Intern Fax Cover Sheet

Transcription

1 California College of Ayurveda 700 Zion St. Nevada City, CA Intern Fax Cover Sheet TO: Fax #: FROM: Intern: Intern Phone #: Patient: Supervisor: Case Meeting Date: Location: GV LA DL SF No. of Pages (including this cover sheet): NOTE: Use a separate fax cover sheet for each Patient visit. Fax each Patient s papers separately. Indicate what forms are being submitted with this cover sheet: Form Name Initial Visit Forms Follow-up Visit Forms Re-do Forms Herb Order (Herbs 1-2) Product Order Other (Specify) Other (Specify) Comments Lotus Form Message: Version: 02/1/11 AHP Intern 2006 California College of Ayurveda

2 AHP Intern Organizer Chart Review IIC-IO Checklist Name of Intern: Name of Patient: IIC Date: Date Received: IO Meeting Date: Lotus Form Received Y N Check/CC Auth. Received Y N Intern needs to redo forms: IO Initials: Confidential Patient Forms (Intakes 1-9) Filled out by Patient Are all questions answered and legible without blanks? Y N Are all parts signed and dated? Y N Are there dates listed on I-3, Section (1)? Y N Challenging Patterns Form (Intake 8) Are there any blanks? Y N Does the MRF contain any red flags and/or unevaluated conditions? Y N Physical Examination Forms (Intakes 10-11) Is VPK circled for each question and all blanks filled in? Y N Does the abdominal exam use the proper language? (Intake 11) (See below) Y N Description of normal and abnormal findings on the abdominal exam Upon visual examination, no unusual markings or distention were noted. Upon percussion, normal tympany was noted in all four quadrants. Upon superficial and deep palpation, there were no masses or tenderness. Upon auscultation, normal bowel sounds were noted and no bruits were present. Abnormal findings should be articulate and describe the location of the finding: i.e., Stretch marks were noted in the right and left lower quadrant 3 inches lateral to the umbilicus and extending to the pelvis. Medical Referral Forms (MRF if applicable) Is the form without white-out and cross-outs? Y N Is Supervisor s name followed by a C.A.S. Y N Report of Findings (ROF 1-6) Are all questions answered without blanks? Y N Is prakruti in percentages with predominant Dosha first? Y N Is the A/A/O evidence in standard language on ROF 2? Y N PRF and Herb Forms (Herb 1-2) Are all questions answered without blanks? Y N Does the PRF have a legible shipping address? Y N Does a single block contain all the formulas ordered for one session? Y N Version: 08/1/09 California College of Ayurveda

3 CALIFORNIA COLLEGE OF AYURVEDA STUDENT INTERN PROGRAM 700 Zion Street Nevada City, CA Phone: (530) Fax: (530) AYURVEDIC HEALTH PRACTIONER INTERN (PLEASE WRITE NEATLY IN BLACK INK ONLY) Appointment Date & Time: Intern Name: Name: Address: City, State, Zip: Telephone Home: Cell: Work: Birth date: Age: Marital/partner status: # of children: Ages: Occupation: Emergency contact name and number: How did you hear about the California College of Ayurveda Intern Program? Please tell us why you have chosen to have an Ayurvedic Consultation: WHAT YOU CAN EXPECT FROM YOUR AYURVEDIC 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 we offer at the California College of Ayurveda Clinic are based on effective, timehonored principles that focus on understanding your particular body-mind constitution and the unique nature of your imbalance. Each individualized program is formulated by a student Intern who has completed the academic requirements of the California College of Ayurveda, under the supervision of graduates of the same program. Your program may include lifestyle adjustments, dietary changes, herbs, color therapy, sound therapy, aroma therapy, massage therapy, and other natural therapeutics. In order to successfully implement these Ayurvedic principles into your life, frequent regular followup visits with your intern 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. Patient s Signature: Date: PATIENT NAME: Section One Intake-1 Version: 02/2/11 AHP Intern Clinic

