Thermal Female Non Breast

All About Herbs Thermal Imaging New Client Intake Form

Name*

Date of Birth*

Date

Age*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

How did you hear about us?

Current Concerns or Symptoms

Diagnosed medical problems high blood pressure diabetes arthritis cancer etc

Infusion port or internal device Breast thermals will need to be rescheduled 90 days after port is removed

Previous surgeries or Biopsies Dates

Date

Current medications Prescriptions only

Family History

This information is confidential. All information is correct and current to my knowledge. No medical information has been intentionally been omitted for the purpose of this report. Doctors need full disclosure to make an accurate reading. Thermograms are not a replacement for mammograms. Please call 907-376-8327 if you have questions or need to reschedule.

Signature*

Date*

Date

Authorization to Use or Disclose Protected Health Information All About Herbs

Patient Name*

Address*

Date of Birth*

Date

Date of Request

Date

As required by the Privacy Regulations, All About Herbs may not use or disclose your protected health information except as provided in our Notice of Privacy Practices without your authorization.

I hereby authorize this office and any of its employees to use or disclose my Patient Health Information to the following person(s), entity(s), or business associates of this office:

EMI, Electronic Medical Interpretations

Patient Health Information authorized to be disclosed: Thermal Images and related health history

For the specific purpose of (describe in detail) Interpretation of said images

Effective dates for this authorization: This authorization will expire at the end of the above period.

I understand I have the right to:

1.Revoke this authorization by sending written notice to this office and that revocation will not affect this office's previous reliance on the uses or disclosure pursuant to this authorization. 2.Knowledge of any remuneration involved due to any marketing activity as allowed by this authorization, and as a result of this authorization. 3.Inspect a copy of Patient Health Information being used or disclosed under federal law. 4.Refuse to sign this authorization. 5.Receive a copy of this authorization. 6. Restrict what is disclosed with this authorization.

Signature or Patient or Patients Authorized Representative*

I also understand that if I do not sign this document, it will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits whether or not I provide authorization to use or disclose protected patient health information.

Date*

Date

Patient Name*

Address*

Date of Birth*

Date

Date of Request

Date

As allowed by the Privacy Regulations, I wish for this office to provide the following "Alternative" means of communicating my Protected Health Information:

If appropriate, please contact me at the following address:

If appropriate please contact me by telephone at the following number

If appropriate please contact me by fax at the following number

If appropriate please contact me by Email at the following Email address: ***A FREE report can be emailed to you, or mailed for a fee.****

example@example.com

I have the following additional requests for confidential communications regarding my Protected Health Information: (Please explain)

I understand that there may be additional costs associated with this request and I agree to reimburse this office for such costs.

Signature*

Date*

Date

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

All About Herbs is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. Disclosure of Your Health Care Information We only submit your health information to EMI for the sole purpose of interpreting you thermal scans. We only submit your EMI Report to you at the mailing or email address you have provided. We do not share your information with anyone else, unless we are required to do so by law. Marketing and Contact. As a courtesy we may contact you via telephone, text message or email to remind you of your appointment, or to remind you to make a follow up/annual appointment. We will not include any personal health information in these messages. We will not use your information for any marketing, unless you request to be on our newsletter email list. Change of Ownership. In the event that All About Herbs is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information Rights You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that All About Herbs is not required to agree to the restriction that you requested. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request. You have the right to inspect and copy your health information. You have a right to request that All About Herbs amend your protected health information. Please be advised, however, that All About Herbs is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s)and information about how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your protected health information made by All About Herbs. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request. Changes to this Notice of Privacy Practices All About Herbs reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, All About Herbs is required by law to comply with this Notice. All About Herbs is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Dawn Nelson by calling the office at 907-376-8327. If Dawn Nelson is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. Complaints Complaints about your Privacy rights, or how All About Herbs has handled your health information should be directed to All About Herbs by calling the office at 907-376-8327. If All About Herbs' manager is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building Washington, DC 20201

This notice is effective as of

Patients Name print*

I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide All About Herbs with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice

Patients Signature*

Date*

Date

Confidential Questionnaire for Women's Health Check

NAME*

Date of Birth*

Date

Please mark YES or NO as it applies to you:

Any close relatives ever had breast cancer?

YesNo

Ever been diagnosed with breast cancer?

