WELCOME TO STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE!
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- Bernice Meredith Jefferson
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1 WELCOME TO STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE! This packet contains the Welcome Letter with information on what to expect at your first appointment, the Fee Schedule, and the Patient Health History Form. Please take some time to read through this introduction, complete the intake forms before your first appointment. We are delighted to be your partner in your healing journey. Tips and information on the day of your first appointment: Please do not wear any perfume, cologne or scented lotions. Wear loose, comfortable clothing with sleeves that can be rolled up to the elbows and pants that can be rolled up to the knees. (this is specially applicable for our community style setting) Patients can also bring their own loose clothing to change at site. Please eat a little something beforehand. Acupuncture is not recommended on an empty stomach. Don't plan to engage in any strenuous activity after receiving acupuncture. Gentle exercise, such as tai chi, gentle yoga or walking, is best. Please be aware that we require 48 hours notice for appointment cancellation. If less than 48 hours notice is given or an appointment is missed without advance notice, full treatment fee will be assessed except a medical emergency, severe weather, or direct family emergency issues. Please bring a check or cash with you; we are unable to accept debit or credit cards currently. What is unique about STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE? We offer acupuncture services both in community style as well as individual whole body full service style. Affordable service fee. We are on mission to make acupuncture affordable and effective. By offering the affordable service fee, we hope the patient can afford more frequent treatments and experience better therapeutic result. Community style service fee: $40 for regular patient, $35 for senior citizen (70 years old or above), new patient needs additional $10 for initial documentation fee. (new rate will be effective starting Dec. 1, 2016) Individual whole body full service fee: $80, new patient is $120. (new rate will be effective starting Dec. 1, 2016) Our acupuncture style is based upon Classical Chinese Medicine practice and trainings. For more information about Classical Chinese Medicine, please visit Jung Tao School of Classical Chinese Medicine at as well as Dr. Hai-Sha Ni at nihaisha.com. We believe the healing is coming from above and from within. You come to us through divine connection and we are on mission to fulfill the calling to be God s healing hands to empower you to restore your health and to renew your spirit so that you can fulfill God s purposes on your life. The healing has begun, Be well! STREAMS OF GRACE Staff 恩典之泉經典中醫
2 Patient Health History Patient Information Contact Information Name Date Address City State Zip Age Birth Date Occupation Company Name Primary Physician How did you hear about us? Health History What are your primary concerns for coming in for treatment? 1) 2) 3) How is your sleep? How is your digestion? How is your energy level overall? How is your stress level? Check illnesses that have occurred in blood relatives: Diabetes High blood pressure Stroke Cancer Heart Disease Kidney Disease When was your last complete medical exam? List any supplements or medications you are taking : Home phone Work phone Cell phone Would you like to be added to our newsletter list? Emergency Contact: Name Relationship Phone Check symptoms you have or have had in the last year: Depression Difficulty focusing Dizziness Easily startled Excessive worry Excessive anger Excessive fear Fatigue Headaches Loss of sleep/poor sleep Weight gain or loss Irritability Anxiety Feeling overwhelmed Check conditions you have or have had in the past: AIDS/HIV/Hepatitis (A,B, C,D,E) Allergies Anemia Arthritis Bleeding disorders Cancer: Diabetes List serious illnesses, accidents or surgeries:
3 Health History continued Check symptoms you have or have had in the last year: CARDIOVASCULAR Chest pain Hardening of arteries High or low blood pressure Poor circulation Heart attack Rapid/irregular heart beat Swelling EYES/EARS/NOSE/THROAT/RESPIRATORY Asthma Blurred or failing vision Difficulty breathing Earache Enlarged glands Eye pain Frequent colds Hay fever Hoarseness Gum trouble Nosebleeds Loss of hearing Persistent cough Ringing in ears Sinus problems SKIN Boils Bruise easily Dry skin Itching/rash Sensitive skin Sore won t heal Sweating GENITOURINARY Frequent urination Blood in urine Urinary incontinence Kidney infections/stones Low libido Signature The information on this form is correct to the best of my knowledge. Signature GASTROINTESTINAL Belching, gas or bloating Constipation Diarrhea Difficulty swallowing Distension of abdomen Excessive hunger Gallbladder problems Hemorrhoids Indigestion Nausea Stomach pain Poor appetite Vomiting FOR MEN: Erectile dysfunction Prostrate problems FOR WOMEN: Bleeding between periods Painful periods Clots in menses Excessive menstrual flow Irregular cycle Menopausal symptoms PMS Previous miscarriage Scanty menstrual flow Infertility Could you be pregnant? MUSCLE/JOINTS/BONE Tremors Cramps Swollen joints Pain, weakness, or numbness in: Arms Hips Back Legs Shoulders Neck Hands Feet Other Date
