Diane Iuliano, M. Ac., Lic. Ac., Dipl. Ac. (NCCAOM) Acupuncture and Herbal Medicine
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1 Diane Iuliano, M. Ac., Lic. Ac., Dipl. Ac. (NCCAOM) Before you come for your acupuncture visit: Please print out this form, fill it out, and bring it to your first appointment. Bring a list of all medications and supplements you are taking Wear minimal make-up and perfume, especially on your first visit. Loose clothing is more convenient. Do not drink coffee at least 3 hours prior to your visit. Have a light meal or snack before the visit. Heavy meals may cause nausea. An empty stomach may cause dizziness after the treatment. Drink enough water on the day of the treatment. Do not drink alcohol. After your acupuncture visit: Keep yourself hydrated, sip on water Do not eat greasy or spicy food Rest is preferable Do not exercise
2 Consent to Treatment I, (Printed Name), hereby authorize Diane Iuliano, L.Ac., M.Ac., Dipl. Ac., to administer any style of Oriental Medicine relevant to my diagnosis and treatment, including but not limited to the following: 1. Insertion of various styles and sizes of acupuncture needles, magnets, zinc and copper pellets on or into my body at various depths and locations. 2. Heat treatment using the herb Arthemesa vulgaris (moxibustion, moxa ) or a conventional heat lamp may be placed on or near any part of my body. For indirect moxibustion treatments, the moxa is placed on the head of the needle or barrier (such as a cardboard holder or shiunko cream) which rests on the skin. When direct moxa is used, the moxa is placed directly on the skin. The heat generated from moxa treatments may involve a sensation of heat or leave a small blister or scar on the skin. With any type of heat, there is a risk of burn. 3. A massage technique gwa sha may produce redness on the skin which remains for 1-5 days. There may be discoloration of tenderness may persist following the treatment. 4. Cupping may be used to promote the circulation of Qi (energy) through the meridians. Cups may produce a red/purple color on the area cupped which may remain for 1-5 days. 5. Electrical stimulation may be used which produces a vibration/tapping sensation on the needles. Ion pumping cords may be attached to the needles. 6. Pediatric Shonishin is a technique of rubbing and tapping acupuncture points and channels on infants and small children. It is used to enhance vitality and immunity, and to treat common pediatric complaints. I have been informed that I have a right to refuse any form of treatment. I understand the nature of the treatment, have been informed of the risks and possible consequences involved with this treatment, and was given an opportunity to ask questions pertaining to my treatment. I also understand there is always a possibility of unexpected complications and I understand that no guarantee can be made concerning the results of the treatment. Signature of Patient: Date:
3 Acupuncture Therapy Financial Policy 1. All payments must be made at time of session unless other arrangements have been agreed to. Acupuncture Therapy accepts cash or checks. 2. Cancellation policy: Because of limited times available and high demand, it is necessary to enforce a strict cancellation policy. a. If a client cancels at least 24 hours prior to the appointment, there is no charge. b. If a client cancels less than 24 hours prior to the appointment or does not show, the client will be charged a fee that is equivalent to the cost of one full session. Please initial that you have read and understand our cancellation policy: 3. Late Policy: Acupuncture Therapy provides you our fullest attention during your allotted time. Your respect of other client s time is appreciated and sessions will end promptly as scheduled. Late arrivals are responsible for the full fee of the session. Fee Schedule Initial Evaluation (45-60 minutes) $85.00 Follow up session (45 minutes) $85.00 Tufts/Harvard Pilgrim/Blue Shield $70.00 Children (under 12) and Seniors (over 65) $70.00 Patient Signature and date:
4 Intake Form How did you hear about Acupuncture Therapy/Diane Iuliano? Google Yahoo NP Physician Other Online Search or Online Yellow Pages Yellow Book Yellow Pages Verizon Yellow Pages Other In case of emergency contact Relationship Address (if different from above) Phone Please describe the reason for your visit today (Chief Complaint) Is it getting better, worse, or staying the same? Are you, or have you been, treated for this problem with any other health professionals? Has it been effective? What was your diagnosis? Are you taking any medication or herbal supplements? If so, which ones? (Add dosage if known) Are you in generally good health, or do you frequently fall ill? What illnesses might you be prone to? (ie, frequent colds, Gastro-intestinal problems)
5 MEDICAL HISTORY Please circle any current health issue. For those diseases which are part of your health history, please note the year of the occurrence. Allergies Epilepsy Polio Anemia Fatigue Scarlet Fever Appendicitis Gout Stroke Arteriosclerosis Heart Disease Surgery (List) Asthma Hepatitis (A, B, C) Bleeding Disorder Hypoglycemia Blood Pressure (Low or High) Injuries Cancer Insomnia Thyroid Disorder Chicken Pox Intestinal Parasites Trauma (falls, accidents) Diabetes Multiple Sclerosis Tuberculosis Digestive Disorders Mumps Ulcers Emotional Difficulties Pacemaker Other: Emphysema Weight Loss Do any of your family members suffer from: (Please list relationship to you) Alcoholism Arteriosclerosis Heart Disease Allergies (list): Asthma High Blood Pressure Cancer Seizures Diabetes Stroke Which of the following are part of your lifestyle? How frequently do you engage in it? Alcohol Nicotine Exercise Coffee Recreational Drug Use Excessive Sugar Do you usually eat three meals a day? Do you follow any particular diet?
