Denise DuPree Acupuncture
Welcome!
We are happy that you have chosen us to assist you in your journey towards optimal health and wellbeing. We understand
that it is a process that requires a relationship of trust, confidentiality and compassion. We look forward to serving you! We
strive to provide a clinic that is warm, friendly and conscious space. Together we can bring balance to your life.
Our goal is to assist you in understanding how the choices you make in all areas of your life affect your health physically,
emotionally, mentally, and spiritually. Diet, exercise, meditation, and other lifestyle choices will be addressed. Awareness of
these choices is the first step towards regaining control of your health. Once aware, you can then make the necessary
changes and begin the journey towards balance.
Many people come in for treatment with the expectation of relieving a particular symptom or set of symptoms. East Asian
Medicine treats not only symptoms, but the underlying causes of roots of these imbalances. Once the root causes are
addressed you may experience other positive changes in your being, such as increased energy and restful sleep.
During the course of treatment you may receive instructions for your care. It is important for you to follow the treatment
plan and other recommendations to achieve optimal care. Working together, we can effectively treat your original
concerns and any other underlying issues.
After your treatment, you may feel very rested and you have more energy than they know what to do with. Others are tired
and feel the need to relax. Use your energy wisely after a treatment. I do recommend that you avoid excessive physical
exercise for a few hours after treatment. Please drink plenty of water. This will help flush the toxins and to help with releasing
the blocked energy. You normally should be drinking ½ ounce for every pound of body weight. In circumstances of
disharmony more water may be needed to aid in the healing process.
What you may receive today or during the course of your treatment:
Herbal Prescriptions
These are for your use only. Take as directed finish any recommended doses, even if you are feeling better. If you have any
questions call. If you experience any changes in your mood, sleep pattern, digestion, emotions, or energy that are
unpleasant, call.
Herbal Cream or Patches
These have Chinese Herbs in them that will increase circulation and release muscle spasms (hyper tonicity). Do not leave
patches longer then overnight and watch for itching or skin irritation. If either occurs, remove patches and discontinue use.
You are most likely having an adverse reaction to the adhesive.
Ear Seeds
These are designed to activate acupuncture points in the ear corresponding to a disharmony in the body. Stimulate the
points three times per day by putting pressure on each seed until you feel the ache or pressure of the acupuncture point.
Keep the ear seed on for three days and remove. If they interrupt your sleep, remove them. Sleep is more important. You
may leave them on when you shower or bath; just towel dry.
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
Enjoy a Healthy Lifestyle and Diet.
There may be dietary and lifestyle recommendations made at any of your appointments. This is an opportunity for you to be
involved in your journey towards wellness and health. Your participation is an important part of the process and often
requires changes in your beliefs about your health as well. If you have any questions – call. I will answer when I can.
In Good Health,
Denise Dupree, EAMP, LAC.
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
Name: __________________________________________________________Today’s Date:_____________________________
Address:_______________________________________________________________________________________________
City:_______________________________________________State:_____________
Zip:_______________________
Home Phone: ______________________________________Cell Phone:____________________________________________
E-mail address: _________________________________________________________________________________________
Sex: Male/Female
Occupation:
Emergency
Birth Date ______/_______/_______ Marital Status: Married Single Separated Divorced Widowed
__________________________________________Children,
Contact:___________________________
Relationship:
Ages__________________________________
_________________Phone:___________________
Insurance
Do you have Health Insurance that covers Acupuncture?
Yes
No
Don’t Know
Insurance Company____________________________________________Phone #___________________________________
MemberID_________________________________________ Group Number______________________________________
Name of Primary Insured Person____________________________________ Birthdate of Primary Insured___/___/___
Employer of Insured__________________________________________Your relationship to Insured_____________________
I hereby assign, transfer, and set over to Denise Dupree Acupuncture, Denise DuPree, L.Ac. all of my right, title and interest to my medical
reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits.
This authorization shall remain valid until written notice is given by me revoking said authorization. Understand that I am financially
responsible for all charges whether or not they are covered by insurance.
