Fan Acupuncture Clinic
Acupuncture & Chinese Herbal Medicine
90 Madison Street, Suite 402, Denver, CO 80206
Phone: (720)244-3035
Patient Name __________________________________ Age ________ Male / Female ________________
Date of Birth ______/______/________Height _________ Weight _________ Marital Status
Referred By ____________________________
Phone (H) (_________) _________ - ___________
______________
E-mail___________________________________________
Phone (Cell) (__________) _________-_____________
Address____________________________________________________________________________________
City __________________________ State__________ Zip _________ Driver’s License No.________________
Emergency Information (Please indicate who to notify in case of emergency)
Name _________________________ ___________
Relationship ___________________________________
Phone (H) (________) ______-______Phone (W) (_____) ________-______Phone (C) (_____) _____-_______
Chief Complaint(s) Please indicate how long you’ve had the condition(s).
What kinds of treatments have you received?
List any Hospitalizations & Surgeries (include Date and Place)
List medications being taken (include dosage)
Family History (please include the relationship)
[] Migraines _________________
[] Stroke ____________
[] High Blood Pressure ________
[] Allergies___________
[] Asthma __________________
[] Gall Stones_________
[] Cancer____________________
[] Diabetes___________
[] Glaucoma__________________
[] Epilepsy___________
Are you allergic to any of the following? If yes, please specify)
[] Medicine
[] Food
[] Herbs
[] Heart Disease ________________
[] Mental Illness ________________
[] Arthritis _____________________
[] Thyroid Disease_______________
[] Others
Do you have or are you any of the following?
[] Pacemaker [] Electric Implants [] Metal Implants [] Severe Bleeding Disorders
[] Pregnant
[] HIV Positive
[] Hepatitis A/B/C
Life style:
[] Exercise
[] Tea
[] Sedentary
[] Coffee
[] Eat three meals every day [] Eat at regular time every day
[] Soft drink
[] Alcohol [] Cigarettes [] Drug
Confidential Patient Health History
Name: ______________________________________
Date: ___/___/________
Please check if you have had (in the past three months):
General
[] Anemia
[] Poor Appetite
[] Fatigue
[] Localized Weakness
[] Fever
[] Bleed or Bruise Easily
[] Weight Loss
[] Peculiar Tastes or Smells
[] Sweats
[] Strong Thirst (hot or cold drinks)
[] Chills
[] Sudden Energy Drop
[] Drug Addiction
[] Poor Sleep Habits
Skin and Hair
[] Rashes
[] Itching
[] Dandruff
[] Change in hair/skin texture
[] Ulcerations
[] Eczema
[]
[]
[]
[]
[]
Open sore
Acne
Corns
Warts
Psoriasis
Head, Eyes, Ears, Nose and Throat
[] Dizziness/Vertigo
[] Concussions
[] Poor Vision
[] Eye Strain
[] Cataracts
[] Night Blindness
[] Ringing in ears
[] Blurry Vision
[] Sinus Problems
[] Poor Hearing
[] Grinding Teeth
[] Nose Bleeds
[] Nasal Congestion
[] Hoarseness
[] Headaches
Cardiovascular
[] High Blood Pressure
[] Low Blood Pressure
[] Palpitations
[] Irregular Heartbeat
[] Mitral Stenosis
[] Mitral Prolapse
Respiratory
[] Cough
[] Bronchitis
[] Difficulty breathing lying down
[] Emphysema
[]
[]
[]
[]
[]
[]
Myocarditis
Pneumatic Heart Disease
Chest Pain
Varicose Veins
Swelling of Hands/Feet
Fainting
[]
[]
[]
[]
[]
[]
[]
Tremors
Poor Balance
Cravings
Weight Gain
Alcoholism
Tetanus Shot
Frequent cold/flu
[]
[]
[]
[]
[]
Recent moles
Loss of Hair
Hives
Nail Problems
Dry skin
[] Migraines
[] Eye Pain
[] Color Blindness
[] Earaches
[] Spots in front of eyes
[] Recurrent Sore Throats
[] Facial Pain
[] Coronary Heart Disease
[] Difficulty in Breathing
[] Hardening of Arteries
[] Phlebitis
[] Blood Clots
[] Cold hands/feet
[] Coughing Blood
[] Pneumonia
[] Asthma
[] Pain w/ deep breath
[] Production of Phlegm
[] Pleurisy
Gastrointestinal
[] Nausea
[] Vomiting
[] Bad Breath
[] Abdominal Pain or Cramps
[] Indigestion
[] Ulcer
[]
[]
[]
[]
[]
[]
Constipation
Gas
Blood in Stools
Rectal Pain
Chronic Laxative Use
Colitis
[]
[]
[]
[]
[]
Genitourinary
[] Bed Wetting
[] Kidney Infections / Stones
[] Genital Herpes
[] Cystitis
[]
[]
[]
[]
Blood in Urine
Painful Urination
Venereal Disease
Incontinence
[] Frequent Urination
[] Bladder Infections
[] Prostate Problems
Diarrhea
Belching
Black Stools
Hemorrhoids
Acid Reflux
Pregnancy and Gynecology
[] Number of Pregnancies
[] Number of Abortions
[] Number of Births
[] Number of Miscarriages
[] Use of Birth Control
[] Hot Flash/Night Sweats
[] Age at 1st Menstruation
[] Unusual Character (heavy/light)
___ Time between Menstruation
[] Vaginal Sores
___ Duration of Menstruation
[] Vaginal Discharge
___ First Date of Last Menstruation [] Breast Lumps
[] Irregular Periods
[] Uterine Fibroids
[] Frequent changes in emotion
[] Osteoporosis
Fertility Information
# of IVF procedures____________# of IUI procedures__________________________________
Has a physician diagnosed a difficulty with fertility due to:[] Female Factor?[] Male Factor?[] Unexplained
Musculoskeletal
[] Neck Pain
[] Back Pain
[] Hand/Wrist Pain
