American Institute of Alternative Medicine Clinic Policies
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- Rodger Hensley
- 5 years ago
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1 American Institute f Alternative Medicine Clinic Plicies AIAM ffers prfessinal and student services fr bth Acupuncture and Massage. The AIAM clinic prvides students and interns a place t integrate their classrm studies. Yur feedback is an imprtant part f ensuring ur student s success in their field f study. Our missin is helping yu achieve yur wellness gals. 1. Clinic treatment may be inadvisable fr certain medical cnditins and medicatins s it is imperative t cmpletely identify yur current medical cnditins and medicatins n the intake frm. A referral frm yur primary care prvider may be required prir t treatment. 2. An infrmed cnsent frm must be signed by the parent r guardian befre anyne under the age f 18 can be treated. Children under 16 r thse under guardianship must be accmpanied fr the duratin f their sessin by the parent, guardian r caretaker. Minrs under the age f 16 r thse under guardianship are nt allwed in the clinic r lbby unless they are patients. 3. If yu arrive late fr yur appintment it is at the clinic s discretin t determine the remaining length f yur sessin r if the appintment must be rescheduled. The full rate f service may apply. 4. Clients deemed t be under the influence f drugs r alchl will be asked t leave the clinic. The client is respnsible fr full payment f the appintment. 5. AIAM reserves the right t refuse service t clients that fail t cmplete the intake frm, d nt exhibit curteus and cnsiderate behavir t ther clients, staff, faculty and students. 6. Sexual miscnduct frm clinic clients is strictly frbidden. Sexual advances, physical cnduct f a sexual nature r any request fr sexual favrs will result in the immediate terminatin f the sessin. The client is respnsible fr full payment f the appintment and will be prhibited frm receiving any future treatment at the clinic. 7. STUDENT MASSAGE CLINIC ONLY: In the best interest f students educatin, we d nt hnr requests fr a specific student therapist fr any reasn including requests fr a specific gender. If yu prefer t chse the gender f yur therapist, please schedule with ne f ur Licensed Massage Therapists. Revised
2 Cntact Preferences? Phne May we leave a vic ? By prviding yur yu agree t receive appintment reminders frm AIAM. Yu may pt ut f Prmtins/Newsletters by checking here: Opt ut f Prmtins/Newsletters Cancellatin Plicy: Yu may cancel yur appintment withut charge any time befre the clse f the business n the day preceding yur appintment. Same day cancellatins will be charged 50% f the scheduled service price. Please arrive at least fifteen minutes befre yur scheduled appintment time in rder t guarantee a full sessin. Tardiness in excess f 20 minutes is cnsidered a N Call/N Shw and will be charged the full price f the sessin. If AIAM must cancel yur appintment fr any reasn, we fllw the same plicy. Emergency situatins will be addressed n a case by case basis. By signing belw I acknwledge the abve plicies and that I have been given the pprtunity t review AIAM s Ntice f Privacy Practices (HIPAA) and have been ffered a cpy f the ntice. Patient/Parent/Guardian Signature Revised
3 Acupuncture & Traditinal Chinese Medicine Clinic New Patient Infrmatin Frm Name First Last / / f birth Age (required) Street address Apartment/Unit City/State/Zip cde Telephne (hme) (cell) Best number t cntact: Hme/ cell/ ther Hw did yu hear abut ur clinic? Internet Referred by a friend/relative, ther patient/client At an event Other Have yu been treated using acupuncture, herbs, r Traditinal Chinese Medicine befre? Yes N In case f emergency, please cntact: Name Relatinship Cntact number 1. Main cncern yu wuld like help with: 2. Hw lng ag did this prblem begin? 3. Have yu been given a diagnsis fr this cncern? Yes/N If s, what? 4. What treatments have yu tried? 5. Are yu currently receiving treatment fr this issue? Yes/N If s, please describe: 6. What, if anything, imprves yur cnditin? 7. What, if anything, makes yur cnditin wrse? 8. D yu have, r have yu ever had any infectius diseases? Yes/N (Hepatitis, Herpes, HIV/AIDS, Other) Revised
4 Past Medical Histry Majr illnesses/medical cnditins(hspitalizatins, flu, brnchitis, etc) : Surgeries (when, fr what reasn): Significant trauma (accidents, falls): Medicatin & Supplements (prescriptin and ver-the-cunter drugs, vitamins, herbs, etc. taken within the last 3 mnths) Medicatin/Supplement Dsage Reasn fr use/cnditin treated Allergies. Please list any seasnal, dietary, skin r ther allergies yu have/may have: Family Medical Histry (General Health) Mther s side: Father s side: Sibling s: If any are deceased, please list cause: Persnal Health & Wellness Histry Birth Histry (premature, prlnged labr, frceps, delivery, etc.): Childhd general health: Lcatin f upbringing (Gegraphically prne t certain diseases, habits, etc.): Current quality f hme life: wrk life: wrk/life balance: Current quality f emtinal/mental health: Current relatinship quality: Current predminant emtin: Occupatin: Stress level: Any unusual/recent stressrs?
