Ayurveda Wellness Counseling

Transcription

1 Patty Hlava, Ph.D., AWC, C.MI., RYT Ayurveda Wellness Counseling Name: DOB: Date: Home Address: City: Phone: State, Zip: Cell Phone: Occupation: Age: Personal Physician: Emergency Contact: Phone: Phone: Who may we thank for the referral? Current Medical Diagnosis (if known): Please describe your present health problems and their duration:

2 Name: 2 How long have you had the conditions about which you are consulting? o Less than 6 months o 6 months to 2 years o 2 5 years o more than 5 years How have your health problems progressed since they began? o Stable o Gradually improving o Rapidly improving o Fluctuating o Gradually worsening o Rapidly worsening Please indicate the overall intensity of your symptoms. o Mild o Moderate o Severe o Very severe How often are you having pain or discomfort? o Less than once per week o Several times per week o Once a day o Several times per day o Most of the time Do you take any nonprescription drugs or vitamins or any other supplement/s? o Yes o No Please list them.

3 Name: 3 Are you currently under the care of a family physician or any other health professional? o Yes o No If yes, include details. Do you currently take medication and/or receive medical treatment for your health condition(s)? o Yes o No If so, include all medications, treatments, and dosages. Do you have any past medical history or problems (e.g., illness, trauma, emotional stress, addictions, drug abuse, etc., that will help understand your health condition)? Is there a family history of the health problem(s) listed above? o Yes o No If yes, please specify.

4 Name: 4 Fill in as appropriate. Age (if living) Age (at death) Cause of death Anemia Cancer Diabetes Epilepsy Glaucoma Heart disease High blood pressure Hay fever Hives Kidney disease Mental illness Rheumatoid arthritis Tuberculosis Sinusitis Stroke Other Self Father Mother Brother Sister Child Spouse Other

5 Name: 5 Please indicate below to what degree the following statements apply to you. Scale: 1 is never or rarely, 5 is always or almost always: 1) I tend to feel a sense of blockage or obstruction in the body (constipation, congestion in the head area, general feeling of non-clarity, etc): 2) When I wake up in the morning, I do not feel clear; it takes me quite some time to feel really awake: 3) I tend to feel physically weak for no apparent reason: 4) I catch colds or similar ailments several times a year: 5) I tend to feel heaviness in the body: 6) I tend to feel that something is not functioning properly in the body (breathing, digestion, elimination, or other): 7) I tend toward feeling a general lack interest in work/school: 8) I feel the need to expectorate phlegm from the lungs frequently: 9) Often I have no taste for food, or no real appetite: 10) I tend to feel tired or exhausted, mentally and physically: Total score:

6 Name: 6 Statement of Understanding I understand that this is an Ayurveda Wellness consultation for the purpose of helping me improve my health and wellness. I understand this does not include medical diagnoses or treatment and is not a substitute for medical care or an agreement for ongoing care. I understand that Patty Hlava, Ph.D., AWC, C.MI., RYT is an Ayurveda Wellness Counselor who provides me with information on the Ayurvedic approach to health care, which may affect my diet and health in a positive way. I understand that Patty Hlava, Ph.D., AWC, C.MI., RYT is not a medical doctor or licensed medical practitioner, has not presented herself as such, and does not seek to diagnose, treat, or prescribe for disease or other pathological conditions. I agree that I am interested in enhancing my own abilities to heal and establish health in mind and body, and this is the reason I have sought Ayurveda Wellness Counseling services. I agree that I may consult a licensed physician for any concern, at any time, about any disease or pathology that now exists or arises during my professional relationship with Patty Hlava, Ph.D., AWC, C.MI., RYT. Furthermore, I understand that Patty Hlava, Ph.D., AWC, C.MI., RYT encourages regular medical check-ups from a licensed medical professional of my choice, and that any medication that I am now taking upon my licensed physician s advice, or will take in the future, is taken strictly according to my licensed physician s directions. Only a licensed physician of my choice can advise on medication dosages or the discontinuance or resumption of such medications. My signature below acknowledges the above statements as fully read and understood. Client signature Date

7 Name: 7 Payment and Cancellation Agreement It is customary to pay for professional services when rendered. This office does not handle insurance billing procedures. How would you prefer to handle payment (check one): Cash Check Credit card Please initial the following: I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment at time of service. I understand that I will be charged in full for any missed appointments, or those cancelled with less than 24 hours notice. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I have read the above information, or have had it read to me. I understand this information. Name (please print) Client Signature (Or Client s Representative; Indicate relationship if signing for patient) Date

8 Name: 8 Consent to Ayurveda Wellness Counseling The undersigned, an adult desiring Ayurvedic Wellness Counseling administered by Patty Hlava, Ph.D., AWC, C.MI., RYT, hereby acknowledges the following: 1. That Ayurveda Wellness Counseling involves careful constitutional analysis (requiring personal information), diet and life-style counseling, herbal therapies, meditation, and breathing therapies. Sessions may include one or more of the following detoxification methodologies: a) Clinical dietary changes. b) Fasting and cleansing therapies, which c) include intestinal laxatives/purgatives, enemas d) Herbal Therapies: internal and external applications of botanical products in the form of decoctions and herbally medicated oils used as enemas, purgatives, and for the general detoxification of the body. 2. That Ayurveda Wellness Counseling may include referrals for body treatments (massage, acupuncture, chiropractic care, marma, abhyanga, shirodhara, etc.), and panchakarma detoxification methods of treatment that can vary depending upon the Counselor s judgment. 3. That Ayurveda is a procedure, which was developed thousands of years ago and has been used in India and other parts of the world, but at present is not universally taught in medical schools in the United States. However, advanced Ayurvedic training programs are taught in schools of Ayurveda in the US. 4. I understand that the administration of Ayurveda Wellness Counseling could directly or indirectly result in minor adverse effects and or temporary discomfort including, but not restricted to, lightheadedness, dizziness, nausea, emesis (strategic vomiting), purgation (strategic intestinal evacuation), loose stools, fatigue, and hope- fully bliss while experiencing and/or re- covering from the above detoxifying and purgative procedures. 5. I further acknowledge that I am not seeking or undergoing Ayurveda Wellness Counseling sessions as a result of any inducement or representation or promises made by the Ayurveda Wellness Counselor or any other person in the office. I wish to proceed freely and voluntarily with such sessions and authorize Patty Hlava, Ph.D., AWC, C.MI., RYT to proceed with such sessions with the full and informed consent on my part of all the relevant facts as set forth in this consent form. This consent shall apply to my initial and all subsequent Ayurveda counseling sessions. I have read the above information, or have had it read to me. I understand this information. Name: (please print) Client Signature (Or Client s Representative; Indicate relationship if signing for patient) Date

9 Name: 9 PATIENT NAME: ARBITRATION AGREEMENT Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider s clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here.. Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. PATIENT SIGNATURE: (Or Patient Representative) PATIENT SIGNATURE: AAC-FED X X (Date) (Indicate relationship if signing for patient) (Date) ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE