRSA	Strep	Any Recurring Infection	Other	N/A
Select all that apply

Please Describe "Other":
Please select your blood type (if you know it):

O NegativeO PositiveA NegativeA PositiveB NegativeB PositiveAB NegativeAB Positive
Do you sleep well?

YesNo
Additional Explanation:
Do you have a hard time falling asleep?

YesNo
Additional Explanation:
Do you have a hard time staying asleep?

YesNo
If Yes, how many times do you wake up each night?
On average, how many hours of sleep do you get each night?
How would you rate the overall quality of your sleep? (1-Terrible, 10-Excellent)
Sleep Quality
Additional Explanation:
Do you feel rested in the morning?

YesNo
Additional Explanation:
Are you often tired or fatigued?

YesNo
Additional Explanation:
Are you irritable?

YesNo
Additional Explanation:
Have you ever experienced depression / anxiety?

YesNo
Additional Explanation:
If Yes, have you taken medication(s) for depression / anxiety?
If yes, are you currently taking medication(s) for depression / anxiety?

YesNoN/A
To your knowledge, do you have any issues with blood pressure?

YesNo
Additional Explanation:
If Yes, have you taken medication(s) for blood pressure?
If yes, are you currently taking medication(s) for your blood pressure?

YesNoN/A
To your knowledge, do you have any issues with your cholesterol?

YesNo
Additional Explanation:
If Yes, have you taken medication(s) for cholesterol?
If yes, are you currently taking medication(s) for your cholesterol?

YesNoN/A
Do you experience joint pain?

YesNo
If Yes, how severe is the pain? (1=no pain, 10=excruciating pain)
Additional Explanation:
Do you experience muscle pain?

YesNo
If Yes, is the pain

DullSharpOther
If Yes, how severe is the pain? (1=no pain, 10=excruciating pain)
Additional Explanation:
Do you experience headaches?

YesNo
If Yes, where are they typically located (on/in your head)?
How many bowel movements do you have each day?*
Additional details regarding bowels:
Additional details

Do you have a history of any of the following?*

	Irritable Bowel Syndrome (IBS)	Diverticulitis	Crohn's Disease	Other	N/A
Select all that apply

Please Describe "Other":

Do you experience any of the following?*

	Indigestion	Bloating	Gas	Belching	Reflux	Other	N/A
Select all that apply

Please Describe "Other":

Please provide any pertinent diagnoses:

	Type of Diagnosis	Date of Diagnosis
Diagnosis #1
Diagnosis #2
Diagnosis #3

In order to improve your health, how willing are you to do the following:*

	Very Willing	Moderately Willing	Neutral	Moderately Unwilling	Not willing	N/A
Have regular bio-feedback scans to assess progress (Service fee for each scan)
Take nutritional supplements each day
Modify your diet
Keep a food diary, if necessary
Modify your lifestyle (work demands, sleep habits, exercise)
Engage in regular exercise/physical activity

In order to improve your health, how aggressive would you like your protocol to be?*

AggressiveModerately AggressiveNon-Aggressive
Initial MSQ (Medical Symptoms Questionnaire)

Rate each of the following symptoms based on your typical health profile for the last 2 weeks.
Select ALL that apply based on your typical health profile for the last 2 weeks.

HeadachesFaintnessDizzinessInsomniaWatery/ Itchy EyesSwollen/ Red/Sticky EyelidsBags/ Dark Circles under EyesBlurred/ Tunnel VisionItchy EarsEaraches/ Ear InfectionsDrainage in EarsRinging/ Hearing LossStuffy NoseSinus IssuesHay FeverSneezing AttacksExcessive MucusChronic CoughingGagging/ Frequent need to Clear ThroatSore Throat/ Hoarseness/ Loss of VoiceSwollen/Discolored Tongue, Gums, or LipsCanker SoresAcneHives/ Rashes/ Dry SkinHair LossFlushing/ Hot FlashesExcessive SweatingIrregular/ Skipped HeartbeatRapid/ Pounding HeartChest PainChest CongestionAsthma/ BronchitisShortness of BreathDifficulty BreathingNausea/ VomitingDiarrheaConstipationBloatingBelching/ Passing GasHeartburnRefluxIntestinal/ Stomach PainPain/Aches in JointsArthritisStiffness/ Limitation of MovementPain/Aches in MusclesFeeling of Weakness/ TirednessBinge Eating/ DrinkingCraving Certain FoodsExcessive WeightCompulsive EatingWater RetentionUnderweightFatigue/ SluggishnessApathy/ LethargyHyperactivityRestlessnessPoor MemoryConfusion/ Poor ComprehensionPoor ConcentrationPoor Physical CoordinationDifficulty Making DecisionsStuttering/ StammeringSlurred SpeechLearning DisabilitiesMood SwingsAnxiety/ Fear/ NervousnessAnger/ Irritability/ AgressivenessDepressionFrequent IllnessFrequent/ Urgent UrinationGenital Itch/ DischargeOther
Legal Documentation
COMMUNICATION / SCHEDULES
Integrated Health Solutions, LLC recognizes that is can be difficult to notify our office with regular health updates, however, we rely heavily on them to give you the best quality care possible.

