Welcome to Apothecary Tinctura! We are a retail medicinal herb

Transcription

Welcome to Apothecary Tinctura!
We are a retail medicinal herb store specializing in natural remedies and health solutions. We have a small but busy
‘clinic’/healing center/spa where we offer private consultation and treatments by skilled practitioners in a safe, nurturing
environment.
Our mission is to provide an environment that allows healing to naturally happen…where all aspects of who you are and
what your life is about is welcome. Our goal is to provide you with the information and educational avenues needed to
support self-healing and integration of herbal medicines, natural remedies and elements of self-care and beauty into your
life. Whether you are here for a nurturing massage or have come seeking support for more serious health challenges, we
welcome you.
How to Find Us
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We are located on the corner of 6
Avenue & Fillmore St. just north of Cherry Creek
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address: 2900 East 6Ave, Denver 80206
tel: 303.399.1175
Cancellation / Re-Scheduling Policy
In order to best serve our clients and respect our clinic practitioners:
● We ask for a credit card number to reserve all clinic appointments
● We require at least 48 hours notice to cancel or reschedule an appointment
● We will not charge your credit card unless you miss your appointment or cancel/change your appointment with less
than 24 hours notice
● A cancellation/rescheduling fee equal to the session booked will be charged with less than 24 hours notice.
I have read and understand the cancellation/re-scheduling policy
Client signature__________________________________ date ________________
Client Confidentiality and Release Form
I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness,
disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the
practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations
(unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified
health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and
take it upon myself to keep the therapist/practitioner updated on my health.
Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost
importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any
information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation.
Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records
I,(name)_____________________________give my permission, for my practitioner to take notes including health
history/ medical and /or personal information I choose to disclose to him/her. All relevant identifying information will not
be disclosed, such as name, address, social security number, date of birth.
Client Signature: ____________________________________ Date: __________________________
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Apothecary Tinctura
∙
2900 E. 6
Ave Denver, CO 80206
∙
(303) 399-1175
www.apothecarytinctura.com
Date of Initial Visit____________________
Name:__________________________________________________________________________
Address_________________________________________________________________________
State___________________________Zip_________ Home Phone__________________________
Cell________________________email________________________________
Date of Birth_____________________
Age__________Occupation_________________________________________
Marital/Relationship status______________________
Referred by_________________________________________
Primary reason for
visit:
___________________________________________________________________________
When did your first notice it?_______________What brought it on?___________________________
Describe any stressors occurring at the time________________ _____________________________
What activities provide relief?_____________what makes it worse?___________________________
Is this condition getting worse?________interfere with work______sleep______ recreation_________
Have you had massage/bodywork before?______________
What type?________________________________________
Medical History
Are you currently under the care of another health care provider(s)?_______________
Reason (s)_____________________________________________________________________
Name(s) of Practitioner_____________________________
Current Medications:______________________________________________________________
Current Supplements:_____________________________________________________________
______________________________________________________________________________
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
Surgical History (year and type) and/or Recent
Procedures:__________________________________________________________________________________
_____________________________________________
Hospitalizations:
_______________________________________________________________________________
Accidents or Phyiscal
Traumas________________________________________________________________________
Falls/Injuries to Sacrum/head/tailbone
(describe)_________________________________________________________
Diagnosed Diseases / Disorders / Surgeries:
_____________________________________ Date _________________
_____________________________________ Date _________________
_____________________________________ Date _________________
_____________________________________ Date _________________
Labs or Diagnostic Tests (relevant to current conditions):
Date
Test/Exam
Results
_______
______________________ _______________________________
_______
______________________ _______________________________
_______
______________________ _______________________________
SYSTEMS REVIEW
Please fill this out carefully, even if some of the symptoms don’t seem at all connected to your current issue! Place
one
check
next to a symptom you have experienced,
two
checks

next to a frequently occurring symptom, and
three checks
next to a symptom that is particularly distressing to you.