4 Fee Schedule STREAMS OF GRACE Classical Chinese Acupuncture is on mission to make Classical Chinese acupuncture affordable and effective to as many people as we can. So our clinic offers two treatment models (community style and individual whole body full service style) to our patient community. For patients with constraint of financial resource, we offer affordable rate with community style acupuncture, patients usually have their own private room lying comfortably on massage table for treatment on body areas below knees and elbows, on the head and ears. For patients seeking personal one to one care and whole body full service treatment, we offer individual whole body full service treatment model. For community style treatment, acupuncture is the only treatment method will be used. For individual whole body full service style, treatment tools include acupuncture, fire cupping, dry cupping, wet cupping, blood letting, Gua Sha (spoon scraping), Pai Sha (patting), Tui Nai (Chinese style acupressure massage) and moxibustion. The best way to understand the treatment result with each different treatment model is to give each model a try so you can experience each treatment model fully. Community Style Acupuncture Fee Schedule/Office Hours: Date of the Week: Tuesday 12:00 PM 6:00 PM Regular Rate: $40. Senior Citizen Discount Rate: $35. New Patient needs additional $10 initial documentation fee. Senior Citizen definition: 70 years old or above Individual Whole Body Full Service Style Acupuncture Fee Schedule/Office Hours: Date of the Week: Monday, Wednesday, Thursday, Friday 9:00 AM- 5:00 PM New patient treatment: $120. (90 minutes session) Follow-up treatment: $80. (60 minutes session) Cancellation and Reschedule an Appointment policy: We will be appreciated for 48 hours advance notice if you need to cancel or reschedule an appointment. All appointments that are rescheduled or cancelled less than 48 hours advance notice or missed without notice will be charged a full session fee based upon the treatment style to their credit card on file automatically. Personal medical emergency, severe weather or direct family emergency will be exempted from the charge. By signing this form below, I am agreeable to the outlined service fee and accepted the cancellation policy. Thank you very much for your understanding, STREAMS OF GRACE STAFF Print Name Signature Date
5 Informed Consent for Treatment I have made a personal choice to receive treatment from the Licensed Acupuncturists of STREAMS OF GRACE Classical Chinese Acupuncture. I understand that no promises or guarantees can be made regarding the outcome of treatment because of the uniqueness of each individual. Each practitioner at STREAMS OF GRACE has completed a Master degree or graduate level Diploma in Acupuncture and Traditional Chinese Medicine, is certified in Acupuncture and/or Oriental Medicine by the National Commission for the Certification of Acupuncturists and Oriental Medicine (NCCOM) and is licensed by the Tennessee Board of Medical Examiners as an Acupuncturist. The scope of practice under acupuncture licensure in Tennessee includes using Oriental medical theory for diagnosis and for development of a treatment plan. Techniques may include insertion of sterile needles, electro-stimulation, heat therapy through moxibustion, cupping, blood letting, dermal friction (Gua Sha and Pai Sha), acupressure (Tui Na), herbal therapies, dietary counseling, breathing techniques and exercise; all of these according to the Oriental medical principles. By signing below, I indicate that I understand that side effects of acupuncture, while not common, may include some pain in the treatment area, minor bruising, temporary faintness, possible worsening of some symptoms for hours before improvement begins, and with any procedure in which the skin is broken, a very slight risk of infection. I have been informed that only sterile disposable, single-use needles are used in treatment. I understand that it is appropriate for me to consult my primary care physician about the acupuncture treatment if I choose to do so, if circumstances warrant, or if my acupuncturist recommends such consultation. I understand that I should inform my acupuncturist whether or not a licensed physician has examined me with regard to my presenting complaint, and if so, what the Western medical diagnosis is. I should also report whether I have any other serious illness, a bleeding disorder or a pacemaker. Print Name Signature Date
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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Patient Health History Questionnaire
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Reason forappointment:
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