YesNo

Diagnosed with any other breast disease, (Fibrocystic, Mastitis, Cystic, Abscess)?

YesNo

Any biopsy or surgery to your breasts?

YesNo

Cosmetic surgery to breast, (implants, reduction, lift)?

YesNo

Do you have dense breast tissue?

YesNo

Have you had a mammogram in the past 12 months?

YesNo

Have you had more than 30 mammograms in your lifetime?

YesNo

Mammogram in the past 5 years?

YesNo

If yes, when?

Date

Any abnormal results from any breast testing?

YesNo

Ever taken a contraceptive pill for more than 4 years?

YesNo

Ever diagnosed with ovarian, uterine or cervical cancer?

YesNo

Ever taken hormone replacement therapy, (pharmaceutical or bio-identical)?

YesNo

Do you have an annual physical breast examination by a doctor?

YesNo

Do you preform a monthly breast self-exam?

YesNo

Did your periods start before the age of 12?

YesNo

Did your periods end after the age of 50?

YesNo

Are you still having a menstrual cycle?

YesNo

Have you ever given birth to a child?

YesNo

Have you ever smoked for more than 5 years?

YesNo

Is your menstrual cycle irregular?

YesNo

Do you experience cramping during your menstrual cycle?

YesNo

Do you have heavy bleeding with your menstrual cycle?

YesNo

Do you have breast pain or tenderness that comes and goes?

YesNo

Do you have any breast lumps that come and go?

YesNo

Do you have a low libido, (low sex drive)?

YesNo

Do you have hot flashes?

YesNo

Confidential Questionnaire for Women's Health Check

Please mark YES or NO as it applies to you

Have you ever been diagnosed with endometriosis?

YesNo

Have you ever been diagnosed with PCOC, (poly cystic ovarian syndrome)?

YesNo

Have you ever been treated for infertility?

YesNo

Do you have any swelling in the neck or trouble swallowing?

YesNo

Any thyroid disorder, (hypothyroid, hyperthyroid, Hashimoto's, Grave's disease)?

YesNo

Do you regularly experience fatigue?

YesNo

Have you experienced recent hair loss?

YesNo

Have you recently had any of these breast symptoms?

Mark Right Breast or Left Breast as it applies

Pain

Right BreastLeft Breast

Tenderness

Right BreastLeft Breast

Lumps

Right BreastLeft Breast

Changes in breast size

Right BreastLeft Breast

Areas of skin thickening or dimpling

Right BreastLeft Breast

Secretions of the nipple

Right BreastLeft Breast

Have you had any type of Vaccination in the last 4 weeks?

Left ArmRight ArmNo

I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report. By signing below, I certify that I have read and understand the statements above and consent to the examination.

Signature*

Date*

Date

Thermal imaging is:

Non Invasive

No Radiation is Emitted

Painless

FDA Cleared

Preparation for your scan is simple but critical to the accuracy of the results. Please be advised. failure to follow these simple guidelines will require us to reschedule your appointment and FEES WILL APPLY if we are unable to proceed with your originally scheduled time slot.

Before the appointment.

Fill out the required forms online

Avoid strong sunlight exposure the day of, and sunburn in the days preceding your appointment

No massage, chiropractic adjustments. acupuncture. physical therapy, infra-red saunas the day of your scan

Avoid the application of creams. liniments, oils. or lotions, including but not limited to perfume and cologne

No smoking for a minimum of 2 hours prior to your scan No vigorous exercise 2 hours prior to your scan.

Remove all jewelry and earrings

Long hair should be wom up

It is very important to wear loose fitting clothing. The thermography scan will be delayed until irritation marks in the skin caused by tightly fitting garments have dissipated.

Deodorant and light make up ARE permitted

At the clinic

Arrive a few minutes early to your appointment. Your body will take some time to adjust to the temperature of the room. You will be given a cover to change into, as you will be disrobing down to your underwear. Speedo type undergarments or thongs are appropriate for both men and women. You will meet your thermographer who will explain and demonstrate the required views and positions necessary for your scan. Thermal images are then taken of either the whole body or just the regions of interest. Neurological testing can include a cold stress test which simply involves placing a hand or foot in a cool bowl of water or having a gel pad applied to any part of the body. You are welcome to bring a friend, partner or spouse into the imaging room for the scan.

REQUEST FOR ALTERNATIVE COMMUNICATIONS