Patient Confidential Information · [email protected] 4336 -11th Avenue, Los Angeles, CA...

BodyMindRevolution

Michele Lamarche, L.Ac. 310 422-1692 2001 S. Barrington Ave., Suite 212, LA, CA 90025 [email protected] 4336 -11th Avenue, Los Angeles, CA 90008

Patient Confidential Information Name:______________________________________________________________________________________________ First Middle Last

Address:_______________________________________________________________________________________________ Street City State Zip

Telephone:Home____________________Cell_____________________Business_______________________

Email:_________________________________________Gender:MFMaritalStatus:SMDW Age:____DateofBirth:____/_____/________ PlaceofBirth:_______________________DriversLicense#:__________________

Month Day Year

Insurance&#:________________________________________Occupation:___________________Employer:_______________________Incaseofemergencycall:____________________________________________________________________________________________________ Name Relation Phone(s) Email

FinancialAgreement:ASSIGNMENTANDRELEASE:IauthorizepaymentofbenefitsbemadedirectlytothishealthcareproviderandIunderstandthattheservice(s)listedabovemayormaynotbecoveredbymyinsurance,andthatIwillberesponsibleforanyandallchargesrelatedtotheservice(s)shown.

DATE:_____________NAME:_________________________________SIGNATURE:________________________________________CancellationpolicyOutofconsiderationforotherpatients,ourcancellationpolicyrequiresaminimum24hoursnotice.Notproviding24hoursnotice,notshowing,orbeingmorethan30minuteslatewithoutinformingusobligatesustochargeyouraccountatastandardfeeforthecostofthetreatmentmissed.Complianceallowsustobetterserveyouandotherpatients.Thankyouforyourunderstanding.

DATE:_____________NAME:_________________________________SIGNATURE:________________________________________

Indicatecondition’sseverityonascaleof1to10(where1issymptom-freeand10issevere):Strikeamark:1_____________________________________________________________________10

PresentComplaint:

Whatisyour#1chiefcomplaint?

Whendidthisconditionbegin?

Whattreatmenthaveyoualreadyreceived?

Whatexacerbatesandwhatalleviatesthecondition?

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InformedConsenttoNutritionandOrientalMedicine

PrintPatient’sName______________________________________________________

Iherebyrequestandconsenttotheperformanceofprocedureswhicharewithinthescopeofpracticeofacupunctureandorientalmedicineincluding,butnotlimitedto,acupuncture,moxabustion,cupping,electro-acupuncture,herbology,nutrition,diagnosis,IASISNeurofeedback,andvariousmodesofphysiotherapy,onme(oronthepatientnamedabove,forwhomIamlegallyresponsible),bytheacupuncturist(s)namedbelow.

Ihavehadanopportunitytodiscusswiththeacupuncturistnamedbelowand/orwithotherofficeorclinicpersonnelthenatureandpurposeofacupuncture,moxabustion,cupping,electro-acupuncture,herbology,nutrition,physiotherapyandotherprocedures(includingLENSneurofeedback).Iunderstandthatresultsarenotguaranteed.

Iunderstandandaminformedthattherearesomeriskstoacupunctureandorientalmedicinetreatment,including,butnotlimitedto,slightbruising,tinglingneartheneedlingsitesthatlastafewdays,nausea,infection,andblisters.Therehavebeenreportsoffaintingandscarring.Therehavebeeninstancesreportedofspontaneousmiscarriageandpneumothorax.Iunderstandthatsomeherbsmaybeinappropriateduringpregnancy.IfIsuspectIampregnant,Iwillimmediatelyinformtheacupuncturist.IfIexperienceanygastrointestinalupsetorallergicreactionstotheherbs,Iwillinformtheacupuncturist.

Idonotexpecttheacupuncturisttobeabletoanticipateandexplainallrisksandcomplications,andIwishtorelyontheacupuncturisttoexercisejudgmentduringthecourseoftheprocedurewhichtheacupuncturistfeelsatthetime,baseduponthefactsthenknown,isinmybestinterest.

Ihaveread,orhavehadreadtome,theaboveconsent.Ihavealsohadanopportunitytoaskquestionsaboutitscontent,andbysigningbelowIagreetotheabove-namedprocedures.Iintendthisconsentformtocovertheentirecourseoftreatmentformypresentconditionandforanyfuturecondition(s)forwhichIseektreatment.

