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
[email protected]
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:
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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
[email protected]
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:
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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:
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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
[email protected]
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
[email protected]
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
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_________________
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:
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Address:
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City:
State:!
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Zip Code: !
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Home Phone:
Cell Phone:!
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Work Phone:!
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Date:
E-mail Address:
Age:
Insurance:!
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Date of Birth: !
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Status:
! Married
! Separated
! Divorced
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Gender:! Male
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Live with:
! Spouse
! Partner
! Parents
Widowed
Single
Partnership
! Female
Children
Friends
Alone
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Education: !
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Occupation: !
Hours per week: !
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Retired
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Employer
Work Address
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In!case!of!emergency,!who!should!we!contact?!
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Name
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Relationship
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Address
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How did you hear about our Wellness and Nutrition Program?
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What is your major complaint and when did these symptoms begin?
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Phone
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What are your current medications?
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What are your current vitamins and/or supplements?
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Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.)
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Is there anything in your medical history that you consider to be relevant?
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What is your employment history? Please provide brief summary.
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Please list past or present allergies, including allergies to medications.
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Please list all past surgeries and the condition each surgery was for.
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Please explain your housing history (type of homes, where and when).
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Patient History
Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.
Mercury
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Yes
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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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
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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
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Yes
Yes
Yes
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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
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Yes
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No
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Yes
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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?
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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
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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
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Yes
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No
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Yes
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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.)? __________.
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Yes
Yes
Yes
Yes
Name:
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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
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Column #1
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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
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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
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Dyslexia or loss of place while reading, even as a child
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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)
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Column #2
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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
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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
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Excessive sweating, especially at night
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Persistent fungal or viral infection, including athletes foot,
warts, jock itch, candidiasis
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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)
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Total Columns 1 & 2