NEW PATIENT INTAKE FORM Today's Date /

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1 NEW PATIENT INTAKE FORM Today's Date / Name Address SS# Marital Status M Q F Birthdate Age Ht Wt City, State, Zip Home Phone Emergency Contact's Name 4& Phone Referred by Reason for visit today Work Occupation Have you had acupuncture before? Yes QNO How long have you had this condition? Is it getting worse? Does it bother your Sleep Work Other (specify) What seemed to be the initial cause? What seems to make it better? What seems to make it worse? Are you under the care of a physician now? Yes No If yes, for what? Physician's name Physician's phone Other concurrent therapies Health Insurance Info: Insurance Co. Name Policy # Address Phone City, State, Zip Medicare Info: Insurance Co. Name Policy # Address Phone City, State, Zip Family Medical History Allergies (list) Your Past Medical History Cell Chinese herbal medicine? Yes NO Arteriosclerosis Cancer (type) Diabetes (Type: ) Seizures Asthma Heart disease Stroke Alcoholism Depression High blood pressure (Check any of the following conditions you currently have, or have had in the past. Please also check if you feel any of the following are a significant part of your medical history.) AIDs/nrV Diabetes (Type: ) MulHple Sclerosis Surgery (list) Tuberculosis Alcoholism Emphysema Mumps Typhoid fever Allergies Appendicitis Epilepsy Goiter Pacemaker (Date: Pleurisy Ulcers Venereal disease Q Arteriosclerosis Gout Pneumonia Thyroid disorders Whooping cough Asthma Heart disease Polio Major trauma Other {Specif}) Birth trauma (your own birth) Cancer Hepatirts (Type: Herpes (Tj-pe: High blood pressure Rheumatic fever Q Scarlet fever Seizures (Car, fall, etc-list) Chicken pox Measles Stroke Your Diet Appetite Low High Coffee/Tea Protein Intake Low Artificial Soft Drinks/Fruit Juices High Sweeteners Sugar Salty foods Thirst for water: # glasses per day: Average Daily Menu Morning Snack Noon Snack Evening Snack Pharmaceuticals taken in the last 2 months: Vitamins/sugglemait^lw^^ eja^ Practitioner Use Only

2 Your Lifestyle Alcohol Tobacco Marijuana Drugs Stress Occupational hazards Regular Exercise Tj'pe Type Frequency_ Frequency_ General Symptoms Poor appetite Hea^y appetite Strongly like cold drinks Strongly like hot drinks Recent weight loss/gaio Poor sleep Hea\-y sleep Dream-disturbed sleep Fatigue Lack of strength Bodily heaviness Cold hands or feet Poor circulation Shortness of breath Fever Chills Night sweats Sweat easily Muscle cramps Vertigo or dizziness Bleed or bruise easily Peculiar taste (Describe) Head, Eyes, Ears, Nose, Throat Glasses (What age: Eye strain Eye pain Red eyes Itchy eyes Spots in eyes Poor vision Blurred Wsion ) Night blindness Myopia or Presbyopia Glaucoma Cataracts Teeth problems Grinding teeth TMJ Facial pain Gum problems Sores on lips or tongue Dry mouth Excessive saliva Sinus problems Excessive phlegm Color: Recurrent sore throat Swollen glands Lumps in throat Enlarged thyroid Q Nosebleeds Ringing in ears (High or Low?) Poor hearing Earaches Headaches Migraines Concussions Other bead or neck problems Respiratory Difficulty breathing when l>'ing down Shortness of breath Tight chest Asthma/wheezing Difficult inhalation? exhalation? Cough Wet or Drj? Thick or thin? Color of phlegm Coughing up blood Pneumonia Cardiovascular High blood pressure Blood clots Low blood pressure Fainting Chest pain Difficulty breathing Tachycardia Heart palpitations Phlebitis Irregular heartbeat Gastrointestinal Nausea Vomiting Acid regurgitation Gas Hiccup Bloating Bad breath Diarrhea Constipation Black stools Bloody stools Mucous in stools Hemorrhoid Itchy anus Intestinal pain or cramping Burning anus Rectal pain Anal fissures Laxative use What kind? How often? Bowel movements: Frequency Color Texture/fonn_ Odor Musculoskeletal Neck/shoulder pain Muscle pain Upper back pain Low hack pain Joint pain Rib pain Limited range of motion Limited use Other (Describe) Skin and Hair Rashes Hi^es Ulcerations Eczema Psoriasis Acne Dandruff Itching Hair loss Change in hair/skin texture Fungal infections Other hair or skin problems Neuropsychological Seizures Numbness Tics Poor memory Depression Anxiety Irritability Easily stressed Abuse survivor Considered/attempted suicide Seeing a 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 Length of cycle (day 1 to day 1) Duration of flow Irregular periods Painful periods PMS Vaginal discharge (color)_ V^aginal sores Vaginal odor Clots Breast lumps # Pregnancies # Live births # Premature births_ Age at menopause_ Date of last PAP Date last period began Other Copyright Blue Poppy Enterprises Inc., 2007

