New Patient Intake Form (#
)
Last name:________________________ First name:______________________________
Date of Birth:_____________________ Age: ______ Gender: F M date: ___________
Address:_________________________ City: _________________________ State: ______
Zip:_____________Phone:__________________ E-mail: __________________________
The reasons for your visit_________________________________________________________________________
What treatments did you have before?__________________________________________________________________
Any medication currently_____________________________________________________________________________
Past Medical History:
Illnesses: ____________________________________________ Surgeries: ____________________________________
Bleeding disorder ______________________________________Infectious disease_______________________________
Allergies: _________________________________________________________________________________________
Pacemaker or other electrical implants ___________________________________________________________________
Medication in the past three month?_____________________________________________________________________
Woman’s menses: Regular/irregular; PMS; scanty/profuse; dark red/light red; with clots or no clots; pregnant or not
Family Medical History (AIDS Alcoholism Allergies, HP, Asthma, Diabetes Heart Disease, Cancer, Seizures, Stroke, or Mental)
Mother’s side: _________________________________________ Father’s side: ________________________________
Siblings: __________________________________________________________________________________________
Personal Health History (Please circle if any of the following apply)
AIDS
Asthma
Alcoholism
Arteriosclerosis
Birth Trauma (yours)
cancel
Childhood illness
Childhood Fevers
Diabetes
Epilepsy
Emphysema
Endocrine Disorder
Hepatitis
Heart Disease
High Blood Pressure
Low Blood Pressure
Hyperthyroid
Hypothyroid
Multiple Sclerosis
Gout
Jaw/Teeth Pain
Lack of Sweating
Muscular Pain
Menstrual Disorders
Menopausal Problems
Night Sweating
Skin Disorders
Sinus Pain/Problems
Spontaneous Sweating
Throat Pain
Urination Difficulties
Weight Loss or gain
Current Symptoms (Please check if any of the following apply)
Anxiety
Breathing Difficulties
Chest Pain
Constipation
Diarrhea
Dizziness
Ear / eye / nose / mouth
Excess or Lack of Thirst
Fever or Chills
Fatigue
Emotional stress
High/Low Blood Pressure
Headaches
Impotence PMS
Indigestion
Insomnia
Infertility
Joint Dysfunction/Pain
*** Please indicate any areas of pain ***
Pain description:
How long?
back
Front
Left
Right
Acupuncture of Dublin by Qin Lu, Ph.D., Dipl. L.Ac
6357 Twonotch Ct. Dublin OH 43016
Phone/Fax: 614-726-5521; cell: 614-743-1195
E-mail: luqinus@yahoo.com, Website: AcupunctureofDublin.com
Patient Consent Form for Acupuncture Treatment
Please read this information carefully, and ask your practitioner if there is anything you do not understand.
While acupuncture, Chinese medicine, and other treatments provided by this office have proven to be highly effective in correcting
conditions and maintaining overall health and well-being, practitioners are required to advise patients that there may be some risks.
Although practitioners cannot anticipate all of the possible risks and complications that may arise with each individual case, you
should be aware that the following side effects can occur. If there are particular risks that apply to you case, your practitioner will
discuss these with you.
What are the possible treatments and side effects that can occur with acupuncture therapy?
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the
application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily
dysfunctions or diseases. I am aware that certain adverse side effects may result. These could include but are not limited to: local
bruising, minor bleeding, fainting, drowsiness, pain or discomfort, and the possible aggravation/worse of symptom. I understand
that no guarantees concerning its use and effects. Direct Moxibustion: I understand if I receive direct moxa as part of therapy that
there is a risk of burning or scarring from its use. I understand that I can refuse these treatments anytime.
Acupressure/Tui-Na: If Acupressure/tui-na is a part of my treatment for relaxing muscle and stop pain, I am aware that certain
adverse side effects include, but not limited to: sore muscles or aches, and the possible aggravation of symptoms existing prior to
treatment. I understand that I can stop the treatment if it is not comfortable for me.
Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered during the treatment. I am
aware that certain adverse side effects include, but are not limited to: electrical shock, pain or discomfort, and the possible
aggravation of symptoms. I understand that there may be extra charge for using it and I may refuse this treatment.
Cupping-Gua Sha: Cupping/Gua Sha are effective way to remove body heat, cold, dampness or phlegm, but it may leave the red
markers on the skin for a few days depends on the body’s condition. I understand that I may be asked to have cupping treatment
and there may be an extra charge for it. I understand that I may refuse this treatment.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I do not expect
every side effect and risk was listed here since each individual may react to the acupuncture differently.
Health Insurance Portability and Accountability Act (PIPAA) Consent: I understand my practitioner may request to review
my other medical records or lab reports, but all my health records and given information includes insurance will be kept
confidential and will not be released anywhere without my written consent.
Agree
Cancellation Policy
In signing this form, I also understand and accept that the full appointment fee could be charged to my account if cancellation is
not done 24 hours prior to the date of the appointment, and Acupuncture clinic is unable to fill that appointment.
Agree
Statement of Consent
By voluntarily signing below, I have carefully read and understand all of the above information, I have been told about the risks
and benefits of treatments provided by this office and have had an opportunity to ask questions. I give my permission and
consent to the entire course of treatment. I am 18 above today and I have the right to sign.
____________________________________
Patient Name in Print
Acupuncture of Dublin (Qin Lu)
____________________________________
Signature of patient or legal representative *
______________________________
Signature of licensed acupuncturist
____________________________________________
_____________________________________
Date
Date
*If signed by legal representative, relationship to the patient _____________________________________________________