Make an Appointment
Please Call: 408.583.7964 for an appointment.
Monday: 10am-6pm
Wednesday: 1pm-7pm
Thursday 10am-7pm
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Complimentary Analysis of your Health
Complimentary Health Analysis: Gain insight on how Chinese Medicine can help you
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Complimentary Health Analysis
Health History Questionaire for Patients
HEALTH HISTORY QUESTIONNAIRE FOR PATIENTS
Self-Assessment Health Profile
Please download this Complimentary Self-Assesment Health Profile.
This profile can be used as an educational device as well as a diagnostic tool. It will aid you in becoming acquainted with the language of Chinese medicine. Check the symptoms you have experienced during the last six months. (Example:.L fatigue) Circle those that have been most troublesome. Example: (l) indigestion)
PATTERNS OF DEPLETION
DEFICIENT QI weak, lethargic, weary lowered libido apathy dull thinking or feeling excessive need for sleep susceptible to colds, flus, allergies prolonged recovery following illness pasty, pale complexion shortness of breath aversion to talking perspires easily with exertion easily chills frequent, profuse urination
SLACK QI perspires easily while at rest atony or prolapse of stomach, intestines, anus constant diarrhea or lack of bowel control hemorrhoids, varicose veins dizzy or weak after meal or bowel movement well-being followed by sudden exhaustion
DEF:;~~~~ ~~::TURE ® extreme dryness of skin or mucous membranes scant secretions and urination constipation uncomfortable feeling of heat in the body low afternoon fever with sweating hot flashes night sweats unstable blood sugar, emotional lability persistent dry cough dry sore throat flushed face
SLACK MOISTURE 0 excessive secretions from eyes, nose, mouth, skin, vagina seminal incontinence or premature ejaculation frequent urination or incontinence dizzy or weak after sex (female)
DEFICIENT BLOOD restless fatigue emotional sensitivity insomnia and anxious sleep itching, prickling skin or scalp dryness without thirst _ blurred or weak vision thinning of hair light headed when fatigued dry or hard stool dry skin, eyes, hair. nails anemIa muscle cramps lack of semen scanty or infrequent menstruation insufficent lactation pale, sallow complexion poor skin healing _ palpitations postpartum weakness or anemia tendency to miscarry dizzy or weak after sex (male)
SLACK BLOOD ~ easy bruising or bleeding ~ _ chronic ulcers of mouth, throat, stomach, intestines, vagina excessive bleeding during menses. pregnancy, postpartum or menopause bleeding hemorrhoids and blood in stool. urine. or sputum
DIMINISHED ESSENCE rH\ profound weakness ~ flaccid and stiff atrophy of muscles and organs ... sagging or wrinkling of skin diminished sexual arousal and pleasure infertility or early menopause repeated miscarriages loosening or loss of teeth thinning or graying of head and pubic hair .. loss of elasticity of tendons, ligaments. and muscles decline of memory, vision or hearing progressive loss of weight or emaciation arthritic changes compromised immunity
What to expect on your first visit
Welcome to The True Chi Clinic. Below we describe what you can expect to experience during and after your appointment with your practitioner of Classical Chinese Medicine and we outline some suggestions to maximize the effectiveness of your treatment.
THE VISIT____________________________________________________
Your appointment will last 45 minutes to an hour.
In the first 15 minutes, your practitioner will follow up on the information on your intake form and ask questions about your health and problems you may be having. These questions, and your answers, allow your practitioner to arrive at a traditional Chinese medical diagnosis on which your treatment will be based. The diagnosis will include looking at your tongue and checking the pulse on both wrists.
Although acupuncture and herbs may be used with other forms of treatment, you should let your practitioner know if you are taking any medications or other herbal supplements.
After the initial interview, you will be asked to lie down. Approximately 4 to 20 acupuncture points will be cleaned with alcohol and the practitioner will then insert very thin, sterile, disposable needles. Usually the patient feels little or no sensation or discomfort. A Heat lamp is available if you feel cold.
The needles will be left in 20-30 minutes. During this time, the practitioner will check on you once or twice. Most people find the treatment very relaxing and many meditate or sleep. Should you, however, feel any discomfort, be sure to tell your practitioner right away and an adjustment will be made.
In Classical Chinese Medicine, herbs are an essential part of the treatment and the practitioner will ask if you are interested in receiving herbal therapy.
