CHINESE ACUPUNCTURE CLINIC
Patient Intake Form
Thank you for coming. Please help us provide you with a complete evaluation by taking the time to fill out this
form carefully. All your information will be confidential. If you have questions, please ask. Thank you.
Last name
First Name
Date of birth
Age
Sex
F
M
Date
Occupation
Main phone #
Other phone #
E-mail address
Emergency contact name & phone
Marital status
Address:
City
Family physician
# of children
State
Zip
Chiropractor
Do you have health insurance? □ Yes
□ No
If yes, name of insurance company
Does your insurance cover acupuncture? □ Yes
□ No
How did you find out about our clinic?
□Friends/Relatives(name)________________________________________
□ Direct mail
□ Location or walk by □ Website
□ Referred by_______________________________________ □ Yellow Pages
□ Other (please specify)
□ Periodicals
Main problem(s): ________________________________________________
What diagnosis, if any, have you received for this problem?
When did this problem begin?
What makes this problem worse?
What makes this problem better?
Is there anybody in your family with the same/similar problems?
Allergies: (drugs, chemicals, foods, environmental): _________________________________________
Medicines taken within the last two months (including vitamins, OTC drugs, herbs, etc., and their
dosages):_________________________________________________________________
Personal
Habits
Height___________________
Weight now_____________________
Do you smoke? □ Yes □ No What? _______How many per day?______ Since when? _______
Please describe any use of drugs for non-medical purposes:_____________________________________
What kind of alcoholic beverages do you usually drink?______Average number of drinks/week?________
Do you crave for any specific flavor? □ sour □ bitter □ sweet □ pungent □ salty
Medical History
Diagnosis
Self
Family
Diagnosis
Cancer
Breathing problems
Diabetes
Heart disease
Hepatitis
Digestive disorders
Thyroid disease
Venereal disease
Seizures
Alcoholism
Arthritis
Depression or anxiety
Self
Family
Self
Tuberculosis
High cholesterol
High blood pressure
Emotional disorders
Anemia
Other:
Surgeries:___________________________ Hospitalization:____________________________
Significant trauma: (auto accidents, sports injuries, etc) __________________________________
Indicate painful or distressed areas
Are there any other health issues you want to discuss with us?
Signature_____________________Date____________________
Chinese Acupuncture Clinic
3613 Williams Dr. #1004, Georgetown, TX 78628
(512) 864-1441
Family
CHINESE ACUPUNCTURE CLINIC
HIPAA Acknowledgement and Informed Consent Form
I hereby request and consent to the performance of the following on myself (or the
patient named below, for whom I am legally responsible) by the licensed acupuncturists on
staff at the Chinese Acupuncture Clinic (CAC) who now or in the future treat me while
employed by, working or associated with or substituting for CAC, including those working at
this clinic:
acupuncture and other Oriental medical procedures including diagnostic techniques such as qu
estioning, pulse evaluation, palpation on a variety of areas of my body, observation, range of
motion, muscle and orthopedic testing; modes of manual or physical therapy such as body wor
k, manipulation of joints and/or viscera, heat and/or coldtherapy and electrical and/or magneti
c stimulation; cupping and/or moxibustion; the prescription of herbal and homeopathic medici
nes as well as dietary supplements; dietary recommendations; exercise advice and healthy life
style counseling.
I have had an pportunity to discuss with my practitioner, and/or with other clinic
personnel the nature and purpose of acupuncture and Oriental Medical procedures. Although I
am aware that acupuncture and the other procedures used in Oriental Medicine have helped
millions of people, I understand that no guarantee of cure or improvement in my condition is
given or implied. I understand and am informed that, as in the practice of conventional Wester
n medicine, in the practice of Oriental Medicine there are some risks to treatment. I
understand that although these risks are unlikely to occur, they are possible. I understand
that these risks include, but are not limited to: bleeding, bruising, pain or other strong
sensation at the location of where a needle is
inserted or radiating from that location, nerve pain, burns, aggravation of current symptoms,
appearance of new symptoms and general aches. Other uncommon but possible risks include
pneumothorax (punctured lung), puncture of other organs, sprains, strains, dislocation,
fractures,disc injuries and strokes. I do not expect the practitioners to be able to anticipate
and explain all risks and complications, and I wish to rely on the practitioners to exercise such
judgment, during the course of my treatment, as the practitioner feels at the time, based on
the facts known, to be in my best interest. I authorize the staff to perform any necessary
services needed during diagnosis and treatment.