_________________________________________ ____________________________________________________

SignatureofPatient/Representative PrintNameofPatient’sRepresentative Date

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1.Haveyouhadanysurgeries?Ifso,whatwerethesurgeriesandwhendidyouhavethem?2.Haveyounoticedanylongtermeffectsfromthesurgeries?3.Haveyouhadseriousinjuriesorillness,ifsowhen?Haveyounoticedlongtermhealthchanges?4.Doyouhaveanyallergies(tomedicationorenvironment)?Pleasenotewhich,andwhentheybegan:5.Whenwasthedateofyourlastphysical?______Werethereabnormalities?Pleaseexplain.6.Doyouhaveahistoryofantibioticuse?Pleaseexplain.7.Whatmedicationsandwhatdosesareyouusing?8.Whatsupplements,vitaminsorherbsdoyoutake?

Lifestyle:Howmuchexercisedoyougetweekly?Whattypesandforhowlong?Whatintensity?Howmuchdoyousleepdaily?Isitrestful?Doyouhaveanydifficultiesfallingorstayingasleep?Briefly,whatisyourdietlike?

ForWomenOnly:Age of first period:_______ Lengthofcycle,day1today1:______Lengthofflow:______Dateoflastperiod:________

Anyvaginaldischarge?______Dateoflastgynecologicalcheckup:______Areyouonthepill?_____

Doyouhaveahistoryofanyofthefollowing?o Menstrualcramps o Breastpaino Menstrualbloodclotso Breastcystso Excessivebleeding o Ovariancystso PMSo Emotionalchangeswperiodo Breastswelling/tendernesso Irregularcycle o Hotflashes

o Watergain o Vaginalyeastinfectionso Abnormalpapsmearo Endometriosiso Infertilityo Historyofhormonetherapyo Problemgettingpregnanto Problemscarryingtotermo Pregnancyo Questionsregardingfertilityo Menopause/Perimenopause

Atwhatagedidyourmotherentermenopause?Pregnancyhistory:Livebirth(s)____ Miscarriage(s)____ Terminatedpregnancy(ies)____MethodofBirthingused:o hospital,o birthingcenter,o athome,o vaginaldelivery,o cesaerianWhatwas/wereyourbirthingexperience(s):howlongdidyoulabor____________,Didyouuseepidural/othersedation,ornot?_____Doyoubelieveyouarepregnantorthatthereisanypossibility?_____

ForMenOnly:UrologicalHistoryo Prematureejaculationo Questionsre-virility o Impotence/ErectileIssueo ViagraUseo Prostateproblemso Slowurinationstream

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Past Medical History

Illness Timing Specifics plus what happened, did it resolve? Chicken Pox o Current o Past

German Measles o Current o Past

Measles o Current o Past

Mumps o Current o Past

Polio o Current o Past

Anemia o Current o Past

Diabetes/Insulin Resistance o Current o Past

Hypoglycemia o Current o Past

Gallstones o Current o Past

Arthritis o Current o Past

Gout o Current o Past

Hepatitis o Current o Past

High blood pressure o Current o Past

Liver disease o Current o Past

Kidney stones/disease o Current o Past

Jaundice o Current o Past

Gallbladder removal o Current o Past

Hernia o Current o Past

Hemorrhoids o Current o Past

Sinusitis o Current o Past

Sleep apnea o Current o Past

Thyroid disease o Current o Past

Loss of voice or hoarseness o Current o Past

Epilepsy, convulsions o Current o Past

Head Injury o Current o Past

Neck Injury o Current o Past

Back Injury o Current o Past

Fracture o Current o Past

History of tobacco use o Current o Past

History of alcohol use o Current o Past

History of recreational drug use o Current o Past

Frequent colds o Current o Past

Nausea/vomiting o Current o Past

HIV/ AIDS o Current o Past

STDs o Current o Past

Cold Sores o Current o Past

Genital Herpes o Current o Past

Epstein Barr/Mononucleosis o Current o Past

Chronic Fatigue o Current o Past

BodyMindRevolution


Past Medical History

Illness Timing Specifics plus what happened, did it resolve?

