ACUPUNCTURE NEW PATIENT INFORMATION

Transcription

1 ACUPUNCTURE NEW PATIENT INFORMATION : Name: Age: Birth : Address: City State Zip Phone: Home ( ) Work: ( ) Cell: ( ) Address: May we contact you via Yes No Social Security No: Referred By: Emergency Contact Name: Emergency Contact Phone: ( ) Relationship to Patient: Employment Status: Full Time Part time Self Unemployed Retired Employer: Occupation: Marital Status: Single Married Partnered Widowed Divorced Separated Height: Weight: of Last Physical: Condition Evaluation Reason for your visit (pain, fatigue): When did you first notice the pain/symptoms: How often do you experience your symptoms: Constant (76 100% of the time Occasionally (26 50% of the time) Frequently (51-75% of the time) Intermittently (1-25% of them time) How has your condition interfered with your work: How has your condition interfered with social activities (ding out, parties, theater and other social functions): How has your condition interfered with recreation (hobbies, exercising, or other leisure activities) How has your condition interfered with self-care (showering, getting dressed, eating) How do you think the problem began (injury, auto accident, falling): What activities aggravate your condition (walking, sitting, standing): What activities make your condition better (ice, heat, resting): Other doctors seen for your condition: MD/DO PT Massage Chiropractic Other 01-December-2014 Page 1

2 Activities & Health Review Habits: Heavy Moderate Light None Coffee/Tea: Weekly/Daily Amount: Alcohol: Weekly/Daily Amount: Soda: Weekly/Daily Amount: Tobacco: Weekly/Daily Amount: Marijuana: Weekly/Daily Amount: Exercise: Weekly/Daily Amount: Water Intake: Weekly/Daily Amount: What activities do you do at work or at home? Sit: Most of the day Half of the day A little of the day Standing: Most of the day Half of the day A little of the day Computer work: Most of the day Half of the day A little of the day On the phone: Most of the day Half of the day A little of the day Surgeries Type of surgery and reason for surgery List medications taken within the last six months (vitamins, drugs, herbs, etc): Food allergies / intolerances Medication allergies 01-December-2014 Page 2

3 Health History Review: symptoms your are currently experiencing or have experience in the past 2 years Constitutional Health Weight change Fatigue Headaches Migraines Eyes Blurred/Double vision Contacts / glasses Dry/Itch/Burning eyes Eye disease/injury Poor/low vision Spots in front of eyes Ears/Nose/Mouth/Throat Hearing loss Ring in the ears Chronic sinus problems Nose bleeds Mouth sores Bad Taste Bleeding gums Cardiovascular Heart trouble/disease Palpitations Shortness of breath Swelling of feet, ankles or hands Respiratory Asthma Shortness of breath Bronchitis Persistent cough Clearing of throat Gastrointestinal Change in appetite Diarrhea Constipation Abdominal pain Genitourinary Frequent urgent urination Painful burning urination Incontinence or dribbling Bladder infections Female pain with periods Female irregular periods Musculoskeletal Joint pain Stiffness or swelling Weakness Cramps / spasm Numbness or tingling Difficulty walking Integumentary Hives / Eczema Rash or itching Breast pain Dry skin Neurological Lighted Headed /Dizzy Tremors Head injury Emotional Depression Anxiety Panic attacks Nervousness Insomnia Other Health/Health History Information: 01-December-2014 Page 3

4 Pain Assessment: Indicate painful or distressed areas. Rate your AVERAGE pain the past week Rate your WORST pain the past week Comments: 01-December-2014 Page 4

