CONFIDENTIAL PATIENT INFORMATION
Personal Information
Full name:
Date:
Address:
Street
City
State
Zip
Home phone:
Work phone:
Cell phone:
Email address:
Date of birth:
*e-mail monthly newsletters are sent out to patients
Age:
No. of children:
Marital status:
Yes □
Pregnant?
M
S
W
No □
Spouse/guardian name:
D
Employer’s name:
Occupation:
Name of person responsible for account:
Emergency Contact person:
Phone #:
Relationship:
If any, please check any and all insurance coverage that may be assisting to pay for care:
□ Major Medical
□Worker's Compensation □Medicaid
□Medicare □ Auto Accident
□Other
( be sure to have us make a copy of insurance card(s)) **Most insurance companies do not cover acupuncture**
Who may we thank for referring you? _________________________________________________________________________
(Relative, friend, yellow-book, Dex, screening event)
Have you had previous Acupuncture Care? Y N
Approximate date of last visit? ____________________________________
Addressing What Brought You Into This Office:
If you have no symptoms or complaints and are here for Acupuncture Wellness Services, please skip to the “General Health History”.
Health Concerns
Please list your health concerns according to
their severity
Rate of severity
1 = mild
10 = worst
imaginable
1.
2.
3.
When did this
episode start?
Days, weeks,
months or years
ago?
If you had this
condition
before, when?
Did the problem
begin slowly,
immediately or
with an injury?
% of the time
pain is present
-Is your pain: Dull □ Sharp □? Does it radiate anywhere? Y or N If so where: _________________________
-Since the problem started is it: About the same? □
-What have you done to help condition: Ice □
Getting better? □
Heat □ Pain Relievers □
Getting worse? □
Massage □
Stretching □
-What activities are aggravated by your condition: Sitting □ Standing □ Working □ Bending □ Carrying □
Lifting □ Climbing □
Concentrating □
Pushing □ Running □
Shoveling □
Dancing □
Doing Chores □
Dressing □
Driving□
Sleeping □ Walking□
Have you seen any other doctors for this condition (Chiropractor, Family Practitioner, MD, etc.)
Y or N
General Health History
Have you EVER had any of the following diseases or conditions? Acupuncture is concerned with how your Qi
system is functioning. If it is not functioning at 100%, a multitude of problems can occur. Please take some time to
fill out the following:
CERVICAL SPINE (Neck): Do you experience…?
� Neck pain
� Pain into your shoulders/arms/hands
� Numbness/tingling in arms/hands
� Weakness in grip
� Hearing disturbances
� Headaches
� Dizziness
� Visual disturbances
� Coldness in hands
� Thyroid conditions
� Sinusitis
� Allergies/Hay fever
� Recurrent Colds/Flu’s
� Low Energy/Fatigue
� TMJ/Pain/Clicking
THORACIC SPINE (Upper back): Do you experience…?
� Heart Palpitations
� Heart Murmurs
� Tachycardia (heart beating rapidly)
� Heart attacks/Angina
� recurrent lung infections/bronchitis
� Asthma/wheezing
� Shortness of breath
� Pain on deep inspiration/expiration
THORACIC SPINE (Mid back): Do you experience…?
� Mid back pain
� Pain into your ribs/chest
� Indigestion/Heartburn
� Reflux
� Nausea
� Ulcers/Gastritis
� Hypoglycemia (altered blood sugar)
LUMBAR SPINE (Low back): Do you experience…?
� Pain into your hips/legs/feet
� Numbness/tingling in your legs/feet
� Coldness in your legs/feet
� Menstrual irregularities/cramping (females)
� recurrent bladder infections
� Frequent/difficulty urinating
� Muscle cramps in your legs/feet
� Weakness/injuries in your hips/knees/ankles
� Low Back Pain
� Sexual Dysfunction
� Constipation/Diarrhea
Accumulation of life’s stress can lead to health problems and influence our ability to heal.
