Download Lipotropic Injection Program New Patient Instructions

Lipotropic Injection Program New Patient Instructions
Thank you for choosing East Lake Acupuncture & Wellness. Attached is the new patient paperwork, please fill it out and
bring it with you to your appointment. If you are unable to fill it out in advance, please allow arrive 20 minutes early to
fill out your paperwork. Arriving within minutes of your appointment without your paperwork may result in your
appointment being rescheduled in order to keep our physicians on schedule.
UPDATE: To be able to make and keep your new appointment for Lipotropic Injections, it is
now REQUIRED that the Adrenal Fatigue Questionnaire is completed before the day of your
appointment.
Appointment date/time:
Physician: Dr. Kerns
Important information:
1. If you are allergic to sulfur please reply to this email and let us know and be sure to verify your allergy at the
time of your appointment. This information is very important in determine which type of injection you need.
2. Please visit the link below and take the adrenal fatigue quiz BEFORE your appointment. Either print out the
results or write down your scores. This information is important in determining your eligibility for the lipotropic
injection program. http://www.adrenalfatigue.org/take-the-adrenal-fatigue-quiz.
3. Due to a high demand for appointments with limited availability, we are strictly enforcing our no-show/late
cancellation policy. New patient no-shows will not be rebooked, so please be sure to call us if you can’t make
your appointment. Our no-show/cancellation policy is outlined below.
4. While some patients have experienced incredible results with these injections, it is important to understand that
they not a substitute for healthy eating habits and exercise, both of which are required to ensure optimal
results. If you are unwilling or unable to eat well and get plenty of exercise, water and sleep, you may not be a
candidate for this program. Think of these injections as boosters to help you reach your goal more quickly, make
your workouts more effective and help you to burn fat much faster.
5. We can help you with obstacles such as poor sleep, digestive issues, adrenal fatigue, pain, food cravings, etc. to
help you reach your fat loss goals.
6. Participants missing 2 or more injection appointments will be dropped from the program and if appropriate, noshow fees may be assessed. Taking planned vacations are of course, an exception and when advance
arrangements are made, we have several protocols to help offset the missed injections.
East Lake Acupuncture & Wellness – 4121 Neptune Rd., St. Cloud, FL 34769
Intake Form
Personal Information
Patient Name:
Address:
Age: _______ Birth Date:___/___/____ Gender: M/F
______
City:
________
State: _______Zip:_______
Telephone:______________________________ Is it okay to leave a detailed message at this number? Y/N
Email Address:____________________________ Occupation:______________________________
Emergency Contact ______________________________________
_
How did you hear about us?
Who is your primary health care provider/MD?___________________________________________________
Main Complaint
Please identify your major health concern
___________________________________________________________________________________
___________________________________________________________________________________
How long have you had this problem(s)
___________________________________________________________________________________
Have you been given a diagnosis for this problem(s)?
___________________________________________________________________________________
What other treatments have you tried and what were the outcomes?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please list any Western Diagnosis (Diabetes, Hypertension, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Please list ALL medications, herbs, supplements, vitamins you are taking and the reason each:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Allergies (Medications, herbs, foods, seasonal, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
East Lake Acupuncture & Wellness – 4121 Neptune Rd., St. Cloud, FL 34769
Puffiness/Edema
Sudden onset/Gradual
Strong Thirst
Preferred Temperature of drinks
Thirsty w/no desire to drink
Desire to drink but only in small
sips
Tinnitus/Ringing in Ears (Low/High
pitched/sudden onset/gradual)
Bruise Easily/Bleed Easily
General
Poor Appetite
Changes in Appetite
