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?
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
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
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
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
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
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
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
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
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
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
© 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
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
© 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
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
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: ___________________