New Acupuncture Patient Information
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- Barnard Lawrence
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1 New Acupuncture Patient Information Your first visit will last about 90 minutes. Follow- up treatments will take minutes. For your first visit, please arrive 15 minutes prior to your scheduled appointment time to make sure all paperwork is completed and we can get your treatment started on time. Acupuncture has been practiced for centuries, but may be very different from any health care experience you ve had before. I will ask you a number of questions about your health and history, some of which may be unfamiliar to you. You may never have had a health intake that includes looking at your tongue and taking multiple pulses. It will only be unfamiliar the first time! I encourage you to ask me questions about your treatment and progress. Your treatment is individual, as is your response to it. By asking questions you are learning how your own body heals. To prepare for your first visit: 1. Complete Forms: Prior to your appointment print and complete Health History and Consent Forms and bring them with you. The questionnaire will form the basis of an in- depth conversation we'll have at your initial consultation and enable me to customize an effective treatment plan for you. 2. What to Bring List of medications, supplements, or herbs, etc. that you are currently taking. Bring any medical and lab reports that are related to your health concern. 3. What to Wear Wear loose- fitting, comfortable clothing that is convenient for accessing areas such as the arms, legs, abdomen and back of the body during treatments. Refrain from wearing any perfume, cologne or scented lotions. Many of our patients are sensitive to fragrances. 4. What to Eat/Drink Eat a light meal prior to your appointment to prevent any possible light- headedness or nausea. Don't drink caffeinated beverages (coffee, tea, energy drinks, etc.) or take any pain medications for at least 4 hours prior to your visits. Don't eat or drink anything that changes the color of your tongue, and don't brush your tongue the morning of your appointments. In Chinese medicine, the tongue gives us valuable information about your health. Use the restroom prior to your appointment. Acupuncture treatments can stimulate your bladder! 5. After Treatment Go home: continue to relax. You may feel sleepy or hazy as your body responds to the treatment. Refrain from overexertion, drugs or alcohol for at least six hours after treatment. 1
2 Health History Name Gender Age Date: / / Date of Birth / / Address City State Zip Code Phone #! Home! Cell Emergency Contact Contact Phone #! Other Relationship Occupation: Height Weight Physician Name Physician Address Physician Phone # Have you Been treated by Acupuncture or Oriental Medicine Before?!No! Yes. Last Treatment / / How Did you hear about our clinic? Relationship status! Single! Divorced! Married! Widowed! Living w/partner! Other! Separated Main Concerns Other Health Concerns When did this start? Pain level- please circle 1 2 Heat makes it: Better no change worse Cold makes It Better no change worse Damp makes it: Better no change worse Exercise makes it Better no change worse 3 Health History You Year Family You Year Family! Cancer type(s)! Osteoporosis! Diabetes! Herpes! Hepatitis! Aids/HIV! High Blood Pressure! Other STD! Heart Disease! Rheumatic Fever! Stroke! Alcoholism! Seizure! Allergies Types! Thyroid Disease! Mental Illness! Asthma! Kidney Disease! Pacemaker! Anemia 2
3 Coffee/Tea Tobacco Alcohol Drugs Habits Amount/Frequency Exercise Regularly?!Yes! No If so, what and How Often: Medications Please note what medications, herbs or supplements you use regularly Medicine/Vitamins Dosage Reason How Long? Injuries & Surgeries Please note area of body & date Temperature How warm / cold you feel (not in degrees) relative to other people? do you wear more or less layers, etc. Please indicate your body s overall relative Temperature Along The Line With An X COLD HOT! Cold hands/ feet! Chills! Cold in the bones! Areas of numbness! Excessive thirst! Thirst for cold /hot drinks! Thirst, no desire to drink! Absence of thirst! Night sweats! Unusual sweats When? am / pm Where on body! Hot hands, feet, chest! Hot flashes! Hot in afternoon! Hot at night Moisture Please indicate your body s relative moisture level along the line with an X Hair, skin, mouth, etc. DRY OILY! Dry skin! Dry hair! Dry eyes! Dry brittle nails! Dry mouth! Dry lips! Dry throat! Dry nose /Nosebleeds! Edema /Swelling! Rashes! Itching! Dandruff! Weight gain / loss! Oily skin! Oily hair! Pimples 3
4 Digestion Please indicate your body s overall digestion along the line with an X DIARRHEA CONSTIPATION BM: How often? x / every days! Alternating diarrhea & constipation (IBS)! Indigestion! Gas! Belching! Bloating! Nausea / Vomiting! Bad breath! Dry Stools! Difficult to pass! Tired after BM! Excessive hunger! Poor appetite! Ulcer! Hemorrhoids ENERGY Please indicate your body s overall energy level along the line with an X LOW HIGH! Sudden energy drop Time of day: am / pm! Energy drop after eating! Fatigue! Dependence on caffeine! Wired / ungrounded feeling! Body / Limbs feel heavy! Body / Limbs feel weak! Shortness of breath! Heart Palpitations! Blood pressure High / Low! Bleed / Bruise easily! Hard to concentrate! Poor memory! Dizziness / lightheaded! Headaches x / week Female Reproductive Are you sexually active? Y! N! MENSES (If applicable) Age at first menses Length of full cycle days Length of menses days Last menses start date / # of pregnancies # of births premature Miscarriages Abortions! Birth control pill (hormonal)! Heavy periods! Light periods! Painful periods! Irregular periods! Changes in body/psyche prior to menstruation (PMS)! Cramps Before bleeding First day During period! Fatigue w/ menses! Digestive changes w/ menses! Mid-cycle spotting! Yeast infections MENOPAUSE Age changes began Age at last menses! Hot flashes x/ day! Vaginal dryness! Night sweats x / week! Loss of sex drive Male Reproductive Are you sexually active? Y! N!! Change of sexual drive! Erectile dysfunction! Premature ejaculation! Sores on genitals! Discharge! Prostate disease! Genital Pain! Jock Itch! Vasectomy! Hernia! Hemorrhoids 4
