Name Today s Date Birth Date. Age Gender M / F Address City. Zip Cell/Home Phone:

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1 Name _Today s Date Birth Date Age Gender M / F Address City State Zip Cell/Home Phone: Work Phone: Can we leave detailed message: Cell: yes / no yes /no Work: yes /no Place of Employment Occupation Emergency Contact Phone Relationship How did you find us? What brings you in today? What treatments have you tried and have they helped? What specific outcomes would you like (e.g., reduce pain, achieve pregnancy, improve sleep)? Prescribed medications Purpose Months/ Years of use Supplements you take Purpose Months/ Years of use Year Surgery/Condition

2 What types of foods do you typically eat for: Breakfast: Lunch: Dinner: Snacks: How many ounces of water do you drink each day? What other beverages do you typically drink(e.g., soda, coffee, wine, tea, etc) Do you smoke? If so, what? How much? Since when? Women are you, or could you possibly be pregnant at this time? Note: Always inform your practitioner if you could possibly be pregnant Please relay any other important information, questions and/or concerns you would like to share regarding your visit, including needle apprehension, comfort preferences, etc:

3 CHECK any in last year: frequent irritability/anger frequent stress recurring depression blurred vision floaters in eyes poor night time vision dizziness red/dry/itchy eyes feeling of lump in throat muscle cramping joints/neck/shoulder pain poor circulation soft/brittle nails bitter taste in mouth insomnia 11pm-3am dry cough nasal discharge post nasal drip dry mouth/throat/nose skin rashes/hives snoring grief/sadness shortness of breath asthma/allergies frequent colds/flu smoke cigarettes bronchitis heart palpitations chest pain insomnia/sleep problems easily startled restlessness/agitation vivid dreams lack of joy in life excessive thirst insulin sensitivity fatigue poor concentration heaviness in body fatigue worse after eating hard to get up in the morning edema (swelling) weak/tired muscles easy bruising bad breath decreased appetite increased appetite sweet cravings hypoglycemia difficulty digesting foods nausea/vomiting gas/belching hemorrhoids constipation diarrhea abdominal pain excess worry over-thinking urinary problems lack of bladder control weakness in low back pain in low back decreased bone density feels cold easily low sex drive excess sexual desire poor memory loss of hair hearing problems salty cravings night sweats/hot flashes dark under eyes weak knees/legs thyroid problems Women, have you had: Pregnancies # Miscarriages # Ectopic Pregnancies # Yeast or vaginitis Ovarian cysts PCOS diagnosis Diminished ovarian reserve diagnosis Uterine cysts, fibroids or tumors Mastitis Positive pap smear PMS Breast tenderness Hot flashes or night sweats Day 1 of last period: Age of onset period: Is there a family history of: Cancer Diabetes Heart trouble High blood pressure Mental illness Others (please list)

4 Education and Experience: COLORADO MANDATORY DISCLOSURE STATEMENT 6059 S Quebec St. #103, Centennial, CO Jackie Sagum earned her Bachelor of Science in Kinesiology from Indiana University in She graduated with a Master of Science in Oriental Medicine from Southwest Acupuncture College with over 3400 hours of classroom and clinical training in acupuncture and Chinese herbs. She is nationally board certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). Jackie s clinical experience includes multiple OB/GYN specialty clinics where she treated a wide variety of women s health conditions. Her licenses, certificates, or registrations have never been suspended or revoked. Grant Sagum graduated with a Master of Science in Oriental Medicine from Southwest Acupuncture College with over 2500 hours of classroom and clinical training in acupuncture and Chinese herbs. He is nationally board certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). His licenses, certificates, or registrations have never been suspended or revoked. Julie Johnson earned her Master of Science in Oriental Medicine from Southwest Acupuncture College with over 3400 hours of classroom and clinical training in acupuncture and Chinese herbs. She is nationally board certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). Her licenses, certificates, or registrations have never been suspended or revoked. This clinic complies with the rules and regulations promulgated by the CO Department of Health, including proper cleaning and sterilization of supplies and sole use of single-use, disposable, factory-sterilized needles. Fee Schedule Payment at Time of Service New Patient Intake and Treatment ( min) $110 (plus cost of herbs) Follow Up (45-60 min) $75 (plus cost of herbs) Herbal Consultation (30-45 min) $50 (plus cost of herbs) Onsite IVF pre and post transfer treatment $250 Package of 5 (Follow Up Visits) $350 (plus cost of herbs) Package of 10 (Follow Up Visits) $680 (plus cost of herbs) Office Policies 1) Safety: Please do not rush to get here. Drive safely and don t worry if traffic holds you up a bit. 2) Comfort: You will be provided a pager during treatment. Please alert me if you experience discomfort. 3) Late Cancel: There is a $25 fee for changes made less than 24 hours before your appointment and $75 for a no show. 4) Noise: Please be mindful that others are resting; please no cell phone calls or ring tones in the clinic. 5) Insurance: It is the patient s responsibility to confirm that acupuncture is covered for the condition being treated. Patients are responsible to pay any amount not covered by insurance. 6) Communications: If you experience any discomfort following a treatment or with herbal preparations, please notify us right away. If you don t hear back within 24 hours, please get in touch again, as sometimes messages do not make it to us. Call 911 if you are having a health emergency. Patient s Rights: The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies. The practice of acupuncture is regulated by the CO Dept. of Regulatory Agencies. If you have comments, questions, or complaints, contact the Director, Division of Registrations, Acupuncturists Licensure, 1560 Broadway #350, Denver, CO (303) I have read and understand this document. PATIENT OR GUARDIAN SIGNATURE DATE

5 CONSENT TO TREATMENT: I consent to acupuncture treatments and other procedures by Grant Sagum, Jackie Sagum, and Julie Johnson ( the acupuncturists ). Methods of treatment may include but are not limited to acupuncture, electrical stimulation, massage, and herbal medicine. Acupuncture is a safe treatment method, but it may have side effects, including bruising, numbness or tingling that may last a few days, and dizziness or fainting. Very unusual and unexpected risks of acupuncture include nerve damage, organ puncture, and infection. Herbs and supplements recommended are considered safe if taken as prescribed. Some possible side effects of taking herbs are abdominal discomfort, vomiting, headache, diarrhea, and rash. Some herbs are contraindicated during pregnancy and breastfeeding. Herbs may have an unpleasant taste or smell, and need to be consumed according to directions. I do not expect the acupuncturists to anticipate and explain all possible risks and complications of treatment. I wish to rely upon them to exercise their best judgment during the course of my treatment, which at the time and based upon the facts then known, is in my best interest. I expect my medical information to be held in confidence, however I give permission for them to communicate with other licensed health care practitioners from whom I have or will receive treatment about my history, condition, and progress in order to provide effective continuity of care. I have read this consent to treatment, have been told the risks and benefits of treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and any future conditions for which I seek treatment. PATIENT OR GUARDIAN SIGNATURE DATE Your Health Information and Privacy 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 (303) PATIENT OR GUARDIAN SIGNATURE DATE