1. health and fitness
2. disorders

Ayurveda Simple ~ Teri Adolfo, LAc.
[email protected]
Client Information
Patient Name: ______________________________________________________
Today’s Date: _______________
Address: ____________________________________ City: ________________ State: _______ Zip: _____________
Gender:
О Female
O Male
Check appropriate box:
O Partner
Date of Birth: _______________________
O Single
O Married
O Divorced
Age:____________
O Widowed
O Separated
Primary phone: _____________________Secondary: ______________________Email address: __________________
Can we leave detailed messages? Yes
No
What number is best to use? ________________________________
Spouse/Partner or parent’s name: ___________________________________ Phone: __________________________
Patient’s Primary Care Physician? ___________________________________ Phone: __________________________
Business Address: ____________________________________ City: ________________ State: ____ Zip: _________
Whom may we thank for referring you? ________________________________________________________________
Person to contact in case of an emergency: _____________________________ Phone: ________________________
Responsible Party
Name of person responsible for this account: _______________________________ Relationship: __________________
Address: _______________________________________________________ Home Phone: ______________________
Birthdate: _______________ Employer: ___________________________ Business Phone: ________________________
Business address: ___________________________________________________________________________________
Insurance Information
Subscriber name: _____________________________________ Relationship to patient: _________________________
Date of Birth: _____________ Insurance company: _________________________ Phone: ______________________
What is your deductible? ____________ How much have you used? ___________ Copay: _______ Coinsurance ______
Subscriber ID# ___________________________ Group #___________________ Visits per year: ______ Used? ______
Secondary Insurance:
Subscriber name: _____________________________________ Relationship to patient: _________________________
Date of Birth: _____________ Insurance company: _________________________ Phone: ______________________
What is your deductible? ____________ How much have you used? ___________ Copay: _______ Coinsurance ______
Subscriber ID# ___________________________ Group #___________________ Visits per year: ______ Used? ______
I authorize release of any information concerning my (or my child’s) health/mental health care, advice and
treatment provided for the purpose of evaluating and administering claims for insurance benefits.
X__________________________________________
Signature of patient (or parent if minor)
_____________________
Today’s Date
Active Wellness (Teri Adolfo, L.Ac.)
What are the concerns for which you are seeking care? (Primary concern first)
1. _____________________________________________________________ Date of onset: _____________
2. _____________________________________________________________ Date of onset: _____________
3. _____________________________________________________________ Date of onset: _____________
4. _____________________________________________________________ Date of onset: _____________
What factors may make it difficult for you to achieve your personal health goals?:
_____________________________________________________________________________________________
Who is your primary care physician? _______________________________________________________________
(Name)
(Phone if known)
For what concern did you last receive health or medical care? ___________________________________________
Medications and Supplements
List all Prescription and over the counter medicines (Brand and dosage) ____________________________________
______________________________________________________________________________________________
Do you, or have you ever, taken any form of Birth Control? (Brand & dosage) ________________________________
Which herbal, homeopathic, and/or natural supplements do you use? Please, include brand and dosage:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Habits
Habit
Alcohol
Tobacco
Street Drugs
Caffeine
Salt Intake
Sugar Intake
Exercise
Other _______
Heavy
Moderate
Light
None
Comments
Family History
Indicate if there have been any of the following diseases in your family including; parents, aunt/uncle,
grandparents, siblings and children. Indicate the number of relatives who have the disease.
Cancer______________________
Diabetes_____________________
Epilepsy______________________
Heart Disease________________
High BP_____________________
Stroke _______________________
Anemia _____________________
Kidney Dz ___________________
Glaucoma ____________________
Allergies ____________________
Asthma _____________________
Mental Illness _________________
Arthritis _____________________
TB _________________________
Alzheimer’s___________________
Father
Mother
Brothers
Sisters
Children
Maternal
Grandparents
Paternal
Grandparents
Ages
(if living)
Current
health
Age at
Death
Cause of
Death
Have you had any of the following Childhood Illnesses (check if yes)
Scarlet fever ____ Diphtheria ____ Rheumatic fever ____ Mumps ____ Measles ____ German Measles __
Have you had any immunizations?
Yes
No Negative Reactions? _____________________________
Hospitalizations, Surgery, X-Ray and Special Studies
What hospitalizations, surgeries, X-rays, or special studies have you had?