Food Cravings (salty/sweet/other)
Weight Loss/Gain
Weakness
Fatigue
Sudden Energy Drops
Hearing Loss
Ear Infections
Skin & Hair
Rashes
Itching
Dry Skin
History of Eczema/Psoriasis/Shingles/Other
Head, Eyes, Ears, Nose, and Throat
Headaches/Frontal/Temples/Behind
Eyes/Vertex/Occipital/Throbbing/Stabbing/
Dull/Band around Head/Other
Head Injury
Dizziness
Vision Changes
Blurry Vision
Night Blindness
Dry Eyes
Red Eyes
Hair Loss
Change in Hair Texture
Brittle Hair
Dry Hair
Itchy Eyes
Floaters
Cataracts
Other Eye Problem_______________
Sinus Problems
Allergies________________________
Nose Bleeds
Poor Sense of Smell
Snoring
Facial Pain/Trigeminal Neuralgia/Bell’
Night Sweats
Spontaneous Sweating (all
over/head/other)
Easy to Sweat
Hot Flashes
Heat Sensation in
Hands/Feet/Chest/Face/Head
Low Libido/Sex Drive
Insomnia/sleep problems
Brittle Nails
Nail Fungus
Other Nail Problems
TMJ Pain
Poor Sense of Taste
Mouth Pain
Mouth Sores
Recurrent Sore Throat
Sensation of something stuck in
throat
Thyroid Problems
East Lake Acupuncture & Wellness – 4121 Neptune Rd., St. Cloud, FL 34769
Cardiovascular
High blood Pressure/Hypertension
Low Blood Pressure
Irregular Heartbeat
Arrhythmia
Palpitations
Pace-Maker
History of Blood Clots
Chest Pain
Heaviness in Chest
Swelling of Hands/Feet
Phlebitis
Fainting/Lightheadedness
Cold Hands/Feet
Shortness of Breath
Respiratory
Cough
Bronchitis
Difficulty Breathing
Phlegm
Sleep Apnea
Coughing Up Blood
Pneumonia
Asthma
Use Inhaler/Nebulizer
Painful Breathing
Easily Winded
Shortness of Breath
On oxygen
Other Breathing Problem
Urology
Painful Urination
Urgency to Urinate
Unable to Hold Urine
Incontinence
Change in Urine Flow
Frequent Urination
Blood in Urine
Cloudy Urine
Kidney Stones
Urinary Tract Infections
Frequent Night Urination
Pain in Groin Area
STDs
Prostate Problems
Inability/Difficulty to
Achieve/Maintain Erection
Gastro‐Intestinal
Nausea
Vomiting
Number of BM/Day____
Constipation (Hard to Pass/Goat Pellets)
Diarrhea
Alternate Constipation/Diarrhea
Loose Stools
Sticky Stools (use a lot of paper or sticks to toilet)
Mucus in Stools
Undigested Food in Stools
Pain after Bowel Movement
Diarrhea when upset
Urgent need for Bowel Movement
early in the morning
Foul Smelling Stools
Bad Breath
Ulcers
Hernia
Abdominal Pain
Chronic Laxative Use
Intestinal Gas
Indigestion
Rectal Pain/Burning
Belching
Blood in Stools
Hemorrhoids
(Bleeding/Prolapse/Pain)
Burning/Itching Anus
Diagnosed w/Colon Polyps, etc.
East Lake Acupuncture & Wellness – 4121 Neptune Rd., St. Cloud, FL 34769
Neuro‐Psychological
Seizures
Areas of Numbness
Tingling/Pins & Needles
Concussion
Twitches (Eye/Fingers/Toes/Other)
Lack of Coordination
Depression
Grief/Sadness
Anger
Irritability
Loss of Balance
Stress
Poor Memory
Anxiety
Tremors
Poor Concentration/lack of focus
Mood swings
Phobias
Over thinking/worrying
Parkinson’s/Alzheimer’s/other
Gynecology
Age of Menses
Irregular Periods
Clots
Painful Periods
PMS
Date of Last Menses
Breast Lumps
Menopausal
# of Pregnancies
# of Births
Miscarriages/Abortions
Spotting
Yeast Infections
Vaginal Discharge
Odor
Fertility Problems
PCOS/Fibroids/PID/HPV
Endometriosis
Uterine Fibroids
STD
Other
Musculo‐Skeletal
Injury
Arthritis
Sciatica
Muscle Weakness
Muscle Cramping
Muscle Spasms
Scoliosis
Joint Pain
Low Back Pain
Hand/Finger Pain
Hand Weakness
Wrist/Elbow Pain
Foot/Ankle Pain
Carpal Tunnel Diagnosis
Buttock Pain
Coccyx (tai bone) Pain
Pain worse w/Damp/Cold/Heat
Pain with movement
Pain Better w/movement
Unexplained Pains
Pain/Bloating on Sides/Ribs
East Lake Acupuncture & Wellness – 4121 Neptune Rd., St. Cloud, FL 34769
Consent to Treat Form
I hereby request and consent to the performance of acupuncture 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 a Jeannette Kerns, Jennifer Ordinas,
John Gorsuch and/or other licensed/certified acupuncturists who now or in the future treat me while employed by, working or
associated with or serving as back-up for/at East Lake Acupuncture & Wellness, LLC, including those working at the clinic or
office listed below or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, bleeding, GuaSha, vitamin injections, liptropic injections, homeopathic injections, bio -puncture, electrical stimulation, Tui-Na (Oriental
massage), Oriental herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas
consumed according to the instructions provided orally or in writing. The herbs may have an unpleasant smell and/or taste. I will
immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the
herbs.
