Condition/ Chief Complaint
Hospitalizations and Surgeries:
Rays/ CAT Scans/ MRI’s/ NMR’s/ Special Studies:
Energy and Immunity
Head, Eye, Ear, Nose and Throat
Female Reproductive/ Breasts
Menstrual/ Birthing History:
FAMILY HISTORY (Please list family health problems)
General Health PracticesSmoking:
Patterns and Pivot Points:
Please label all PROBLEM AREAS as 1, 3, OR, 5. (1=MILD, 3=MODERATE, 5=SEVERE)
Cancellation Policy Please give 24 hours’ notice if you need to cancel or reschedule. Missing your scheduled appointment time compromises the effectiveness of your treatment plan, and keeps others from being able to make an appointment in that time slot. You may be charged a “no show” fee of $20 if you fail to cancel your appointment in a timely manner. Thank you for your understanding.
Acupuncture involves the insertion of pre-sterilized, disposable needles into specified points on the body in order to affect a change. In most cases the changes are pleasant and lead to healing. In some cases, there may be side effects such as: bruising, discomfort, redness, slight bleeding, fainting, temporary pain/ discomfort/ dizziness or weakness, and temporary aggravation of symptoms existing prior to treatment. While this outlines the most commonly occurring adverse effects of treatment, other effects and risks may occur. Please be in communication with your practitioner if you have any concerns. We make no attempt to replace your primary care doctor. We encourage you to see your doctor when necessary and to have routine checkups. We are happy to refer you to the appropriate medical professional should the need arise.
Signing below indicates that you have completed the form as accurately as possible. Additionally, you understand that it is your responsibility to inform your practitioner of any health changes prior to each treatment. At any time, you or your practitioner may refuse treatment.
HIPPA is a US law designed to provide privacy standards to protect patient’s medical records and other health information provided to health plans, doctors, hospitals, and other health care providers. We work to protect your privacy and do not share any medical or personal information without your consent. Please see the Complete Notice of Privacy Practices posted Here on our Web Site
The sharing with these people may continue until terminated by me in writing.
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