At the end of your rest, the needles will be removed and the practitioner will describe in detail how the herbs are to be prepared and taken. The practitioner may also give you dietary recommendations and will propose a treatment plan for continued treatment of your health problem.
The practitioner will escort you back to the reception desk and will address any last questions or concerns you may have.
AFTER THE VISIT______________________________________________
1 Plan to take it easy after your treatment.
2 Sometimes after receiving an acupuncture treatment you may feel a little light headed. If that is the case, please sit for a while in the waiting room. In a few minutes you'll feel relaxed and clear headed.
3 It's best if you do not come to your appointment on an empty or too full stomach.
4 Herbal prescriptions and herbal patent medicines are intended only for the person for which they are prescribed. Do not give herbal formulas to anyone else.
5 Very rarely, symptoms may become worse for a while following an acupuncture treatment. This is often a sign that previously dormant conditions are being awakened so that healing may occur. This should pass quickly. If you have any questions or concerns at any time, please contact the clinic.
Dear Patients:
Below is a copy of the Notice of Privacy Practices, which we are required by law to provide to you.
HIPAA (Health Insurance Portability and Accountability Act) was established by Congress to develop national safeguards to protect the confidentiality of patient medical information. The Privacy Section of this law was put into effect on April 14, 2003.
Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice.
Please sign the acknowledgment of receipt to indicate that you have received the notices for you and other minor family members and/or dependents who receive care at our clinic.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED BY Center for East West Medicine AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CAREFULLY
What is this Notice and Why is it Important?
This notice is required by law to inform you of how your health information will be protected, how Center for East West Medicine may use or disclose your health information, and about your rights regarding your health information. If you have any questions about this notice, please contact Five Branches Clinic Privacy Officer atus at (408)-583-7964.
Understanding Your Health Information
Each time you visit our Clinic, a record of your visit is made. Typically, this record contains a description of your symptoms, medical history, examination and test results, diagnosis, treatments, °a and a plan for future care. This information, referred to as your medical record, serves as a:
Basis for planning your care and treatment Means of communication among the health professionals who contribute to your care Legal documents of the care you receive Means by which you or a third-party payer (e.g. health insurance company) can verify that services you received were appropriately billed
- A data source for medical research and public health
- A source of data for planning facilities, marketing healthcare services and fundraising
- A tool for education health professionals
- A tool with which we can assess and work to improve the care we provide
Understanding what is in your record and how your health information is used helps you to ensure its accuracy; better understand how others may access and use your health information; and make more informed decisions when authorizing disclosures to others.
Your Health Information Rights
You have the following rights related to your medical and billing records kept at Center for East West Medicine Clinic:
Obtain a copy of this notice. You will receive a copy of this notice at your first visit after its publication. Thereafter you may request a copy of this notice or any revisions from the Front Desk Receptionists or by calling (408) 583-7964..
Authorization to use your health information. Before we use or disclose your health information, other than as described below, we will obtain your written authorization, which you may revoke at any time to stop future use or disclosure.
Access to your health information. You may request a copy of your health information that our clinic keeps in your medical or billing record. Your request must be submitted in writing. We may charge for the costs of providing you access and for your copies.
Amend your health information. If you believe that the information we have about you is incorrect or incomplete, you may request that we correct or add information. Your request must be in writing and you may request a form for this purpose by calling (408)583-7964.
Request confidential communications. You may request that when we communicate with you about your health information, we do so in a specific way (e.g. at a certain mail address or phone number.) We will make every reasonable effort to agree to your request.
Limit our use or disclosure of your health information. You may request in writing that we restrict the use or disclosure of your health information for treatment, payment, health care operations, or any other purpose except when specifically authorized by you, when we are required by law, or in an emergency situation in order to treat you. We will consider your request and respond, but we are not legally required to agree if we believe your request would interfere with our ability to treat you or coiled payment for our services.
Accounting of disclosures. You may request a list of disclosures of your health information that we have made for reasons other than treatment, payment or health care operations. Disclosures that we make with you authorization will not be listed. We will provide one list per year free of charge, but will charge for subsequent lists in the same year.
Our Responsibilities
We are required by law to protect the privacy of your health information, establish policies and procedures that govern the behavior of our workforce and business associates, and provide this notice about our privacy practices, and abide by the terms of this notice.
We reserve the right to change our policies and procedures for protecting health information. When we make a significant change in how we use or disclose your health information, we will also change this notice. The new notice will be posted in the clinic and will be available at the front desk.
