College of Naturopathic Medicine (CNM) Clinical Handbook: Herbal Medicine

CNM HERBAL PATIENT INFORMATION FORM (CONFIDENTIAL)

Dear Sir / Madam

This is an introduction to our student clinic, and explains a few frequently asked questions. Please read the following information carefully.

Background: The College of Naturopathic Medicine offers professional training in Naturopathy. Once firmly grounded in the Naturopathic approach students then specialise in Herbal Medicine, Acupuncture, Homeopathy or Nutrition. You will be attending the Herbal medicine student clinic.

What can I expect? You will be assigned a student who will be responsible for you and who is your point of contact. A clinic supervisor or student practitioner will take your case history. As well as the person taking your case there may be up to 4 students observing in the consulting room. There may also be a live video link to allow further students to benefit from your consultation; however your consultation will not be recorded.

What’s going to happen? A clinic supervisor or student practitioner will take your case history, so you will be asked LOTS of questions. You may also have an examination performed if appropriate. This may range from the type of examination that your doctor may perform such as having your blood pressure taken to having your tongue and pulse examined. No internal examinations are performed at the CNM student clinic.

What do I need to bring / wear? All pharmaceutical medicines and supplements you are currently taking (or at least a list of them) and any recent medical test results if available. Please wear comfortable every day clothing.

Costs: In addition to the consultation fee, herbal medicines cost approximately £10 for 100mls of tincture (approximately 1 week’s medicine). Dried herbs and creams are charged per item. Please ensure that you have the means to pay for your medicines. Only cash and cheques are accepted.

Safety: Our clinic supervisors are all highly trained experienced herbalists and will oversee and maintain responsibility for your consultation and herbal treatment. Whilst every care is taken to provide you with the highest level of care and security, herbal medicine, like any medicine, can cause reactions which differ from person to person. Therefore if you have ANY concerns or queries please do not hesitate to contact your student practitioner or the student clinic direct.

Consent: I consent to the use of a confidential video link to external students for observational purposes only. I understand my case will not be videotaped. Other students will be present in the consultation room. I further understand the student practitioner must have all prescriptions authorised by a qualified supervisor. The supervisor may therefore enter the clinic room at any time. With these understandings, I consent to participating as a client in the student clinic.

Signed Date: College of Naturopathic Medicine (CNM) Clinical Handbook: Herbal Medicine

Clinic Details: Date: ……………………………………………..Clinic no:…………………………….... Practitioner: …………………………………… Student:………………………......

Patient’s Details: Name: ………………………………………….Date of Birth:……………Age…...... Address:……………………………………………………………………………………. ………….…………………………………………………………………………………... Telephone number/s:……………………………………………………………………….. E-mail address:…………………………………………………………...... Sex:………….Marital status: …………………Children:...………………………...... Occupation:………………………………………………………………………………… Height:…………………………………………Weight:………………………………...... Referred by:…...……………………………………………………………………………

General Practitioner’s Details: Name:………………………………………………………………………………………. Address:………………………………………..Tel. No:………………………….…….....

PRESENTING COMPLAINT/S: History of Presenting Complaint; Symptoms; Onset; Progression; Precipitating Factors; Aggravating Factors; Relieving Factors; Associated Symptoms; Investigations; Previous Diagnosis and Treatments

RED FLAGS/FOR SPECIAL ATTENTION:

PREVIOUS MEDICAL HISTORY: Childhood Diseases; General health, Major/recurrent Illnesses; Accidents; Hospitalisations; surgery, Immunisations; allergies

DRUG HISTORY: Name of Drug/s; Dosage & Frequency; Duration Taken; Reason for prescribed/self administered drug/supplement

FAMILY HISTORY: Major health problems in the family

LIFESTYLE: Smoking, alcohol, caffeine, exercise, pastimes; recreational drugs

DIET: Breakfast, lunch, evening, snacks, fluid intake

SYSTEM CHECKS

GENERAL immunity, infections, wellbeing, energy

CVS chest pain, SOB, palpitations, cold hands/feet, ankle oedema, varicose veins, orthopnoea

RESPIRATORY / ENT SOB, cough, blood, infections, hard inhale/exhale, wheeze, sputum, ENT

DIGESTION appetite, dental, swallow, indigestion, reflux, acidity, bloating, gas, nausea/vom., blood, number of motions daily, bowel habit, stool colour / consistency, blood in stool

URINARY frequency, urgency, pain, burning, loin pain, blood, stream, incontinence, colour, quantity

GYN / REPRODUCTIVE menarche, cycle length, regularity, duration, PMT, pain, colour, clots, libido, STDs, male pain / dysfunction

OBS fertility, pregnancies, miscarriages, terminations, menopause

NERVOUS / EMOTIONAL / SLEEP mood, memory, anxiety, stress, energy, Sleep (disturbed, hard going off, early waking, night sweats, dreams, urination)

NEUROLOGICAL faint, headache, tremor, numbness, visual disturbance, dizzy, hearing loss/tinnitus

SKIN acne, rashes, fungal infections, herpes, itching, dry, eczema, psoriasis

MUSCULOSKELETAL joint or muscle pain, crepitation, stiffness, swelling, back pain

DIAGNOSTIC INVESTIGATIONS clinical examination, tests

EVALUATION summary, differential diagnosis, further investigations

PRINCIPLE OF TREATMENT

PRESCRIPTION with justification

ADDITIONAL ADVICE

CNM HERBAL MEDICINE FOLLOW UP FORM (CONFIDENTIAL)

Patient name: ………………………….. DOB: ……………. Date: ………………………………. Student: …………………………………Practitioner: ……………………………………………..

REVIEW OF COMPLAINTS AND NEW COMPLAINTS

EXAMINATION

ASSESSMENT AND MANAGEMENT PLAN

PRESCRIPTION

ADDITIONAL ADVICE