Studio DEE Integrative Wellness
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- Katrina Hodges
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1 ractitioner Use Only Appt. Date & Time: Studio DEE Integrative Wellness 900 Airport Rd West Chester, A hone: info@studiodeewellness.com Website: AYUREDIC CONSULTATION INTAKE FORM Name Address Telephone Home Cell Work Birthdate Age: Marital partner/status # of children Ages Emergency contact name and number Occupation How did you hear about atriot Integrative Health? lease tell me why you have chosen to have an Ayurvedic consultation. WHAT YOU CAN EXECT FROM YOUR AYUREDIC HEALTH CARE Ayurveda is a natural healing system that has been successfully practiced for thousands of years. Originating in ancient India, this medical tradition states that each person s path toward optimal health is unique because each person is unique. The healing programs offered are based on effective, time-honored principles that focus on understanding your particular body-mind constitution and the unique nature of your imbalance. In Ayurveda, each individualized program formulated by the practitioner may include lifestyle adjustments, dietary changes, herbs, color therapy, sound therapy, aromatherapy, massage therapy, and other natural therapeutics. In order to successfully implement these Ayurvedic principles into your life, frequent regular follow-up visits are recommended over a six to twelve-month period. The goal of all Ayurvedic programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself. atient s Signature: Date: [Type text] [Type text] [Type text]
2 INFORMED CONSENT to authorize complimentary or alternative health care through atriot Integrative Health & Chiropractic All patients who participate in Ayurvedic Health Care through atriot Integrative Health should be advised of the following information: 1. atriot Integrative Health is not a medical practice. 2. ractitioners of atriot Integrative Health are not trained in Western Medicine diagnosis or treatment and may not make suggestions about altering your medical care. 3. In the State of ennsylvania, Ayurveda is a non-licensed profession. Its practice was formally legalized under the passage of Senate Bill 577 in January 2003 in the State of California. 4. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, atriot Integrative Health recommends that you receive a proper evaluation and may provide you with a referral form. If you are provided with a referral form, you are required to go or to sign an acknowledgment that one was recommended to you. 5. No one at atriot Integrative Health may recommend altering your prescription with the approval of your medical doctor. It may be suggested that you speak with your doctor about reducing medication when appropriate. 6. While your practitioner may take your blood pressure and vital signs, and perform some examination techniques similar to a routine medical examination, your practitioner is evaluating these findings from an Ayurvedic perspective only and not from a Western medical perspective. This examination does not take the place of a medical evaluation. If, as a result of the examination, any findings suggestive of a possible medical imbalance are found, your practitioner will refer you to a medical doctor for further examination. 7. Deidre erson owner and practitioner at atriot Integrative Health, is certified as an Ayurvedic Health ractitioner and Educator trained at California College of Ayurveda. California College of Ayurveda operates with the approval of the state of California, and exceeds the educational guidelines of the National Ayurvedic Medical Association (NAMA) and the California Association of Ayurvedic Medicine (CAAM). She is also a Certified Yoga Therapist, Certified Meditation Instructor, a Certified ersonal Fitness Trainer and has been an avid practitioner of yoga since In addition to her Ayurvedic and Yogic training, she received a Bachelors of Science degree from The United States Naval Academy. Acknowledgement and Consent to Receive Services: I have read and understand the above disclosure about the Ayurvedic treatment offered by atriot Integrative Health. I have discussed with my practitioner at atriot Integrative Health the nature of the services to be provided. I understand that my practitioner at atriot Integrative Health is not a licensed physician and that Ayurvedic services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by atriot Integrative Health, and agree to be personally responsible for the fees of atriot Integrative Health in connection with the services provided to me. atient s Signature: Date:
3 CONFIDENTIAL ATIENT HISTORY atriot Integrative Health FINANCIAL OLICY AGREEMENT 1. There is a $125 charge for each Initial Consultation. There is a $100 charge for each Follow-up isit. 2. Your customized program often includes one or more herbal formulas. There is an additional cost for herbal preparation and shipping. 3. ayment for consultations, herbs, and body therapies may be made by cash, check or credit card. ayment for services is to be received upon completion of rendered services. atriot Integrative Health does not provide monthly billing services. 4. atriot Integrative Health does not bill insurance companies for services or herbs. 5. atriot Integrative Health adheres to a 48-hours cancellation policy. Out of respect for your Ayurvedic practitioner and other patients, please be sure to cancel or reschedule at least 48 hours in advance. atients who miss an appointment, reschedule or cancel within 48 hours will be charged 100% of the appointment fee. 6. I have read and understood the financial policies of atriot Integrative Health. atient s Signature: Date: 1.) AST MEDICAL HISTORY a. Serious Illness b. Hospitalizations c. Operations d. List other past pertinent conditions e. Have you been under the care of a licensed health care professional in the past year? If so, for what reason? f. Have you had any cosmetic surgery or procedure performed? If so, please list with dates.
