Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone
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(###)
###
####
Date of Birth
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MM
DD
YYYY
Occupation / Passion
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Please share what you do for work, what you are passionate about and how you spend your leisure time.
Relationship Status
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Please share a little about your relationship status.
Medications
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Please list all medications, supplements and herbs, including frequency of use and dosage.
Medical History
Please list all medical history and conditions, including hospitalizations, surgeries and procedures.
Current Health Conditions
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Please list your primary pelvic health concerns and how they impact you.
Urinary Health
Please, check any that apply.
Urinary Health Further Discussion
Feel free to elaborate on any areas checked above or any other conditions.
Rectal Health
Please, check any that apply.
Rectal Health Further Discussion
Feel free to elaborate on any areas checked above or any other conditions.
Women's Health
Please, check any that apply.
Women's Health Further Discussion
Feel free to elaborate on any areas checked above or any other conditions.
Men's Health
Please check any that apply.
Men's Health Further Discussion
Feel free to elaborate on any areas checked above or any other conditions.
Digestive Health & Nutrition
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Please tell us about your current diet, your digestive health and your bowel movements.
Consumption
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Please tell us if and how much you consume: water, alcohol, tobacco, marijuana, recreational drugs.
Sleep
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Please tell us about your sleep habits, how well you sleep and if you feel refreshed after sleep.
Physical Activity
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Please list your activity status.
Emotional Stress
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Please rate your emotional stress on a scale of 1-10 (10 being max) and your greatest stressors.
Acupuncture and Chinese Medicine
What is your previous experience with acupuncture and TCM?
Qi: Deficiency
Qi: Stagnation
Qi: Rebellious
Qi: Prolapse
Xue: Deficiency
Xue: Stagnation
Xue: Heat
Yang: Excess Heat
Yang: Deficient
Yin: Excess Cold
Yin: Deficient
Jing
Body Fluids
Wind: External
Wind: Internal
Damp
Phlegm
Lungs
Heart
Liver
Spleen
Kidney
Large Intestine
Small Intestine
Gall Bladder
Stomach
Bladder
Anything else?
Please feel free to use this space to share anything else that seems relevant, but didn't fit anywhere else on the form.
Informed Consent
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I hereby request and consent to the performance of physical therapy / acupuncture services and other types of physical evaluations, procedures and treatments, including various modes of physical therapy / acupuncture, on me (or on the patient named below, for whom I am legally responsible) by the physical therapist / acupuncturist I made an appointment with and/or other licensed physical therapists who now or in the future work at Pure Balance Holistic Healing, LLC.
I have had an opportunity to discuss with my treating physician and the physical therapist named below and/or with other office or clinic personnel the nature and purpose of my physical therapy / acupuncture and other procedures. I understand that results are not guaranteed.
I further understand and have been informed that physical responses to a specific treatment can vary widely from person to person and it is not always possible to accurately predict my response to certain physical therapy /acupuncture modalities or procedures. I also understand that the physical therapist / acupuncturist is not able to predict precisely what my reaction to a particular treatment might be, or guarantee that my treatment will help or cure the condition I am seeking treatment for. I also understand that there are some risks that my treatment may cause pain or injury, or may aggravate a previously existing condition. I do not expect the physical therapist / acupuncturist to be able to anticipate and explain all the risks and complications, and I wish to rely upon the physical therapist / acupuncturist to exercise judgment during the course of my treatment which the physical therapist / acupuncturist feels at the time, based upon the facts then known to him or her, is in my best interest.
I have the right to ask my physical therapist / acupuncturist what type of treatment he or she is planning based on my history, diagnosis, symptoms and testing results. I have had the opportunity to discuss with my physical therapist /acupuncturistwhat the potential risks and benefits of a specific treatment might be. I have also been informed that I have the right to decline any portion of my treatment at any time before or during my treatment session.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content and all of my questions have been answered to my satisfaction. I understand the risks associated with the program of physical therapy /acupuncture discussed with me and I wish to proceed. By signing below, I agree to the above-named physical therapy / acupuncture services. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Notice of Privacy Practices / Bill of Rights
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PURE BALANCE HOLISTIC HEALING, LLC’S NOTICE OF PRIVACY PRACTICES
6 October 2016
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
I. UNDERSTANDING YOUR HEALTH RECORDS/INFORMATION:
Each time you visit Pure Balance Holistic Healing, LLC (hereinafter “Pure Balance”), a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, and a plan for future care. This information, often referred to as your health record or health information, serves as a:
* • Plan for your care and treatment.
* • Communication source between health care professionals.
* • Tools with which we can check result and continually work to improve the care we provide.
* • Means by which Medicare, Medicaid or private insurance payers can verify the services billed.
Understanding what is in your health record and how the information is used helps you to:
* • Ensure its accuracy.
* • Better understand why others may review your health information.
* • Make an informed decision when authorizing disclosures.
II. PURE BALANCE’S RESPONSIBILITY
Pure Balance is required by law to:
* • Maintain the privacy of your health information.