Year: ___ What:
______
Year: ____ What:
Year: ____ What:
______
Year: ____ What:
______
Have you experienced significant traumas? If so, please explain: ____________________________________
________________________________________________________________________________________
Allergies
Are you hypersensitive or allergic to foods, drugs, or environmental substances? Please list:
________________________________________________________________________________________
Weight
Max Weight
lbs.
lbs.
Height
When
General
Weight 1 year ago
lbs.
Blood Type _____________
Review of Symptoms
Pain/Stress
Please circle and/or shade in areas where you are experiencing pain or distress (if applicable).
Include date of onset and level of pain (using scale 1-10, 10= worse).
Stress and Pain Relief
What activities do you participate in that bring you stress and/or pain relief (Include hobbies, passions)
______________________________________________________________________________________
______________________________________________________________________________________
How often you make time for yourself?
______________________________________________________________________________________
______________________________________________________________________________________
Review of Symptoms
Check any of the following you have or have had in the past 6 months.
SKIN
___Rashes
___Eczema, Hives
___Acne, Boils
___Itching
___Fungal Infections
___Color change
___Hair Loss
___Dry skin / scalp
___Lumps
___Night Sweats
___Slow healing ulcerations
HEAD / NECK
___Headache/migraine
___Faintness
___Dizziness
___Jaw Pain
___Swollen Glands
___Goiter
___Pain or stiffness
___TMJ
___Flushing or hot flashes
___Wheezing
___Asthma
___Bronchitis/Pneumonia
___Emphysema
___Difficulty/Pain breathing
___Shortness of breath
___Tuberculosis
___Cough ___Wet or ___Dry
___Coughing blood
NOSE AND SINUSES
___Frequent colds
___Nose Bleeds
___Stuffiness
___Hay fever
___Sinus problems
___Loss of smell
EYES AND EARS
___Itchy eyes
___Watery eyes
___Dry eyes
___Swollen/painful eyes
___Red Eyes
___Impaired vision/Blurriness
___Floaters in vision
___Cataracts
___Color blindness
___Double Vision
___Glaucoma
___Hearing difficulty
___Ringing
___Earaches/Infection
MOUTH AND THROAT
___Sore throat
___Excessive saliva
___Teeth grinding
___Sore tongue/lips
___Gum problems
___Hoarseness
___Gagging/choking
___Difficulty swallowing
RESPIRATORY
___Chest congestion
CARDIOVASCULAR
___Heart disease
___Angina/Chest pain
___High/Low Blood Pressure
___Murmurs
___Blood clots
___Irregular heart beat
___Palpitations/Fluttering
___Swelling in ankles
CIRCULATION
___Easy bleeding or bruising
___Anemia
___Deep leg pain
___Varicose veins
___Cold hands/feet
ENDOCRINE
___Hypothyroid
___Heat or cold intolerance
___Hypoglycemia
___Diabetes
___Excessive thirst
___Excessive hunger
___Fatigue
___Seasonal depression
IMMUNE
___Chronic infections
___Chronically swollen glands
___Slow wound healing
MUSCLES / JOINTS/ BONES
___Joint pain
___Muscle pain
___Muscle spasms / cramps
___Restless leg Syndrome
___Sciatica
___Osteoporosis/Osteopenia
___Fibromyalgia
NEUROLOGIC
___Seizures
___Paralysis
___Muscle weakness
___Numbness or tingling
___Easily stressed
___Vertigo or dizziness
___Loss of balance
___Tics
DIGESTION
___Trouble swallowing
___Heartburn / Acid Reflux
___Change in thirst/appetite
___Ulcer
___Nausea/Vomiting
___Gas/Bloating
___Belching or passing gas
___Diarrhea
___Constipation
___Pain or cramps
___Mucous in stools
___Black / Bloody stool
___Hemorrhoids
___Itchy / Burning Anus
___Rectal Pain
___Liver/Gall Bladder trouble
___Jaundice (yellow skin)
Bowel Movements: How
often?___
Is this a change? _____________
Stools ___Hard ___Firm
___Soft ___ Loose
Review of Symptoms
Check any of the following you have or have had in the past 6 months.
