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MM slash DD slash YYYY
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Referred By
I prefer to be contacted at: (check one)
Home
Work
Cell
E-mail
Emergency Contact - Name
Emergency Contact - Phone
Family Physician - Name
Family Physician - Phone
Have you tried Acupuncture or Chinese Herbal Medicine before?
Yes
No
If yes, please explain:
General Information
Why are you seeking treatment with us today?
To what extent does your condition affect your daily activities (work, sleep, etc)?
How long has it been since you first noticed any symptoms?
Have you been given a diagnosis for the issue by your family physician?
Yes
No
If yes, what is the diagnosis?
Past Medical History
Please check all that apply:
Allergies
Cancer
Diabetes
Hepatitis
High Blood Pressure
Heart Disease
Seizures
Rheumatic Fever
Surgeries
Asthma
Thyroid Disease
Birth Trauma (prolonged labor, forceps delivery, etc)
Other significant illness (please describe)
Accidents or significant trauma (please describe)
Please include dates:
Please describe:
Other Relevant Medical History
Family Medical History
Family Medical History
Allergies
Asthma
Cancer
Diabetes
Heart Disease
High Blood Pressure
Seizures
Stroke
Other
Other - Please describe:
Occupational
Any occupational stress factors?
(physical, psychological, chemical...)
Lifestyle
Do you follow a regular exercise program?
Yes
No
If yes, please describe:
Please describe your average daily diet:
Please check any of the following that apply with the frequency of use:
Cigarette smoking
Caffeine
Alcoholic beverages
List any medications, supplements, herbs, etc taken within the last 2 months:
List any use of drugs for non-medicinal purposes:
General
Please check any conditions you have experienced within the last 3 months. Indicate the legnth of time you have had this condition.
Poor Appetite
Weight Gain
Night Sweats
Insomnia
Weight Loss
Fever
Disturbed Sleep
Changes in appetite
Chills
Localized weakness
Sweating easily
Sudden energy drop
Cravings
Tremors
Strong thirst
Bleeding or bruising easily
Poor balance
Time of day for sudden energy drops:
Indicate the legnth of time you have had each condition.
Other unusual or abnormal conditions you have noticed in your general sense of health:
Skin and Hair
Please check all that apply:
Rashes
Eczema
Recent moles
Ulcerations
Pimples
Changes in texture of hair/skin
Hives
Dandruff
Itching
Hair Loss
Any other hair or skin problems?
Head, Eyes, Ears, Nose, and Throat
Please check all that apply:
Dizziness
Concussions
Migranes
Glasses
Spots in front of eyes
Eye pain
Poor vision
Night blindness
Color blindness
Cataracts
Blurry vision
Earaches
Ringing in the ears
Poor hearing
Eye strain
Sinus problems
Recurrent sore throats
Nose bleeds
Grinding teeth
Sores on lips or tongue
Facial Pain
Teeth problems
Headaches (describe when/where below)
Jaw clicks
Any other head or neck problems?
(or expand on when and where headaches occur)
Cardiovascular
Please check all that apply:
Dizziness
High blood pressure
Swelling of feet
Low blood pressure
Fainting
Blood clots
Chest Pain
Cold hands or feet
Difficulty in breathing
Irregular heartbeat
Swelling of hands
Phlebitis
Other other heart or blood vessel problems?
Respiratory
Please check all that apply:
Cough
Bronchitis
Difficulty breathing when lying down
Coughing up blood
Pain with deep inhalation
Asthma
Pneumonia
Excessive Phlegm
What color phlegm?
Other other lung problems?
Gastrointestinal
Please check all that apply:
Nausea
Belching
Rectal Pain
Vomiting
Black stools
Hemorrhoids
Diarrhea
Blood in stools
Abdominal pain / cramps
Constipation
Indigestion
Chronic laxative use
Gas
Bad breath
Other other problems with stomach or intestines?
Genitourinary
Please check all that apply:
Pain on urination
Unable to hold urine
Prostate problems
Urgent / frequent urination
Decrease in flow
Impotence
Blood in urine
Kidney stones
Sores on genitals
Do you wake up at night to urinate?
Yes
No
If so, how often?
Any particular color to your urine?
Other other genital or urinary problems?
Reproductive and Gynecologic
Please check all that apply:
Premenstrual changes
Heavy menstrual flow
Premature births
Menstrual clots
Light menstrual flow
Miscarriages
Painful menses
Irregular menses
Abortions
Unusual menses
Other problems
How many miscarriages?
How many abortions?
Age at first menses:
Age at first menopause:
Number of pregnancies:
Time between cycles:
Duration of bleeding
First day of last menses:
Do you practice birth control?
Yes
No
If so, what type and for how long?
Musculoskeletal
Please check all that apply:
Neck pain
Back pain
Hand / Wrist pains
Muscle pains
Muscle weakness
Shoulder pains
Knee pain
Foot/ankle pains
Hip pain
Other joint or bone problems?
Neuropsychological
Please check all that apply:
Seizures
Poor memory
Anxiety
Dizziness
Lack of coordination
Bad temper
Loss of balance
Concussion
Easily susceptible to stress
Areas of numbness
Depression
Have you ever been treated for emotion problems?
Have you ever considered or attempted suicide?
Any other neurological or psychological problems?
Comments
Please list any other problems you would like to discuss:
ACUPUNCTURE INFORMED CONSENT TO TREAT
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage). Chinese herbal medicine, and nutritional counseling. Il understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.
I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy, Some possible side effects of taking herbs are nausea, gas. stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.
While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the Clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.
I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me. the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
ACUPUNCTURIST NAME:
X: Signature
Or Patient Representative, indicate relationship if signing tor patient
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Today's Date:
06/05/2023
PATIENT QUESTIONNAIRE
1) Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operation):
2) Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY:
(Name + Phone #)
3) Please print the address of where you would like you billing statements and/or correspondence from our office to be sent if other than your home:
4) Please indicate if you want all correspondence from our office to be sent In a sealed envelope marked "CONFIDENTIAL":
Yes
No
5) Please print the telephone number where you want to receive calls about your appointments, lab and x-ray results, or other health care information if other than your home phone number?
6) Can confidential messages (i.e. appointment reminders) be left on your telephone answering machine or voicemail?
Yes
No
Patient Name:
(Guardian if under 18 years)
X: PATIENT / GUARDIAN SIGNATURE
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Today's Date:
06/05/2023
PATIENT CONSENT FORM
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing the Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
Protected health information may be disclosed or used for treatment, payment or health care operations
The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
The Practice reserves the right to change the Notice of Privacy Policies
The patient may revoke this Consent in writing at any time and all future disclosures will then cease
The Practice may condition treatment upon the execution of this Consent
Name of Patient or Representative:
Relationship to Patient:
X: Signature of Patient or Representative
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Today's Date:
06/05/2023
Witness - Printed Name of Practice Representative:
Today's Date:
06/05/2023
Name
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