I have read, or have had read to me, this informed consent form. I have also had an
opportunity
to ask questions about its content, and by signing below I agree to the above named
procedures
and conditions of treatment. 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 at the
CAC clinic.
____________________________
Patient’s name (please print)
________________________________
Patient’s signature
____________________________
___________________________
Print Name of Patient’s Representative (if applicable)
Relationship or Authority of Patient’s Rep.
_____________________________
___________________________
Signature of Patient’s Representative (if applicable)
Date Signed
Chinese Acupuncture Clinic
3613 Williams Dr. #1004, Georgetown, TX 78628
(512) 864-1441
CHINESE ACUPUNCTURE CLINIC
Notification Form Regarding Evaluation of Patient by Physician
Important: Read this part about receiving acupuncture in Texas
Texas law pertaining to the practice of acupuncture is a little behind the times.
Prior to providing services - unless treating for chronic pain, smoking, alcohol/substance abuse,
or weight loss - Texas acupuncturists are required to determine that a patient has been
evaluated for the condition being treated by a physician or dentist within the last 12 months,
or referred by a chiropractor within the last 30 days.
As a result, CAC is required to have you respond to the following statements before you may
be treated. Please be advised that we will not be permitted to treat you with
acupuncture if your response to all of these statements is no.
(Pursuant to the requirements of 22 TAC §183.7 of the Texas State Board of Acupuncture Examiners’ rules
(relating to Scope of Practice and Tex. Occ. Code Ann., §205.351, governing the practice of acupuncture.)
I (patient's name) ____________________________________________ am notifying the
practitioners at Chinese Acupuncture Clinic of the following:
___ Yes ___ No
I have been evaluated by a physician or dentist for the condition being
treated within 12 months before the acupuncture was performed. I recognize that a physician
should evaluate me for the condition being treated by the acupuncturist.
OR
___ Yes ___ No I have received a referral from my chiropractor within the last 30 days for
acupuncture. After being referred by a chiropractor, if after two months or 20 treatments,
whichever comes first, no substantial improvement occurs in the condition being treated, I
understand that the acupuncturist is required to refer me to a physician.
It is my responsibility and choice whether to follow this advice.
OR
I have not been evaluated by a physician or dentist for the condition being treated, nor have I
received a referral from a chiropractor, but I seek treatment for symptoms related to one or
more of the following conditions:
___
___
___
___
___
Chronic pain
Smoking addiction
Weight loss
Alcoholism
Substance abuse
___________________________________________________________________________
Patient Signature Required
Date
Chinese Acupuncture Clinic
3613 Williams Dr. #1004, Georgetown, TX 78628
(512) 864-1441
CHINESE ACUPUNCTURE CLINIC
New Patient Information
Welcome to the Chinese Acupuncture Clinic. Our Clinic is a professional clinic
specializing in Oriental Medicine which includes acupuncture, moxibustion,
cupping, herbal consultation and Asian bodywork.
Clinic Appointments
Treatments are by appointment only. In order to better serve you, it is
important that we receive 24 hours notice if you need to cancel or reschedule
an appointment. This enables us to fill the time slot. We reserve the right to
charge a current acupuncture treatment fee for appointments canceled with
less than 24 hours notice or for no show appointments.
Payment for Services Rendered
Payment is due at the time of service and may be paid in cash or by check or
credit card (Master Card, Visa or Discover only). We reserve the right to
charge $25.00 fee for any returned check.
Insurance
We will file insurance claims on your behalf after we have been able to
establish with your insurance company that they will honor our claim filing.
Until such willingness has been established, it will be necessary for you to
pay for your treatment and we will provide you with an insurance receipt
which you may use to file your claim. It is your responsibility to pay off
unpaid balance related to your treatment.
Please sign and date on the line provided below. Thank you for allowing us
to provide you with a quality, low cost alternative to traditional health care.
Patient Signature:______________
Chinese Acupuncture Clinic
Date:_________________
3613 Williams Dr. #1004, Georgetown, TX 78628
(512) 864-1441