4 INFORMED CONSENT To authorize Complementary or Alternative Health Care through the CALIFORNIA COLLEGE OF AYURVEDA AHP Internship Program All Patients who participate in Ayurvedic Lifestyle Counseling through this program should be advised of the following information: 1. Your Ayurvedic Health Practitioner Intern has completed all of the academic requirements of the California College of Ayurveda leading up to internship. During internship, your practitioner will work with you on the promotion of optimal health and well-being. Please note that your practitioner will not be working with you on specific symptoms or diseases. 2. By changing your lifestyle and living more harmoniously, you will create within your body the optimum environment for healing to take place and a greater sense of well-being that will help you to thrive and not simply survive. 3. If you have specific symptoms that you are concerned about we recommend that your condition be evaluated by a licensed healthcare professional or Clinical Ayurvedic Specialist (CAS). 4. If you are under medical care or the care of another healthcare provider, your work with your Ayurveda Health Practitioner Intern will compliment the work being done by you other providers. 5. If you are not under the care of another healthcare provider, the work that you do with your Ayurvedic Health Practitioner Intern will help prevent disease and support your overall well-being. 6. The California College of Ayurveda is not a Medical College and its Staff, Interns, and Residents are not trained in Western medical diagnosis and may not alter your prescription medications. 7. Dr. Marc Halpern, the College s founder and director is a Chiropractor and not a Medical Doctor. 8. While your intern may take your blood pressure and vital signs, and perform some examination techniques similar to a routine medical examination, your intern is evaluating their 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 their examination, any findings suggestive of a possible medical imbalance are found, your intern will refer you to a Medical Doctor for further evaluation. 9. The California College of Ayurveda is responsible for your health program only until the date of graduation by your Intern. After this time, your Intern is no longer under the supervision of the College. 10. By signing below, you give your permission to the California College of Ayurveda to use the information in your chart for research purposes (Note: No patients names, addresses, phone numbers or addresses are included in research records). I have read and understand the above information and give my permission to begin a program health promotion with an intern at the California College of Ayurveda. Patient's Signature: Date: PATIENT NAME: Section One Intake-2 Version: 02/2/11 AHP Intern Clinic

5 CONFIDENTIAL PATIENT HISTORY CALIFORNIA COLLEGE OF AYURVEDA Internship Program FINANCIAL POLICY AGREEMENT 1. Your customized program often incorporates herbal formulas designed by the student Intern. All formulations are reviewed by a college supervisor prior to ordering and then custom-made at the California College of Ayurveda Health Care Center. The Intern is required to place the orders for herbal formulas on your behalf. There is a charge for herbal formula design, preparation and shipping. The Intern should always inform you of these costs before ordering the herbs. 2. Payment for herbs may be made by check or major credit card. The College does not provide monthly billing services. 3. The College does not bill insurance companies for herbs. 4. If Pancha Karma services are recommended and provided at the College Health Clinic, payment for those services is made through the College when the appointments are scheduled. I have read and understood the financial policies of the California College of Ayurveda Patient s Signature: Today s Date: \ \ FOR INTERN USE ONLY: Intern Name: Initial Appointment: \ \ IO Date: \ \ CM Date: \ \ ROF Date: \ \ (1) PAST MEDICAL HISTORY Please list any major condition(s) and dates of diagnosis, treatment, and procedures performed. a. Are you under the care of a licensed health care professional or any other healthcare provider? Yes No If so, for what reasons: b. Serious illnesses: c. Hospitalizations: d. Operations: e. List other pertinent current or past conditions: f. Have you had any cosmetic surgery or procedures performed? Yes No If so, please list: PATIENT NAME: Section One Intake-3 Version: 02/2/11 AHP Intern Clinic

6 (2) FAMILY HISTORY Indicate what members of your immediate family have had these conditions. (Go back one generation) (If adopted, answer according to family heritage, if known.) High Blood Pressure Heart Disease Other Cancer Mental Disorder Stroke Diabetes (3) ALCOHOL, TOBACCO AND SUBSTANCE USE PRACTITIONER NOTES: a. Do you drink alcoholic beverages? Yes No If yes, how often: Daily 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) Please list all substances (either current or long-term past usage): (4) REGULAR PRACTICES EXERCISE/HATHA YOGA (Specify) None/Never Occasional Several times per week Daily Several times per month TEAM SPORTS/RECREATION (Specify) None/Never Occasional Several times per week Daily Several times per month TRAVEL (Include commute if applicable) None/Never Occasional Several times per week Daily Several times per month SPIRITUAL PRACTICES (Specify) None/Never Occasional Several times per week Daily Several times per month MEDITATION/PRAYER/PRANAYAMA (Specify) None/Never Occasional Several times per week Daily Several times per month OTHER (Include creative activities) None/Never Occasional Several times per week Daily Several times per month (5) RELATIONSHIP a. Please indicate how nourished you feel in your relationship: (1 being the least nourished, 10 being the most nourished) b. How often do you engage in sexual activity (include sex with partner and masturbation): Daily Several times per week Several times per month Occasionally Not at all c. Is your current sexual activity satisfactory? Yes No Practitioners Notes: PATIENT NAME: Section One Intake-4 Version: 2/1/11 AHP Intern