Our office staff tries their best to reach out to our patients regularly via email or phone. Please keep in mind that our patient load is quite large, so if you don't hear from us, it's not because you're not on our hearts. You are welcome to email or call our office at any time.

I understand and accept that I may be added to an online mailing list to receive office updates. I understand that I can unsubscribe from this mailing list at any time.

Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. By signing below, I am giving my consent to communicate via email.

Our bio-feedback schedule is important for us to keep, so that we can stay focused on your health. The scan is our biggest tool to really inform Dr. Debbie about what is going on within. More often than not, we are questioned about how the scan works. It is difficult for most people to comprehend, however, the bio-feedback machine works in the realm of quantum entanglement (quantum physics).

I understand that I need to notify Integrated Health Solutions, LLC about how I am doing on my recommended protocol, regularly. I also understand that Dr. Debbie prefers to have an update prior to doing follow-up bio-feedback scans.

I know that Integrated Health Solutions, LLC cares about my health, and I can reach out to them via email or phone at any time.
NOTICE OF PRIVACY PRACTICES
Integrated Health Solutions, LLC is committed to providing you with high quality health care and to forming a relationship with you that is built on trust. This means respecting the privacy and confidentiality of your medical information. Any violation of confidentiality or the failure of an employee to protect your information from accidental or unauthorized access will not be tolerated. Corrective action will be taken and may result in the employee being terminated.

We will not allow others outside of Integrated Health Solutions, LLC to access your medical information unless we have the appropriate authorization to do so, or are required to do so by law. In most circumstances we will request your authorization to release personal health information. There are certain circumstances under which we may use or disclose identifiable health information about you without your authorization.

We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided at the end of this notice. We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

Our policies may change at any time and without notice. Before we make any significant changes, we will notify our clients in a Newsletter. You can request a copy of the change(s) at that time.

I understand that Integrated Health Solutions, LLC is committed to keeping my healthcare information confidential, unless they are required to release it by law.
NOTICE OF DISCLOSURE
Integrated Health Solutions, LLC does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than one who is licensed health practitioner to state that any product might cure any disease, disorder, or condition.

Dr. Debbie Alsheimer consults and gives recommendations based on her knowledge of genetics, functional medicine, Chinese medicine, and bio-feedback technology. She works with her patients to develop function and balance within the body by detecting and correcting deficiencies and stresses.

It is understood that Dr. Debbie is not a licensed medical practitioner. She does have a doctorate degree through Parker University. To view her credentials, please visit her website: www.ihsvt.com

I agree not to hold Dr. Debbie, her staff, and Integrated Health Solutions, LLC liable for consequences that may result from nutritional recommendations, supplementation, or bio-feedback treatments administered from this office.

I authorize Dr. Debbie Alsheimer to assist me in my healthcare endeavors. This may include, but is not limited to the use of bio-feedback scanning which uses long-distance technology (quantum entanglement), and/or the use of dietary supplementation.

I authorize Integrated Health Solutions, LLC to use my provided healthcare information, as well as information derived from this office to create a clinical case study, if desired.
PAYMENT PROCESSES
Integrated Health Solutions, LLC does not accept insurances. All services must be paid for prior to, or at the time of service. All products must be paid for prior to the order being processed.

I understand that Integrated Health Solutions, LLC does not accept insurance, and that I am legally responsible for all charges associated with services provided.