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 and Gua-Sha. 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 disposable sterile
needles and maintains a clean and safe environment. Some potential risks of injections of any type are bruising, tenderness, allergic
reaction, numbness, muscle soreness or nerve damage. 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 risks may occur. The herbs and
nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally
considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may
be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache,
diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become
pregnant.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to
rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon
the facts then known is in my best interest. I understand that results are not guaranteed.
I understand 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 show that I have read, or have had read to me, 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. 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.
PATIENT SIGNATURE
X
(Date)
(Indicate relationship if signing for patient)
(or Patient Representative)
(Date)
OFFICE SIGNATURE
Copy of this document available upon request
Notice of Privacy Practices
East Lake Acupuncture & Wellness LLC's Responsibilities
East Lake Acupuncture & Wellness, LLC (ELAW) is required by law to maintain the privacy of your protected health information. We must
provide you with notice of its legal duties and privacy practices with respect to your health information. We must also follow the terms of this
notice, which become effective on October 2, 2012.
YOU DO NOT NEED TO RESPOND TO THIS NOTICE
How ELAW Uses and Safeguards your Health Information
We use your health information to pay for your health services and to operate the Medicaid program. We may also use your health information to tell
you about treatment alternatives or other health related benefits and services.
The following are some examples of how we may use your health information:
 Your doctor may send medical release form requesting copies of your records. We will transmit your records only with a written, HIPAA
complaint consent form signed by you.
 We may send copies of progress note, lab results or other documents contained in your file to your insurance company to facilitate payment
of services.
 We may send appointment reminders for services.
ELAW may also use and disclose your health information as permitted by law, such as:
 To entities outside the agency only if the information is used to verify income, eligibility and the amount of public assistance payment.
 In responding to public emergencies, access to your health information may be granted to persons or agency representatives who are
subject to standards of confidentiality comparable to those of ELAW. Such other agencies may include the Federal Emergency
Management Agency (FEMA) or the Centers for Disease Control (CDC).
 To law enforcement, correctional facilities, medical examiners, funeral directors, and organ donor program personnel where disclosure
would determine eligibility for benefits, amount of medical assistance payment or otherwise assists the agency in the administration of the
Medicaid program.
 To the confidential Florida abuse hotline in order to report abuse, neglect and/or domestic violence as per criteria and conditions imposed
on the agency by law.
 For health oversight activities and/or administration of your insurance program, such as inspections, investigations and audits.
 As otherwise required by law.
Other uses or disclosures of your protected health information require your or your personal representative’s written authorization. At any time, you
may revoke such authorization in writing. If you cannot give your authorization due to an emergency, we may release your health information if it is
in your best interest.
Your Health Information Rights
You have the following rights with respect to your protected health information:
To see or obtain a copy of your health information that is maintained by ELAW. We may not be able to provide health information that includes
psychotherapy notes, is part of a legal case, or is otherwise excluded from disclosure by law. We may charge a copying fee.
To request that we amend health information we maintain that you believe is incorrect or incomplete.
To request a list of where we have sent your health information since October 02, 2012. The list may not include disclosures authorized by you,
disclosures for treatment, payment and health care operations or other disclosures permitted by law.
To request that we contact you at a different address or phone number, if contacting you about your health information at your present location would
endanger you.
To request that we limit the use and disclosure of your health information. We are not required to agree to your request.
Contact Information
If you have any questions, wish to make a request regarding your health information, or would like another paper copy of this notice, please contact
the ELAW at the telephone number listed below. We may ask you to make the request in writing.
Filing a HIPAA Complaint
If you believe your privacy rights have been violated by ELAW or one of its employees, you may file a complaint with ELAW and/or the Secretary
of the Department of Health and Human Services at the addresses below. You will not be retaliated against for filing a complaint.
Privacy Officer
Agency for Health Care Administration
2727 Mahan Drive, Mail Stop #5
Tallahassee, Florida 32308
850-488-3849
Secretary
Department of Health and Human Services
200 Independence Avenue, SW
Washington D.C. 20201
800-368-1019
Future Changes to the Notice of Privacy Practices
ELAW reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information that we
maintain. If we make a material revision to this notice, we will send a revised copy of the notice to recipient households within sixty (60) days of the
revision.
Community Acupuncture Privacy Policy Notice:
Community acupuncture is conducted in a communal setting. You will be surrounded by other people quietly receiving treatment at the
same time. Your intake interview will be conducted in a semi-private setting and we make our best efforts to avoid being overheard, but
due to the type of environment community acupuncture requires, it is possible others may overhear. If you are concerned about this,
you may want to consider foregoing the community acupuncture setting and booking a private appointment.
Copy of this document available upon request