7 (6) FOOD CHOICES What types of foods do you eat on a regular basis? BREAKFAST: LUNCH: DINNER: SNACKS: (7) DAILY LIQUID INTAKE (Indicate number of 8 ounce cups per day) Plain water Caffeinated Coffee/Tea Herbal Tea or Juice Cow or Goat Milk Decaffeinated Coffee/Tea Soda or soda pop Grain/nut/soy milk (8) HABITUAL EATING PATTERNS 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 INTERN NOTES MORNING Awaken Mealtime Activities DAY Mealtime Activities NIGHT Mealtime Activities Bed-time (10) ALLERGIES OR SENSITIVITIES: Do you have allergic reactions to any substances (including food, pollen, medicines?) If yes, please list. PATIENT NAME: Section One Intake-5 Version: 2/1/11

8 (11) AYURVEDIC HISTORY For each category please identify your tendency over time by placing an X in the box that is most appropriate for you. If you are unsure or would like to speak to your practitioner about this please check ( ) in the column to the right. CATEGORY PRACTITIONER USE ONLY I prefer to eat frequently but my hunger I have a strong appetite I prefer to eat I prefer to eat 2-3x/day, but I can go Appetite level is variable, and I often forget to 3x/day and rarely skip meals. without eating with no discomfort. eat. If I miss a meal, I often get lightheaded, anxious or cranky. angry. me. If I miss a meal, I often get irritable or If I miss a meal, it doesn t really bother Appetite Digestion Elimination Elimination Weight Body Temperature Skin Skin After eating, I often experience gas or bloating I tend to have irregular bowel movements one time per day or less. My bowel movements are often dry and hard. At times I may strain or push. I usually don t gain weight very easily. My hands and feet often feel cold, and I prefer warmer climates. My skin tends to be dry. When very dry it tends to feel rough. When I have rashes, they tend to be dry and itchy. Blemishes are usually blackheads. V P After eating, I often experience heartburn or acidity. V P I tend to have 1 to 2 bowel movements daily, usually with regularity and ease. My bowel movements are usually wellformed, but sometimes they are loose and may burn. When I gain weight, it is easy to lose it. I am warm most of the time no matter what the climate is. My skin flushes easily and has a reddish or yellowish shade. V P When I have rashes, they tend to be red and burning. Blemishes are usually acne. After eating, I often feel heavy or sleepy. V P I tend to have one bowel movement per day with no straining or difficulty. My bowel movements are usually wellformed, slow and easy. I gain weight easily and lose it slowly. I adapt easily to most conditions, but tend to feel cool. My skin is thick, smooth and often feels damp or oily. When I have rashes, they tend to be wet and oozing. Blemishes are usually white pimples. PRACTITIONER USE ONLY: V PRAKRUTI: P PRAKRUTI: K PRAKRUTI: V VIKRUTI: P VIKRUTI: K VIKRUTI: PATIENT NAME: Section One Intake-6 Version: 02/1/11 AHP Intern

9 CATEGORY PRACTITIONER USE ONLY Sleep Stress I tend to sleep lightly and awaken very easily. It can be difficult for me to go to sleep. MENTAL & EMOTIONAL PATTERNS Decision Making Projects Personality Under stress I often become worried or overwhelmed. I am changeable and often have difficulty making decisions. I like to start projects, but at times have difficulty finishing them. When I am balanced I feel creative, enthusiastic, and vivacious. V P P I tend to sleep soundly and awaken with ease. V P Under stress I often become irritable, but usually rise to the challenge. I make decisions easily, but can change my mind with new information. I like to start and finish projects. Completion is important to me. When I am balanced I feel perceptive, disciplined, and logical. P My sleep tends to be deep and long. It can be difficult for me to awaken in the morning. Under stress, I often withdraw to observe or become reclusive. I am careful but easy-going about decisions. I like working on a project, but prefer to let others start them. When I am balanced I feel nurturing, calm, and devotional. V P P FOR WOMEN ONLY Is there a possibility you are pregnant? Yes No Possible Are you menopausal? Yes No If yes, date of last period If menopausal, please answer below according to your past menstrual patterns. My menstrual cycle is irregular. It comes every to days and lasts days. My menstrual flow is often light, but may vary. I often have severe, cramping pain during menses. PRACTITIONER USE ONLY: My menstrual cycle is regular. It comes every days, and lasts days. My menstrual flow is medium heavy, and is usually consistent. At times, I have mild pain during menses. I experience PMS: often sometimes not at all cramps bloating headache weight gain irritable breast tenderness My menstrual flow is heavy and is very consistent. I rarely have pain during menses. V PRAKRUTI: P PRAKRUTI: K PRAKRUTI: V VIKRUTI: P VIKRUTI: K VIKRUTI: PATIENT NAME: Section One Intake-7 Version: 02/1/11 AHP Intern