Head and Face
Headaches
Dizziness
Memory Loss
Other
Eyes
Blurry Vision
Eyelid Twitch
Floaters
Pain
Other
Nose
Frequent Colds
Sinus Issues
Bleeding
Other
Heart and Chest
High Blood Pressure
Low Blood Pressure
Chest Pain
Chest Tightness
Difficulty Lying Down
Pace Maker
Other
Circulation
Easy Bruising
Easy Bleeding
Cold Hands or Feet
Cold Limbs
Raynaud’s Syndrome
Other
Gastrointestinal
Energy Level
Low
High
Skin
Acne
Dryness
Moles that Change
Lumps
Excessive Sweating
Night Sweats
Rarely Sweat
Other
Neurological
Tremors
Numbness or Tingling
Nerve Pain
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
Always Thirsty
Never Thirsty
Excessive Appetite
Gas/Bloating
Abdominal Pain
Nausea
Diarrhea/Loose Stools
Constipation
Rectal Bleeding
Colon Problems
Other
Mouth
Dental Problems
Gum Problems
Teeth Grinding/TMJ
Unusual Tastes
Other
Throat
Sore Throat
Hoarseness
Lump in Throat
Dryness
Other
Urination
Frequent
Difficult
Painful
Nocturnal
Bleeding
Other
Respiration
Difficulty Inhaling
Difficulty Exhaling
Pain
Cough
Congestion
Shortness of Breath
Other
Sleep
Insomnia
Drowsiness
Excessive Dreaming
Restless
Wake up at night
Other
Emotions
Depression
Anxiety
Sadness
Anger/Irritability
Worry
Other
Pain
– Please Describe
______________________________
______________________
Allergies
– (ANY)
Gastroinstestinal Health History
Describe your typical:
Breakfast:_______________________________________________________________________
Lunch:__________________________________________________________________________
Dinner:_________________________________________________________________________
Snacks:__________________________
Water Intake(glasses/day)_________________Caffeine_________________
What is the worst item in your diet______________
What foods are your weakness__________________________
Are you subject to binge eating?_________________________What foods_____________________
Do you experience bloating/gas/burps after eating?_____________
What foods trigger this?__________________
How often are your bowel movements?___________________________
Do your stools: sink______float_______
Constipation?__________Blood in stool ?_________Mucus in stool?____________Pain when
stooling?_________Diarrhea?___________________________Other?
Lifestyle, Emotional & Spiritual
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
What is your opinion of
yourself?________________________________________________________________________
Describe the most positive emotion you
experience__________________________________________________________________
When and Where do you experience this
emotion?__________________________________________________________________
Describe the most negative emotion you
experience_________________________________________________________________
When and Where do you experience this
emotion?__________________________________________________________________
Describe your Spiritual and/or Religious
practice:____________________________________________________________________
On a scale of 1 – 10
( 1 being the lesser, 10 the greater
) Please rate yourself in each of these qualities:
Faith______Hope____Charity____Generosity________ Sense of Humor_______
Fear_____Grief_____Sense of Fun_____
What hobbies/ activities provide you with pleasure and accomplishment
__________________________________________________
Describe your exercise routine (type, frequency)__________________________________________________
What changes would you like to experience in the next 6
months:_________________________________________________
One Year:___________________________________________________________________________
Do you use Tobacco?______ Quantity_____/ppd
Alcohol?______Quantitiy______ounces/ day
Marijuana?_______Quantity______Other:__________________ Have you been under treatment for substance use?
Female Reproductive Health History
Method of Contraception (circle) pills patch diaphragm injection condoms IUD abstinence NFP or Fertility Awareness
Other:_____________Length of time using method________
Last Pap smear____Results _____
Are now or in the past experiencing Fertility Challenges? Yes___No___
Describe any assistance or treatments (IVF,
IUI):____________________________________________________________________________
Menstrual History Review and check as indicated:
Age of Menses:__________________________What was this like for
you?___________________________________
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
Last Menstrual Period:_______________________
Average Length of Menses____________________ Average length of cycle:____________________
Are you trying to Conceive? Yes_____No_______
Are you Pregnant? Yes____No____Unsure____
Irregular cycles
Early?
