Cervical
Are you having neck pain? Yes / No
Does the pain radiate into your arms? Yes / No
If Yes, which arm?
Right Left Both
How far down the does the pain radiate? _________________
THORACIC/LUMBAR
Are you having back pain? Yes / No
Does the pain radiate into your legs? Yes / No
If Yes, which leg?
Right Left Both
How far down does the pain radiate?_________________
______________________________
Musculoskeletel
Please describe any symptoms you may be having:
For how long: _____________________________________
Is this a sport or work relate injury? Yes / No
If Yes, details:
Please indicate where you are experience pain and/or tingling/numbness.

17200 State Hwy. 249, Suite 100 Houston, Texas 77064
Phone# 832-463-4526 Fax# 832-446-3631
Acupuncture Treatment Acknowledgement
I acknowledge that for the best results during my acupuncture treatment, I should obtain treatment within one(1) hour after a meal or on an empty stomach. I should not obtain treatment within 24 hours of donating blood, or if I plan to donate blood within 24 hours. I also understand that I should abstain from drinking any alcoholic beverages while undergoing acupuncture treatment.
I acknowledge fully and specifically state that I understand that treatment with acupuncture
(like treatment by other branches of health services) cannot, will not and does not guarantee specific results or cures, and that treatment with acupuncture, just like leaving my condition untreated, carries risk. I also understand that acupuncture treatment may cause bruising, temporary dizziness, light-headed, and rarely may cause fainting or blistering of the skin following cupping and/or moxibustion.
I acknowledge that I and legally and mentally competent to sign this authorization and that I have read and do fully understand it. I further understand that I may revoke this authorization at any time by notifying Holistic Acupuncture in writing.
_________________ _________________ _________
Patient's Name Patient's Signature Date
_____________________ ____________________ _________
Witness's Name Witness Signature Date

Form to be Completed by Patient, Notifying the Acupuncturist of Whether He/She Has Been Evaluated by a Physician, and Other Information
(Pursuant to the requirements pof "183.6(e) of this title ( relating to Denial of License;Disipline of License) and Tex: Occ
Code Ann., "205.351, governing the practice of acupuncture.)
I (patient's name) _____________________________________________ im notifying the acupuncturist ( practitioner's name), ______________________________ 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 I should be evaluated by a physician or dentist for the _________ (initials of patient) date: ___________
_____ 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 2 months or 20 treatments, whichever comes first, no substantial improvement occurs in the condition being treated, I understand tha the acupuncturist is required to refer me to a physician. It is my responsibility and choice whether to follow this advice.
_______________ (initials of patient) Date: ______________
Patient's signature__________________________________ Date: ________________
Note:
Exemptions according pto Rule 183.6(e) Scope of practice
3)... an acupuncturist holding a current and valid license may without an evaluation or a referral from a physician, dentist, or chiropractor perform acupuncture on a person pfor smoking addiction, weight loss alcoholism, chronic pain, or substance abuse.

17200 State Highway 249, Suite 100, Houston, Texas, 77064
I hereby request and consent to the performance of acupuncture treatments and other Oriental Medicine procedures on me (or on the patient named below, for whom I am legally responsible) by Daniel Yu-I Lee, a licensed acupuncturist.
I understand the methods of treatment may include but are not limited to : acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), bleeding and Chinese herbal medicine.
I have had the opportunity to discuss with the above named acupuncturist the nature and purpose of acupuncture treatment and other procedures.
I have been informed that acupuncture is a safe method, but that it may have side effects, including bruising, numbness or tingling near the needle site that may last few days, with possible dizziness or fainting. Bruising is common side effects of cupping. Unusual risks of acupuncture include spontaneous miscarriages, nerve damage and organ puncture, including lung puncture (pneumothorax).
I understand that the risk of infection is negligible when all needles are sterile.
The herbs and nutritional supplements (which are from plant, animal and mineral sources) that may be recommended are traditionally considered safe, although some may be toxic in larger doses. I understand that some herbs may be inappropriate during pregnancy. some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives and tingling of the tongue.
I understand that the herbs need to be prepared and the tea consumed according to the instruction provided orally and in writing.
The herbs may have an unpleasant smell or taste. I will immediately inform the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbal teas.
I will notify the acupuncturist who is caring for me if I am or become pregnant.
I do not expect the acupuncturist to be able to anticipate and explain all risk and complications, and I wish to rely on the acupuncturist to exercise judgment during the course of the procedure which the acupuncturist feels, based on the facts then known, is in my best interest.
I understand that clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
I have read, or have read to me, the above consent. I have also had the opportunity to ask questions about its consent, and by signing below I agree to the above-named procedures. 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.
Patient’s Name: _______________________________________________
Patient’s Signature: ____________________________________________ Date: _____________