10 (11) CHALLENGING PATTERNS Please indicate any physical and emotional patterns that you find challenging by assigning a Frequency (a number of times per week, month or year) and Intensity (a number from 1 to 10): INTENSITY 1 TO 3 = MILD DISCOMFORT 4 TO 6 = MODERATE DISCOMFORT 7 TO 10 = SEVERE DISCOMFORT Worry Anxiety EMOTIONS Frequency Number of times per week, month or year Intensity 1-10 Excessive gas Excessive belching Acid reflux Burning indigestion Nausea or vomiting Sleepy after eating Heaviness after eating Bloated after eating DIGESTION Frequency Number of times per week, month or year Intensity 1-10 Overwhelm Self-destructiveness Anger Resentment Critical/Blaming Intense Lethargic Melancholy Depression Stubbornness ELIMINATION Practitioner Notes: Constipation (less than 1 BM/day) Alternating constipation & diarrhea Food particles in stool Frequency Number of times per week, month or year Intensity 1-10 Diarrhea Rectal pain or hemorrhoids Blood in stool Mucus in stool Abdominal pain Vikruti V: P: K: Please describe your energy level: PATIENT NAME: Section One Intake-8 Version: 02/1/11 AHP Intern

11 (12) CURRENT MEDICATIONS, HERBS OR SUPPLEMENTS What medications, herbs, and supplements are you currently taking? Please include significant remedies that you have stopped taking, including birth control and hormone replacement therapies. Substance Over-the-counter (OTC) Prescription? (Rx) Herb/Drug/ Vitamin? Prescribed by? (Self, MD, other) For what purpose? For how long? What dosage? What have the benefits been? Page a b c d e PATIENT NAME: Section One Intake-9 Version: 02/2/11 AHP Intern

12 (13) AYURVEDIC PHYSICAL ASSESSMENT Category Qualities Prakruti Observations/Conditions oval Face Shape angular, square round Facial Energy delicate, subtle passionate, intense soft, sweet Eyes small, darting medium, deep set, piercing, large, moist, gentle Nose (size) small medium large Nose (bridge) narrow medium wide Lips thin medium thick Neck long medium short Hair Traits dry, kinky, sparse fine, balding, early grey coarse, dense, oily Skin Thickness thin medium thick Skin Condition dry, rough, wrinkles, slightly oily, moles, soft, moist, oily, smooth Complexion lacks luster ruddy, rosy pale Physique slight, irregular moderate stocky, solid Bones narrow moderate stocky Palm of Hand rectangular square Fingers long, narrow medium, short, thick Other Observations Speech Patterns enthusiastic, rambling concise, clear thoughtful, deliberate TOTAL PRAKRUTI PATIENT NAME: Section Two Intake-10 Version: 02/2/11 AHP Internship

13 (14) VITAL SIGNS Height: Blood pressure: Respiration: Weight: Temperature: Pulse rate: (15) TONGUE ASSESSMENT AMA nirama samavata samapitta samakapha gray, brown coating yellow, green coating white, pale coating Thickness of ama: OBSERVATIONS/CONDITIONS: VIKRUTI tremors bumps scallops red cracks froth dry neutral moist PRAKRUTI thin, small, long (V) medium, pointed (P) large, round, thick (K) pink, gray (V) dark pink, red (P) pale, white (K) (16) PULSE DIAGNOSIS SUPER- FICIAL AIR (Motion and Rhythm) ETHER (SPACE AND ETHER) FIRE (AMPLITUDE) WATER (Crest) EARTH (Width) DOMINANT POSITION OJAS (Relative Strength) OVERALL VIKRUTI (Present Moment) DEEP AIR (Motion and Rhythm) Ether (Space and Ether) FIRE (Amplitude) WATER (Crest) EARTH (Width) DOMINANT POSITION OJAS (Relative Strength) OVERALL PRAKRUTI (Innate Tendancy) OTHER PERCEPTIONS: (17) ABDOMINAL EXAM VISUAL EXAM (describe what you see) Upon visual examination AUSCULTATION (describe what you hear with stethoscope) Upon auscultation PERCUSSION (describe what you hear when tapping) Upon percussion PALPATION (describe what you feel) Upon superficial and deep palpation PATIENT NAME: Section Two Intake-11

14 (18) PRAKRUTI WORKSHEET FORM VATA PITTA KAPHA Intake-6 Intake-7 Intake-10 Intake-11 Tongue/Pulse TOTALS: Fractions to determine percent: Numerator (repeat VPK totals) Denominator (sum of VPK totals) Prakruti Percent PATIENT NAME: Section Two Intake-12 Version: 02/1/11 AHP Intern