SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781) 925-1941 info@szabofitness.com
ACUPUNCTURE INITIAL INTAKE
PROGRAM INFORMATION AND POLICIES
Welcome to the SZABO FITNESS & ACUPUNCTURE acupuncture program! We are delighted that you
chose us as a part of your commitment to health and fitness. Our skilled licensed acupuncturists are
ready to provide you with the necessary information and motivation to help you reach and maintain your
personal goals. The following information will provide you with important program policies. Before getting
started, please read and sign this form so that we can be sure that you have been provided with and
understand this information.
PAYMENT & RESPONSIBILITY
Payment for sessions must be made at the time of meeting with your acupuncturist, and at the time of
purchasing any prepaid packages.
EXPIRATION DATE
All SZABO FITNESS & ACUPUNCTURE acupuncture sessions and packages have an expiration date of
3-months from the date of purchase. After the expiration date, any remaining sessions will be invalid.
Cards can be frozen for medical purposes only and require medical documentation. Frozen cards will be
held for one year after which time any remaining sessions will become invalid.
CANCELLATIONS
In order to cancel or reschedule an appointment, you must contact SZABO FITNESS & ACUPUNCTURE
at least 24 hours in advance of the scheduled appointment or you will be charged for that session.
TARDINESS
All patients and practitioners are encouraged to be prompt. If a patient arrives late, this time will be
deducted from the session. Please be advised that practitioners are required to wait 15 minutes for a
scheduled patient, after which time the session is subject to cancellation and patients will be charged for
a full session.
REFUNDS AND CREDITS
SZABO FITNESS & ACUPUNCTURE does not offer refunds or credits, so please be sure that our
services will match your needs before committing through payment. If you find that your needs change
once you have begun this program, please let us know; we are eager to find a way to accommodate you
within this program.
I have read and will comply with the above information.
____________________________________________________
Name (please print)
____________________________________________________ _______________
Signature
Date
SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781)925-1941 szabofitness@gmail.com
General Information and Consent for Acupuncture Treatment
General information about Acupuncture:
Acupuncture is a 2500 year old Chinese tradition performed by licensed practitioners. It is based on the
premise that illness, dysfunction, pain, lack of energy, etc., are due to the improper flow of energy (Qi) in
the body. There are many theories explaining Qi, some of which equate it with the electrical impulses of
the nervous system or the Autonomic Nervous system. With the use of sterile, disposable needles,
massage, heat therapy, cupping, electrical stimulation, diet, herbs, movement/exercise and topical
applications, the acupuncture practitioner can correct the imbalance and dysfunction of energy that is
causing ill-health and pain.
The powerful combination of Acupuncture and Herbs can not only treat painful conditions, but has a great
degree of success in reducing the symptoms of many health problems, including, but not limited to:
-related disorders
-related problems
tions
Licensed acupuncturists do not make conventional diagnoses, but often require the information from you
or your primary health providers in order to properly evaluate your overall health.
Potential risk: Pain, discomfort, discoloration, bruising and very occasionally, fainting and aggravation
of pre-existing symptoms can occur with treatment.
Potential benefits: Restoration of health and the body’s maximal functional capacity, relief of pain and
symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its
progression.
Facial Rejuvenation Acupuncture: Facial acupuncture can result in bruising of the face at the sight of
treatment. It is important to tell your practitioner if you bruise easily or have any major illness considered
contraindicated for facial treatment.
Notice to Pregnant Women: If you are pregnant, suspect you may be, or are trying to get pregnant,
please alert your practitioner. Certain therapies used could present a risk to the pregnancy. No laborstimulating acupuncture points or labor-stimulating substances will be used.
I understand that I may ask questions regarding my treatment before signing this form and that I am free
to withdraw my consent and discontinue participation in these procedures at any time. With this
knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to
me by Szabo Fitness& Acupuncture or any of its personnel regarding cure or improvement of my
condition. I understand that a record will be kept of the health services provided to me. The record will
be kept confidential and will not be released to others unless so directed by my representative or me or
otherwise permitted or required by law.
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patient signature
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guardian/personal representative signature
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date
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date
SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781) 925-1941 szabofitness@gmail.com
ACUPUNCTURE PERSONAL HEALTH HISTORY
Note: Information provided on this form is confidential
It is very important the information given is complete and accurate to assist you properly in your
healing process.
Please PRINT Today’s Date ___/___/___
Name _______________________________ Date of Birth ___/___/___ Sex: Male � Female �
Address_______________________________________________________________________
City/ State/ Zip _______________________________email______________________________
Telephone (home)____________________(work)___________________
Occupation_________________________________
Emergency Contact Person /Relationship___________________________ Tel:______________
Physician______________________________________________________________________
Physician’s phone #____________________________________
How did you hear of us?__________________________________________________________
What do want treated with acupuncture?______________________________________________
How long have you had this condition?__________________ The onset was sudden � gradual �
Symptoms relieved by____________________________________________
Symptoms worsened by___________________________________________
What medical diagnosis have you received for this condition?_____________________________
What other treatments have you received for this condition?______________________________
What medications are you taking?___________________________________________________
Is this your first experience in Oriental Medicine and acupuncture?________________________
How do you feel about acupuncture?_________________________________________________
Are you currently pregnant? Yes � No �
Are you presently trying to get pregnant? Yes � No �
Do you drink coffee? ____ How much/ day? _________________________________________
Do you drink alcohol?____ How much?_______________How often?____________________
Past Medical History:
Have you had any of this condition(s)? Circle all that apply:
AIDS/HIV
Alcoholism
Allergies (food, latex) Asthma
Birth Trauma
Cancer
Diabetes
Drug Addictions
Emphysema
Fibromyalgia
Heart Disease Hepatitis A/B/C Herpes
Joint Replacements
Lyme Disease Lymph Nodes removed Multiple Sclerosis
Pacemaker
Polio
Rheumatic Fever
Scarlet Fever
Seasonal Allergies
Seizures
Sinus Infections
Tuberculosis
Operations______________________________ Other____________________________
Family Medical History: (Please list any significant family illnesses, e.g. diabetes, heart disease,
respiratory conditions, blood pressure, neurological disorders, psychological disorders, arthritis)
Mother:________________________________________________________________________
Father:________________________________________________________________________
Siblings:_______________________________________________________________________
Grandparents:___________________________________________________________________
Exercise & Energy:
How is your energy?_____________________________________________________________
What time of day is your energy: Highest?__________________Lowest?___________________
Do you fatigue easily?____________________________________________________________
What do you do for weight management?_____________________________________________
Are you interested in nutritional recommendations for weight management?_________________
What kind of exercise do you do?___________________________________________________
How often do you exercise?________________________________________________________
Emotions & Sleep:
How do you feel emotionally?______________________________________________________
Do you have (circle all that apply): Panic attacks Depression Anxiety Bad temper
Nervousness
Fear attacks
Poor memory
Difficult concentration
Are you in a relationship? Yes � No �
How do you feel about your relationship?_____________________________________________
How do you hold stress?__________________________________________________________
How do you relax?_______________________________________________________________
How do you feel about your work?__________________________________________________
How long do you normally sleep? _____________hours per night_________________________
I have difficulties with (circle all that apply): Falling asleep Staying asleep
Dream-disturbed sleep Waking up at about _____am/pm and not being able to fall asleep again
Gastrointestinal:
I have (circle all that apply): Belching Nausea Vomiting Vomitting of blood Ulcers
