Minister Medical ^Acupuncture

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1 Minister Medical ^Acupuncture t^wellness Clinic What is acupuncture? Acupuncture is a therapy in which fine needles are inserted into specific points on the body. Is acupuncture safe? Acupuncture is generally very safe. Serious side effects are very rare. Does acupuncture have side effects? You need to be aware that: 1) Drowsiness occurs after treatment in a small number of patients, and, if affected, you are advised not to drive. 2) Minor bleeding or bruising occurs after acupuncture in about 3% of treatments. 3) Pain during treatment occur in about 1 % of treatments. 4) Symptoms can get worse after treatment (less than 3% of patients). You should tell your acupuncturist about this, but it is usually a good sign. 5) Fainting can occur in certain patient, particularly at the first treatment In addition, if there are particular risks mat apply in your case, your practitioner will discuss these with you. Is there anything your practitioner needs to know? Apart from the usual medical details, it is important that you let your practitioner know: 1) If you have ever experienced a fit, faint or funny turn; 2) If you have a pacemaker or any other electrical implants; 3) If you have a bleeding disorder; 4) If you are taking anti-coagulant or any other medication; 5) If you have damaged heart valves or have any other particular risk of infection Single-use, sterile, disposable needles are used in the clinic. Statement of Consent I confirm that I have read and understood the above information, and I consent to having acupuncture treatment. I understand that the focus is on the overall picture of my health and if I am not responding to this approach I will not hesitate to consult with other healthcare providers. Signature Print name in full Date

2 tfrix Munster Medical Acupuncture Wellness Clinic NEW PATIENT INTAKE FORM Today's date. NAME BIRTHDATE / /_ ADDRESS Marital Status Age _ CITY STATE ZIP address Home Phone # Work Phone # Occupation, EMERGENCY CONTACT (name & phone) Referred by: Have you had acupuncture before? Yes No Chinese herbal medicine? Yes No Reason for visit today: How long have you had this condition? Are you being following by primaiy care physician? Who is your physician? Physician's phone #_ Would you like me to discuss your acupuncture treatment with your physician? Yes No YOUR PAST MEDICAL HISTORY Previous Illness and Surgeries Medications and Supplements Diet (amounts /types of foods, meals / snacks) Allergies

3 YOUR LIFESTYLE Alcohol Marijuana Stress Regular Exercise Tobacco Drags.Occupational Hazards: Type: Frequency: GENERAL SYMPTOMS Poor Appetite Poor Sleep Bodily Heaviness _ Chills Bleed or Bruise easily Heavy Appetite Heavy Sleep Cold Hands or Feet Night Sweats Peculiar Taste (describe) Prefer Cold Drinks Dream Disturbed Sleep Poor Circulation Sweat Easily - Prefer Hot Drinks Fatigue Shortness of Breath Muscle Cramps Weight Gain or Loss Lack of Strength Fever Vertigo or Dizziness HEAD/EYES/EARS/NOSE/THROAT Glasses Night Blindness Eye Strain Glaucoma Eye Pain Cataracts Red Eyes Teeth Problems Itchy Eyes Grinding Teeth _ Spots in Eyes _ TMJ Poor Vision Facial Pain Blurred Vision _ Gum Problems. Sores on Lips or Tongue. Dry Mouth. Excessive Saliva. Sinus Problems. Excessive Phlegm Color of Phlegm. Sore Throat. Lumps in Throat. Enlarged Thyroid. Nose Bleeds. Ringing in Ears. Poor Hearing Earaches. Headaches. Concussions. Other Head/Neck Problems RESPIRATORY Difficulty Breathing when Tight Chest Cough Color of Phlegm Coughing Blood laying down Asthma/wheezing Wet or Dry? Pneumonia Shortness of Breath Fainting Thick or thin? CARDIOVASCULAR High Blood Pressure Low Blood Pressure Chest Pain Tachycardia Phlebitis Blood Clots Fainting Difficulty Breathing Heart Palpitations Irregular heartbeat GASTROINTESTINAL Nausea Vomiting Acid Regurgitation _Gas Hiccup Bloating Bad Breath. Diarrhea. Constipation. Laxative Use. Black Stools. Bloody Stools. Mucous in Stools. Intestinal Pain/Cramp. Itchy Anus. Burning Anus. Rectal Pain. Hemorrhoid. Anal Fissures Bowel Movements Frequency Color Texture/Form. Odor MUSCULOSKELETAL Neck/Shoulder Pain Upper Back Pain Joint Pain Limited Range of Motion Other (describe) _ Muscle Pain Lower Back Pain _ Rib Pain Limited Use SKIN/HAIR Rashes Eczema Dandruff Change in Hair Other Hair/Skin Problems Hives Psoriasis Itching Ulcerations Acne Hair Loss Fungal Infections NEUROPSYCHOLOGICAL Seizures Numbness Tics Poor Memory Depression Anxiety. Irritability. Easily Stressed Abuse Survivor. Considered Suicide _ Attempted Suicide. Seeing Therapist Other (specify) GENITOURINARY Pain on Urination Frequent Urination Urgent Urination. Blood in Urine. Unable to Hold Urine. Incomplete Urination. Venereal Disease. Bedwetting. Wake to Urinate. Increased Libido. Decreased Libido. Kidney Stone Impotence Premature Ejaculation Nocturnal Emission GYNECOLOGY Age Menses Began Duration of Flow Vaginal Discharge Breast Lumps Date of Last PAP (color) # Pregnancies / / Length of Cycle Irregular Periods Vaginal Sores # Live Births (day 1 to day 1) Painful Periods Vaginal Odor Premature Births Date Last Period Began PMS Clots Age of Menopause / /

4 Thank you for taking the time to complete this intake form. It is extremely helpful to me, as I do the initial evaluation. I would like to find out some of your preferences, as well as what you would like to treat at this initial visit. I also recommend that my clients have their own primary care physician, since my practice is limited to medical acupuncture. I would be glad to discuss acupuncture with your physician, if you would like me to help provide an integrated approach to your health care. PREFERENCES: Favorite color: Favorite season of the year: Favorite flavor (salty, sweet, sour, spicy, bitter or roasted): Time of peak and low energy throughout the day: Favorite activities (during free time): Predominant emotions (introspection, anxiety, fear, anger, joy/creativity, depression): Please feel free ot share information about your family, or job or other activities, which can impact on your health, and might be important for me to be aware of: At this initial visit, what area(s) would you like me to focus on the most?

5 MUNSTER MEDICAL & ACUPUNCTURE WELLNESS CLINIC th Avenue, Suite E Munster, IN (219) Website: munsteracupuncture.com NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third party payers. Conduct normal healthcare operations, such as quality assessments and physician certifications. I have received, read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. PATIENT NAME MAY RELEASE MEDICAL INFORMATION TO (FAMILY MEMBERS, ETC.): OK TO LEAVE MESSAGE ON HOME PHONE? YES NO OK TO LEAVE MESSAGE ON CELL PHONE YES NO SIGNATURE DATE OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgement of this Notice of Privacy Practices Acknowledgement but was unable to do so as documented below: DATE: INITIALS: REASON: 2015

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