ITM’S PRACTITIONER REFERRAL INFORMATION FORM 2014

IMPORTANT NOTE: Please fill out this form completely and accurately. It will serve as background information for making referrals to you (essential for inclusion in our practitioner guide) and will be utilized in developing statistics about the practice of Chinese medicine in the U.S. Answer all questions on both sides; please write clearly or type. Your listing in our practitioner guide is free. If there are several practitioners at one clinic, have one person fill out this form. We currently have listings of approximately 500 practitioners. Even though you may have filled out a previous form, we need this updated information to retain your listing (this form is usually sent for updating every two years). The practitioner referral listing is mailed to individuals seeking this type of health care and is posted on ITM’s website (www.itmonline.org).

Your name, with any credentials you wish to have listed (e.g., L.Ac., N.D., M.D.):

________________________________________________

Clinic name (if any), complete address (primary site), and primary contact information:

(see reverse for listings of multiple practitioners or multiple sites)

Clinic name:__________________________________________________

Address: __________________________________________________

City: ___________________________________ State: _____________________ Zip: ________

Primary phone: _____________ E-mail: _____________

The school(s) where you received your professional training and received degrees/diplomas:

(mention names of professional schools granting degrees)

1. _________________________________

2. _________________________________

3. _________________________________

Therapeutic specialties in addition to general practice for which you have considerable experience

(e.g., infectious diseases, women’s health concerns, pain syndromes, cancer, allergies, etc.):

(list in order of priority in your practice and experience)

1. _________________________________

2. _________________________________

3. _________________________________

4. _________________________________

Diagnostic methods (e.g., traditional Chinese, modern lab tests, kinesiology, etc.):

(in approximate order of emphasis or frequency of use)

1. _________________________________

2. _________________________________

3. _________________________________

4. _________________________________

What are the main therapeutic methods you employ? (acupuncture, Chinese herbs, massage, hydrotherapy, Western herbs, etc.):

(in approximate order of emphasis or frequency of use)

1. _________________________________

2. _________________________________

3. _________________________________

4. _________________________________

Years in practice (with licensing): ____________

Fees for a typical office visit (if several fees apply, please list):

Initial visit fee: $ _____________ Typical duration: _____________ (minutes)

Follow up visit fee: $_________ Typical duration: _____________ (minutes)

MULTIPLE-PRACTITIONER FACILITIES

Names of individuals working in the same clinic; include their medical licensing (e.g., L.Ac.):

1. _________________________________

2. _________________________________

3. _________________________________

SURVEY QUESTIONS

Please give us the following information for your most typical situation:

How many patient visits per week? ______ [number of scheduled treatment slots actually filled]

How many days per week are you available at your office to see patients? _____

How many hours per week do you spend seeing patients? ___________

How full is your practice compared to what you consider ideal? ___________ %

What percentages of your patients are given herb prescriptions? ___________ %

What is the most frequently used forms of herb prescriptions; list in order of frequency, items such as teas, patent pills, capsules, tablets, tinctures, granules, others (specify; do not include homeopathics in this section):

1. _____________________

2. _____________________

3. _____________________

How many professional books on Chinese medicine are in your library? ___________

How many journals about Chinese medicine do you subscribe to? _________________

Please list journals: _____________________

_____________________

_____________________

How many hours of continuing education (i.e., medical seminars) do you attend in a year? ______

THANKS FOR FILLING OUT THIS FORM.

Mail promptly to:

ITM

2017 SE Hawthorne

Portland, OR 97214