Except for the purpose related to your treatment, to collect payment for our services, to perform necessary business functions, or when otherwise permitted or required by law, we will not use or disclose your health information without your authorization. You have the right to revoke your authorization at any time. We are unable to take back any disclosure we have already made with your permission.
Examples of Uses and Disclosures for Treatment, Payment and Healthcare Operations
We will use your health information to facilitate your medical treatment.
For example: Any information obtained by a member of our healthcare team will be recorded in your record and used to determine the course of your medical treatment. This information is then available to subsequent health care providers, keeping treatments cohesive and progress documented.
2)We will use your health information to collect payment for health care services that we provide.
For example: A bill may be sent to you, your health insurance company or the responsible party. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used. In some cases, information from your medical record is sent to your insurance company to explain the need for or provide additional information about your treatment.
We will use your health information to facilitate routine healthcare operations.
For example: Members of our medical staff or quality improvement teams may use information in your record to assess the care you have received and how your progress compares to others. This information will then be used in efforts to improve the quality and effectiveness of the healthcare and other services that we provide.
We will use your health information to help us educate staff, faculty and students.
For example: All Employees and interns must sign a confidentiality agreement before accessing any health information maintained by Center for East West Medicine Clinic.
We will use your health information to notify your family and friends about your condition.
For example: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care or your general condition. Health professionals, using their best judgment may disclose to a family member, other relative, close personal friend or any other person you identify, relevant health information to facilitate the person's ability to assist in your care or make arrangements for payment of your care. We may use your health information to inform persons about your death.
For example: We may disclose health information to funeral directors, coroners, and medical examiners consistent with applicable law to carry out their duties.
Examples of Uses and Disclosures for Other Purposes
Appointment Reminders: We may contact you to provide appointment reminders
Marketing: We may use your health information to inform you about our healthcare services, treatment alternatives or other health-related benefits and services that may be of interest to you.
Research: We may contact you to request your participation in an authorized research study. If the study provides any type of healthcare treatment, the researcher will explain the benefits and risks of the treatment, how your health information will be use during the course of the study and whether any of your health information rights are affected. YOU will need to authorize the use of your health information and agree to any suspension of your rights to participate in the study, however you may revoke this authorization at any time. In some cases, we may disclose your health information to researchers when an institutional review or privacy board has approved their research. Prior to giving any information, special procedures will be established to protect the privacy of your information.
Workers Compensation: We may disclose your health information to the extent authorized by and necessary to comply with laws relating to workers' compensation or other similar programs established by law.
3)Public Health: We may disclose your health information as required by law to public health or legal authorities charged with preventing or controlling disease, injury or disability.
To avert a serious threat to health or safety: We may use and disclose your health when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person. Any disclosure would be made only to someone able to help prevent the threat.
Correctional Institutions: Should you be an inmate of a correctional institution, we may disclose to the institution or their agents health information necessary for your health and the health and safety of other individuals.
Law enforcement: We may disclose your health information for law enforcement purposes as required by law or in response to a valid subpoena, or court or administrative order.
Food and Drug Administration (FDA): We may disclose to the FDA your health information relating to adverse events with respect to food, nutritional supplements, products and product defects, or postmarketing surveillance information to enable product recalls, repairs or replacement.
Business Associates: There are some services provided in our organization through contracts with business associates. When contracted business associates provide these services, we may disclose the appropriate portions of your health information to our business associates so they can perform the job we have asked them to do. To protect your health information, however, we require all business associates to sign a confidentiality agreement verifying they will appropriately safeguard your information.
Special Situations
Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.
Regulatory Oversight: We may disclose your health information to appropriate health oversight agencies, public health authorities or attorneys, when required bylaw. Your health information may also be disclosed if a workforce member believes in good faith that Five Branches Clinic has engaged in unlawful conduct or has otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public.
For More Information or to Report a Problem
If you have questions, would like additional information, or want to request an updated copy of this notice, you may contact the Privacy Officer at (408)583-7964.
If you believe we have not properly protected your privacy, have violated you privacy rights, or you disagree with a decision we have made about your rights, you may contact Center for East West Medicine Clinic. You may also send a written complaint to the U.S. Department of Health and Human Services at 200 Independence Ave., S.W. Washington, DC 20201. Five Branches Clinic will ensure that the care you receive at our facility will in no way be impacted if you file a complaint
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