FINANCIAL POLICY AGREEMENT
Please fill out and hit the "Submit" button at the end of the form
 

1. There is a $90 charge for each initial consultation with Dhyana.
2. There is a $60 charge for each follow-up visit with Dhyana.
3. Your customized program will often incorporate herbal formulas designed by Dhyana.
4. The   Golden Lotus Ayurveda does not bill insurance companies for services or herbs.
5. If you miss an appointment with Dhyana without giving 24 hours notice, a $50.00 fee is charged to your account.
 

I have read and understood the financial policies of   Golden Lotus Ayurveda.    Please initial to indicate understanding of the above financial agreement. Electronic signature is required below. 
 

Name:

Address:

City:   State:   Zip:

Telephone Home:   Cell:   Work:

E-mail: Birthdate: Age:

Marital/partner status:   # of children:   Ages:

Occupation:

How did you hear about   Golden Lotus Ayurveda?

Please tell us why you have chosen to have an Ayurvedic Consultation:

**Entering your name by typing in the box below will be considered the same as your signature:

Patient’s Signature:   Date:

INFORMED CONSENT
to authorize Complementary or Alternative Health Care through   Golden Lotus Ayurveda
Oregon

All Patients who participate in Ayurvedic health care through this program should be advised of the following information:

1.   Golden Lotus Ayurveda is not a Medical Clinic.

2. Dhyana is not trained in Western diagnosis or treatment and may not make suggestions about altering your medical care. Dhyana is not a medical doctor.      

3. In the State of Oregon, Ayurveda is a non-licensed profession. Its practice was formally legalized under the passage of Senate Bill 577 in January 2003.

4. If you are suffering from a disease or symptom that has not been evaluated by a Medical Doctor or another licensed health care professional, we recommend that you receive a proper evaluation and may provide you with a referral form. If Dhyana refers you to a Medical Doctor, you will be required to go or sign an acknowledgment that one was recommended to you.

5. Dhyana will not recommend altering your prescriptions without the approval of your medical doctor. Dyhana may suggest that you speak to your doctor about reducing medication when she feels that it is appropriate.

6. While Dhyana may take your blood pressure and vital signs, and perform some examination techniques similar to a routine medical examination, Dhyana is evaluating her findings from an Ayurvedic perspective only and not from a Western medical perspective. This examination does not take the place of a medical evaluation. If, as a result of their examination, any findings suggestive of a possible medical imbalance is found, Dhyana will refer you to a Medical Doctor for further evaluation.

I have read and understand the above information and give my permission to begin a program of Ayurvedic health care with Dhyana.

**Entering your name by typing in the box below will be considered the same as your signature:

Patient's Signature: Date:
 

CONFIDENTIAL PATIENT HISTORY

(1) PAST MEDICAL HISTORY
Include major conditions and dates of treatment and procedures performed.

a. Serious illnesses:

b. Hospitalizations:

c. Operations:       

d. List other pertinent past conditions:

e. Have you been under the care of a licensed health care professional in the past year?  Yes  No
If so, for what reasons:

f. Have you had any cosmetic surgery or procedures performed?  Yes  No

If so, please list with dates:
 

(2) FAMILY HISTORY
Indicate what members of your immediate family have had these conditions. (Go back one generation)
(If adopted, answer according to family heritage, if known.)

High Blood Pressure:   Heart Disease: 

Other:

Cancer:   Mental Disorder:

Stroke: Diabetes:

(3) ALCOHOL, TOBACCO AND SUBSTANCE USE PRACTITIONER NOTES:

a. Do you drink alcoholic beverages?  Yes  No
If yes please answer the following:
how often:  Daily   Several times weekly   Several times monthly   Seldom   Never
I usually choose:   Beer   wine   sweet or hard liquor   mixture  None

b. Have you ever smoked tobacco?  Yes   No   If yes, how much per day?
If you have quit smoking,  when did you quit?

c. Any current or past use of addictive or habitual substances?   Yes   No 
 (Note: This will be kept confidential)

Please list all substances (either current or long-term past usage):