5 Favrite seasn f year: Least favrite: Hbbies & recreatinal habits: D yu have a regular exercise/mvement prgram? Yes/N If yes, please describe: Have yu traveled abrad in the past year? Yes/ N If yes, where? Please describe smking, alchl, recreatinal drug, caffeine, sugar, water intake (Hw much, hw ften, any nticeable effects): Neurlgical, emtinal, mental (please check if yu ve experienced in the past 3 mnths) Anxiety Dizziness Areas f numbness Depressin Cncussin Tremrs Mania Seizure Strke/paralysis Easily stressed Fainting Emtinal changes Easily angered Lss f balance Nervus habits Lack f mental fcus Disrientatin Grief Pr memry Lack f crdinatin Other: Are yu, r have yu ever been under care fr emtinal/mental cncerns? Yes/N If yes, please describe: Have yu cnsidered suicide? Have yu ever attempted suicide? General (please check if yu ve experienced in the past 3 mnths) Fever Day time sweating Weight lss Chills Night sweats Weight gain Fatigue Absence f sweating Areas f weakness Energy drps Dream disturbed sleep Difficulty falling asleep (time f day?) Sleeping mre than usual Difficulty staying asleep Other: Cardivascular (please check if yu ve experienced in the past 3 mnths) High bld pressure Palpitatins Cld hands/feet Lw bld pressure Swelling f hands Bld clts Anemia Swelling f feet Other: Irregular heartbeat Phlebitis Chest pain/tightness Cld sweats
6 Respiratry (please check if yu ve experienced in the past 3 mnths) Cugh Brnchitis Sleep apnea Asthma Easily winded with exertin r when lying dwn Difficulty breathing Cughing bld Shrtness f breath Prductin f phlegm Pain with deep breaths Clr f phlegm Other, describe: Musculskeletal (please check if yu ve experienced in the past 3 mnths) Injuries, falls Muscle sprain, strain Jint inflammatin Muscle weakness Arthritis Other, describe: Muscle atrphy Jint instability Other, describe: Muscle cramps Muscle spasms Bne spurs Easily bruised Reprductive (male/female) Age at first menses Irregular perids Emtinal changes w/perid # Days between menses Painful perids Number f pregnancies # f days perid lasts Breast tenderness/lumps Number f live births Recent menstrual changes Sptting Number f miscarriages Clts Very heavy r light flw f last perid Birth cntrl methd Fr hw lng Vaginal discharge Lw libid Fertility cncerns f last pap smear Imptence Other: Digestive, Gastrintestinal (please check if yu ve experienced in the past 3 mnths) Change in appetite Irregular eating Indigestin Pr appetite Lse stls Ulcers Excessive appetite Cnstipatin Hemrrhids Fd cravings Vmiting/nausea Bld in stl Blating, distentin Belching Digestive disrders Eating disrders Bad breath Other, describe:
7 Urinary(please check if yu ve experienced in the past 3 mnths) Pain/burning n urinatin Bld in urine Waking at night t urinate Urgent urinatin Kidney stnes Hw ften? times Frequent urinatin Difficulty hlding urine Urinary tract infectin Changes in urine Hesitatin r pain n Other: flw/vlume urinatin Please circle n the diagram any areas f pain r injury. 1. Is the pain cnstant? 2. Is the pain sharp, dull, achy, burning, stabbing, radiating? 3. Which areas experience numbness r tingling? Signature Signature f parent r guardian Guardian is required t accmpany patient thrughut duratin f treatment
8 ' Fr patient review, regarding diagnstic exam: Please sign ne f the 2 ptins belw Optin 1 I have received a diagnstic exam by a physician r chirpractr within the last six mnths regarding the cnditin fr which I am seeking treatment. X Patient signature Optin 2 I have NOT received a diagnstic exam by a physician r chirpractr within the last six mnths regarding the cnditin fr which I am seeking treatment. Ohi law requires that a Licensed Acupuncturist recmmend that yu receive a diagnstic exam by a physician r chirpractr regarding the cnditin fr which yu are seeking treatment. X Patient signature
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