4 Indicate what members of your immediate family have these conditions after those checked. High Blood ressure Mental Disorder Cancer Diabetes Stroke Other Heart Disease 3) ALCOHOL, TOBACCO, AND SUBSTANCE USE ractitioner Notes a. Do you drink alcoholic beverages? Yes No If yes, how often: Several times weekly Several times monthly Seldom I usually choose: Beer Wine Sweet or hard liquor b. Have you ever smoked tobacco? Yes No If yes, how much per day? If you have quit smoking, when did you quit? c. Any current or past use of addictive or habitual substances? Yes No (Note: This will be kept confidential.) lease list all substances (either current or past) long-term use: 4) REGULAR RACTICES Exercise/Hatha Yoga (specify): None/Never Occasional Team sports/recreation (specify): None/Never Occasional Travel (include commute, if applicable): None/Never Occasional Spiritual practices (specify): None/Never Occasional Meditation/prayer/pranayam (specify): None/Never Occasional Other (include creative activities): None/Never Occasional 5) RELATIONSHI a. lease indicate how nourished you feel in your relationship, on a scale of 1 thru 10. If you are currently not in a relationship with a partner, please indicate how nourished your feel by your closest relationships of family and/or friends ( 1 being least nourished, 10 being most nourished): b. How often do you engage in sexual activity (include sex with partner and masturbation): Several times per week Several times per month Occasionally Not at all c. Is your current sexual activity satisfactory? Yes No
5 6) FOOD CHOICES What kind of foods do you eat on a regular basis? a. Breakfast: b. Lunch: c. Dinner: d. Snacks: 7) LIQUID INTAKE (indicate # of 8 oz cups per day) lain water: Caffeinated Coffee/Tea: Decaf Coffee/Tea: Herbal Tea or Juice: Soda: Cow or goat milk: Grain/nut/soy milk: 8) HABITUAL EATING ATTERNS Describe any current or past eating patterns or any other food related issues: 9) DAILY SCHEDULE (include approximate times) What are your habitual activities from the time you wake up until you go to sleep? Include mealtimes, sleeping, exercise, work, and any activities that occur on a regular basis. Time Habitual Activities ractitioner Notes Morning Awaken Mealtime Activities Afternoon Mealtime Activities Evening Mealtime Activities Bedtime 10) ALLERGIES OR SENSITIITIES Do you have allergic reactions to any substances (include food, pollen, medications)? If yes, please list.