5 Emotions What emotion(s) dominate your experience?! Anger! Irritability! Anxiety! Worry! Obsessive thinking! Sadness! Grief! Depression! Fear! Timid / shy! Indecision! Decrease in flow! Dribbling! Difficulty starting / stopping! Incontinence Urinary (if applicable)! Kidney stones! Urgency to urinate! Frequent urination! Pain on urination! Burning sensation! Cloudy urine! Blood in urine Sleep # hours per night! Difficulty falling asleep! Wake x/ am / pm! Wake to urinate How often?! Disturbing dreams! Restless sleep! Not rested upon waking Head, Eyes, Ears, Nose, Throat! Poor hearing! Ringing in ears! Excess earwax! Sore throat! Frequent Coughs! Swollen Glands! Hoarseness! Trouble Swallowing! Poor vision! Night Blindness! Headache! Migraine! Head Injury! Dizziness! Vertigo! Hay Fever! Sinus congestion! Nose Bleeds! Loss of Smell! Phlegm (color )! Red eyes! Itchy eyes! Teary Eyes! Dry Eyes! Cataracts! Glaucoma! Spots in front of eyes! Dental problems! Mouth sores! Jaw Problems /TMJ! Teeth Grinding Thank You For Taking The Time To Complete Prior To Your First Treatment 5
6 INFORMED CONSENT FOR ACUPUNCTURE I hereby request and consent to the performance of Acupuncture treatments and other Chinese Medicine procedures on me by Gabrielle Applebaum, or other licensed acupuncturists who may be employed by or contracted with Fabric Spa, LLC. Acupuncture is the stimulation of a certain point or points on or near the surface of the body by the insertion of special needles. Acupuncture may allow for the relief of one s symptoms without the need for medications or other invasive therapies, and improve the balance of bodily energies leading to the prevention of illness, or the elimination of the presenting problem. I understand that methods or treatments may include, but are not limited to: Acupuncture, Moxabustion, Cupping, Electro- Acupuncture, Tui- Na (Chinese massage), Gua- sha, and Nutritional Counseling. I have been advised that only pre- sterilized needles are used, which are disposed of after each use/treatment. I understand that in the practice of acupuncture there are some risks including but not limited to: slight pain or discomfort at the site of needle insertion, infection, minor bruising/bleeding, weakness, fainting, nausea, burning, pneumothorax, spontaneous miscarriage, and aggravation of problematic symptoms existing prior to acupuncture treatment. I understand that it may be necessary for my acupuncturist to contact another one of my health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to share appropriate medical information. My signature gives permission to release any medical records for the reasons set forth in this paragraph. I have read the above consent form. I have had an opportunity to ask questions, and by signing below, I agree to the above- mentioned procedures. I intend this consent form to cover the entire course of treatment, present and future. With this knowledge, I voluntarily consent to the above procedures. Patient Name (Please Print) Signature of Patient Date 6
7 Fabriq Spa Protects Your Health Information And Privacy Dear Valued Patient, This notice describes our office s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company with Worker s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize. Safeguards in place at our office include: Limited access to facilities where information is stored. Policies and procedures for handling information. Requirements for third parties to contractually comply with privacy laws. All medical files and records (including , regular mail, telephone, and faxes sent) are kept on permanent file. Types of information that we gather and use: In administering your health care, we gather and maintain information that may include non- public personal information: About your financial transactions with us (billing transactions). From your medical history, treatment notes, all test results, and any letters, faxes, s or telephone conversations to or from other health care practitioners. From health care providers, insurance companies, workman s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information). We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at (215) Yours truly, Gabrielle Applebaum, Acupuncturist L.Ac, M.Ac, Dipl.Ac, MTS 7
8 Acknowledgement of Privacy For Purposes of Treatment, Payment and Health Care Operation I consent to the use or disclosure of my identifiable health information by Fabric Spa, LLC Gabrielle Applebaum (collectively, the Recipients ) for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. The Recipients are not required to agree to the restrictions that I may request. However, if the Recipients agree to a restriction that I request, the restriction is binding upon them. I have the right to revoke this consent, in writing, at any time except to the extent that the Recipients have taken action in reliance on this consent My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have the right to review the Recipients Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the Recipients. This Notice of Privacy Practices also describes my rights and the duties of my practitioners with respect to my identifiable health information. The Recipients reserve the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by accessing the website or requesting the most current notice during any office visit. Signature of Patient or Authorized Representative Date Printed Name and Relationship 8
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Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
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Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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An Hao Natural Health Care Clinic 2348 NW Lovejoy St. Portland, OR
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