5 CONSENT FOR ACUPUNCTURE & EAST ASIAN MEDICINE TREATMENT I hereby authorize Lory Lee, Licensed Acupuncturist and East Asian Medicine Practitioner to perform the following procedure: Acupuncture: The insertion of pre-sterilized, single use only disposable needled or lancets through the skin into the underlying tissues at specific acupuncture points on the surface of the body. Electro acupuncture: Using very small amount of electricity to stimulate acupuncture points on the surface of the body. Laserpuncture: A laser light beams are applied to specific acupuncture points on the surface of the body. Acupressure: The same points on the body are used as in acupuncture, but are stimulated with finger pressure instead of with the insertion of needles. Infrared Therapy: Applying heat generated by an infrared lamp over a specific area of the body. Cupping: Applying glass cups on the skin with a vacuum created by heat or suction device. Dermal friction therapy: Called gua sha is a method that involves increasing circulation at the surface of the skin by means of scraping the skin vigorously with a blunt edged object. Dietary Advice and Health Education: Based on East Asian medical theory, including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements. I recognize the potential benefits and risks of these procedures, including but not limited to: Potential Benefits: Drugless relief of presenting symptoms and improved balance of body energies that may led to prevention, improvement or elimination of the presenting condition. Potential Risks: Discomfort, pain, bruising, blistering, bleeding, infection at the site of the procedure, temporary discoloration of the skin, possible aggravation of symptoms existing prior to the acupuncture treatment, dizziness, nausea, fainting, stuck or broken needle. Patients with bleeding disorders, pacemakers, who are pregnant, attempting to become pregnant or nursing should inform the practitioner prior to the treatment. Qualifications: Lory Lee, L.Ac., EAMP is licensed by the State of Washington, since April 2004 to practice Acupuncture and East Asian medicine (license number AC2478). She attended Northwest Institute of Acupuncture and Oriental Medicine and where she received a Master in Acupuncture. She continued her training at Southwest Acupuncture College and received a Master of Science in Oriental Medicine. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me regarding cure or improvement of my condition. I do not expect Lory Lee or any other representative thereof to be able to anticipate and explain all possible risks and complications of the treatment. I have carefully read and understand all the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation of anything regarding my treatment. I hereby release Lory Lee from any and all liability, which may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. I understand that I am free to withdraw this consent and to discontinue participation in these procedures at any time. I agree to the release of medical and billing information necessary for treatment, payment and healthcare operations. I assign benefits payable to Lory Lee. I have received or decline a copy of the privacy notice. And to the best of my knowledge, the questions on the Acupuncture New Patient Information and Pain Assessment Form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the practitioner of any changes in my medical status. I also authorize the practitioner to perform the necessary services I need. Signature of patient or legal authorized individual Printed name and relationship, if other than patient 01-December-2014 Page 5

6 FINANCIAL AGREEMENT FULL PAYMENT (DEDUCTIBLES AND CO-PAYS) IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS AND MOST CREDIT CARDS. It is our goal for patients to clearly understand their financial responsibility before their treatment begins. We want to make your financial responsibilities as easy as possible. Therefore, we offer the following financial agreements. 1. Patients with insurance: Copay and/or coinsurance estimated portion not covered is due at time of service. If your health insurance does not cover your First Office Visit there will be additional minimum of $45 charge. 2. Patients without insurance: Payment is due at the time of service. 3. Patients with treatment related to an accident must inform Jade River Acupuncture dba Lory Lee, L.Ac, EAMP at the time of the first appointment. 4. Balances due that are not paid within 120 days will be sent to collections. 5. A $3.00 service charge per monthly will be attached to unpaid balances past 30 days. Health Insurance: As a courtesy we bill your insurance carrier. Your health insurance contract is between you and your insurance carrier and you are fully responsible for any amount that they do not pay. Our office does not guarantee that your insurance will pay for you Acupuncture treatment. If for any reason your claim is denied, you are responsible for the full amount of your bill. Our office will not enter into a dispute with your insurance company over any unpaid claim. If your insurance company has not paid your account in full within 45 days, the balance will be automatically transferred to you for payment. Failure to provide us with adequate information regarding your insurance may result in a denial from your insurance carrier and you will be responsible for any unpaid balance. Authorization Requirements: When insurance companies require pre-authorization, we will apply on your behalf. However, your insurance company may refuse to authorize the treatment plan. You will be financially responsible for the non-authorized visits. Third Party Payment: In certain cases, a third party may be responsible for payment of your account. We may hold any outstanding bills and file a medical lien to secure the payment of this debt. The lien will be filed with the County Auditor s office and will remain on file until the account is settled or the claim is closed, at which time payment is due. A charge for processing the lien and administrative fees will be applied to your account balance. Missed Appointments: If you fail to show up for your scheduled appointment or do not provide a 24 hours cancellation notice will be considered a no-show and will be charged $ You will be personally responsible for this charge. This charge will not be billed to nor paid for by your insurance company. We reserved the right to refuse to schedule future appointments until the fee is paid. Package Duration Policy Packages must be used within 12 month from date of purchase unless otherwise agreed to other terms before the package was purchased. Package refunds will be prorated at the single treatment fee ($75) for each treatment used. Gift Certificate Policy Gift Certificates must be used within 12 months from date of purchase unless otherwise agreed to other terms before the gift certificate was purchased Arbitration Agreement: Should any dispute as to malpractice arise, the case will be determined by submission to arbitration as provided by state and federal law. By signing this you are giving up your constitutional right to have such dispute decided in a court of law before a jury and are accepting the use of arbitration. I have read the Financial Policy. I understand and agree to this Financial Policy: I hereby assign payment of Insurance benefits to Jade River Acupuncture & Wellness Center, Inc. BY SIGNING BELOW, YOU ARE ACKNOWLEDGING YOUR UNDERSTANDING OF THE OFFICE POLICIES DESCRIBED ABOVE. Signature of patient or legal authorized individual Printed name and relationship, if other than patient 01-December-2014 Page 6