* • Inform you about our privacy practices regarding health information we collect and maintain about you (hereinafter “Privacy Practices”).
* • Honor terms of this Notice.
Pure Balance will keep your oral, written, and electronic health information safe using physical, electronic, and procedural means. These safeguards follow federal and state law.
Pure Balance reserves the right to change its Privacy Practices and to make the new provisions effective for all health information it maintains. We may tell you about any changes to our Notice in a number of ways. We may tell you about the changes in a newsletter or post them on our website. We may also mail you a letter that tells you about any changes. Pure Balance will also post any revised Notice of Privacy Practices at public places in its physical facility.
Note: The federal privacy law (the Health Insurance Portability and Accountability Act of 1996, hereinafter “HIPPA”) generally does not preempt, or override other laws that give people greater privacy protections. As a result, if any state or federal privacy law required us to provide you with more privacy protections, then we must also follow that law in addition to HIPPA.
Pure Balance will not use or disclose your health information without your permission, except as described in this Notice and as permitted by the HIPPA Privacy Regulations.
III. HOW PURE BALANCE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The following categories describe how we may use and disclose health information about you.
* • We will use and disclose your health information to provide your treatment.
For example, we may disclose your personal health information to primary care providers or other medical care providers who request it to aid in your treatment.
If Pure Balance consults with a health care facility, Pure Balance will exchange your health information with that health care facility for treatment decisions.
* • We will use your health information for health care operations.
For example, we may use your health information to evaluate your care and outcomes. This information will be used to continually improve the quality and effectiveness of the services we provide.
IV. PURE BALANCE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITHOUT YOUR CONSENT OR AUTHORIZATION FOR THE FOLLOWING PURPOSES:
Required by Law: We may use or disclose your personal health information, as we are required to do by federal, state, or local law. As required by law, we will disclose your health information to public health, or health oversight authorities or legal authorities charged with preventing or controlling disease, injury, or disability. We will also disclose your health information to legal authorities charged with receiving reports of child abuse or neglect or domestic violence. We may disclose your health information to an individual who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition. We may disclose your health information to the extent necessary to avoid a serious and imminent threat to your health or safety or to the health and safety of others. We may also have to report certain work-related instances and injuries to your employer so your work place can monitored for safety. We may disclosure your health information in response to a court order or upon the request from your military command authorities, if applicable, or for any workers’ compensation or similar program as required by law. It will not be a violation of this Notice if we, or any of our employees, business associated or contractors discloses information pursuant to whistleblowers and disclosures by workforce member crime victims
Communication with your designee: If you have directed that your health information may be disclosed to a family member, relative, friend or any other person you identify. This disclosure of health information is relevant to that person’s involvement in providing care or payment for services.
Appointment Reminders: We may contact you to remind you about an appointment for services.
Note: Except for the situations listed above, we must obtain your specific written authorization for any other release of your health information. An authorization is different that consent. One primary difference is that unlike with consents, a provider must treat you even if you do not wish to sign an authorization. If you sign an authorization, you may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to Pure Balance directly.
V. YOUR RIGHTS TO YOUR HEALTH INFORMATION
Although your health record is the physical property of Pure Balance, the information belongs to you. All requests in connection with the following rights must be in writing. You have a right to:
* • Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. Pure Balance may charge a copying fee of 10 cents per page after the first 10 pages.
* • Request a restriction on certain uses and disclosures of your health information. Pure Balance is not required to agree to any requested restriction.
* • Request an amendment to your health records if you believe your health information is incorrect or incomplete.
* • Request confidential communications about your health information. You may request confidential communications by an alternative means and Pure Balance will accommodate all reasonable requests.
* • Request an accounting of disclosure of your health information. You have a right to ask for an accounting of disclosures of your health information we have made up to six (6) years prior to when the request is made. The accounting of disclosures must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. Pure Balance my not charge you for the list, unless you request such a list more than once per year. In addition, we will not include in the list disclosures made to you, or for purposes of treatment, payment, health care operations, national security, law enforcement/corrections, and certain health oversight activities.
* • Request a new copy of this Notice at any time. Even if you have agreed to get this Notice by electronic means, you still have the right to a paper copy upon request.
VI To exercise your rights under this Notice, to ask for more information, or to report a problem, you may contact the Privacy Official below:
Krystal Couture
Pure Balance Holistic Healing, LLC
875 Islington St
Portsmouth, NH 03801
Telephone (603) 387-3347
If you believe your privacy rights have been violated, you may file a written Complaint with the above individual or the Office of Civil Rights in the U.S. Department of Health and Human Services, Washington, DC . There will be no retaliation for filing a Complaint. You may file a Complaint at either entity.
I have read and understand the Patient Bill of Rights and Notice of Privacy Practices for Protected Health Information, which provides a detailed description of the potential uses and disclosures of my protected health information and my rights as a patient. I understand that I may request a hard copy of this form at anytime during my treatment at Pure Balance Holistic Healing, LLC. My signature on this page is required by HIPPA (Health Insurance Portability and Accountability Act).
