Please fill out the following information as completely as possible. In order for us to
verify your insurance benefits, we must have the information listed below. This is a
confidential record of your medical history and will be kept in this office.
Information contained here will not be released to any person except when you
have authorized us to do so.
PLEASE PRINT
NAME___________________________________________________________DATE________________________
ADDRESS_____________________________________________________________________________________
CITY/STATE/ZIP CODE______________________________________________________________________
HOME PHONE ______________________________CELL PHONE__________________________________
WORK PHONE______________________________EMAIL ADDRESS______________________________
PLACE OF
EMPLOYMENT_______________________________OCCUPATION_________________________________
HOW DID YOU FIND ABR
ACUPUNCTURE?_____________________________________________________________________________
REASON FOR TREATMENT TODAY/MEDICAL
COMPLAINT:________________________________________________________________________________
SURGICAL HISTORY: PLEASE LIST ALL HOSPITALIZATIONS IN THE PAST 10 YEARS
AND ALL RELEVANT INJURIES AND SURGERIES THAT MAY BE RELEVANT TO
YOUR CURRENT
CONDITION___________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
MEDICATIONS THAT YOU ARE CURRENTLY TAKING/DOSAGE/ REAON
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SUPPLEMENTS/DOSAGE/REASON_________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PLEASE MARK THOSE ILLNESS LISTED BELOW THAT YOU HAVE EXPERIENCED IN
THE PAST OR ARE CURRENTLY DEALING WITH
CANCER
HEART DISEASE
THYROID DISEASE DIABETES
HIV/AIDS
HIGH BLOOD PRESSURE
HEPATITIS
OTHER SIGNIFICANT ILLNESS____________
WHAY TYPES OF FOODS DO YOU TYPICALLY EAT?
BREAKFAST__________________________________________________________________________________
LUNCH________________________________________________________________________________________
DINNER_______________________________________________________________________________________
SNACKS_______________________________________________________________________________________
DO YOU DRINK COFFEE/TEA? HOW MUCH?_____________________________________________
DO YOU DRINK ALCOHOL? HOW MUCH?_________________________________________________
DO YOU CURRENTLY SMOKE? HAVE YOU EVER SMOKED? HOW LONG HAS IT
BEEN SINCE YOU QUIT SMOKING?_________________________________________________________
DO YOU EXERCISE REGULARLY? WHAT TYPE OF EXERCISE? HOW OFTEN?
ABR ACUPUNCTURE CONSENT TO TREATMEN
I, the undersigned, authorize ABR Acupuncture to perform treatment methods used in this practice
which may include, but are not limited to acupuncture, trigger point dry needling, massage therapy,
electrical stimulation, cupping, gua sha (scrapping), and nutritional counseling.
I understand that acupuncture, trigger point dry needling, massage therapy, electrical stimulation,
cupping, gua sha (scrapping), are all safe methods of treatment. Potential risks include temporary
bruising, swelling, bleeding, numbness and tingling, and soreness at the needling site that may last
for a few days. Unusual risks of treatment include accidental puncture of a lung (pneumothorax),
dizziness, fainting, or nerve damage. If a pneumothorax were to occur, it may likely require a chest xray and no further treatment. The symptoms of shortness of breath may last for several days to
weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare
complication, and in skilled hands it should not be a major concern. Infection is possible, although
ABR Acupuncture uses alcohol and sterile disposable needles and maintains a safe and clean
environment. Temporary bruising or redness lasting several days is a common side effect of cupping
and gua sha. I fully understand that there is no implied or stated guarantee of success or
effectiveness of a specific treatment or series of treatments.
I will notify ABR Acupuncture should I become pregnant or if I am in the process of trying to get
pregnant so that my practitioner can avoid points that can induce a miscarriage.
I understand that ABR Acupuncture may review my medical records and lab reports, but all my
records will be kept confidential. If it becomes necessary to share my health information, this will be
handled in accordance with the stipulations detailed in the Notice of Privacy Practices document that
has been provided to me, and of which I have acknowledged receipt.
I understand that I can discuss risks and benefits further with ABR Acupuncture before signing if I so
choose. However, I do not expect my practitioner to be able to anticipate and explain all possible
risks and complications of treatment. I rely on the practitioner to exercise his/her judgment in my
best interest during the course of treatment, based on the facts then known.
I recognize that scheduling an appointment involves the reservation of time specifically for me, and
that consequently, A MINIMUM OF 24 HOURS NOTICE IS REQUIRED TO RESCHEDULE OR CANCEL
AN APPOINTMENT. UNLESS OTHERWISE AGREED TO IN ADVANCE, THE FULL FEE WILL BE
CHARGED FOR THE SESSION MISSED WITHOUT SUCH ADVANCE NOTIFICAITON. I understand
that most insurance companies do not reimburse for missed sessions.
In signing this form, I acknowledge any inherent risks, and give my consent for treatment, payment
and healthcare operations received, incurred or carried out at this practice.
Patient’s Name (please print)______________________________________________________________________________
Patient’s
Signature_______________________________________________________________Date_____________________________________
Parent’s Signature signing for a minor_________________________________________________Date__________________