Fibromylagia o Current o Past

Asthma o Current o Past

Pneumonia o Current o Past

Bronchitis o Current o Past

Whooping cough o Current o Past

Emphysema o Current o Past

Tuberculosis o Current o Past

Bloating after meals o Current o Past

Indigestion o Current o Past

Acid Reflux o Current o Past

Crohn’s/Colitis/ Diverticulitis/IBS o Current o Past

H-Pylori/GI Infection/Parasite o Current o Past

Peptic Ulcer o Current o Past

Cancer o Current o Past

Insomnia o Current o Past

Change in appetite or thirst o Current o Past

Abnormal weight loss or gain o Current o Past

Abnormal sweating o Current o Past

Heart disease o Current o Past

Heart attack/Angina o Current o Past

Heart failure o Current o Past

Rheumatic fever o Current o Past

Stroke o Current o Past

Other (describe) o Current o Past

o Current o Past

o Current o Past

o Current o Past

BodyMindRevolution


BodyMindRevolution


© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________

PART I

Please list your 5 major health concerns in order of importance:

1. ____________________________________________ 4. ___________________________________________ 2. ____________________________________________ 5. ___________________________________________3. ____________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Formtm

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently

Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats; undigested food found in stools

Category VStomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 3

Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipationIncreased gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

Category VIII Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?

Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat

Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision

Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

BodyMindRevolution


© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Category XII Cannot stay asleep

Crave salt

Slow starter in the morning

Afternoon fatigue

Dizziness when standing up quickly

Afternoon headaches

Headaches with exertion or stress

Weak nails

Category XIIICannot fall asleep

Perspire easily

Under a high amount of stress

Weight gain when under stress

Wake up tired even after 6 or more hours of sleep

Excessive perspiration or perspiration with little

or no activity

Category XIV Edema and swelling in ankles and wrists

Muscle cramping

Poor muscle endurance

Frequent urination

Frequent thirst

Crave salt

Abnormal sweating from minimal activity

Alteration in bowel regularity

Inability to hold breath for long periods

Shallow, rapid breathing

Category XVTired/sluggish

Feel cold―hands, feet, all overRequire excessive amounts of sleep to function properly

Increase in weight even with low-calorie diet

Gain weight easily

Difficult, infrequent bowel movementsDepression/lack of motivation

Morning headaches that wear off as the day progresses

Outer third of eyebrow thins

Thinning of hair on scalp, face, or genitals, or excessive

hair loss

Dryness of skin and/or scalp

Mental sluggishness

Category XVIHeart palpitations

Inward trembling

Increased pulse even at rest

Nervous and emotional

Insomnia

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Category XVI (Cont.) Night sweats

Difficulty gaining weight

Category XVII (Males Only)Urination difficulty or dribblingFrequent urination

Pain inside of legs or heels

Feeling of incomplete bowel emptying

Leg twitching at night

Category XVIII (Males Only)Decreased libido

Decreased number of spontaneous morning erections

Decreased fullness of erections

Difficulty maintaining morning erectionsSpells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decreased physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

Category XIX (Menstruating Females Only)Perimenopausal

Alternating menstrual cycle lengths

Extended menstrual cycle (greater than 32 days)

Shortened menstrual cycle (less than 24 days)

Pain and cramping during periods

Scanty blood flowHeavy blood flowBreast pain and swelling during menses

Pelvic pain during menses

Irritable and depressed during menses

Acne

Facial hair growth

Hair loss/thinning

Category XX (Menopausal Females Only)How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Hot flashesMental fogginess

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness, or itching

PART IIIHow many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?How many times do you work out per week?

BodyMindRevolution


Notice of Privacy Practices For Patients (HIPPA) The privacy of your medical information is important to us and we are committed to protecting it. This notice describes how information about you may be used and disclosed, as well as, how you can get access to this information. Please read this information carefully. Disclosure of your protected health information without authorization is strictly limited to defined situations. These emergency care, quality assurance activities, payment, public health, research and law enforcement activities. Any other disclosures for the purposes of treatment, or practice operations will be made only after obtaining your consent. You may request restrictions on disclosures. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment. You may inspect and receive copies of your records within 30 days of a written request to do so. There may be a reasonable cost-based fee for photocopying, postage and preparation. You may request changes to your records. Our practice has the right to accept or deny your request. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. Our practice is required to abide by this notice. We have the right to change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law. We have the right to make changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes. If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the information to file your complaint with the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint. Office for Civil Rights U.S. Department of Health and Human Services 50 United Nations Plaza - Room 322 San Francisco, CA 94102 415-437-8310 (VOICE); 415-437-8311 (TDD); 415-437-8329 (FAX) Contact Person Michèle Lamarche, L.Ac. 2001 S. Barrington Ave, Suite 212, Los Angeles, CA 90025 / 4336 11th Ave, Los Angeles, CA 90008 I, __________________________________ Hereby acknowledge receipt of the Notice of Privacy Practices given to me. Signed: _____________________________ Date: ___________________

Patient Confidential Information · [email protected] 4336 -11th Avenue, Los Angeles, CA...

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