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                            Clinic Intake Form

                              Please answer all questions.  If the question does not pertain to you, just mark it n/a or none.

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                              This is a confidential record of your medical history and will be kept in the Back to the Basics clinic.  Information contained here will not be released to  any person except when you have authorized us in writing to do so.  Please complete this questionnaire as thoroughly as possibly.
                              Give a brief overview. Example: Seasonal allergies, back pain.
                              Please list any medications and/or food supplements you are currently taking:
                              FAMILY MEDICAL HISTORY
                              PERSONAL HEALTH HABITS

                              PLEASE READ:
                              Dr. Donna Chambers, ND is a complementary and alternative health care provider and is not licensed by the state of New Mexico.  There is currently no license available for the services provided.  All services and treatments are complementary or alternative to health care services provided by health care practitioners currently licensed by the state of New Mexico.

                              A patient has the right to complete and current information concerning the complementary and alternative health care practitioner's assessment and recommended complementary and alternative health care services that are to be provided prior to commencement of service(s) for each appointment including: the expected duration of the complementary and alternative health care services to be provided.

                              Dr. Donna Chamber's degrees, education, training, experience, and other qualifications regarding this complementary and alternative health care services are as follows:
                              Clinical Herbal studies, Homeopathy, Clinical Nutrition, Hydrotherapist, Emotional Balancing, Laser Therapy, Reflexology, and Accupressure.

                              The nature and expected results of the service or services that are offered:
                              • A session will include discussion of the patient's concerns and reason(s) for the visit, assessment of the patient by the practitioner, jointly exploring: past treatment results, short term and long term treatment goals, current treatment options and patient home health care plan.  The patient will be given a recommendatoins sheet that includes the jointly agreed upon home health care plan and expected results.
                              • Laser Therapy: Light Amplification of Stimulated Emission of Radiation (LASER) is a light beam from the electromagnetic spectrum.  The current function of laser therapy is to treat a variety of articular, neural, and soft tissue conditions.
                              • Lymphatic Therapy: is useful for health conscious individuals and athletes for its benefits to the immune system in prevention, anti-aging regimens, greater vitality, performance, by assisting in detoxification regimens.  It improves lymphatic fluid flow and accelerates detoxificaiton of tissues.  This system helps to improve edema, fibrotic conditions, swollen lymph nodes, and healing of injuries and burns.  Some conditions reported to have benefited from lymphatic therapy include breast lumps, inflammation due to muscular trauma, lymphedema, chronic pain, allergy and sinus symptoms, headaches, hormone imbalance and female conditions, digestive and bowel problems, post dental procedures, fibromyalgia, toxicity, and fatigue syndromes.  It can be used before and after athletics to increase performance and decrease muscle tendon strain.
                              • Colonics: also known as colon hydrotherapy or colonic irrigation, involves the use of warm, sterile water which is inserted into the rectum to wash out waste products from the colon, the final section of the intestines.
                              • Blood analysis: is a laboratory examination of the physical and chemical properties and components of a sample of blood.  Analysis includes enzyme activity and chemistry.  Special tests detect substances characteristic of specific infections.  The examination of live blood is valuable for the early detection of serious health conditions.  It is possible to see at what stage of pathological development the body is in, simply from using one drop of blood.
                              • Lab testing:  We do a variety of different lab tests, such as saliva, blood, hair, urine, feces, etc., all depending on each patient's individual needs.

                              Payment in full is required immediately following every session.  Payment is accepted in the form of cash, check, or credit card (VISA, Debit, MasterCard).

                              A patient has a right to reasonable notice of changes in services and/or charges for services.  Notice of any future changes in services or fees will be posted in the office of Dr. Donna Chambers one month before taking effect.

                              Notice regarding patient records:
                              • A patient has the right to access their own patient's records and written information therein.
                              • Patient records and transactions are confidential unless the release of these records is authorized in writing by the patient or as required by law.
                              • A patient has the right to a coordinated transfer when there will be a change in the provider of the complementary and alternative health care services.
                              Dr. Donna Chambers will not: perform surgery on an individual, set fractures on an individual, administer x-ray radiation to an individual, prescribe or dispense dangerous drugs or controlled substances to an individual, directly manipulate the joints or spine of an individual, physically invade the body except for the uyse of non-prescribed topical creams, oils, salves, ointments, tinctures or any other preparation that may penetrate the skin without causing harm, make a recommendation to discontinue current medical treatment prescribed by a licensed health care practitioner, make a specific conventional medical diagnosis, have sexual contact with a current patient or a former patient within one year of rendering service, falsely advertise or provide false information in documents described in this document, illegally use dangerous drugs or controlled substances, reveal confidential information of a patient without the patient's written consent, engage in fee splitting or kickbacks for referrals, refer to the practitioner's self as a licensed doctor or physician or other occupational title pursuant to chapter 61 NMSA 1978; or perform massage therapy on an individual persuant to the New Mexico Massage Therapy Practice Act.