Signature___________________________________________________________________________Date___________________
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
Have you had Acupuncture or Oriental Medicine before?____________________________________________________
Are you presently under a doctor’s care? Y / N Are there any other therapies in which you are involved? Y / N
If yes, who do you see and for what?________________________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________________________
Primary Physician:______________________________________________________________ May we contact them? Y / N
What is your primary reason for seeking care at our office?___________________________________________________
____________________________________________________________________________________________________________
Are you interested in:
_____Pain Relief _____ Preventative Care _____Oriental Nutrition _____ Performance Care _____ Herbal Therapy
_____ Holistic Health _____ Meridian Yoga _____ Maintenance Care _____ Stress Relief _____ Other*
*if Other, please explain____________________________________________________________________________________
What are your health goals?________________________________________________________________________________
Sports/Exercise/Activities you participate in (include frequency and duration):_________________________________
____________________________________________________________________________________________________________
List any significant surgeries or trauma, and dates if applicable:_______________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
Pain (complete if you are interested in being treated for pain or a particular condition)
Where in your body are you experiencing pain?____________________________________________________________
How frequent?___________________________________ How severe is it?_________________________________________
When did it begin? ________________________________What was the initial cause?______________________________
What makes it better or worse?_____________________________________________________________________________
How does it affect your sleep? (circle one) Mildly Disturbed
Moderately Disturbed
Greatly Disturbed
Cannot Sleep
How does this problem interfere with your daily activities?____________________________________________________
____________________________________________________________________________________________________________
What have you done about this?____________________________________________________________________________
Health History
Do you have any allergies? If so, to what?___________________________________________________________________
Do you take any medication? If so, what types and how often?______________________________________________
___________________________________________________________________________________________________________
Have you had any of the following? Hepatitis
HIV/AIDS
Herpes
Other Contagious Disease______________________________
Do you smoke? Yes/No If Yes, how much and how often? ___________________________________________________
Do you consume alcohol? Yes/No If Yes, how much and how often?_________________________________________
Do you consume caffeine? Yes/No If Yes, what type, how much and how often?_____________________________
What is your stress level like, on average? ___________________________________________________________________
What is your diet/nutrition like?______________________________________________________________________________
How is your appetite? Circle all that apply:
Varied
Poor
Constant Hunger
Loss of Taste
Normal
Do you have a family history of any of the following? Circle all that apply:
Diabetes
Heart Disease
Cancer
High Blood Pressure
Stroke
Seizures
Asthma
Allergies
If female, date of last menstrual period:____________________Do you have problems with your cycle/period? Y/N
If Yes, please describe______________________________________________________________________________________
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
Approximate height and weight: _________________________ Any weight loss or gain recently?__________________
How is your energy level? Circle all that apply:
Low Varied
Tired after eating
Wake up tired
Excessive
Normal
Circle any of the following that are current concerns:
Abdominal Pain/Distention
Decreased Libido
Impotence
Peculiar tastes
Abuse
Depression
Increased Libido
Poor appetite
Acid regurgitation
Dizziness
Indigestion
Poor circulation
Acne
Dry throat/Mouth
Insomnia
Poor memory
Anger problems
Diabetes
Intestinal Pain
Poor sleep
Anxiety
Diarrhea
Irritability
Premature ejaculation
Asthma
Difficulty Breathing
Itchy eyes or skin
Psoriasis
Back Pain
Earaches
Joint Pain
Rash
Bad Breath/ Bad Taste in Mouth
Eczema
Kidney Stones
Seizures
Blood in Stools
Enlarged Thyroid
Limited range of motion
Seasonal Affective Disorder
Blood in urine
Emotional Trauma
Loss of hair
Shortness of breath
Bloody Stools
Eye pain/Strain
Low Blood Pressure
Sinus pressure
Breast Lump
Excessive Phlegm
Low Blood Sugar
Sweat easily
Bruise easily
Excessive Saliva
Migraine
Spots in eyes
Chest pain
Fatigue
Mouth Sores
Sore throat
Chills
Fever
Mucous in stools
Sudden energy drop
Cold hands/feet
Flu
Muscle cramps/pain
Swollen glands
Concussion
Frequent Urination
Nasal congestion
Teeth/gum problems
Confusion
Gas
Neck/Shoulder Pain
Ulcers
Congestion
Grinding teeth
Night Sweats
Urgent urination
Constipation
Headache
Nose Bleeds
Vomiting
Cough
Hemorrhoids
Numbness
Waking to urinate
Dandruff
Heart Palpitations
Odorous Stools
Dark Stools
High Blood Pressure
Pain upon urination
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com
Denise DuPree Acupuncture
CANCELLATION POLICY
All fees for services are due at the time of each appointment. In order for us to provide efficient and consistent care for all of our patients,
we discourage canceling appointments if at all possible. If you cannot keep an appointment, please notify us 24 hours in advance so we
may give up your time to another patient. Failing to attend your scheduled appointment or call to cancel with sufficient notice will result in
a $40 charge to be paid prior to the next appointment. If you call to cancel on the same day, and reschedule for the same week, we will
not charge you for a late cancellation.
Credit Card #:_________ __________________________________________ Expiration Date___________________3-digit code on back_____________
_____(initial) I have have read and fully understand the above statement.
Print Name____________________________________Signature____________________________________________________Date_____________________
CONSENT TO TREAT
When a client seeks acupuncture and I accept a patient for such care, it is essential for both of us to be working toward the same
objectives. Acupuncture is focused upon a few goals: to detect and correct the quality, quantity and balance of Qi, Blood, and other
body fluids. When this is done correctly, the body will have the capacity to obtain and maintain health and well-being. It is important that
each client understand the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
I do not offer to diagnose or treat any disease or condition other than the quality, quantity, and balance of Qi. However, if during the
course of an acupuncture examintation I encounter non-acupuncture or unusual findings, I will advise you. If you desire advice, diagnosis
or treatments of those fidngings, I will recommend that you seek the services of a health care provider qualified to treat those problems.
Regardless of what a disease is called, I do not offer to treat it. Nor do I offer adice regarding treatment prescribed by others. The ONLY
practice objective is to detect and correct imbalances within Meridian pathways using Acupunctire and Chinese Medical Techniques. This
can help to facilitate healing and potentially lead to a full expression of your body’s innate wisdom.
_____(initial) I have have read and fully understand the above statements.
All questions regarding the acupuncturist’s objectives pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept acupuncture care on this basis.
Print Name____________________________________Signature____________________________________________________Date_____________________
NOTICE OF PRIVACY POLICY
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose
my protected health information to carry out: my treatment; obtaining payment from third party payers. I have also been informed of and
given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses
and disclosures of my protected health information and my rights under HIPAA.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out
treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do
agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any
use or disclosure that occurred prior to the date I revoke this consent is not affected.
Print Name____________________________________Signature____________________________________________________Date______________________
182 Ericksen Ave, N.E., Bainbridge Island, WA 98110
206-201-3358
denise.dupree@gmail.com