IMPORTANT - PLEASE COMPLETE THE FORM BELOW AND SUBMIT IT ONLINE BEFORE YOUR APPOINTMENT.
REGULAR PHYSICAL EXERCISE?
HAVE YOU EVER BEEN DIAGNOSED WITH CANCER, A MASS OR TUMOR?
CONVENTIONAL TREATMENT HISTORY
CURRENT/RECENT HEALTH CARE PROVIDERS (Surgery, Oncology, Primary Care Providers, etc.)
ACCIDENTS/INJURIES (briefly describe):
Please include any of the following: alcoholism, high blood pressure, cancer, diabetes, heart disease, osteoporosis, other addiction or illness.
CAUSE OF DEATH
*M = Maternal *P = Paternal *GM = Grandmother *GF = Grandfather
PLEASE RATE THE FOLLOWING ON A SCALE OF 1 TO 10 (10 BEING THE BEST). AND WRITE IN ANY COMMENTS:
ANY GAS, BLOATING OR OTHER DISCOMFORT AFTER EATING?
DO YOU RELY ON ANY OF THE FOLLOWING FOR BOWEL ELIMINATION?
HOW DO YOU FEEL ABOUT THE FOLLOWING AREAS OF YOUR LIFE?
Please choose appropriate descriptions and make any comments you would like to.
PLEASE RATE YOUR STRESS LEVEL ON A SCALE OF 0 TO 10 (10 BEING THE MOST), AND WRITE IN ANY COMMENTS.
1. I WORRY A GREAT DEAL
2. I FEEL LONELY
3. I AM BORED WITH MY LIFE
4. I THINK A LOT ABOUT DYING
5. I HAVE PARTICULAR CONCERNS RELATING TO MY RELIGION
6. I FEEL FEARFUL OR AFRAID
7. I FEEL NERVOUS MOST OF THE TIME
8. I OFTEN FEEL DEPRESSED
9. I FEEL ANXIOUS OFTEN
10. I AM ILL FREQUENTLY
11. I SOMETIMES FEEL WEAK OR LIGHT-HEADED
12. I OFTEN HAVE PAINS IN MY SHOULDERS, NECK OR BACK
13. I OFTEN FEEL LIKE CRYING
14. I LOSE MY TEMPER MORE THAN I USED TO
15, OTHER PERSONAL CONCERNS
DIET AND NUTRITION
SAMPLE OF DAY'S MENU:
TO THE BEST OF YOUR KNOWLEDGE, HAVE YOU EVER BEEN EXPOSED TO PESTICIDES, TOXIC CHEMICALS, HEAVY METALS, RADIATION OR OTHER TOXINS BEYOND THOSE ENCOUNTERED IN DAILY LIFE?
CURRENT DIETARY SUPPLEMENTS & HERBS
(mg or IU, etc,)
Please list all prescriptions and over-the-counter medications you are currently using (except chemo and radiation)
WHAT IT'S FOR
FOR HOW LONG?
Medical history (for example, heart disease, diabetes, high blood pressure, high cholesterol, bowel problems, autoimmune disorders such as thyroid and musculoskeletal issues, such as arthritis). Please include those here:
DO YOU HAVE ANY PAIN(S)?
AREA OF PAIN
DESCRIPTION OF PAIN
(0 to 10)
FOR WOMEN ONLY!
Please complete this section to the best of your ability even if you no longer menstruate. It provides valuable information for an accurate assessment.
Mark the following: 1 - IF CURRENT, 2 - IF PAST
PLEASE SUBMIT THE NEW PATIENT INTAKE FORM
Here are the instructions for ordering:
1. Go to https://integrativetherapiesnaturalpharmacy.ehealthpro.com/
2. Create new account profile and password or Log in with your account information if you’ve already registered.
*Note* Option to register at time of checkout as well.
3. Once you’ve logged in shop and search for supplements, manage current and past orders or update account addresses and information.
4. For supplements you’d like to purchase, click on the product, adjust quantity and click “Add to Cart”
5. Free Ground Shipping.
6. Proceed to checkout on right hand side when ready and follow prompted instructions to complete your transaction.
Included but not limited to care of diabetes, high blood pressure, thyroid and adrenal problems, bone health, digestive disorders, irritable bowel and inflammatory bowel disease, cardiovascular disease, depression and anxiety, as well as sexual dysfunction in men and women.
A functional medicine approach, including evaluation of contributing imbalances with a functional medicine evaluation and approach to care which aims to heal the roots of these health issues with nutritional and herbal medicine approaches within a holistic framework.
Coaching and support is also offered on site.
