Julie Magram Acupuncture LLC
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- Jean Francis
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1 Julie Magram Acupuncture LLC Risks and Benefits of Acupuncture The World Health Organization recognizes numerous conditions in which acupuncture is successful in treating. The goal of acupuncture is to balance the whole person: body, mind, and spirit. When the person is brought into balance, many conditions such as pain, sickness, and disease can be eliminated. Acupuncture is quite safe. Acupuncturists are trained according to strict standards set by the National Commission for the Certification of Acupuncturists, and must abide by the criterion set by the Occupational Safety and Health Administration regarding hygiene, sterilization of equipment, disposal of hazardous materials, as well as precautions regarding blood borne pathogens and clean needle technique. I only use sterile and disposable needles. The risks of acupuncture are low, and could include some pain in the area of treatment and fainting (which can be avoided by eating 1 to 2 hours before the treatment). Occasionally you may get a small hematoma (a small dimesized bruise under the skin) after and acupuncture needle is removed. This is not a cause for concern it will go away in a few days. Slight bleeding may occur is the needle strikes a capillary. The risks of moxa could include a slight burn or scarring, which can be avoided by good technique and clear communication between practitioner and patient. The cupping technique may leave a mark that lasts up to several days. Sometimes after receiving an acupuncture treatment you may feel a little bit lightheaded. If that is the case, please sit for a while in the waiting room. In a few minutes you ll feel relaxed and clear headed. You must advise your acupuncturist if you have a pacemaker, bleeding disorder, or if you are or may be pregnant. It is also very important to notify you acupuncturist if you have a contagious disease. Your acupuncturist needs to know any medications that you are taking, especially if you are taking blood thinners such as Coumadin/Warfarin. Herbal prescriptions are intended only for the person for whom they are prescribed. Do not give herbal formulas to anyone else. If the patient has a serious disorder such as: cardiac pain/arrest, unexplained weight loss, fracture, respiratory distress, or a hemorrhagic disorder, they should go to the emergency room immediately. CONSENT FOR ACUPUNCTURE TREATMENT I, the undersigned, agree to undergo acupuncture treatment by Julie Magram, L.Ac. I am aware of both the benefits and risks of acupuncture and its conjunctive therapies (herbs, moxa, and cupping). I fully understand that there is no guarantee of success of a specific treatment. I do not expect the acupuncturist to be able to anticipate all risks and complications. I intend the consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. I realize that acupuncture may or may not be covered by my insurance company and I accept full responsibility for payment of all services at the time they are rendered. Printed Name: Signature: Date: Parent or Guardian Signature (if under 18): Date:
2 Symptom List Circle any problem or disease you have now. Underline items that affected you in the past. Head: Headaches Facial pain Head Injury Concussion Eyes: Blurred vision Eye strain Eye pain Red Eyes Glaucoma Cataracts Night Blindness Spots in Eyes Floaters Itchy Eyes Mouth: Bleeding Gums Grinding Teeth TMJ Dry Mouth E xcessive Saliva Sores on lips/tongue Toothaches without cavities Unusual taste in mouth Ear, Nose and Throat: Deafness Tinnitus (Ringing in ears) Ear Pain Frequent Ear Infections Sinus Headaches Yellow Mucus Stuffy Nose Post Nasal Drip Dry Throat Itchy Throat Difficulty swallowing Frequent colds Excessive Flem Respiratory: Bronchitis Shortness of Breath Emphysema Wheezing Cough Pneumonia Cardiovascular: High Blood Pressure Low Blood Pressure Palpitations Irregular Heartbeat Fast Pulse (over 100 beats / min)slow Pulse (less than 60 beats / min) Feeling of pressure in the chest short of breath Chest Pain Dizziness Migraines Headache with nausea Cold hands/feet Flushed Face Fainting Anemia Blood Clots Heart Disease Gastrointestinal: Diarrhea Constipation Stomach or abdominal pain Indigestion Nausea Vomiting Heartburn Bloating /Intestinal gas Stomach Acid Belching Ulcer Hemorrhoids Loose Tool Pancreatitis Irritable Bowel Intestinal cramping Intestinal Parasites Hormone Balance: Low Thyroid Overactive Thyroid Diabetes Hypoglycemia Blood sugar Low Adrenals Other