(4) REGULAR PRACTICES

EXERCISE/HATHA YOGA
(Specify)  None/Never   Occasional   Several times per month  Several times per week   Daily

TEAM SPORTS/RECREATION
(Specify)    None/Never  Occasional   Several times per month   Several times per week  Daily

TRAVEL
(Include commute if applicable)  None/Never  Occasional   Several times per month  Several times per week   Daily

SPIRITUAL PRACTICES
(Specify)    None/Never  Occasional   Several times per month   Several times per week  Daily

MEDITATION/PRAYER/PRANAYAMA
(Specify)    None/Never  Occasional   Several times per month   Several times per week  Daily

OTHER
(Include creative activities)  None/Never  Occasional   Several times per month   Several times per week  Daily

(5) SEXUAL ACTIVITY

According to Ayurveda, a person’s level of sexual activity impacts health and well-being in the same way as other aspects of daily life--such as diet or sleep.

a. How often do you engage in sexual activity (include sex with partner and masturbation): 
Daily   Several times per week   Several times per month   Occasionally   Not at all

b. Is your current sexual activity satisfactory?  Yes   No

(6) FOOD CHOICES

What types of foods do you eat on a regular basis?

BREAKFAST:

LUNCH:

DINNER:

SNACKS:

(7) DAILY LIQUID INTAKE (Indicate number off 8 ounce cups per day)

Plain water:    Caffeinated Coffee/Tea:   Herbal Tea or Juice:   Cow or Goat Milk:   Decaffeinated Coffee/Tea:

Soda or pop:   Grain/nut/soy milk:

(8) HABITUAL EATING PATTERNS
Describe any current or past eating patterns or any other food related issues.

(9) DAILY SCHEDULE (include approximate times)
What are your habitual activities from the time you wake up until you go to sleep? Include mealtimes, sleeping, exercise, work, and any activities that occur on a regular basis.

TIME HABITUAL ACTIVITIES:

MORNING
Awaken:

Mealtime:

Activities:

DAY
Mealtime:

Activities:

NIGHT
Mealtime:

Activities:

Bed-time:

(10) ALLERGIES OR SENSITIVITIES

Do you have allergic reactions to any substances (including food, pollens, medicines)?  If yes, please list.

(11) CHALLENGING PATTERNS

A. DIGESTION  PROBLEMS
Please indicate any digestion patterns that you find challenging by assigning a
Frequency (a number from 1 to 3) and Intensity (a number from 1 to 10):

B. ELIMINATION  PROBLEMS
Please indicate any elimination patterns that you find challenging by assigning a
Frequency (a number from 1 to 3) and Intensity (a number from 1 to 10):

C. EMOTIONS
Please indicate any emotional patterns that you find challenging by assigning a
Frequency (a number from 1 to 3) and Intensity (a number from 1 to 10):

(12) ADDITIONAL SYMPTOMS OF CONCERN
[please give frequency (1-3) and intensity (1-10)]

(13) PREVIOUSLY DIAGNOSED & CURRENT CONDITIONS
Please describe symptoms of diagnosed condition

WHAT YOU CAN EXPECT FROM YOUR AYURVEDIC HEALTH CARE

Ayurveda is a natural healing system that has been successfully practiced for thousands of years. Originating in ancient India, this medical tradition states that each person’s path toward optimal health is unique--because each person is unique. The healing programs we offer at   Golden Lotus Ayurveda are based on effective, time-honored principles that focus on understanding your particular body-mind constitution and the unique nature of your imbalance.

Each individualized program is formulated by Dhyana who has completed at least 600 hours of instruction at California College of Ayurveda. Your program may include lifestyle adjustments, dietary changes, herbs, color therapy,sound therapy, aroma therapy, massage therapy, and other natural therapeutics. In order to successfully implement these Ayurvedic principles into your life, frequent regular follow-up visits with Dhyana are recommended over a six to twelve-month period.

The goal of all Ayurvedic programs is to create within your body and mind an optimum environment for healing to take place and to maximize your body's ability to heal itself.

**Entering your name by typing in the box below will be considered the same as your signature:

Patient's Signature: Date:

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