Oceanpoint Acupuncture Patient History Form

Transcription

1 Oceanpoint Acupuncture Patient History Form Name Today s Date / / Occupation Sex: Male Female Marital status DOB / / Address Phone (Home) (Work) Primary Care Physician Phone Emergency Contact Phone Have you ever received acupuncture? Yes No Are you currently pregnant? yes No Are you currently on any blood thinners, seizure medications or antipsychotics? Y/N (if yes please list) How did you hear about us? Website Relative Referral Other Google Friend What would you like us to treat today? How long have you had this condition? What alleviates your symptoms Oceanpoint Acupuncture 813 Broadway South Portland, Me ( ) 1

2 What makes your symptoms worse? What other modalities of treatment have you tried for this? What medications/supplements are you currently taking? Do you have any medically diagnosed illnesses? Medical History (Check all that apply) Pacemaker Diabetes Joint pain AIDS/HIV Allergies Emphysema Lyme disease Hepatitis Cancer COPD Seizures Multiple Sclerosis Drug addiction Alcoholism Personality disorder Fibromyalgia Depression Rheumatic fever Low Blood Pressure Mumps Surgeries: High Blood Pressure High Cholesterol Migraines Bi-polar Schizophrenia Family Medical History (Please list any major illnesses or diseases in your immediate family such as diabetes, high blood pressure, cancer, etc) Digestion ( check all that apply): Bloating Acid reflux Heartburn Fatigue after eating Gas Ulcers Abdominal pain Food Allergies Nausea Vomiting Vomiting blood Thirst : Above average Below average Normal Appetite: Above average Below average Normal Digestion Number of Bowel movements per day Quality (Check all that apply) Constipated Soft Loose Mucous Blood Undigested food Well-formed What does your diet mainly consist of? Do you crave foods with: salty Sweet Bitter sour Spicy How much water do you drink daily? Urination (Check all that apply) Burning Blood Stones UTI s Incomplete Cloudy Dribbling Frequent Nighttime 2

3 Sleep I have trouble with (Check all that apply) Falling asleep Staying asleep Dream disturbed sleep Waking frequently Energy & Exercise Energy level (Scaled 1-10) Exercise & amount per week Emotions What do you struggle with the most? Check all that apply) Anxiety Anger Irritability Sadness Depression Over thinking Eyes Dryness Watering Redness Burning Floaters Poor Eyesight Nose Dry Congestion Bleeds Easily Runny Sinus Pressure Ears Excess wax Ringing Itchiness Poor Hearing Infections Throat Dryness Phlegm Soreness Skin Eczema oily Dry Bruise easily Bleed easily Psoriasis Nails Brittle Flaky Ridged Soft Fungus Hair Falling out Thin Oily Dry Mouth sores Dry Excess saliva Respiratory Wheezing Pain Shortness of breath Body Temperature (This is not actual temperature but your subjective feeling) Warm Cold Even Fluctuates Do You Have Trouble With? Focus Memory Perspiration Night sweats Spontaneous Lacking Profuse Pain Are you currently experiencing pain anywhere in your body? Y/N (If yes where?) Please rate scaled 1-10 The pain is: Shooting Stabbing Aching Deep Superficial Lifestyle: Cigarettes Alcohol Marijuana Coffee Oceanpoint Acupuncture 813 Broadway South Portland, Me ( ) 3

4 Cardiovascular/Circulatory Palpitations Chest pain Numbness Cold hands Cold feet Do you get sick easily? Yes No Women s health Are you sexually active? Y/N Menopause: Current Post Pre IUD Birth Control Number of: Pregnancies Abortions Miscarriages Do you ever get vaginal infections? Y/N Length of periods? Length of Cycle PMS: Y/N What age did you first get your period? What day are you on your cycle currently? Quantity: Heavy Light Average Continually Spotting Quality: Dark Red Bright Red Brown Purple Even Red Clots PMS: Cramping Irritability/Emotional Breast Distention Men s Health Are you sexually active? Y/N Do you have sexual problems? Y/N 4

