Mission Acupuncture & Herbal Medicine
31307 Fm 2978 Rd, Suite 105
Magnolia, TX 77354
www.missionacupuncture.com
allison@missionacupuncture.com
936 . 689 . 1717
Patient Intake Form
Welcome to Mission Acupuncture & Herbal Medicine. Please help us provide you with a complete
evaluation by taking the time to fill out this questionnaire carefully. Even though some of the questions
may seem unrelated to your condition, they may play a contributing role in diagnosis and treatment. All
your information will be confidential and if you have any questions, please ask. Thank you.
Today’s Date: __ /__
Contact Information
Name:
Sex: F
Street:
Email Address:
City:
Martial Status: M
S
D
State:
Zip:
W
# of Children:
Occupation:
DOB:
/
/
Age:____
Phone Number:
Alternative Phone Number:
Employer:
Emergency Contact:
Phone:
How did you find out about us? Direct Mail
Periodicals
M
/______
Yellow Pages
Location or Walk By
Other
Have you had acupuncture before? Y
Website
Referred By:
N
___
Allow email/mail/phone contact by MAHM? Y
Primary Insurance Company:
Name of Insured:
Friend/Relative
ID #:
N
____ Group #:
Relationship to Patient: Self
Spouse
____
Parent
Customer Service Phone Number:
Secondary Insurance:
Name of Insured:
ID #:
____ Group #:
Relationship to Patient: Self
Spouse
Parent
Customer Service Phone Number:
Major Health Complaint(s)
Please list in order of significance to you and check which you would like us to focus on today.
1.
4.
2.
5.
3.
6.
When did the checked problem begin?
__
What are the precipitating factors?
_
Have you been given a diagnosis for this problem? If so, please describe.
What kind of treatments have you tried?
What makes this problem worse?
Is there anybody in your family with the same problem?
_
Better?
____
Please describe how these conditions affect or impair your daily activities? Examples may include your
overall quality of life, work, family life, hobbies or self-esteem.
___
Past Medical History
Check any conditions that you have had in the past or are currently experiencing: P=Past C=Current
P C
P C
P C
P C
Alcohol/Drug Abuse
Digestive Disorder
Hypertension
Nervous Disorder
Anemia
Epilepsy/Seizures
Jaundice
Pneumonia
Arthritis
Glaucoma
Kidney Disease
Stroke
Asthma
Heart Disease
Liver Disease
Thyroid Disorder
Auto Immune
Heavy Bleeding/Hemorrhage
Tuberculosis
Blood Transfusion
Hepatitis
Mental Illness
Vein Condition
Cancer
High Cholesterol
Migraines
Venereal Disease
Diabetes
HIV/Hepatitis
Other:
___
Known allergies (food, medications, or other):
__
Significant trauma (car accident, sports injuries etc.):
_
Immunizations:
_
Hospitalizations/Surgeries (procedures and dates):
___
Dental Procedures (include any silver fillings/mercury amalgams):
_
Do you have a history of frequent antibiotic use? Please Describe.
Allergy shots? Currently
In the past
Never
Please briefly describe your health as a child. (e.g. allergies/asthma, prone to illness, etc):
___
Family Medical History (please specify family member)
Alcoholism/Drug Abuse
Asthma/Allergies
Cancer
Depression/Mental Illness
Diabetes
Other
___
Heart Disease
Hypertension
Miscarriage
Osteoporosis
Stroke
___
____
____
_
Current Health & Lifestyle
Do you smoke? Y
Do you exercise? Y
N
If yes, how many per day?
N
Do you travel frequently? Y
If yes, how many times per week?
N
Weight: Now
Please Describe.
Have you traveled overseas to ‘developing’ countries? Y
Do you sit in traffic/commute as a daily routine? Y
Height:
For how long?
One year ago
N
Maximum
@ Year
How many hours do you sleep in general?
When do you usually go to bed?