URINARY
___Pain on urination
___Increased frequency
___Frequency at night
___Frequent infections
___Inability to hold urine
___Kidney stones
___Blood in urine
MENTAL/ EMOTIONAL
___Mood Swings
___Anxiety or nervousness
___Considered/Attempted suicide
___Depression
___Poor concentration
___Poor Memory
___Panic
___Other__________________
GENERAL
___Poor Sleep / Insomnia
___Disturbed Sleep
___Fatigue / Low Energy
___Do you generally feel Hot?
___Do you generally feel Cold?
___Chills
___Fevers
___Poor Appetite
___Constant Hunger
___Cravings ___________
___Peculiar taste in mouth
___Low Libido
___Experience High Stress
___Chronic Fatigue Syndrome
MALE ONLY
___Hernias
___Testicular masses
___Testicular pain
___Prostate disease
___Sexually transmitted disease
___Discharge or sores
___Sexual dysfunction
Are you sexually active? Yes No
Sexual orientation? ____________
Birth control? Type? __________
FEMALE ONLY
___Irregular cycles
___Bleeding between cycles
___Pain during intercourse
___Clotting
___Heavy or excessive flow
___PMS
___Endometriosis
___Difficulty conceiving
___Painful menses
___Vaginal discharge? Color? ______
___Vaginal Odor
___Ovarian cysts
___Menopausal symptoms
___Abnormal PAP
___Sexually transmitted disease
___Breast pain/tenderness
___Nipple discharge
___Breast Lumps
Age at which menses began
_______________
Age of last menses (if menopausal) _______________
Length of Cycle (Day 1 to Day 1)
_______________
Duration of Flow
_______________
Date of last period
_______________
Are you sexually active?
Yes No
Sexual orientation?
_______________
Birth control? Type?
_______________
Number of pregnancies
_______________
Number of live births
_______________
Number of miscarriages
________________
Number of abortions
_______________
Difficult or premature births?
_______________
Could you be pregnant now?
______________
Do you do breast self-exams?
Yes No
Date of last Pap smear
_______________
Date of last mammogram
______________
Any other feminine difficulties?
____________________________________________
____________________________________________
____________________________________________
Ayurvedic Constitution Quiz
Determining Your Dominant Ayurvedic Psychophysiological (Mind-Body) Constitutional Type: Vata, Pitta or Kapha
The following simple test will give you a fairly good idea of the levels of your doshas. We have to remember that
everyone has all three doshas, but in varying degrees. After reading each description, mark 0 to 7 in front of the
question. Note that values 2 and 5 are not assigned at all (don't use them).
0, 1 = Does not apply
3, 4 = Applies sometimes
6, 7 = Applies most of the time
Evaluating My Vata
Physical Attributes:
1. My physique is thin - I don't gain weight easily.
2. I am quick and active.
3. My skin is usually dry, more so in winter.
4. My hands and feet are usually cold.
5. My energy fluctuates and comes in bursts.
6. I usually develop gas or constipation.
7. I usually have difficulty falling asleep or having a sound night's sleep.
8. I am uncomfortable in cold weather.
Mental, Emotional, and Behavioral Attributes:
9. My nature is lively and enthusiastic.
10. I have difficulty memorizing things and remembering them later.
11. It is easy for me to learn new things quickly, but I also forget quickly.
12. I am not good at making decisions.
13. I am anxious or worrisome by nature.
14. People think I'm talkative and that I talk quickly.
15. I am usually emotional by nature and my moods fluctuate.
16. My mind is restless, but also imaginative.
17.I have irregular eating and sleeping habits.
Total Vata:
Evaluating My Pitta
Physical Attributes: .
1.
2.
3.
4.
5.
6.
7.
8.
9.
My hair is fine, straight, light, blonde, red, graying early, or balding.
I don't tolerate hot weather.
I sweat easily.
I can't tolerate delaying or skipping a meal.
My appetite is very good and I can eat big meals.
My bowel movements are regular. I might have occasional loose stool but not much constipation.
I like cold drinks and such foods as ice cream.
I often feel hot:
Spicy, hot foods upset my stomach
Mental, Emotional, and Behavioral Attributes:
10. I consider myself efficient.
11. I try to be organized and accurate.
12. I have a strong will and my friends think I am stubborn.
13. I am impatient by nature.
14. I tend to become irritable or angry quite easily.
15. I try to be meticulous and am a perfectionist by nature.
16. I get angry easily, but I don't hold a grudge.
17.I am usually critical of myself and others.