5 Mandatory Consent and Disclosure Form About Traditional Chinese Medicine Traditional Chinese Medicine (TCM) has been practiced in China for over 3,000 years. It has long been considered the medicine of the layman, because it treats the individual, not only the ailment. TCM takes a root and branch approach to health, in that true healing cannot take place until both the root of the disharmony and the branch are treated simultaneously. These concepts are taken from the Taoist philosophy that harmony and balance are elemental to the natural order of life and thus, health. Education and Experience Gabe is a native to Maine and grew up in South Portland. He received his Masters degree in Traditional Chinese Medicine in from The Colorado School of Traditional Chinese Medicine in Denver, Colorado. This 4 year program consists of 1,280 hours of education and 795 hours of clinical practice. Gabe s training covers therapies such as Moxibustion, Tui Na massage, Cupping, auricular therapy, E-Stim, herbal therapy and lifestyle and dietary recommendations. He was Board certified as an Acupuncture and Traditional Chinese Medicine practitioner by the National Certification Commission for Acupuncture and Oriental Medicine and is a registered and licensed acupuncturist in the state of Maine. Memberships include the American Acupuncture Association, the American Association of Acupuncture and Oriental Medicine and the Maine Association of Acupuncture and Oriental Medicine. None of these licenses, registrations or memberships has ever been revoked. This clinic complies with the rules and regulations set by the Maine Department of Health, including the proper cleaning and sterilization of needles and the sanitation of offices. Patient s Rights The patient is entitled to receive information about methods of treatment, techniques and duration. * The patient may seek a second opinion from another healthcare practitioner or terminate treatment at any time for any reason. * The practice of acupuncture is regulated by the Maine Department of Regulatory Agencies. If you have questions, comments or complaints, contact the Office of Professional and Occupational Regulation at Acknowledgments I understand that acupuncture may cause dizziness, bruising, skin irritation, nausea, pain discomfort and possible pneumothorax. I also understand acupuncture and herbal medicine is not a substitute for western medicine and may be referred to my Primary Care physician or Emergency Room if necessary. I will notify Gabe Schiff-Verre if I am or become pregnant at any time. I understand that not disclosing this information may cause risks to pregnancy. I have read and understand the preceding document Patient Signature Date Oceanpoint Acupuncture 813 Broadway South Portland, Me ( ) 5

6 Financial Policies - Payment is expected at the time of service. We accept all credit cards and applicable insurance hour notice of cancellation is required. If notice is not given it will be necessary for us to charge the cost of that visit. - There will be a $20 service fee for checks returned due to insufficient funds - Patients who are later than 15 minutes to their appointment must reschedule Signature Date Privacy Practices And Rights Oceanpoint Acupuncture maintains health records for in office health history, third party medical use and plans for future care and treatment. I have the right to deny use of my health information and that I will be notified if my health records are requested. I may request a copy of my health records and this notice of privacy practices for a copying fee. My health information will not be given out unless I give written permission and that my health information may be subpoenaed by law if necessary. I have the right to contact HIPPA if I feel that my privacy rights have been violated. My health information my be disclosed for these reasons: Lawsuits Deceased patient s organ/tissue donation Law enforcement Public risk ** In some cases your health information may be used in an anonymous research-based case study. Actual names and contact info will not be used. If you wish to refuse please inform us. Is it ok for us to contact your doctor? Yes No Oceanpoint likes to check in with patients occasionally to see how they are doing with their treatments and offer promotions. Is it ok if we add you to our mailing list? Yes No I have read and understand these privacy rights and practices Signature Date 6

7 1.) Indicate the area of pain with an X mark 2.) Circle the appropriate type of pain below Stabbing Aching Referring (To: ) Electric Pain scale rating: Oceanpoint Acupuncture 813 Broadway South Portland, Me ( ) 7

8 SOAP Notes (Practitioner Use) Objective/Treatment Protocol: Tongue: Pulse D&D Points/Modalities Herbs/Supplements 8