List 3 things you do currently that support
List your 3 favorite vices (eg smoking, social
your overall health.
drinking, sweet tooth…)
Overall, do you feel that your lifestyle contributes to or takes away from your health?
___
N
Diet
Soft drinks per day
Cups of tea per day
Glasses of water per day
Are you a vegetarian? Y
Cups of coffee per day
Alcoholic beverages per week
N
Yes, but not strict
Explain:
__
Please describe your average daily diet:
Breakfast:
Lunch:
___
Dinner:
__
Snacks:
__
Foods you tend to crave:
___
Please indicate painful or distressed areas by using the symbol that best describes the feeling:
Mark with appropriate symbols:
XXX Sharp / Stabbing
PPP Pins and Needles
DDD Dull / Aching
NNN Numbness
Please rate your current level of pain: Very mild 1
2
3
4
5
6
7
8
9
10 Very severe
Medications and Supplements
Medications you are currently taking (please include prescription medicines, vitamins, supplements, over
the counter drugs, herbal supplements, etc.):
___
___
___
Profile
Please check any of the following symptoms that currently pertain to you.
General
Cold hands
Cold feet
Sweaty hands
Sweaty feet
Hot body temperature
Cold body temperature
Afternoon flushing
Hot flashes
Profuse perspiration
Lack of perspiration
Perspire easily
Night sweating
Chills
Fever
Strong thirst
Lower back pain
Frequent cavities
Broken/loose teeth
Weak bones
Hearing loss
Ringing in ears/tinnitus
Early graying of hair
Weak knees
Knee soreness
Hair loss
Cold lower back
Cold hips/buttocks
Cold knees
Dizziness
Forgetfulness
Fainting
Weak nails
Emotions
Mood swings
Sadness
Nervousness
Bipolar
Anxiety
Panic attacks
Irritability
Obsessive/Compulsive
Fits of laughter
Depression
Anger
Mania
Fear
Frequent worrying
Easily stressed
Skin
Acne
Dandruff
Dry or Flaky Skin
Eczema
Hives
Psoriasis
Rashes
Ulcerations/Boils
Neuro-Muscular
Seizures
Paralysis
Lack of coordination
Loss of balance
Tingling in extremities
Muscle spasms
Numbness
Cardiovascular
Heart palpitations
Restless dreams
Chest Pain/Angina
Mental restlessness
Tongue ulcers
Insomnia
Speech impediment
Hallucinations
Nasal dryness
Chronic allergies
Sore throats
Chest congestion
Sneezing
Wheezing
Chest tightness
Difficulty Breathing
Shortness of breath
Low or weak appetite
Gurgling in intestines
Bruise easily
Fatigue following a meal
Easily fatigued
Gas
Hypoglycemia
Strong cravings
Hemorrhoids
Stomach ache
Acid reflux
Bad breath
Ravenous appetite
Bleeding gums
Heartburn
Stomach ulcer
Belching
Hiccups
Nausea
Vomiting
Mouth ulcers
Loose stools
Mucous in stools
Blood in stools
Difficulty moving bowels
Less than 1 BM per day
Small, hard, dry stools
Constipation
Diarrhea
Lymphatic System/Accumulated Dampness
Swollen hands
Mental fogginess
Swollen feet
Mental sluggishness
Edema in the legs
Edema in the abdomen
Heavy limbs/head
Joint stiffness
Liver/Gall Bladder Function
Headaches
Migraines
Gall stones
Respiratory
Persistent cough
Nosebleeds
Sinus congestion
Frequent colds/flu
Gastrointestinal
Indigestion
Abrupt weight gain
Abrupt weight loss
Eyes
Itchy eyes
Dry eyes
Urinary
Cloudy
Dark yellow
Clear color
Reddish color
Pain in ribcage
Chronic neck or shoulder tension
Watery eyes
Red and irritated eyes
Poor night vision
Floaters/Seeing spots
Cataracts
Glaucoma
Blurry vision
Small amount
Large amount
Dribbling
Night-time urination
Difficulty initiating urination
Very frequent
Incontinence
Strong odor
Pain or burning
Male
Prostate Problems
Testicular pain/swelling
Low sex drive
Premature ejaculation
Nocturnal emission Infertility
Low sperm count
Poor sperm motility
Feeling of coldness or numbness of genitalia
Do you have any bothersome symptoms? Y
Do you get up at night to urinate? Y
N
Ejaculation problems
Erectile dysfunction/impotence
Difficulty maintaining an erection
Irregular sperm morphology
Discharge
N
Describe:
__
How often?
__
To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)?
___
Have you sought medical intervention for these problems? If so, when?
_
___
What treatment have you tried for these problems and how successful have they been?
___
Female
Pelvic infection
Fibroids
Breast tenderness
Low sex drive
Endometriosis
Ovarian cysts
Breast lumps
Fertility problems
Vaginal dryness
Abnormal pap smear
Spotting between periods
Pain during intercourse
Frequent vaginal infections
Abnormal vaginal discharge
Hot flashes
Night sweats
Do you experience any of the following associated with your period each month?
Water retention
Migraine/headache Lower back pain
Change in bowel movement
Mood swings
Irritability
Abdominal cramps
Breast tenderness/swelling
Food cravings
Acne
Heavy bleeding
Scanty/light bleeding
Clots
Other:
number of pregnancies
number of live births
miscarriages
premature births
difficult delivery
cesareans
At what age did you get your first period:
abortions
First day of last menstrual period:
Are your menstrual cycles spaced regularly? Y
N
Cycle length:
___
_ Period length :
Are you currently using birth control? Y
N
If yes, what type and for how long?
Have you experienced menopause? Y
N
When?
_
_____
__
If you are experiencing menopausal symptoms, please describe:
_______
___
___
Is there any possibility you are pregnant now? Y
Patient Signature
N
Date
LEFT BLANK ON PURPOSE
PATIENT NAME:
ACUPUNCTURE INFORMED CONSENT TO TREAT
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the
practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist
named below 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 acupuncturist named below, including those working at the clinic or office
listed below 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, acupuncture, moxibustion, cupping, electrical
stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and 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 be 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 moxibustion and cupping, or when treatment involved 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.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and 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 the 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.
Patient Signature (or Patient Representative)
Date
Acupuncturist Signature
Date
(Indicate relationship if signing for patient)
Mission Acupuncture and Herbal Medicine
Allison Hebert, L.Ac. MAOM
31307 Fm 2978 Rd, Suite 105
Magnolia, TX 77354
936-689-1717
www.missionacupuncture.com
allison@missionacupuncture.com
PATIENT NAME:
ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services
rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined
by submission to arbitration as provided by the state and federal law, and not by a lawsuit or resort to court process except as state and federal
law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right
to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes
as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the
parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or se rvices provided by the
health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium.
This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim.
This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or pr eceptorship interns
who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider,
including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health
care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation,
claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select
an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the
parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the
arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the
arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for
such party’s own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in
a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending
arbitration.
The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable
as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a
judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further
agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this
Arbitration Agreement.
Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one
proceeding. A Claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action,
would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the
procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and
if not revoked will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example,
emergency treatment) patient should initial here. _______ Effective as the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be
affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my
signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY
NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS
CONTRACT.
Patient Signature (or Patient Representative)
Date
Acupuncturist Signature
Date
Mission Acupuncture and Herbal Medicine
Allison Hebert, L.Ac. MAOM
31307 Fm 2978 Rd, Suite 105
Magnolia, TX 77354
936-689-1717
www.missionacupuncture.com
allison@missionacupuncture.com
(Indicate relationship if signing for patient)
NOTIFICATION FORM REGARDING
EVALUATION OF PATIENT BY PHYSICIAN
In the state of Texas, acupuncture and Oriental medicine is not considered "primary health care". As a result,
Mission Acupuncture and Herbal Medicine is required to have you respond to the following statements before
you may be treated. Please be advised that we will not be permitted to treat you with acupuncture if your
response to all of these statements is no.
Pursuant to the requirements of 22 TAC §183.7 of the Texas State Board of Acupuncture Examiners’ rules relating to Scope of Practice and
Tex. Occ. Code Ann., §205.351, governing the practice of acupuncture.
I (patient's name) ____________________________________________ am notifying the practitioners of
Mission Acupuncture and Herbal Medicine 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 condition
being treated by the acupuncturist.
OR
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 two months or 20 treatments, whichever comes first, no substantial improvement
occurs in the condition being treated, I understand that the acupuncturist is required to refer me to a physician.
It is my responsibility and choice whether to follow this advice.
OR
I have not been evaluated by a physician or dentist for the condition being treated, nor have I received a
referral from a chiropractor, but I seek treatment for symptoms related to one or more of the following
conditions:
Chronic pain
Smoking addiction
Weight loss
Alcoholism
Substance abuse
_________________________________________________________________________________________________
Patient’s Signature
Date
Mission Acupuncture and Herbal Medicine is not responsible for untrue statements made by patients.
Mission Acupuncture and Herbal Medicine
Allison Hebert, L.Ac. MAOM
31307 Fm 2978 Rd, Suite 105
Magnolia, TX 77354
936-689-1717
www.missionacupuncture.com
allison@missionacupuncture.com
MAHM HIPAA ACKNOWLEDGEMENT AND APPOINTMENT REMINDERS
I acknowledge that I have been provided access to Mission Acupuncture & Herbal Medicine (MAHM) “Notice of
Privacy Practices”. I understand that I have the right to review the “Notice of Privacy Practices” prior to signing
this document.
I understand that MAHM staff members may need to contact me with appointment reminders or information
related to my treatments. If this contact is to be made by phone, and I am not at home, a message will be left
on my answering machine or with anyone who answers the phone.
Information stripped of any personal identifiers may also be used for research and educational purposes by
MAHM. By signing this form, I am giving MAHM authorization to contact me with these reminders and to utilize
my information for research and educational purposes.
___________________________________
Patient Name (print)
___________________________
Date
___________________________________
___________________________
Patient Signature
MAHM Privacy Rep/Date
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐----------------------------AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (Optional)
I, ___________________________________________________, hereby authorize Mission Acupuncture &
Herbal Medicine the use or disclosure of my individually identifiable health information to the party(s) described
below. I understand this authorization is voluntary. I understand if the party(s) authorized to receive my
information is/are not a health plan or health care provider, the released information may no longer be
protected by federal privacy regulations.
Persons/Organizations authorized to receive information: (please print name)
________________________________
_______________________________
_______________________________
Patient Signature
Date
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐----------------------------NEW PATIENT INFORMATION
For All Clinic Appointments:
Welcome to Mission Acupuncture and Herbal Medicine. Please read our office policies and sign below.
Cancellation Policy: Treatments are by appointment, although walk‐ins are occasionally accepted. If you find
that you need to cancel an appointment, it is important that we receive 24‐hour notice. This enables us to fill
the time slot. We reserve the right to charge a fee equal to the cost of a scheduled appointment for an
appointment canceled with less than 24‐hour notice or for a “no show” appointment.
Payment for Clinic Services Rendered: Payment is due at the time of service and may be paid by cash,
check or all major credit cards. Any checks returned due to insufficient funds will be charged an additional $30
by this clinic. We do accept insurance and we will be happy to check your acupuncture benefits and file your
insurance claim for you granted you have coverage.
Herbal Prescriptions: All herb sales are final. Mission Acupuncture and Herbal Medicine is not able to offer
refunds on herbal products. Herbal prescriptions are intended only for the patient for whom they have been
prescribed.
Thank you for allowing us to provide you with quality health care. ___________________________________
Patient Signature
Date