Hormone Imbalance Autoimmune & Inflammatory Conditions: Hashimoto s Disease Rheumatism Systematic Lupus Colitis Crohn s Disease Fibromyalgia Myofacial Syndrome Arthritis Skin and Hair: Eczema Rashes Hives Acne Ulceration Psoriasis Warts Fungal InfectionDermatitis Moles Dry Skin Hair Loss Neuropsychological: Numbness / Tingling Tics Tremors Seizures Nerve Pain Sadness Lack of coordination Poor Memory Depression Anxiety Irritability Anger Easily Stressed Seeing a therapist Other Urination: Frequent Difficult Urgent Painful Burning Nighttime Incontinence Bedwetting Kidney Stones Woman: Menstrual Problems Cramping Heavy/light/irregular periods PMS Emotional reactions Menopause symptoms Tubal ligation Infertility Low libido
3 Men: Impotence Premature ejaculation ppostate gland problems Vasectomy Ifertility Other: Thank you for taking the time to complete this form. Childhood illnesses, surgery or accidents? Adolescent illnesses, surgery or accidents? Adulthood illnesses, surgery or accidents? Family Medical History: Please note all major illness in your immediate family, like diabetes, heart disease, blood pressure, neurological disorders, psychological disorders, blood disorders, orthopedic disorders, cancers, etc. Past Medical History Abortion Addiction (alcohol or drugs) AIDS / HIV+ Chicken Pox Hepatitis _A_B_C Herpes Measles Multiple Sclerosis Mumps Pacemaker Polio Rheumatic Fever Scarlet Fever Stroke Tuberculosis Venereal Disease
4 Problems during you birth? Any reactions to vaccinations? Allergies? Which of the following is part of your lifestyle? Tobacco smoking Exercise Relaxation/Meditation Special Diet Recreational Drugs Alcohol Drinking Coffee Drinking Vitamins / Supplements Birth Control Pills General Symptoms Poor appetite Strong appetite Thirsts for cold drinks Thirsts for warm drink Dream-disturbed sleep Insomnia Cold hands or feet Fatigue Shortness of Breath Hot palms, soles, and chest Sweats Easily Dizziness Easily car / air / sea sick Bodily Heaviness Never Sweats Poor Circulation Muscle Cramps Chills Night sweats Lack of Strength Bleeds Easily Bruises easily Vertigo
5 Julie Magram Acupuncturist LLC Mutual Understanding in the Therapeutic Relationship Confidentiality Matters regarding care will be kept confidential except in the following circumstances: you sign a release of information giving permission to release information to a specific individual or agency; child abuse; patient or client is in imminent danger to self or others; subpoena of records. Cancellation and Missed Appointments If you need to cancel an appointment, please give us a minimum of 24 hours notice. It if our policy to charge a $20 cancellation fee for less than 24 hour notification. Initials: It is Agreed: I agree to hold harmless the practitioner of Julie Magram Acupuncture LLC or to present any issue or concern of medical malpractice by letter to the practitioner and if taken further, it will be decided by neutral arbitration; and therewith give up my right to jury or court trial should an issue arise. Because of the differences in human constitution and response, I understand that there is no way possible to warrant the outcome of such medical care and service. Initials: It is Also Agreed: I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment at the time of visit. If your insurance company covers acupuncture, I will give you a super bill to be sent to the company, and they will reimburse you after we have received your payment. Initials: Printed Name: Signature: Date: Parent or Guardian Signature (if under 18): Date:
6 Julie Magram Acupuncturist LLC Welcome to Julie Magram Acupuncture LLC. Thank you for choosing our clinic for your healthcare needs. To provide you with the best possible care, please fill out this form as accurately as possible. This information will remain confidential. Please Print: First name: Last Name: MI: Social Security #: - - Sex: F M Birthdate: / / Street Address: City: State: Zip: Home Phone: Work Phone: Cell: Occupation: In case of emergency, contact: Relationship: Phone: How did you hear about us? Does your insurance cover acupuncture? Yes / No / I don t know Name of company: Policy Number: If Yes: Please Describe your major health concern(s): Do you have a western medical diagnosis? Are you currently taking any prescription or herbal medicine? Please List.
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Joseph S. Weiner, MD, PC Patient History Form
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Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
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