Total Pitta:
Evaluating My Kapha
Physical Attributes:
1. It is easy for me to gain weight but difficult to lose.
2. Skipping meals is easy for me and does not cause any problems.
3. I tend to have congestion, mucus, or sinus problems.
4. I'm a sound sleeper.
5. I have thick, oily, dark, wavy hair.
6. My skin is smooth and soft with an almost pale complexion.
7.My body frame is large and solid with a heavy bone structure.
S. My digestion is slow, so I feel full after eating.
9. I have a steady energy level with good endurance and strong stamina.
10. I'm sensitive to cool and damp weather.
Mental, Emotional, and Behavioral Attributes:
11. I tend to be slow, methodical, and relaxed. . .
12. I need to sleep a minimum of eight hours to feel well the next morning.
13.By nature I am calm and composed. I don't get angry easily.
.
14. I am not a quick learner but I am good at memorizing things and remembering them later.
15. Many people consider me affectionate, forgiving, and peaceful.
16. I usually oversleep and have difficulty waking up the next morning.
17.I am very reluctant to take on new responsibilities.
Total Kapha:
My total scores are:
Vata
Pitta
Kapha
I am ________ first, ________ second, and ________ third
Active Wellness (Teri Adolfo, L.Ac.)
4206 Stone Way North, Seattle, WA 98103
Tel: (425) 672-7559 Email: [email protected]
Patient Financial Agreement
Cancellation Charge:
• We request and appreciate a minimum of 24 hour notice.
• A fee of $50 will be charged if 24 hour notice is not given.
Payment:
• Payment for visit co-pays and/or medication and supplements is to be rendered at time of service and
can be made by cash, check, debit or credit.
• There is a minimum billing fee of 12% APR for account balances due beyond 30 days.
• There is a $35 NSF fee on all returned checks.
• Patients will be held responsible for non-payment by their insurance company. Accounts unpaid by
the insurance company greater than 90 days will be billed to the patient.
• Outstanding balances greater than 120 days will be turned over to a collection agency unless prior
arrangements have been made with the Emerald Center in writing.
Active Wellness is committed to providing quality care for your acupuncture needs. Our office appreciates your
patronage.
IF I HAVE INSURANCE, I UNDERSTAND THAT I AM RESPONSIBLE TO READ MY MEDICAL BENEFIT
BOOK AND UNDERSTAND IT. WHEN APPLICABLE, I AM RESPONSIBLE TO PAY A PERCENTAGE OF
THE COST OF MY VISIT AT THE TIME OF TREATMENT. I AGREE THAT I AM FULLY RESPONSIBLE FOR
THE TOTAL PAYMENT OF ALL PROCEDURES PERFORMED IN THIS OFFICE. THIS INCLUDES ANY
TREATMENT THAT IS NOT A BENEFIT OF ANY MEDICAL INSURANCE THAT I MAY HAVE
I, ________________________________________________ agree to the above defined financial policies of
Active Wellness. In the case of default of payment, I am responsible for full payment of the balance, interest
accrued, and any collection costs and legal fees incurred to collect on this account.
I, the undersigned, have read, understand, and accept the information and conditions specified in this document.
____________________________
Patient’s Signature
__________________________________
Printed Name
_____________________
Today’s Date
Active Wellness (Teri Adolfo, L.Ac.)
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
Dear Patient:
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose
your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this
acknowledgement, if you wish.
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
_________________________________________
_________________________
Please print your name here
Date
_________________________________________
Signature
Can we put you on our monthly email list for specials and newsletters?
Please provide the best email here: ______________________________
If you would not like to be put on our email list please check here:
Is there anyone you would like to be able to request medical information on your behalf?
Yes__ Please, print first and last name of the person _______________________________________ No__
FOR OFFICE USE ONLY
We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:
The patient refused to sign.
Due to an emergency situation it was not possible to obtain an acknowledgement.
We weren’t able to communicate with the patient.
Other (Please provide specific details)
________________________________________________________________________________________________________________
____________________________________________________
Employee/Practitioner signature
___________________
Date