Late?
Absent?
Uterine Infection(s)
Dark Thick Blood at:
Beginning
End
Both
Cysts:
Location:
Uterine or Cervical
Polyps
Headache or Migraine
with menses
Urinary Incontinence
Vaginal Infection(s)
Bloating:
Vaginal Dryness
Ovulation:
Painful
Anovulation
Fibroids
Location (if known)
Water Retention
Painful Periods
Heaviness in Pelvis
prior to menses
Excessive Bleeding
Pads per Hour
Endometirosis:
Location:
Painful intercourse
Endometriosis
Location (if known)
Bladder Infection(s)
Rate your interest in Sex: High_________Moderate__________Low______________None___________________
Do you have or ever had difficulty experiencing orgasms________________________________________________
Have you experienced trauma? Yes___No____Describe________________________________________________
Have you received support and healing related to your trauma? Do you need additional
support?__________________________________________________________________
Pregnancy History
regnancy History
Number of Pregnancies:_______Dates_________________
Miscarriage(s)_______Dates___________________
Termination(s)______Dates:___________________
Number of Births:_________ Dates:______________________________________________________________
Complications or information related to any of the above, please
describe:_____________________________________________________________
Premature Births?______ Spotting During Pregnancy? _____
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
Describe your experience with:
Pregnancy:___________________________________________________________
Labor:_______________________________________________________________
Birthing______________________________________________________________Post
Partum:_____________________________________________________________
Maternal Family History of (
please circle
) Infertility
Fibroids
Endometriosis------PMS
Menopause
Cancer(type)_____________Menstrual Problems ______________ Other_________________________________
Your Birth Trauma (if known) ___________________________________________________________________
Menopause
Age symptoms began:____________Are they getting worse__________better________________same________
Are you on/ or ever been on hormone replacement therapy?______if so, how long__________________________
Name and dose________________________________________________________________
Reason for stopping_____________________________________________________________
Age of Mother at menopause:______Concerns/Experience____________________________________
Circle all of the following symptoms that apply to you:
Age of Mother at menopause:______Concerns/Experience_____________________________________________
Check the following symptoms that apply to you:
Hot flashes
Vaginal Discharge
Spotting
Insomnia
Fatigue
Memory Loss
Mood
Swings
Dry Vagina
Depression
Anxiety
Irritability
Painful Intercourse
Increased/
Decreased
Libido
Flooding
Irregular Menses
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
Male Reproductive Health History
Please check the symptoms below that apply
Painful Urination
Pain or Burning with
Urination
Urinary
Incontinence or
Dribbling
Nocturnal Urination
How many times?
Weak or
Interrupted
Urine flow
Pain in lower back,
esp
After intercourse
Pain or Discomfort in:
Penis
Testicles
Rectum
Pelvic pressure
Frequent Bladder or
Kidney Infections
When?
Insatiable sex drive
Pain or Discomfort in
Inner thighs:
Left
Right
Both
Pain or Discomfort
Between scrotum and
Testicles
Erection:
Difficulty in Obtaining
Maintaining
Painful ejaculation
Results of PSA (prostate specific antigen) Test if known________________________ Date
done_____________________
Results of Sperm count (if applicable and known)__________________________________Date done____________
Family History of Prostate Disease: Yes___No___Type_________Relationship_______________________________
Family History of Cancer
Yes____No______Type_______________________Relationship______________________
Sexually transmitted disease Yes___ No___ Type if Known_______________________________________________
Rate your interest in Sex:
High___________Moderate____________Low____________None_________________
Do you have a history of trauma: describe ____________________________________________________________
Did you undergo counseling for this
_________________________________________________________________
What was this like for you
________________________________________________________________________
Additional Comments:
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Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175
th
Apothecary Tinctura
∙
2900 E. 6
∙
(303) 399-1175