Based in South Portland, Maine, Creative Transformations, LLC, was created as a response to the needs of individuals as they recover emotionally from a life threatening illness or injury. Stephanie is an art therapist, who has personal experience with battling breast cancer and caring for her mother who died from breast cancer, which has given her a deep passion for the complexity of healing one’s body, mind, spirit, and sense of self. Through Creative Transformations, she is offering an individual sessions package, offered in person or via the Internet, that guides participants in building a practice of healing through creativity and meditation.
Additionally, Creative Transformations offers workshops for cancer patients and/or their loved ones, plus a weekly blog on the process of treatment and recovery.
For more information, please visit our website, www.creative-transformations.com, which has links to our Facebook, Twitter and Instagram profiles. You may contact Stephanie via email: firstname.lastname@example.org or by phone (207) 939-4166.
A message from Mary Moskowitz, MS CHC
(Certified Integrative Health Coach)
I wanted to remind all of you that I am here to support you in anyway I can with your wellness goals.
It can be really frustrating and challenging to make all the dietary and lifestyle changes we suggest by yourself and we want you to get better and succeed!
Your symptoms and disease states don’t happen overnight. It takes patience and support to heal, as we work with you to discover what works and doesn’t work for your individual body and physiology.
Below is an update on how you can work with me. We will continue to offer an initial 60 minute office session with me and Colleen (covered by your insurance). After your first session I am offering all of Colleen’s patients ongoing, 45 minute phone sessions that you would schedule with me (see info. below).
I will also be sending you a monthly newsletter with helpful wellness tips and updates to keep you informed and motivated.
We love supporting you all in creating a healthier, happier more joyful life!
HEALTH COACHING SERVICES AT INTEGRATIVE THERAPIES
Why DO I Need a Health Coach?
As your health coach, Mary is your wellness guide and supportive mentor. Working with Mary Moskowitz MS CHC, our Integrative Health Coach, will give you a deeper understanding of the foods and lifestyle choices that work best for you.
She will guide you toward lasting changes that will improve your energy, balance and health.
It’s hard to do it alone!
Mary teaches the concept of bio-individuality which means that each person has her or his own food and lifestyle needs. So, when the experts say, “Dairy is good for you” or “Fat is unhealthy,” it doesn’t apply to everyone.
By embracing the principle of bio-individuality, she will support you in making positive changes that are based on your unique needs, lifestyle, personal preferences, and background. Mary believes that we are fed not only by food, but by other factors in our lives. Healthy relationships, a fulfilling career, regular physical activity and a spiritual practice are essential forms of nourishment.
Together we will explore balancing the primary foods in your life and supporting you towards lasting health and happiness.
To Get Started:
Book your first intake session with Mary and Colleen to go over your health history and treatment plan. This session is covered by insurance and available to all patients who are practice members.
Contact Carol at 699-3838 to set up your initial session.
Follow up Phone Sessions with Mary:
Call or email Mary at 776-9769 or email@example.com to get started and learn more about the follow up session options.
You deserve to be happy and feel your best- We are here to help you get there!!!
Primary care that emphasizes lifestyle counseling/coaching and the use of herbal and nutritional medicine for optimal wellness, healthier aging and less chronic disease, as well as a healthy body weight.
More time with your provider and access to your provider are emphasized.
Pharmaceuticals are de-emphasized—we work instead on improving nutrition, sleep, physical activity, and stress management.
Healing health issues paramount to the approach.
Functional medicine evaluation and approach to care (see www.functionalmedicine.org/).
Our goal as practitioners is to enhance oncology care by reducing side effects, enhancing the efficacy of chemotherapy, radiation or hormonal therapy, targeting mechanisms involved in multidrug resistance and radiation resistance and create an internal terrain or environment that is not conducive to cancer. This is an integrative approach to care which is highly individualized to the person and the type of cancer, working with you and your oncologist, and emphasizing nutrition as well as herbal and nutritional medicine which targets the cancer in a variety of ways. These therapies can dramatically improve your odds against cancer and reduce risk of cancer recurrence.
Integrative cancer care, using appropriately selected nutritional and herbal medicine, may help your conventional treatments to work better by taking away the “tools” cancer uses to resist conventional treatments and by fortifying the person against cancer. We encourage personalized chemotherapy when possible through tumor testing of various types which help us to know the best drugs to use in your situation.
We also work with patients who have completed conventional treatments and are looking to reduce their risk of recurrence utilizing a targeted approach specific to the patient and the type of cancer. Current research in the field of cancer is looking at ways to effect the environment and microenvironment of cancer – we have the ability to do this already with well-targeted treatment plans including nutritional and herbal medicine.
A Comprehensive Protocol: