NEW PATIENT INTAKE AND HEALTH HISTORY
Name __________________________________________________________________
First
Last
Middle
Medical Care is only possible when the practitioner completely understands the patient’s physical, mental
and emotional conditions. The information you provide will help us to understand your needs and how to
help you reach your health goals. Please write legibly and answer all the questions thoroughly.
Address: _____________________________________________________________
City_____________________ State________________ Zip code: ______
Phone: Cell _______________________ Work_____________________
Email: ________________________________
The best way of contacting you is ______________________________________
Birth sex: Male/Female
Gender you identify with: Male/Female
Occupation: _____________________ Number of children: ___________________
Birth date: ______________________
Date and reason of last visit to doctor’s office, medical clinic or hospital:
________________________________________________________________________
Main reason for visiting the clinic today? ______________________________________
How did you hear about the clinic? ___________________________________________
Self/Family History
Previous hospitalizations/surgeries: __________________________________________
What diagnostic imaging studies have you had?
Bone density scan
Mammogram
Electrocardiogram
Electroencephalogram
X-rays
CT scan
MRI
Medications/Supplements: do you take or use any of the following
Pain relievers (asprin/ibuprofen)
Antacids
Laxatives
Diet pills
Thyroid medications
Cortisone (cream or pills)
Sleeping pills
Tranquilizers
Antibiotics
Anti-depressants
Please list any prescription medications, over-the counter medications, vitamins or other
supplements you are taking:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Allergies:
________________________________________________________________________
________________________________________________________________________
General
Height:________________ Weight___________ lbs. Weight one year ago_______ lbs.
Maximum Weight: ______________________ lbs. When? ________________________
When is your energy the best?______________________ The worst? _______________
Family history of disease: Please circle
Diabetes
Hayfever/hives
Heart Disease Mental illness
Glaucoma
Goiter
Tuberculosis Stroke
Liver disease
Heart murmer
Kidney disease
Asthma
Father still living? Yes; his age______
Mother still living? Yes; his age______
No: age at time of death_____ Cause______
No: age at time of death_____ Cause______
Childhood illnesses: Please circle
Mumps
Rheumatic Fever
Measles
Rubella
Scarlet fever
Mono
Other:_________________
Review of Symptoms: Please circle:
condition P= problem of the past
Headaches
Head injury
Ear ringing
Mumps
Y
Y
Y
Y
N
N
N
N
P
P
P
P
Skin
Rashes
Acne
Y N P
Y N P
Epilepsy
Gall bladder disease
High blood pressure
Y= yes present condition N= no never had the
Migraines
Dizziness
Earaches
Pain/stiffness
Y
Y
Y
Y
N
N
N
N
P
P
P
P
Psoriasis
Hair Loss
Y N P
Y N P
Jaw/TMJ problems
Impaired hearing
Swollen Gland
Goiter
Y
Y
Y
Y
N
N
N
N
P
P
P
P
Eczema/hives
Color changes
Y N P
Y N P
Itching
Y N P
Bumps
Y N P
Musculoskeletal
Joint Pain
Y N P
Arthritis
Y N P
Muscle Spasms Y N P
Broken Bones Y N P
Weakness
Sciatica
Y N P
Y N P
Eyes:
Blurred Vision Y N P
Eye pain
Y N P
Spots in Eye Y N P
Cataracts
Glaucoma
Color Blind
Glasses/contacts
Tearing/dryness
Double vision
Y N P
Y N P
Y N P
Nose/Sinuses:
Stuffiness
Y N P
Hayfever
Y N P
Loss of smell Y N P
Nose Bleeds Y N P
Sinus problems
Frequent Colds
Y N P
Y N P
Mouth/Throat
Hoarseness Y N P
Jaw clicks
Y N P
Gum Problems Y N P
Dental Cavities Y N P
Frequent Sore throat Y N P
Sore lips/tongue
Y N P
Respiratory
Asthma
Y N
Cough
Y N
Sputum
Y N
Pleurisy
Y N
Shortness of Breath
Wheezing
Y
Bronchitis
Y
Pneumonia Y
Emphysema Y
at night? Y N P
P
P
P
P
Y N P
Y N P
Y N P
Y N P
N P
Spitting up Blood Y N P
N P
Difficulty Breathing Y N P
N P
Pain with Breathing Y N P
N P
Tuberculosis
Y N P
lying downs? Y N P
Cardiovascular
Angina
Y N P
Chest pain
Y N P
Murmer
Y N P
Fainting
Y N P
Ankle swelling Y N P
Rheumatic Fever Y N P
High blood pressure Y N P
Blood clots
Y N P
Heart disease
Y N P
Low blood pressure Y N P
Gastrointestinal
Diarrhea
Y N P
Constipation Y N P
Changes in thirst Y N P
Ulcers
Y N P
Black Stool Y N P
Coughing up blood Y N P
Jaundice
Y N P
Hemorrhoids Y N P
Gall Bladder disease Y N P
Liver Disease Y N P
Abdominal Pain Y N P
Blood in stool
Y N P
Mucous in stool Y N P
Undigested food in stool Y N P
Number of bowel movements per day ______
Urinary
Incontinence Y N P
Frequent infections Y N P Painful urination
Y N P
Kidney Stones Y N P
Frequency at night Y N P Hesitancy
Y N P
Blood/Peripheral Vascular
Anemia:
Y N P
Leg pain
Y N P
Cold hands/feet Y N P
Easy Bruising Y N P
Thrombophlebitis
Varicose Veins
Y N P
Y N P
Muscle weakness Y N P
Numbness/tingling Y N P
Emotional
Mood swings Y N P
Tension
Y N P
Nervousness Y N P
Stress
Y N P
Depression
Anxiety
Y N P
Y N P
Endocrine
Hypothyroid Y N P
Excessive Hunger Y N P
Hyperthyroid Y N P
Heat intolerance Y N P
Excessive thirst
Cold intolerance
Y N P
Y N P
Testicular Masses Y N P Discharge/sores
Premature Ejaculation Y N P Hernias
Y N P
Y N P
Neurological
Paralysis
Y N P
Loss of Memory Y N P
Male Reproductive
Prostate Issues Y N P
Testicular Pain Y N P
STD
Y N P
Female Reproductive
Age of First Menses ___________
Age of last menses (if menopausal)_______
Length of Cycle: ______________
Duration of Menses (bleed time) ________
Date of last annual exam: ________
Birth control: yes/no
If yes: what type:
Number of pregnancies _____ Miscarriages _____ Abortions_____ Live Births______
Endometriosis Y N P
Ovarian Cysts Y N P
Cervical dysplasia Y N P
Fertility Issues Y N P
Venereal Disease Y N P
Cycles regular
Y N P
Abnormal pap Y N P
Nipple discharge Y N P Do self breast examsY N P
PMS
Y N P
Menopausal Symptoms Y N P
Bleeding between cycles Y N P
Breast lump Y N P Spotting
Y N P
Sexually active Y N P
Painful Menses Y N P
Heavy bleeding
Y N P
COLORADO MANDATORY DISCLOSURE STATEMENT & INFORMED CONSENT
This disclosure statement is in compliance with the State of Colorado, Department of
Regulatory Agencies, Colorado Statue Title 12 Article 29.5. All rules and regulations set forth
by the Department of Health are strictly adhered to, including proper cleaning, sterilization,
and sanitation of equipment and office. Only single-use, disposable, factory-sterilized needles
are utilized. The practice of acupuncture and of Naturopathic Medicine is regulated by the
Director of Registrations, Colorado Department of Regulatory Agencies. If you have any
comments, questions, or concerns, please contact the Acupuncturists Registrations Office, 1560
Broadway, Suite 1350, Denver, CO 80202 (phone: 303.894.2440). The patient is entitled to
receive information about the methods of therapy, the techniques used, and the duration of
therapy, if known. The patient may seek a second opinion from another healthcare professional
or may terminate therapy at any time. In a professional relationship, sexual intimacy is never
appropriate and should be reported to the Director of the Division of Registration in the
Department of Regulatory Agencies.
Licenses:
The staff of White Willow Healing Arts all hold appropriate licenses and certificates in the
state of Colorado.
Practitioner Education, Certification, and Experience:
Dr. Mueller holds N.D. and M.Ac. degrees from the National College of Naturopathic
Medicine. Her Training includes:
 Four years of post-graduate medical instruction
 4 years of masters level training for acupuncture and Chinese Medicine
 Studies in basic sciences, conventional diagnosis, pharmacology, and natural
therapies including homeopathy, botanicals, nutrition and hydrotherapy,
acupuncture, qi gong, sound healing, massage
 3000 hours of Rotations- Clinical Training Hours
 Medical degree accredited by the Council on Naturopathic Medical Education
(CNME) and The Higher Learning Commission of the North Central Association of
Colleges and Schools.
 Diplomate of Acupuncture accredited by the National Certification Commission for
Acupuncture and Oriental Medicine. (NCCAOM)
 Dr. Mueller is also trained in functional medicine, herbs, nutrition, magnet
therapy, sound healing, qi gong, electrical stimulation, cuping and applied
kinesiology.
 ND License Number: 0054; LAc license number 1681.
Miles Nichols holds a M.S.O.M degree and is a licensed acupuncturist. His training includes:
 Bachelor of Arts in contemplative psychotherapy from Naropa University.
 Over 3000 hours of training from Southwest Acupuncture College, a 4-year masters
level program for acupuncture and Oriental Medicine.
 Over 1000 clinical training hours
 Holds a Diplomate of Oriental Medicine (Dipl. O.M.) from the NCCAOM as of 2014
 Has an acupuncture license in the state of Colorado, license number 2038
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Is a certified Sheng Zhen Gong teacher
Miles Nichols is also trained in tuina, shiatsu, cupping, moxabustion, electrical
stimulation, gua sha, functional medicine, herbs, nutrition, injection therapy,
sound healing, qigong, hypnosis, NLP, Eden Energy Medicine & craniosacral therapy
Clinic Fee Schedule (due at time of service):
Initial Consultation & Treatment, 60 min
Follow-Up Treatment, 45 min
$230
$95
Herbs, supplements, and lab kits are extra and not included in treatment fee
The practitioners at White Willow Healing Arts are not contracted with insurance
providers. We do accept payment from Health Savings Accounts (HSA) and Flex Spending
Accounts (FSA). Patient is responsible for submitting this information to the appropriate
people. Some insurance companies will accept payment for acupuncture services. If
necessary, we can provide a superbill with correct insurance codes for possible
reimbursement.
Payment to White Willow Healing Arts is expected at the time of service, via cash, check,
or with credit card.
Appointments can be changed or cancelled up to 24 hours before the scheduled time.
Missed appointments are subject to a $95 missed appointment fee.
You will be notified if there are any changes of services or charges.
Product Sales:
Nutritional supplements are available to purchase through White Willow Healing Arts. This
is a service that is available for your convenience. These products are also higher quality
than most products offered in stores.
You are not required to purchase items
recommended by your doctor from White Willow Healing Arts. You are free to purchase
these or similar products at the retailer of your choice.
Rights:
You have the right to be informed of the procedure involved in your care, the options and
alternatives for treatment and the risks involved. You have the right for your questions to
be answered completely.
You have the right to know your practitioner’s assessment and recommendation.
You have the right to courteous service, free from verbal, physical, or sexual abuse.
You have the right to confidentiality. Your records and transactions with this office are
confidential. This information will not be released outside of this clinic unless authorized
by you or required by law (see privacy policy)
You have the right to access other community services, to change practitioners at any
time, and to refuse services unless otherwise provided by law.
Informed Consent
I hereby request & consent to the performance of acupuncture and/or naturopathic
treatments and other procedures within the scope of the practice of acupuncture and/or
naturopathic medicine on me (or on the patient named below, for whom I am legally
responsible) by the acupuncturist and/or naturopathic doctor indicated in this form and/or
other licensed acupuncturists who now or in the future treat me while employed by,
working or associated with or serving as back-up for the White Willow Healing Arts, INC,
including those working at the clinic or office listed above or any other office or clinic,
whether signatories to this form or not. I understand that methods of treatment may
include, but are not limited to, naturopathic medicine, acupuncture, functional medicine,
moxabustion, cupping, electrical stimulation, Eden Energy Medicine Applied Kinesiology,
injection therapy, Tui-Na (Chinese massage), Chinese herbal medicine, Western herbal
medicine, hypnosis, craniosacral therapy, qigong, and lifestyle/nutritional counseling. I
understand that the herbs may need to be prepared and the teas consumed according to
the instructions provided orally and in writing. The herbs may have an unpleasant smell or
taste. I will immediately notify a member of the clinical staff of any unanticipated or
unpleasant effects associated with the consumption of the herbs. I have been informed
that acupuncture is a generally safe method of treatment, but that it may have some side
effects, including bruising, numbness or tingling near the needling sites that may last a few
days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxabustion
and cupping, or when treatment involves the use of heat lamps. Bruising is a common side
effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve
damage and organ puncture, including lung puncture (pneumothorax). Infection is another
possible risk, although the clinic uses sterile disposable needles and maintains a clean and
safe environment. I understand that while this document describes the major risks of
treatment, other side effects and risks may occur. The herbs and nutritional supplements
(which are from plant, animal, and mineral sources) that have been recommended are
traditionally considered safe in the practice of Chinese Medicine, although some may be
toxic in large doses. I understand that some herbs may be inappropriate during pregnancy.
Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting,
headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff
member who is caring for me if I am or become pregnant. While I do not expect the
clinical staff to be able to anticipate and explain all possible risks and complications of
treatment, I wish to rely on the clinical staff to exercise judgment during the course of
treatment which the clinical staff thinks at the time, based upon the facts then known, is
in my best interest. I understand that results are not guaranteed. I understand that
clinical and administrative staff may review my patient records and lab reports, but all my
records will be kept confidential and will not be released without my written consent. By
voluntarily signing below, I show that I have read, or have had read to me, the above
consent to treatment, have been told about the risks and benefits of acupuncture and
other procedures, and have had an opportunity to ask questions. 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. I acknowledge that neither claims of cure nor
promises of outcome have been made regarding my therapy. I have read the above
information and consent to treatment by the practitioners at White Willow Healing Arts.
Signed: ______________________________________ Date: ______________
PRIVACY POLICY
This notice explains how medical information about you may be used and how you
may get access to this information. Please review it carefully.
White Willow Healing Arts, INC respects your privacy. We understand that your personal information is
very sensitive. We will not disclose your information to others outside of practitioners and employees of
the clinic unless you tell us to do so, or unless we are required by law to do so. We do reserve the right,
when appropriate, to share information between practitioners and employees working at the clinic. This
allows us to better serve you and helps with the smooth operations of our business.
The law protects the privacy of the health information we create and obtain while treating you. Federal
state law allows us to use and disclose your protected health care information for the purpose of treatment
and health care operations. State law requires us to your authorization to disclose this information for
payment purposes.
Examples of Use and Disclosure of Health Information for treatment, payment and
health operations:
For treatment:
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Information obtained by our health care team will be recorded in your medical record to
help determine what is the best care for you.
We may also provide information to others providing your care. This will help them stay
informed about your care.
For payment:

We may request payment from your health insurance plan. Health plans need information
from us about your medical care. Information reported to health plans may include your
diagnosis, procedures performed and recommended care.
For health care operations:
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We use your medical records to assess quality and improve services.
We may use and disclose medical records to review the qualifications and performance of
our health care providers and to train our staff.
We may contact you to remind you of appointments and to give your information about
treatment alternatives.
We may use and disclose your information to conduct services for accounting and legal
services, audit functions including fraud and abuse detection and compliance programs.
Your Health Information Rights
The health and billing records we create here are the property of White Willow Healing Arts, INC. The
protected health care information in it generally belongs to you. You have the right to:
 Receive, read and ask questions about this notice.
 Ask us to restrict certain uses and disclosures. You must do this in writing. We are
not required to grant this request.
 Request and receive from us the latest notice of privacy practices
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Request that you be allowed to obtain a copy of your protected health information.
You may make this request in writing.
Have a review a denial of access to your health information – except in certain
circumstances.
Ask us to change your health information. You must make this request in writing.
You may make a statement of disagreement if your request is denied. This will be
stored in your medical records and included with any release of records.
When you request, we will give you a list of disclosures of health information. The
list will not include disclosures to third party payers. You may receive this
information without charge once every 12 months. We will notify you of the cost
involved if you request this more than once every 12 months.
Ask that your health information be given to you by another means. This request
must be signed and dated.
Cancel prior authorizations to use or disclose your health information. This does not
affect information already released. Sometimes you cannot cancel an authorization if
its purpose was to obtain insurance benefits.
Our Responsibilities
We are required to:
 Keep your information private
 Give you this notice and follow its terms
We have the right to change our practices regarding the protected health information that we
maintain. If we make changes we will update this notice. You may receive the most updated copy
by calling or asking at your next visit for one.
If you feel that your privacy has been violated you may speak with Dr. Diane Mueller, Miles
Nichols, or contact the U. S. Secretary of Health and Human Services.
Other Disclosures
Notification of Family and Others
 Unless you object, we may release medical information to family members
involved in your care. We may also release information to someone who pays
for your care. We may tell family and friend your condition if you are
hospitalized. In addition, we may disclose information about you to help with
disaster relief efforts. We may give your name, general condition and location to
a hospital if necessary.
 You have the right to object to the disclosure of this information. We will not
use it or disclose it if you object.
We may disclose your information without your authorization in cases such as:

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With medical research: if the research has been approved and the policy is to protect
your health information. We may also share your information with researches
preparing to conduct a health study.
To funeral directors/coroners: consistent with laws designed to help them carry out
their duties.
To organ procurement organizations
To the Food and Drug Administration: relating to problems with food, supplements,
and products
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To apply with worker’s compensation laws: if you make a worker’s compensation
claim.
For public health and safety purposes as required by law.
To report suspected neglect or abuse as required by law.
To correctional institutions if you are in jail or prison, as necessary for the health and
safety of others.
For law enforcement purposes: such as when receive a subpoena, court order, or
other legal process or you are a victim of a crime.
For health and safety oversight activities
For disaster relief purposes: For example: your information may be shared with
disaster relief agencies to assist in notification of your condition to your family or
others.
For work related conditions that could affect employment health. For example an
employer might ask us to assess health risk of a job site.
To military authorities of the U.S. and foreign military personnel. For example the
law might require us to provide information necessary to a military mission.
For specialized government functions: for national security purposes.
In the course of Judicial/Administrative Proceedings: at your request or as directed
by a subpoena or court order.
Other uses and protected health information:

Uses and disclosures not in this notice will only be made as allowed or required by law or
with your written authorization.
HIPPA Notice of Privacy Practices and Consent
I hereby consent to the use and disclosure of my protected health information by White Willow Healing
Arts, INC for the purposes of treatment, payment and healthcare operations or as otherwise required by
law.
 White Willow Healing Arts has shown me a copy of their Privacy Practices which
provides more detailed information about the usage and disclosure of my protected health
information. I have a right to review the notice prior to signing this consent and to receive
a printed copy of this policy.
 I have the right to request restrictions to the usage and disclosure of my protected health
information.
 I have the right to request and alternative to the standard method of communication of my
protected health information.
 I have the right to revoke this consent in writing at any time. Revocations will be honored
as of the date they are received by White Willow Healing Arts, INC.
 I understand that while White Willow Healing Arts, INC may honor these requests, they
are not required by law to do so.
 I am aware that White Willow Healing Arts, INC reserves the right to change the terms
of their Notice of Privacy Practices and to make new notice of Privacy Practices
provisions effective for all protected health information that they maintain. In the event of
amendments, White Willow Healing Arts, INC will make available a revised notice of
privacy practices for my review.
Signed: _____________________________ Date: ___________________
DR. DIANE MUELLER N.D. L.AC.
MILES NICHOLS L.AC.
PHONE AND EMAIL POLICY
Please keep in mind that communications via email are not secure. Although it is unlikely,
there is a possibility that information you include in an email or sent to you in an email can be
intercepted and read by other parties besides the person to whom it is addressed. Also please
keep in mind that we cannot formally diagnose your condition from information via email and
communications via email cannot replace the relationship you have with your healthcare
practitioner.
There is no charge for emails or phone calls regarding clarification of your current treatment
plan such as supplement or medication doses, or when your physician has requested that you
check in about your response to a treatment.
There will be a fee, however, of $35 to $95 depending on length of time required,
for emails or phone calls regarding a new health problem, information requiring medical
advice or an issue that requires your chart being pulled and information being recorded.
You are always welcome to schedule an appointment or hold your questions until your next
session if it’s not an urgent matter.
When it comes to question regarding research that you have read or heard from others, we
request that you write these down and bring them to your next appointment. Dr. Mueller and
Mr. Nichols do take your questions seriously and want to address them. However, the
appropriate time for this is during a visit and not via email.
Thank you for your patience and your understanding of our policy. Please note: insurance does
not cover this expense and this fee will be your responsibility. Also please note that your
practitioner may call or email a response saying that it is easier to discuss your questions
during an office visit or that she will answer your questions in person during your next session.
We will do our best to answer your questions via email or phone within 3 business days. We do
not check or respond to emails or phone calls on the weekend. If you have an urgent health
problem that needs to be addressed, please go to urgent care or the hospital. In an effort to
respond in a timely manner, responses may be brief and direct. Should you need more detailed
description or explanation, please schedule an appointment. Feel free to ask if you need any
clarification about this policy.
Signed ___________________________ Date: _____________________