6 11) AYUREDIC HISTORY For each category please identify your tendency over time by placing an X in the box that is most appropriate for you. Category ractitioner Use Only Appetite My hunger level is variable, and I often forget to eat. I have a strong appetite and don t like to miss meals. I like to eat, but I can go without eating with no discomfort. ractitioner use only ractitioner use only ractitioner use only Appetite If I miss a meal I often get anxious, cranky, or If I miss a meal, I often get irritable or angry. If I miss a meal it doesn t really bother me. light-headed. ractitioner use only ractitioner use only ractitioner use only Appetite I prefer to eat frequently I prefer to eat 3 meals I prefer to eat 2 to 3 times with no set schedule, but I a day at about the same per day but can go without often forget to eat. time. I rarely skip meals. eating. ractitioner use only ractitioner use only ractitioner use only Digestion After eating, I often After eating I often After eating I often feel experience gas or bloating. experience heartburn or heavy or sleepy. acidity. ractitioner use only ractitioner use only ractitioner use only Elimination I tend to have irregular I tend to have 1 to 2 I tend to have 1 bowel bowel movements one time bowel movements daily, movement daily with no per day or less. usually with regularity and straining or difficulty. ease. ractitioner use only ractitioner use only ractitioner use only Elimination My bowel movements My bowel movements My bowel movements are are often dry and hard. At are usually well formed, usually well-formed, slow, times I may strain or push. but sometimes they are easy and large. loose and may burn. ractitioner use only ractitioner use only ractitioner use only RACTITIONER USE ONLY rakruti: rakruti: K rakruti: ikruti: ikruti: K ikruti:
7 Weight I usually don t gain weight When I gain weight, I I gain weight easily and very easily. usually lose it. lose it slowly. ractitioner use only ractitioner use only ractitioner use only Body My hands and feet often I am warm most of the I adapt easily to most Temperature feel cold, and I prefer warmer time no matter what the conditions, but tend to feel climates. climate it. cool. ractitioner use only ractitioner use only ractitioner use only Skin My skin tends to be dry, My skin flushes easily My skin is thick, smooth and it tends to feel rough. and has a reddish or and often feels damp or oily. yellowish shade. ractitioner use only ractitioner use only ractitioner use only Sleep I tend to sleep lightly and I tend to sleep soundly My sleep tends to be deep awaken very easily. It can and awaken with ease. and long. It can be difficult for be difficult for me to go to me to awaken in the morning. sleep. ractitioner use only ractitioner use only ractitioner use only Mental and Emotional atterns Stress Under stress I often become worried or overwhelmed. Under stress I often become irritable but usually rise to the challenge. Under stress I often withdraw to observe or become reclusive. ractitioner use only ractitioner use only ractitioner use only Decision Making I am changeable and often have difficult making I make decisions easily but can change my mind I am careful but easy going about decisions. decisions. with new information. ractitioner use only ractitioner use only ractitioner use only rojects I like to start projects but I like to start and finish I like working on a project at times have difficulty projects. Completion is but prefer to let other people finishing them. important to me. start them. ractitioner use only ractitioner use only ractitioner use only ersonality When I am balanced I feel When I am balanced I When I am balanced I feel creative, enthusiastic, and feel perceptive, disciplined, nurturing, calm and vivacious. and logical. devotional. ractitioner use only ractitioner use only ractitioner use only RACTITIONER USE ONLY rakruti: rakruti: K rakruti: ikruti: ikruti: K ikruti:
8 For Women Only Is it possible that you might be pregnant? Yes No ossible Are you menopausal? Yes No If yes, date of last period: If menopausal, please answer below according to your past menstrual patterns. Menstrual My menstrual cycle is My menstrual cycle is Cycle irregular. It comes every regular. It comes every days and lasts days. days and lasts days. I experience MS: Often Sometimes Not at all Cramps Headaches Irritability Breast tenderness Bloating Weight gain ractitioner use only ractitioner use only ractitioner use only Menstrual Flow My menstrual flow is often light, but may vary. My menstrual flow is medium heavy, and is My menstrual flow is heavy and is very consistent. usually consistent. ractitioner use only ractitioner use only ractitioner use only Menstrual I have severe cramping At times I have mild pain I rarely have pain during Discomfort pain during menses. during menses. menses. ractitioner use only ractitioner use only ractitioner use only RACTITIONER USE ONLY rakruti: rakruti: K rakruti: ikruti: ikruti: K ikruti:
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