DR. MIRIAN BOYD ORGAN'S
WOMEN'S DAY SPA
Informed Consent
(Please read to sign at appointment)
INFORMED CONSENT
The operations at this location:
Services include the medical skills that involve the practice observing and palpation of the skin. The treatments are superficial and noninvasive. The treatments are done only with gentle soft hand touch. There are no deep tissue treatments offered. The treatments are not meant to do harm, cause pain or discomfort, but are meant to promote relaxation to help improve physical health and well-being. The treatments do not include deep tissue treatment with the use elbows, knees, feet, needles or balls. This location does not offer massage therapy, physical therapy or behavior therapy. It does not offer cosmetic surgery, body work enhancement procedures, surgical removal of tissue, injury repair, antiaging procedures or pain management. There are no pharmaceutical medicines on site. If further treatments are needed beyond the scope of care within this location, as a primary care board certified physician, Dr. Organ is licensed to recognize urgent concerns and make recommendations or referral to the appropriate therapist or specialist as needed.
I have read the above information. I fully understand and agree to services on these terms. It is my choice to receive Touch treatments. I am aware of the benefits and risks of the treatments and give my consent. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that touch treatment is not a substitute for medical care, medical examination, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
Name (Print)____________________________________________
Signature________________________________________
Date_____________
Menstrual and Medical History
(Please review we will fill out and sign at appointment)
Dr. Mirian Boyd Organ’s Women’s Day Spa
History form
Name _________________________________________________
DOB_______________
Address _______________________________________________
City ______________________________________State __________
Zip _____________________________ Phone____________________________
Email ____________________________________________________________
Menstrual History (Complete as much as you can even if you are menopausal)
Age ______________ Preg___ Live biriths____ LMP_____________
Age periods started_______________ Breastfeeding history: yes or no
If your menstrual periods are regular ____________, How many days apart_____
If your menstrual periods are irregular__________, How many times a month___
How heavy is your bleeding, ____mild _____moderate______heavy (clots)
Which symptoms are associated with your periods, (before, during or after)
___anger ____depression ____loss of interest
___anxiety ____headaches ____self-depreciating thoughts
____clotting _____hot flashes ___Sensitive to rejection
____cramping ____heart palpitations ___difficulty concentrating
____cravings _____irritability ___leg swelling
____crying ____insomnia ____Binge eating
____bloating ____Fatigue or exhaustion ____Brain fog
____bowel changes ____mood swings ____Rage
____Breast tenderness ___less productive _____Panic attacks
___Back ache ____Nause/vomiting _ ___Family is concerned _____acne
____Overthinking ____ Overtalking _____more sensitive
Gynecological/ obstetric surgery:
Ovaries: yes ______ no________
Uterus: yes _____ No________
Fallopian tubes: yes_______ No_______
Cesarean Section: yes______ No_______
Abdominal surgery: yes______ No______
Breast Surgery: yes_______ No_______
OtherSurgeries____________________________________________________
Hospitalizations in the last 5 years___________________________________
Allergies________________ Occupation______________________________
PMH:
Heart Dx _____ Diabetes ________ High Blood Pressure____ Strokes _____
Cancer(type)_______ Neuropathy______ Kidney Dx_______
Gastrointestinal Dx_______ Arthritis______ Anemia______
Musculoskeletal ______Seizures______ Asthma_______Thyroid DX_______
HIV/Aids_______Smoking______Alcohol_______Illicit Drugs_________
Obesity_______, Eating Disorder_______ Mental Health_________
Depression and Anxiety________ Family loss_______
Financial loss_______ other____________________________
_______________________________________________________________
Do you take your regular prescribed medicines? Yes_______ No______
Last Primary Care Physician visit________________
Signature____________________________________ Date_______________