Medical Qigong Questionnaire

Medical Qigong

New Patient Intake Form
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Main Phone #*
Mobile
Emergency Name*

First NameLast Name
Emergency Contact #*
Please enter a valid phone number.
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState

Post Code
First, think why you are seeking a Medical Qigong Treatment with me.

Next, setting goals seems like a good idea, but a lot of the times they end up being unattainable. Why? It is due to the system you use to get to this goal. The small changes, STEPS, you make in your habits end up adding up and that is where the sustainable habits form.

So think of picking a STEP you would like to introduce into your life that will create new and long lasting healthy patterns.

Remember to Keep It Simple & attainable. Start the statement with "I...":

Ex. "I want to introduce deep breathing every time I feel stressed." Or "I would like to be in the present moment more."

Write your STEP at the bottom of this intake form once you get there.

Remember, be HONEST with yourself, because you are investing in yourself.:)
Gender
Please list dates of past surgeries/major illnesses/traumas (incl. hospitalizations, childhood illnesses, injuries, & anything that could finish the statement-->"Things were never the same since I had..."
Do you ever have problems sleeping?

YesNo
Do you have a problem:

Falling asleepStaying asleep
Do you smoke tobacco products?
If yes, how often?
Do you consume alcohol?
How often do you consume alcohol?

NeverWeeklyMonthlyOccasionallyNever
Are you under care of a Primary Care Physician?
Are you pregnant?
If you are pregnant I cannot treat you with a Medical Qigong treatment. This requires specialized training and is a specialized field.

I can, however, offer a Qigong set that I teach. This involves breath work and movement to invigorate the tissues with Qi, which will support you and strenghten you through your pregnancy. This can be a one on one (I can come to your house) or I teach it every Thursday at The Yoga Connection (see link on my website under 'Qigong for Health.'
How many pregnancies have you had?
Do you have an active cancer diagnosis?*
If yes, what type, stage, and when were you diagnosed? I will arrange a FREE video chat so we can talk more in-depth about treatment options. :)
Are you under care of a couselor/psychologist/psychiatrists?
Do you believe in a Higher Power (Ex. could be God, Source, you inner voice, etc)?*
If yes, can you please explain how you incorporate your Higher Power in your daily life? Thank you.
Past Medical History*

AIDS/HIVAlcoholism/Substance AbuseAllergiesAnxietyAsthmaCancerCeliac DiseaseDepressionDiabetesEmphysemaEndocrine DisordersFibromyalgiaGoutHeart DiseaseHepatitis A/B/CHerpesHigh Blood PressureInfectious DiseaseLow Blood PressureLyme DiseaseMultiple SclerosisObesityOsteoarthritisOsteoporosisPacemakerSeizuresStrokeThyroid DisorderTransfusionsTuberculosisVaricose VeinsOther
Draw on Image any sites of acute or chronic pain.
Please describe the quality of pain or distress in the above indicated areas:
Which describes your discomfort now, 1-10 (10 being your worst pain, like an elephant stepping on your big toe).

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Write what new and health STEP you want to start introducing below (WOOT WOOT!! YASSSSS):
Lastly, (got to get to the business aspect, lol). How much do you want to pay for each session? Sliding Scale range is $95-$150. I usually bill after the first session.:)

Ripple InnerQi Holistics Consent Form
I understand that the completion of this form is recommended to develop a full Medical Qigong Treatment Plan, but such completion is based on my willingness to disclose this information. I further understand that a comprehensive Medical Qigong Treatment Plan will be more effective if this information is disclosed to the Medical Qigong Practitioner so that all aspects of my physical, mental, emotional, and lifestyle components can be taken into consideration for a plan tailored to my specific needs. Any information will remain confidential and not disclosed to any other parties until or unless I direct the Medical Qigong Practitioner to do so.

I understand that Medical Qigong Treatments are not to be considered as a replacement for Western Medical Treatment, which my regular physician may have prescribed to me [PCP or consulting Physician(s)]. The Medical Qigong Practitioner is willing to communicate with me and/or my regular physician(s) as needed to provide an optimal holistic treatment plan with the permission of both myself and my physician(s). Any medical records or information disclosed to the Medical Qigong Practitioner by myself or my physician(s) will be kept in the strictest confidence and not disclosed to any other parties without my permission.

I acknowledge that Christopher Paul “Kiki” Apodaca, the Medical Qigong Practitioner, is not a Western Medical Physician, Psychologist, or Counselor, and the Medical Qigong Practitioner’s recommendations are based on his training that originates from Energetic Chinese Medicine, which originates from Traditional Chinese Medicine. I acknowledge that I am not entering into a Western Physician-Patient relationship & the Medical Qigong Practitioner does not practice and is not licensed as a Western Medicine Physician.

I understand that Medical Qigong is a complementary and alternative medicine not licensed by the state of Arizona. Therefore, by practicing complementary and alternative medicine, the practitioner seeks to support rather than replace the care of your existing physician, therapist, or acupuncturist.

I acknowledge my commitment to my self-improvement process. I recognize that any Medical Qigong Treatment Plan, which is tailored for me, must be followed to be truly effective, just as the prescribed medication is only effective if taken as directed.
By signing below, I (fill in your name) blanks* understand the nature of Medical Qigong Therapy and the aforementioned Practitioner’s qualifications to practice Medical Qigong Therapy. I consent to participate in Medical Qigong treatments and/or instruction.
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Medical Qigong

Ripple InnerQi Holistics Consent Form