docWelcome to Apothecary Tinctura! We are a retail medicinal herb
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Welcome to Apothecary Tinctura! We are a retail medicinal herb
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 th We are located on the corner of 6 Avenue & Fillmore St. just north of Cherry Creek th 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: __________________________ th 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:_____________________________________________________________ ______________________________________________________________________________ th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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 th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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 th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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?___________________________________ th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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? _____ th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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 th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com 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: th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com th Apothecary Tinctura ∙ 2900 E. 6 Ave Denver, CO 80206 ∙ (303) 399-1175 www.apothecarytinctura.com