Bloating Acid regurgitation Heartburn Hernia Indigestion Severe stomach pain
Bowel movements: How often? _________time(s)/day _________days/week
I have (circle all that apply): Irregular Constipation Diarrhea Gas Burning sensation
Hemorrhoids Undigested food in stool
Loose stool Hard stool Blood in stool Itchiness
Painful bowel movements
Urinary:
Urination: How often?______/day Color: Pale yellow Dark yellow/orange
I have or had (circle all that apply): Trouble starting stream Frequent urination
Incontinence Pain
Burning Dribbling when sneezing Blood in urine Kidney stones
Urinary tract infections
Other______________________________________________
Women:
At what age did you start menstruating? _______ Number of days between cycles:____________
Number of days of flow:____Color: _______________Number of pregnancies_______________
I have or had (circle all that apply): Irregular menstruation Heavy flow Light flow No flow
Clots Vaginal itching/burning Spotting between periods Discomfort/pain before period
Discomfort/pain during period Other______________________________________________
Any vaginal discharge? No � Yes � Color___________________________________________
Men:
I have (check all that apply): Prostatitis�
Impotence �
Penis blood/mucous discharge �
Other:_________________________________________________________________________
Muscles, Joints & Bones:
Do you have pain or tightness? No � Yes � Where?___________________________________
The pain is (check all that apply): Sharp � Dull � Aching � Numb � Superficial Pain �
Deep Pain � Burning � Tingling � Shooting � Pain worse/better with heat �
Pain worse/better with cold � Pain worse/better with pressure � Pain worse in am/pm �
I have (check all that apply): Swollen joints � Arthritis/joint pain � Tendonitis � Bone pain �
Muscle cramping � Muscle pain � Repetitive Strain Injury � Fractured Bone(s) �
Where?____________
Other__________________________________________________
Eyes, Ears, Nose, Throat, & Head:
Do you smoke? No � Yes � ______________per day, for _________years
I have (check all that apply): Frequent colds � Chronic runny nose � Frequent sore throat �
Chronic cough � Coughing blood � Cough up mucous � Pain inhaling �
Shortness of breath on exertion/at rest � Asthma � Nose bleeds � Painful/red eyes �
Poor vision � See spots/floaters � Dizziness � Cold sores � Bleeding gums � Dry mouth �
Ear pain � Ringing in ears � Clogged/popping in ears � Frequent headaches/migraines �
describe:_______________________________________________
Cardiovascular:
I have (check all that apply): Chest pain � Palpitation � Varicose veins � Phlebitis � Cold
hands and feet � Irregular heart beat � Poor circulation � Other:_________________________
Skin & Hair:
I have or often have (check all that apply): Dry skin � Skin rashes � Itching � Acne �
Eczema � Hives � Hair loss � Premature graying �
Other:___________________________________________
INSURANCE INFORMATION
Name_______________________________________Birthday_______________
Address___________________________________________________________
Insurance claim number _______________________________________________
Insurance company ___________________________Group #_______________________
Subscriber’s Name _____________________________________________________
Referring Doctor______________________________ Date of injury____________
Social security number _______________________ Email address _____________________
(only if you are using personal health insurance)
By signing below I authorize all insurance payments to be made directly to Szabo Fitness & Acupuncture. I
understand that my signature explicitly allows the release of my medical record to my “first party” payer
identified above as necessary to have my bill paid. Chart note copies and billing information to a “third
party” will only be processed with my valid written authorization. All record requests require payment of
appropriate fee. I further give permission to this provider to consult with my primary care and or referring
doctors as it pertains to the heath concerns at hand. I understand that my primary insurance company will
be billed directly on my behalf for these acupuncture sessions as a courtesy. I agree to take full
responsibility for any remaining balance not paid by my insurance company or related companies,
including co-pays, deductibles, and non-covered services and denied services. If the treatment is for injures
sustained in an auto accident where payment is pending form a “third party” I understand that my full
cooperation will be necessary to secure payment from that party. In the event no payment is made, I will be
held fully responsible for the charges incurred. I understand my insurance will not cover missed
appointments therefore payment for cancellations without 24-hour notice is my responsibility.
Signed____________________________________________Date_________________