The following three areas of stress can contribute to your loss of health. It also affects your body’s ability to heal and repair.
Please circle stressors you currently or previously what you would consider to be the major stressors you deal with:
C=Currently
P=Previously
1. Physical Stress
Slips/Falls
C
P
Car Accidents
C
P
Sports/Work Injuries
C
P
Poor Posture
C
P
Sleeping Position
C
P
Repetitive Heavy Lifting
C
P
Continuous Sitting/standing
C
P
C
C
C
C
C
P
P
P
P
P
2. Emotional Stress
Relationships/Children
Career
Money
Fast Paced Life
Loss of Loved One
3. Chemical Stress (pollution, chemicals, toxins, unhealthy foods)
Smoker
C
P
Poor Diet
C
P
Prescription/OTC Drugs
C
P
Circle Current Medications you are taking
Tylenol
Advil/Ibuprofen
Cholesterol Medication
Blood Pressure Medication
Aspirin
Anti-Depressants
Anti-Anxiety
Thyroid Medication
Other? _________________________
Please List any Nutritional supplements, vitamins, homeopathic remedies you presently take:
_____________________________________________________________________________________
____________________________________________________________________________________
How many hours do you sleep per 24 hour period? ______________
Do you exercise? Y
N
How much water do you drink daily? _____________________________
Please list any other Hospitalizations, Accidents and/or Surgeries not mentioned and Date: ___________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
AUTHORIZATION FOR CARE
I hereby authorize the Doctor to work with my condition through the use of acupuncture to my body, as he or she deems appropriate. The
Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. If the Doctor does
accept my case, it does not guarantee nor does it imply a guarantee of being able to cure or prevent any condition, illness, or injury.
I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I
also understand that if I suspend or terminate my care, any fees for professional services rendered me will become immediately due and
payable.
X______________________ _____________
Patient signature
Date
___________________________
Guardian or Spouse’s Signature
Authorizing Care
________
Date
Patient Acknowledgement for Receipt of HIPAA Compliance Information
Please complete the information below. Whether you are a new patient and recently provided us with this information or if there have
been no changes since you started care we are required to have this acknowledgment on file in your hand. If you would like to read over a
copy please let front desk staff know.
X________________________
Patient Signature
__________
Date
__________________________
___________
Parent/Guardian Authorizing Care Date
*Missed Appointments will be billed a cash charge of $35. Please give at least an hour notice if you can’t keep your appointment.
*Balances that are not paid within 30 days of receipt of statement will incur a $5 monthly service charge.
Informed Consent for Acupuncture Care
When a patient seeks acupuncture health care and we accept a patient for such care, it is essential for both to be working for the same
objective. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any
confusion or disappointment. You have the right, as a patient, to be informed about the condition of your health and the recommended care
and treatment to be provided so that you may make the decision whether or not to undergo acupuncture care after being advised of the
known benefits, risks and alternatives.
Acupuncture is a science and art which concerns itself with the relationship between the body's Qi and function as that relationship may affect
the restoration and preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease
or infirmity.
Acupuncture is an effective form of health care that has evolved into a complete and holistic medical system. Practitioners of acupuncture and
Chinese medicine have used this noninvasive medical system to diagnose and help millions of people get well and stay healthy.
An acupuncturist will place fine, sterile needles at specific acupoints on the body. This activates the body's Qi and promotes natural healing by
enhancing recuperative power, immunity and physical and emotional health. It can improve overall function and well-being. It is a safe, painless
and effective way to treat a wide variety of medical problems.
If during the course of care we encounter non-acupuncture or unusual findings, we will advise you of those findings and recommend that you
seek the services of another health care provider.
All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits,
risks and alternatives of acupuncture care have been explained to me to my satisfaction. I have read and fully understand the above statements
and therefore accept acupuncture care on this basis.
X __________________________________
Patient Signature
_______________
Date