[] Muscle Pains
[] Muscle Weakness
[] Shoulder Pain
[] Knee Pain
[] Foot/Ankle Pain
[] Hip Pain
Please indicate on the figures below the areas of the body you experience your pain:
[] dull/achy [] sharp/stabbing [] burning [] tingling
[] numbness
[] electrical
Neuropsychological
[] Seizures
[] Areas of Numbness
[] Concussion
[] Bad Temper
[] Difficulty Concentrating
[]
[]
[]
[]
Infection
[] Measles
[] Rheumatic Fever
[] Malaria
[] Small Pox
[] Mumps
[] Tuberculosis
[] Chicken Pox
Dizziness
Lack of Coordination
Depression
Easily susceptible to stress
[]
[]
[]
[]
Loss of Balance
Poor Memory
Anxiety
ADD
[] Whopping Cough
[] Typhoid Fever
[] Scarlet Fever
Fan Acupuncture Clinic
Acupuncture & Chinese Herbal Medicine
90 Madison Street, Ste 402, Denver, Colorado 80206
Phone: (720)244-3035
Car Accident Information
(Just for car accident patient)
Patient’s Name____________________________________
Injury Location
Date of injury ____/____/________
________________________________________
City______________________
Patient’s Car Insurance __________________________________ Phone _______________________
Claim #__________________________Adjuster______________________
Address__________________________________________ City__________
Phone______________
Zip _____________
Person at Fault’s Name __________________________
Person at Fault’s Auto Insurance Carrier _____________________ Phone____________________
Claim # _________________________ Adjuster ______________________ Phone _______________
Address ________________________________________ City ______________ Zip ____________
Patient’s Attorney ______ ________________________________ Phone _____________________
Address _____________________________________ City ________________ Zip ______________
Contact person _____________________________________________ _______ Fax ______________
AUTHORIZATION TO RELEASE INFORMATION & PAYMENT OF MEDICAL BENEFITS
I certify that I have read and understand the above information to the best of my knowledge. The above
question has been accurately answered. I hereby authorize the release of any medical information
necessary to process insurance claim. I also authorize the release of payment of medical benefit to Dr.
Cheng / Dr. Fan for service or product rendered. I understand that my insurance carrier may pay less than
actually billed for services. I agree to be responsible for payment of all service rendered on my behalf for
my dependants in accordance with my plan benefit. By signing below I have accepted and consent to the
treatment recommended.
Patient or responsible parties’ signature __________________________ Date ___________________
Fan Acupuncture Clinic
Acupuncture & Chinese Herbal Medicine
90 Madison Street, Suite 402, Denver, Colorado 80206
Phone: (720)244-3035
Insurance Information
(For the patient whose insurance covers acupuncture benefits)
PRIMARY Insurance
Insurance ______________________________
Subscriber’s Name _______________________
Date of Birth _______/________/___________
S. S # (I.D#) ___________________________
Group #: _______________________________
Insured Employer________________________
Phone __________________________________
SECONDARY Insurance
Insurance _______________________________
Subscriber’s Name _______________________
Date of Birth _______/________/____________
S. S # (I.D#) ___________________________
Group #: _______________________________
Insured Employer________________________
Phone __________________________________
AUTHORIZATION TO RELEASE INFORMATION & PAYMENT OF MEDICAL BENEFITS
I certify that I have read and understand the above information to the best of my knowledge. The above
question has been accurately answered. I hereby authorize the release of any medical information
necessary to process insurance claim. I also authorize the release of payment of medical benefit to Dr.
Cheng / Dr. Fan for service or product rendered. I understand that my insurance carrier may pay less than
actually billed for services. I agree to be responsible for payment of all service rendered on my behalf for
my dependants in accordance with my plan benefit. By signing below I have accepted and consent to the
treatment recommended.
Patient or responsible parties’ signature __________________________ Date ___________________
Fan Acupuncture Clinic
90 Madison Street, Suite 402, Denver, CO 80206
720-244-3035
CANCELLATION & RE-SCHEDULING POLICY
We understand that there are times when you will need to cancel and/or re-schedule your appointment. We
are pleased to accommodate your needs.
It is our policy, however, that all cancellations and/or re-scheduling occur at least two business days prior to
the date of your appointment.
A fee of $50.00 will be charged if your cancellation/re-scheduling is not completed at least two business days
prior to the date of your appointment.
Thank you for your understanding.
Please sign here indicating that you understand and accept this policy:
Signature: _______________________________________
Date: ___________________