3 Acupuncture Specialists of Golden Rhonda Marr L.Ac * Street, Suite 102 Golden, CO 804OI Phone: Education and Experience COLORADO MANDATORY DISCLOSURE STATEMENT Rhonda Marr earned her Master of Acupuncture degree from Finger Lakes School of Acupuncture and Oriental Medicine at New York Chiropractic College in August This three-year program consists of over 2,265 hours of education including 660 hours of clinical practice. She was certified as a Diplomate in Acupuncture and Traditional Chinese Medicine by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in October This includes certification in Clean Needle Technique. Rhonda's training includes adjunctive therapies such as Aroma Acupoint Therapy, Nutrition Response Testing, Moxibustion, Tui Na, Cupping, Auriculotherapy, dietary and lifestyle recommendations, and handcrafted topical herbal medicines. Rhonda is a member of the Acupuncture Association of Colorado (AAC). Rhonda is a licensed acupuncturist in Colorado and New York. None of these licenses, certificates, or registrations has ever been suspended or revoked. This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized in our clinic. Fee Schedule New Patient Intake Consultation and Treatment $125 + cost of herbs (House Calls $150) Follow-up Treatment $75 + cost of herbs (House Calls $100) Nutritional Consultation $40.00 Patient's Rights The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if know. 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 Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Licensure Office, Director of Registrations, 1560 Broadway, Suite 1350, Denver, Colorado Telephone (303) have read and understand this document. Patient's or Guardian's Signature Date

4 Acupuncture Specialists of Golden Rhonda Marr L.Ac, M.S.Ac., Dipl. Ac. (NCCAOM) By signing below, 1 do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica. 1 understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is strongly recommended by this clinic's practitioners. Acupuncture / Moxibustion: 1 understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. 1 am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, burning, scarring, pneumothorax, spontaneous miscarriage, and the possible aggravation of symptoms existing prior to acupuncture treatment. 1 understand that no guarantees concerning its use and effects are given to me and that 1 am free to stop acupuncture treatment at any time. Chinese Herbs: 1 understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. 1 understand that 1 am not required to take these substances but must follow the directions for administration and dosage if 1 do decide to take them. 1 am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. 1 am aware that topical herbs are subject to the above, as well as local skin irritation or discoloration. Should I experience any problems, which I associate with these substances, I should suspend taking them and call the Chinese Medical Clinic as soon as possible. Cupping/Gua Sha/ Massage: 1 understand that 1 may also be given cupping, gua sha, massage as part of my treatment to modify or prevent pain perception and to normalize the body's physiological functions. 1 am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bnjising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. 1 understand that 1 may stop the treatment if it is too uncomfortable. Electro-Acupuncture: 1 understand that 1 may be asked to have electro-acupuncture administered with the acupuncture. 1 am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. 1 understand that 1 may refuse this treatment. 1 understand that there may be other treatment alternatives, including treatment offered by a licensed physician. 1 have carefully read and understand all of the above information and am fully aware of what 1 am signing. 1 understand that 1 may ask my practitioner for a more detailed explanation. 1 give my permission and consent to treatment. Signature: Date:

5 Acupuncture Specialists of Golden Rhonda Marr L.Ac, M.S.Ac., Dipl. Ac. (NCCAOM) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION (HIPAA) FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME DATE OF BIRTH SOCIAL SECURITY # I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care. A source of information for applying my diagnosis and information to my bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals. 1 understand that 1 have the right: To object to the use of my health information for directory purposes. To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon. 1 request the following restrictions to the use of disclosure of my health information: Patient: X Patient Signature or Legal Representative Date Witness Signature

6 Acupuncture Specialists of Golden wwwacuspeciali8t8ofgo1den.com Our Clinic Protects Your Health Information and Privacy (HIPAA) Dear Valued Patient, 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 oflice, we may need to share limited personal medical and financial information with other medical practitioners that you authorize as well as Worker's Compensation (and your employer as well in this instance), or in Personal Injury cases. Safeguards in place at our oflrce 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 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, personal injury cases, workman's comp and your employer, and other third party administrators {e.g. requests for medical records, claim payment information). In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you - e.g. your name, address. Social Security number, etc.). We value and respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours. Please sign and date below, indicating that you have read and understand this document. Patient or Guardian's Signature Date "^ Street, Suite 102, Golden, CO Phone:

7 Acupuncture Specialists of Golden Rhonda Marr L.Ac, MS.Ac, Dipl. Ac. (NCCAOM) Financial and Cancellation Policy We accept cash, check. Visa, MasterCard, American Express, and Discover cards. We can also accept payment via HSA and flex-spending accounts. Gift Card Program: We offer a special incentive payment program for our patients, as well as gift cards. We work with Personal Injury and Worker's Compensation cases within the State of Colorado. Payment is due when services are rendered. While we do not provide insurance billing, we can provide a superbill on our patients' request for convenient insurance processing. Appointments must be canceled 24 hours in advance to allow us to schedule other patients. Appointments canceled less than 24 hours in advance will be billed full charge. Exceptions will be made at our discretion in the event of inclement weather or real emergencies. Please be considerate of our staff and other patients and call our office as soon as possible if you cannot keep your appointment. Patient Signature Date "^ Street, Suite 102, Golden, CO Phone: