Harmony Health & Healing, Inc. PATIENT INFORMATION INSURANCE INFORMATION PHONE NUMBERS ACCIDENT INFORMATION PATIENT CONDITION

Transcription

1 Harmny Health & Healing, Inc. PATIENT INFORMATION Date SS/HIC Patient ID# Patient Name Last Name First Name Middle Initial Address City State Zip Sex M F Age Married Widwed Single Minr Separated Divrced Partnered fr years Patient Emplyer/Schl Occupatin Emplyer/Schl Address Emplyer/Schl Phne ( ) Spuse s Name SS# Spuse s Emplyer Whm may we thank fr referring yu? INSURANCE INFORMATION Wh is respnsible fr this accunt? Insurance C. Grup # Is patient cvered by additinal insurance? Yes N Subscriber s Name Insurance C. SS# Grup # ASSIGNMENT AND RELEASE I certify that I, and/r my dependent(s), have insurance cverage with And assign directly t Name f Insurance Cmpany(ies) Dr. all insurance benefits. If any, therwise payable t me fr services rendered. I understand that I am financially respnsible fr all charges whether r nt paid by insurance. I authrize the use f my signature n all insurance submissins. The abve-names dctr may use my health care infrmatin and may disclse such infrmatin t the abve-named insurance Cmpany(ies) and their agents fr the purpse f btaining payment fr services and determining Insurance benefits r the benefits payable fr related services. This cnsent will end when my current treatment plan is cmpleted r ne year frm the date signed belw. Signature f Patient, Parent, Guardian r Persnal Representative Please print name f Patient, Parent, Guardian r Persnal Representative Date PHONE NUMBERS Cell Phne ( ) Hme Phne ( ) Best time and place t reach yu IN CASE OF EMERGENCY, CONTACT Name Relatinship Hme Phne( ) Wrk Phne( ) ACCIDENT INFORMATION Is cnditin due t an accident? Yes N Date Type f accident Aut Wrk Hme Other T whm have yu made a reprt f yur accident? Aut Insurance Emplyer Wrker Cmp. Other Attrney name (if applicable) Reasn fr Visit When did yur symptms appear Is this cnditin getting prgressively wrse? Yes N Unknwn Mark an X n the picture where yu cntinue t have pain, numbness, r tingling. PATIENT CONDITION Rate the severity f yur pain n a scale frm 1 (least pain) t 10 (severe pain) Type f pain: Sharp Dull Thrbbing Numbness Aching Shting Burning Tingling Cramps Stiffness Swelling Other Hw ften d yu have this pain? Is it cnstant r des it cme and g? Des it interfere with yur Wrk Sleep Daily Rutine Recreatin Activities r mvements that are painful t perfrm Sitting Standing Walking Bending Lying Dwn Frm 203 Patient Infrmatin

2 HEALTH HISTORY What treatment have yu already received fr yur cnditin? Medicatins Surgery Physical Therapy Acupuncture Chirpractic Services Massage Nne Other Name and address f ther dctr(s) wh have treated yu fr yur cnditin Date f Last: Physical Exam Spinal X-Ray Bld Test Spinal Exam Chest X-Ray Urine Test Dental X-Ray MRI, CT-Scan, Bne Scan Place a mark n Yes r N t indicate if yu have had any f the fllwing: AIDS/HIV Yes N Chicken Px Yes N Liver Disease Yes N Rheumatid Arthritis Yes N Alchlism Yes N Diabetes Yes N Measles Yes N Rheumatic Fever Yes N Allergy Shts Yes N Emphysema Yes N Migraine Headaches Yes N Scarlet Fever Yes N Anemia Yes N Fractures Yes N Miscarriage Yes N Strke Yes N Anrexia Yes N Glaucma Yes N Mnnuclesis Yes N Suicide Attempt Yes N Appendicitis Yes N Giter Yes N Multiple Sclersis Yes N Thyrid Prblems Yes N Arthritis Yes N Gnrrhea Yes N Mumps Yes N Tnsillitis Yes N Asthma Yes N Gut Yes N Osteprsis Yes N Tuberculsis Yes N Bleeding Disrders Yes N Heart Disease Yes N Pacemaker Yes N Tumrs, Grwths Yes N Breast Lump Yes N Hepatitis Yes N Parkinsn s Disease Yes N Typhid Fever Yes N Brnchitis Yes N Hernia Yes N Pinched Nerve Yes N Ulcers Yes N Bulimia Yes N Herniated Disk Yes N Pneumnia Yes N Vaginal Infectins Yes N Cancer Yes N Herpes Yes N Pli Yes N Venereal Disease Yes N Cataracts Yes N High Chlesterl Yes N Prstate Prblem Yes N Whping Cugh Yes N Chemical Kidney Disease Yes N Prsthesis Yes N Other Dependency Yes N Psychiatric Care Yes N EXERCISE WORK ACTIVITY HABITS Nne Sitting Smking Packs/Day Mderate Standing Alchl Drinks/Week Daily Light Labr Cffee/ Caffeine Drinks Cups/Day Heavy Heavy Labr High Stress Level Reasn Are yu pregnant? Yes N Due Date Injuries/Surgeries yu have had Descriptin Date Falls Head Injuries Brken Bnes Dislcatins Surgeries MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS Pharmacy Name Pharmacy Phne ( )

3 HARMONY HEALTH & HEALING, INC. PATIENT SYMPTOM CHECKLIST NAME DATE It is very imprtant in Chinese Medicine t knw hw lng a patient has experienced his/her symptms. It is essential t indicate time n the symptms. Water Element Hearing Lss Dizziness Lwer Back Pain/Neck Pain Sinus Cngestin Edema Darkness under the eyes Emtinal instability Aversin t cld Hair thinning r lss Pre-mature aging Frequent urinatin Kidney stnes Perspire very easily Weakness f the Legs/Knees Asthmatic Cugh Rapid Weight Change Asthmatic Cugh Lse teeth Reduced sexual energy Thyrid Prblems Diabetes Earth Element Indigestin Flatulence Fd Allergy Stmach ache/ulcer Diarrhea Anemia Halitsis Muth sres Heartburn Strng appetite Weak appetite Nausea Abdminal blating Lw bdy weight Wd Element Headache Migraines Ringing in the ears Pr eyesight Eye infectins Dry eyes Eczema Shingles Herpes Simplex Warts Nervusness Cnvulsins/Spasms Irritability Cnstipatin Hemrrhids Hepatitis Irregular Menstruatin Painful Menstruatin Ulcer Vmiting Gallstnes Indecisiveness Fullness belw ribs Shulder/neck tensin Insmnia 11pm-3am Fire Element Dry Scalp Skin eruptins, rashes Cysts, tumrs Ear infectins Sre thrat, tnsillitis Lymphatic swelling Ht palms and sles Heart palpitatins Aversin t heat Bitter taste in muth Gum prblems Nse bleed Facial redness Itching/burning skin Ht hands/ feet Thirst Dark urine Nightsweats Metal Element Brnchitis Asthma Shallw breathing Cugh Sinus cngestin Nasal infectins Other Fatigue Arthralgia Sciatica / nerve pain Cld hands/ feet Tendnitis Bursitis Pain (please describe) Other Cmments Frm 204

4 Cnsent fr Treatment Brenda Yanfsky EdD, DOM, LAc. By signing belw, I d hereby vluntarily cnsent t be treated with acupuncture and/r substances frm the Oriental Materia Medica by a licensed acupuncturist at the Chinese Medical Clinic. I understand that acupuncturists practicing in the State f Flrida are nt primary care prviders and that regular primary care by a licensed physician is an imprtant chice that is strngly recmmended by this clinic s practitiners. Acupuncture/Mxibustin: I understand that acupuncture is perfrmed by the insertin f needles thrugh the skin r by the applicatin f heat t the skin (r bth) at certain pints n r near the surface f the bdy in an attempt t treat bdily dysfunctin r diseases, t mdify r prevent pain perceptin, and t nrmalize the bdy s physilgical functins. I am aware that certain adverse side effects may result. These culd include, but are nt limited t: lcal bruising, minr bleeding, fainting, pain r discmfrt, and the pssible aggravatin f symptms existing prir t acupuncture treatment. I understand that n guarantees cncerning its use and effects are given t me and that I am free t stp acupuncture treatment at any time. Direct Mxibustin: I understand that if I receive direct mxibustin as part f therapy, there is a risk f burning r scarring frm its use. I understand that I may refuse this therapy. Chinese Herbs: I understand that substances frm the Oriental Materia Medica may be recmmended t me t treat bdily dysfunctin r diseases, t mdify r prevent pain perceptin, and t nrmalize the bdy s physilgical functins. I understand that I am nt required t take these substances but must fllw the directins fr administratin and dsage if I d decide t take them. I am aware that certain adverse side effect may result frm taking these substances. These culd include, but are nt limited t: changes in bwel mvement, abdminal pain r discmfrt, and the pssible aggravatin f symptms existing prir t herbal treatment. Shuld I experience any prblems, which I assciate with these substances, I shuld suspend taking them and call the Chinese Medical Clinic as sn as pssible. Acupressure/Tui-Na Massage: I understand that I may als be given acupressure/tui-na massage as part f my treatment t mdify r prevent pain perceptin and t nrmalize the bdy s physilgical functins. I am aware that certain adverse side effects may result frm this treatment. These culd include, but are nt limited t: bruising, sre muscles r aches, and the pssible aggravatin f symptms existing prir t treatment. I understand that I may stp the treatment if it is t uncmfrtable. Electr-Acupuncture: I understand that I may be asked t have electr-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are nt limited t: electrical shck, pain r discmfrt, and the pssible aggravatin f symptms existing prir t treatment. I understand that I may refuse this treatment. I understand that there may be ther treatment alternatives, including treatment ffered by a licensed physician. I have carefully read and understand all f the abve infrmatin and am fully aware f what I am signing. I understand that I may ask my practitiner fr a mre detailed explanatin. I give my permissin and cnsent t treatment. Signature: Date: Printed Name: Date f Birth: Address: City: State: Zip Cde: Phne: SIGN BELOW ONLY IF YOU REQUESTED AND RECEIVED MORE DETAILED INFORMATION I requested and received, in substantial detail, further explanatin f the prcedure r treatment, ther alternative prcedures r methds f treatment, and infrmatin abut the material risks f the prcedure r treatment. I give my permissin and cnsent t treatment. Patient s Signature Date Explained by me and signed in my presence Date 5049 Ringwd Meadw Suite K Sarasta, FL Frm 201

5 HIPAA CONSENT Brenda Yanfsky EdD, DOM, LAc. Our Ntice f Privacy Practices prvides infrmatin abut hw we may use and disclse prtected health infrmatin abut yu. The Ntice cntains a Patient Rights sectin describing yur rights under the law. Yu have the right t review ur Ntice befre signing this Cnsent. The terms f ur Ntice may change. If we change ur Ntice, yu may btain a revised cpy by cntacting ur ffice. Yu have the right t request that we restrict hw prtected health infrmatin abut yu is used r disclsed fr treatment, payment r health care peratins. We are nt required t agree t this restrictin, but if we d, we shall hnr that agreement. By signing this frm, yu cnsent t ur use and disclsure f prtected health infrmatin abut yu fr treatment, payment and health care peratins. Yu have the right t revke this Cnsent, in writing, signed by yu. Hwever, such a revcatin shall nt affect any disclsures we have already made in reliance n yur prir Cnsent. The Practice prvides this frm t cmply with the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). The patient understands that: Prtected health infrmatin may be disclsed r used fr treatment, payment r health care peratins The Practice has a Ntice f Privacy Practices and that the patient has the pprtunity t review this Ntice The Practice reserves the right t change the Ntice f Privacy Plicies The patient has the right t restrict the uses f their infrmatin but the Practice des nt have t agree t thse restrictins The patient may revke this Cnsent in writing at any time and all future disclsures will then cease The Practice may cnditin treatment upn the executin f this Cnsent. This Cnsent was signed by: Printed Name - Patient r Representative Signature (if ther than patient): Date: / / Witness Date: / / Dr. Brenda Yanfsky, EdD, DOM, Lac. Printed name - Practice Representative 5049 Ringwd Meadw Suite K Sarasta, FL Frm 202