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:
Clinic name:__________________________________________________
Address: __________________________________________________
The school(s) where you received your professional training and received degrees/diplomas:
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.):
1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
Diagnostic methods (e.g., traditional Chinese, modern lab tests, kinesiology, etc.):
1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
What are the main therapeutic methods you employ? (acupuncture, Chinese herbs, massage,
hydrotherapy, Western herbs, etc.):
1. _________________________________
2. _________________________________
3. _________________________________
4. _________________________________
Years in practice (with licensing): ____________
Fees for a typical office visit (if several fees apply, please list):
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? ______
ITM
2017 SE Hawthorne
Portland, OR 97214