LOTUS EAST-WEST MEDICAL CENTER
LOTUS EAST-WEST MEDICAL CENTER 2104 Wilshire Blvd, Santa Monica, CA 90403 t: 310.828.8258 f: 310.828.5258 info@lotusew.com www.lotusew.com New Patient Welcome Letter Dear New Patient, Welcome! Thank you so much for your interest in our east-west medical center. At Lotus we do our best in every way possible to assure that you receive the best quality care. We want you to know that everyone on our staff is trained to: • • • • Make sure that our customer service always meets the highest standards. Make sure that any questions you have about your care are answered in a way that you can understand. Make sure that your phone calls are returned promptly. Make sure that your private health care information is kept secure and private. Enclosed you will find several forms that we’d like you to fill out and bring with you to your first appointment. If you have any questions about these forms, please call us at 310.828.8258 and any one of us will be happy to help you. Please understand your appointment time is reserved for you. We recognize there may be occasions when you need to cancel or reschedule an appointment. If you need to cancel or reschedule your appointment for any reason, we require a minimum of 24-hour advanced notice to avoid cancellation/rescheduling fees in the full amount of your scheduled visit. Thank you for respecting this policy. Again, welcome to Lotus East-West Medical Center. You have taken an important step on the road to more vibrant health. We look forward to serving you. Yours sincerely, Lotus East-West Medical Center 1 Lokaha Samastaha Sukhino Bhavantu -- May All Beings Be Healthy LOTUS 2104 Wilshire Blvd, Santa Monica, CA 90403 EAST-WEST MEDICAL CENTER t: 310.828.8258 f: 310.828.5258 info@lotusew.com www.lotusew.com Our Clinic Protects Your Health Information and Privacy Dear Valued Patient, This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize. Safeguards in place at our office include: • • • • Limited access to facilities where information is stored. Policies and procedures for handling information. Requirements for third parties to contractually comply with privacy laws. All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file. Types of information that we gather and use: In administering your health care, we gather and maintain information that may include non-public personal information: • • • About your financial transactions with us (billing transactions). From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners. From health care providers, insurance companies, workman’s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information). In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you - e.g. your name, address, Social Security number, etc.). We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at 310.828.8258. Kindly, Lotus East-West Medical Center Lokaha Samastaha Sukhino Bhavantu -- May All Beings Be Healthy LOTUS EAST-WEST MEDICAL CENTER 2104 Wilshire Blvd, Santa Monica, CA 90403 t: 310.828.8258 f: 310.828.5258 info@lotusew.com www.lotusew.com Consent for Purposes of Treatment, Payment and Health Care Operation I consent to the use or disclosure of my identifiable health information by healthcare practitioners at Lotus East-West Medical Center for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or treatment of me at Lotus East-West Medical Center may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Healthcare practitioners at Lotus East-West Medical Center are not required to agree to the restrictions that I may request. However, if healthcare practitioners at Lotus East-West Medical Center agree to a restriction that I request, the restriction is binding upon healthcare practitioners at Lotus East-West Medical Center. I have the right to revoke this consent, in writing, at any time except to the extent that Lotus EastWest Medical Center has taken action in reliance on this consent. My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have the right to review Lotus East-West Medical Center’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Lotus East-West Medical Center. The Notice of Privacy Practices is also provided at the front desk and on the organization’s web site at www.lotusew.com. This Notice of Privacy Practices also describes my rights and the duties of my practitioners and Lotus East-West Medical Center with respect to my identifiable health information. Lotus East-West Medical Center reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by accessing the website or requesting the most current notice during any office visit. ________________________________________ Signature of Patient or Authorized Representative _________________ Date _____________________________________________________________ Printed Name of Patient or Authorized Representative and Relationship Lokaha Samastaha Sukhino Bhavantu -- May All Beings Be Healthy LOTUS EAST-WEST MEDICAL CENTER 2104 Wilshire Blvd, Santa Monica, CA 90403 t: 310.828.8258 f: 310.828.5258 info@lotusew.com www.lotusew.com Informed Consent for Acupuncture Treatment I hereby request and consent to the performance treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by: Brendan Armm, DAOM, LAc Richard C. Hsu, LAc Won mi Lauren Kim, LAc Sarah Murphy, ND, LAc Kristin Rotblatt, LAc ______________________________. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, acupressure, shiatsu, Chinese herbal medicine, exercise prescriptions, and nutritional counseling. I also understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I agree to immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. Because of the possibility of interaction of drugs with herbal formulas, I will inform the practitioner of any medications or recreational drugs I may be taking, including dietary supplements and herbs. Herbal formulas and acupuncture treatment may have effects on pregnancy. Patients must inform the practitioner of any possibility pregnancy. I hereby state my understanding that as per California Prop. 65, herbal supplements may contain chemicals known to the State of California to cause cancer, birth defects, and/or other reproductive harm. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effects and risk may occur. The herbs are nutritional supplements (which are from plants, animals, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. I further understand that results are not guaranteed and realize that a series of treatments and some long-term maintenance may be necessary depending on the severity and chronic nature of problem. It has been made clear to me that any herbal supplement is intended only for my consumption as prescribed and directed by my qualified practitioner on staff and under no circumstances is any herbal supplement intended to replace medication(s) prescribed by my medical doctor. I have also been informed that the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I acknowledge that I understand that acupuncture is NOT a substitute for the traditional medical management of my condition but rather it is considered complementary and alternative medicine. I agree to discuss the progression of my symptoms with my primary care physician should acupuncture not relieve these symptoms. I have read the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. This consent form is intended to cover the entire course of treatment for my present condition and for any future condition(s) for which I may seek treatment. Patient’s Name (please print): _______________________________________________________ Patient’s Signature: ________________________________________ Date: ______________ (or patient representative, indicate relationship) Lokaha Samastaha Sukhino Bhavantu -- May All Beings Be Healthy ! Nutritional Informed Consent According to the Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.” A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy. Although a Vitamin, a Mineral, Trace Element, Amino Acid, or Herb may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment and or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. I have read and understand the above information: ________________________________________ Signature ! _________________ Date Name:____________________________ DAY TWO DAY THREE DINNER SNACK LUNCH SNACK BREAKFAST DAY ONE Date:_____________________________ Plese list what you have eaten the last three days. If you cannot remember specifics, please list what 3 typical days of eating are. Name:____________________________ Date:_____________________________ P l e a s e l i s t h o w m a n y d a y s p e r w e e k y o u a r e e a t i n g out ( 1 - 7 ) b e s i d e e a c h meal time, give me some examples of your most frequented spots. Breakfast: ___________ Days per week. Where:__________________________________________________________ _____________________________________________________________________ Lunch: ___________ Days per week. Where:__________________________________________________________ _____________________________________________________________________ Dinner: ___________ Days per week. Where:__________________________________________________________ _____________________________________________________________________ What time do you wake up in the morning? _____________ What time do you leave your house for work/school/errands? _____________ What is your favorite food? ______________________________________________ What is your favorite restaurant? _________________________________________ Do you wake up hungry? ______________________________________ Name: ! Address: ! City: State:! ! Zip Code: ! ! Home Phone: Cell Phone:! ! Work Phone:! ! Date: E-mail Address: Age: Insurance:! ! ! Date of Birth: ! ! ! Status: ! Married ! Separated ! Divorced ! ! ! ! Gender:! Male ! ! ! ! Live with: ! Spouse ! Partner ! Parents Widowed Single Partnership ! Female Children Friends Alone ! Education: ! ! Occupation: ! Hours per week: ! ! Retired ! Employer Work Address ! ! ! In!case!of!emergency,!who!should!we!contact?! ! Name ! Relationship ! Address ! ! ! ! ! How did you hear about our Wellness and Nutrition Program? ! ! ! ! ! What is your major complaint and when did these symptoms begin? ! ! ! ! ! Phone ! ! ! ! ! ! ! ! ! What are your current medications? ! ! ! ! ! ! ! ! ! ! ! ! What are your current vitamins and/or supplements? ! ! ! ! ! ! ! ! ! ! ! ! Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.) ! ! ! ! ! ! ! ! ! ! Is there anything in your medical history that you consider to be relevant? ! ! ! ! ! ! ! What is your employment history? Please provide brief summary. ! ! ! ! ! ! ! Please list past or present allergies, including allergies to medications. ! ! ! ! ! ! ! Please list all past surgeries and the condition each surgery was for. ! ! ! ! ! ! Please explain your housing history (type of homes, where and when). ! ! ! ! ! ! ! ! Patient History Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank. Mercury " " " " " " " " " Yes " " " Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes " " " " " " " " " No Do you have amalgam (silver) fillings in your teeth? No No Have you ever had them in the past? Did your mother have amalgam when pregnant with you? No No Have you ever worked in a dental office? If so, how long? ____________ Have you had any dental crowns, bridges, root canals, dry sockets or infected tooth extractions? No No Do you have any dental implants or other metal in your mouth? Did you wear contact lenses during the 1980’s or early 1990’s? No No " " " No No Did you take oral contraceptives during the 1980’s or early 1990’s? Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination? Have you noticed any adverse reactions to these shots? Do you have any tattoos with red ink? No Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon? Lead " " " ! Yes Yes Yes " " " No No Does your occupation involve soldering, metal salvage, old home repair or sandblasting? Was your home built before 1978? No Have you ever worn cosmetics containing kohl? General Toxicity " Yes " No " Yes " No Have you ever lived near, on or by a golf course, freeway or tension wires? If yes, please explain. Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.) Mold How old is the house you are living in? ____________ How long have you lived there? ____________ " Yes " No Do you see mold growing at home, work or school? " Yes " No Have you ever had water damage at home, work or school? " " " " " " " " Yes Yes Yes Yes No No Does your home, workplace or school have a damp or mildew smell? Does spending time in your basement cause or worsen your symptoms? No No Does your basement ever get wet? Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms? Lyme Disease " " " " " " " " " " " " Yes Yes Yes Yes Yes Yes No No Have you ever been diagnosed with Lyme Disease? Have you ever been bitten by a tick or recluse spider? No No Have you ever seen a bulls-eye rash appear on any part of your body? Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors? No No Was your mother ever diagnosed with Lyme Disease? Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)? Health History " Yes " No " Yes " No Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities? Does anyone in your family experience similar symptoms to yours? What is your birth order (i.e. first born, second, third, etc.)? __________. " " " " " " " " " " " " " " " " " " " " Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Name: ! No Do you have any history of kidney dysfunction? No No Do you or any immediate family member have a history with cancer? Do you have any history of heart disease, myocardial infarction (heart attack), etc.? No No Are you currently having any thoughts of suicide? Have you ever been diagnosed with bipolar disorder, schizophrenia or depression? No No Do you have a history of strokes? Have you ever been diagnosed with diabetes mellitus? No No Have you ever been in an auto accident, fallen or received a major physical injury? Are you in menopause? No Do you have any allergies to food or medication? Date:! Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank. Point Scale 0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect ! ! Column #1 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Anxiety Mood swings Enraged behavior or anger for no reason Excessive shyness, timidity, social phobia (not typical to your personality) Irritability (not typical to your personality) Low body temperature (below 97.5o) Insomnia (can’t get to sleep or return to sleep Dizziness Sound in ears (ringing or hearing your heart beat) Psychological symptoms, even thoughts of suicide Sensitivity to sound ! Indecisiveness Feeling of being overwhelmed or fearful Metallic taste in your mouth Bad breath Bleeding gums Sensitive teeth Canker sores or other sores in the mouth Floaters, shadows or swimmers when you read or look into the sky ! ! ! Dyslexia or loss of place while reading, even as a child ! ! ! ! ! ! ! ! ! ! ! ! ! Dry skin Swelling eyelids Peeling on top layer of skin (hands, feet) Heart pain (angina) and you are under 45 years old Depression Gout (arthritic pain, especially in big toes) Pain in shoulders or upper back Twitching eyelids Anemia (low iron/hemoglobin on blood test) Wrist/ankle drop or weak extensor muscles Hair falls out (not normal male pattern baldness) ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Column #2 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Sensitivity to light Fatigue after exercising (feeling worse) Bad night vision or seeing halos around lights Shortness of breath, with very little effort Excessive thirst and/or frequent urination Red eyes or tearing Blurred vision at times Morning stiffness Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners Chronic fatigue or weakness Non-restful sleep ! Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.) Trouble processing new information Word reversal or trouble finding words Sensitivity to touch Short-term memory loss Chronic sinus congestion Dry non-productive cough Muscle twitching ! ! ! ! ! ! Excessive sweating, especially at night ! ! ! ! ! ! ! ! ! ! ! ! ! Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis ! ! ! ! ! ! ! ! ! ! ! ! ! Joint pain-not necessarily true arthritis-can move from joint to joint Difficulty losing weight regardless of diet or exercise Frequent illness, prolonged illness or sick days Numbness or weakness in arms and legs Headaches Trouble adding or dividing numbers in your head Fluctuating constipation and diarrhea Stomach pain for no apparent reason Appetite swings Frequent muscle aches, cramps, unusual sharp sudden pains Rashes or rosacea Cold extremities (hands and feet) ! Total Columns 1 & 2
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