6 On the scale of 1-10, how would you rate the level of stress in your life currently? What is the level of stress in your life in general (1-10)? How does stress affect you? (ie, more headaches, stomach pain, etc.) Are there any other concerns you would like to address?
7 REVIEW OF SYSTEMS Please fill this out carefully, even if some of the symptoms don t seem at all connected to your current issue! Place one check next to a symptom you have experienced, two checks next to a frequently occurring symptom, and three checks next to a symptom that is particularly distressing to you. Head and Face Heart and Chest Skin Headaches High Blood Pressure Acne Dizziness Low Blood Pressure Dryness Memory Loss Chest Pain Moles that Change Chest Tightness Lumps Difficulty Lying Down Excessive Sweating Night Sweats Eyes Rarely Sweat Eyes Blurry Vision Eyelid Twitching Circulation Floaters Easy Bruising Pain Easy Bleeding Neurological Cold Limbs-Hands or Feet Nervousness Nose Numbness or Tingling Frequent Colds Lack of Coordination Sinus Trouble Gastrointestinal Nerve Pain Bleeding Always Thirsty Mouth Excessive Appetite Never Thirsty Dental Problems Low Appetite Sleep Gum Problems Gas / Bloating Insomnia Teeth Grinding / TMJ Stomach or Abdominal Pain Drowsiness Unusual Tastes Nausea Excessive Dreaming Diarrhea / Loose Stools Waking Easily Constipation Colon Problems Throat Rectal Bleeding Sore Throat Hoarseness Difficulty Swallowing Dryness Frequent Urination Difficult Urination Painful Respiration Difficulty Inhaling Difficulty Exhaling Bleeding Cough Shortness of Breath Congestion Other: Energy Level: Low Pain: Please Describe: Energy Level: High Are there any other health concerns you'd like to address?
8 WOMEN ONLY Are you, or could you be pregnant? If so, how far along? Number of pregnancies Births Abortions Miscarriages What form of birth control do you use? Do you have regular PAP smears? How Often? Age of first menses Age of menopause, if applicable Do you bleed between periods? Do you bleed after intercourse? Have you ever had any gynecological surgeries or any abnormal findings on any tests? Are your periods uncomfortable or painful, either emotionally or physically? Are your periods: Short (Less than 28 days) Long (28+ days) Varied Regular Painful? If so, Before During After Do you bleed heavily? Lightly? Very little? Do you have clots? Early in the cycle or throughout? Relative to the blood that comes from a wound, is your menstrual blood: The same color More pale Purple More Red More Brown How many days do you bleed? Do you have any of the following Pre-Menstrual Symptoms? (Emotions are not judged in Chinese Medicine, they are neither good nor bad. They are, however, important diagnostic tools. Please answer honestly.) Irritability Depression Crying Rage Nausea Cravings, and if so for what? Breast Tenderness Any other symptoms around the time of your period? Are you experiencing any low or high sexual desires? Do you have any concerns surrounding this? Do you have any other gynecological concerns or complaints?
9 MEN ONLY Do you experience any of the following: Reduced Libido Excessive Libido Impotence Urinary Frequency Premature Ejaculation Discharge Genital/ Testicular pain Any other concerns? Consent I have provided correct and complete information to the best of my knowledge. Patient s or Guardian s signature Date
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New Client Intake Form Name DOB Age Gender Address City State Zip Preferred phone # Alternate phone # Email address Occupation Referred by Have you had acupuncture before: When Emergency, contact: Phone
Mayflower Acupuncture LLC
536 Hopmeadow St. Simsbury, CT 06070 Phone: (860) 413-2118 Email: Forms@mayfloweracupuncture.com Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
135 Delaware Ave. Buffalo, NY (716)
New Patient Packet Toni Haugen L.Ac MSTOM 135 Delaware Ave. Buffalo, NY 14202 haugentoni@gmail.com (716) 218-9338 Thank you for choosing Queen City Acupuncture. I look forward to working with you soon.
Ayurvedic Intake Form
Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
Placer Private Physicians: Patient Health Questionnaire [2]
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
CONSULTATION & CONSENT FORMS p. 1 of 5
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your
Rachel Beth Dorfman, L.Ac., C.M.T.
Rachel Beth Dorfman, L.Ac., C.M.T. Classical Acupuncture, Chinese Medicine and Asian Bodywork Patient Information Name: Today's date: Address: Age: Date of birth: City: State: Zip: Email: Best phone to
OKANAGAN HEALTH & PERFORMANCE Inc.
OKANAGAN HEALTH & PERFORMANCE Inc. Chiropractic, Massage Therapy, Kinesiology, Physiotherapy, Acupuncture, Naturopathic Medicine & Osteopathy 104-1100 Lawrence Ave, Kelowna, BC, V1Y 6M4 (250) 860-6295
Patient Admittance Form
Patient Admittance Form Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB. T3A 2X7 Phone: (403) 241-1886 Fax: (403) 241-0995 Name: (Family) (First) (Initial) Sex: Male Female
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please