*Some patients have been able to pay for products and/or services with a HSA/FSA-type card. Integrated Health Solutions, LLC does not take any responsibility in understanding the patient's terms and conditions regarding the use of these types of cards*

I understand that Integrated Health Solutions, LLC will not send me products until the invoice is paid in full.

I agree to pay in-full for any products or services rendered by Integrated Health Solutions, LLC.

I understand that a payment not received within 15 days of the invoice being sent will be subject to a late payment penalty.

If I choose to provide Integrated Health Solutions, LLC with a CC to hold on file, I authorize them to run the card after a service has been rendered. They are to send me an invoice showing the paid status.

If I do not choose to provide Integrated Health Solutions, LLC with a CC to hold on file, I will make a timely payment through the quickbooks online invoice.

In the event of non-payment, I understand non-payment can be reported to credit reporting agencies and I agree to pay all reasonable costs of collection, including attorney's fees.
RETURNS / REFUNDS / EXCHANGES
RETURNS

Integrated Health Solutions, LLC will do it's best to accommodate product returns from patients. Each return will be applied to the patient's account as a CREDIT; cash refund or credit card refunds will not occur. Integrated Health Solutions, LLC will accept all returns up to 30-days following a product purchase. Integrated Health Solutions, LLC is not required to accept returns after 30-days' time. Products returned for credit as follows:

Unopened, unexpired products -- 100% refund

Expired products -- 0 % refund

Opened, unexpired products -- 40% refund

Opened, unexpired products with less than 1/2 bottle/container -- 0 % refund

Patient assumes all costs for return shipping. Shipping costs are non-refundable. We recommend sending packages with trackable service with insurance. If sending a package to Integrated Health Solutions, LLC via:

USPS -- PO BOX 262, Northfield, VT 05663

UPS / FedEX -- 310 N. Main St., Northfield, VT 05663

REFUNDS / CREDITS

Refunds and/or credits will be applied to the patient's account upon receipt of the returned product(s). Product must be received in non-damaged condition.

There are no refunds for services rendered at any time. Service costs are non-refundable.

EXCHANGES

Integrated Health Solutions, LLC will exchange/replace an item if it is received in damaged or defective condition. Please be ready to show proof of the product(s) condition(s). Contact Integrated Health Solutions, LLC immediately upon receipt of a damaged product so we can take care of it ASAP. *Time to resolve may vary*
INFORMED CONSENT
I am solely responsible for the decision to see Dr. Debra Alsheimer (Dr. Debbie) for Alternative Medicine care. My choice has been voluntary and I understand that I may terminate my treatment at any time. I recognize that some recommendations may not prove to be successful, and that it may take a significant amount of time to restore function in my body. I understand that by not following the recommended supplement schedule provided by Integrated Health Solutions, LLC, I may not see optimal results. I agree to participate in an active manner, to monitor my progress, and report any concerns to Dr. Debbie Alsheimer or her staff.

I also understand that any significant symptoms should be reported to my primary doctor or oncologist. It is also recommended that I discuss the use of any nutritional supplements with my doctor before implementing.
SIGNATURE
I fully understand and have read all the above legal documentation. By signing below, I accept all terms and conditions set forth by Integrated Health Solutions, LLC in regards to becoming a patient of theirs.
Clear
Patient / Guardian Signature & Date
Patient / Guardian Name Printed*

First NameLast Name
By signing and/or printing above, I am committing to becoming a new patient of Integrated Health Solutions, LLC.

I understand that once my paperwork is received, Integrated Health Solutions, LLC will get me on Dr. Debbie's schedule for an initial workup, only after I have paid my new patient fee.
We are so pleased to be working for you to help you achieve better health!

Blessings to you!

(Be sure to hit the "Submit" button so that IHS receives your documentation, you will get a confirmation email if it has been submitted properly)
By submitting this form I am commiting to becoming a patient of Integrated Health Solutions, LLC.

I understand that I will not be placed on Dr. Debbie's schedule for an initial workup scan until my new patient fee has been paid.
Should be Empty:

IHS New CANCER Patient Questionnaire

Oncology Information:

Bio-Feedback Information

Lifestyle

Initial MSQ (Medical Symptoms Questionnaire)

Legal Documentation