McKay Chinese Herbal Medicine & Acupuncture

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McKay Chinese Herbal Medicine & Acupuncture Notice Receipt Acknowledgement ************************************************************************ Purpose: This form is used to confirm that an individual has received a copy of the notice of primary practices. ************************************************************************ I,, acknowledge that I received a paper copy of McKay s Notice of Privacy Practices. Signature: Date: If this acknowledgement is signed by a personal representative on behalf of the individual, complete the following: Personal Representative s Name: Relationship to Individual:

INFORMED CONSENT TO ACUPUNCTURE TREATMENT AND CARE I hereby request and consent to the performance of acupuncture and other procedures within the scope of the practice of acupuncture on me (or the person listed below, for whom I am legally responsible) by one of the licensed acupuncturists at McKay Healing Arts. I have had the opportunity to discuss with one of the acupuncturists the nature and purpose of acupuncture. I understand and am informed that, as in the practice of medicine, in the practice of acupuncture, there are some potential risks to treatment, an example being nausea. I do not expect the acupuncturist to be able to anticipate and explain all risks and complications prior to administrating acupuncture. I wish to rely on him or her professional judgment during the course of the procedure, and based upon the facts then known, to proceed with treatment in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Print Patient s name Patient s signature Date If this consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative s name Relationship to patient

Welcome to Chinese Herbal Medicine & Acupuncture Name Today s Date Address City State Zip Phone: (Hm) (Other) E-mail Birthdate Male Female Social Security # Weight Height Pulse Rate Normal Blood Pressure Are you pregnant or think you might be? Current Medications, Herbs, Drugs Major Operations, Surgeries, Illnesses (with dates) Chief complaint; Describe your problem Date it began Was cause an accident? Rate pain 1-10 10 Does anything make it worse? Make it better? Do you have a medical diagnosis for your problem? Were X-rays, MRI, or lab tests taken? Do you have any other major health problems such as pacemaker, heart condition, or diabetes? Primary Physician How did you hear about us? (Please circle) Search Engine: Google Publication: Encore Yahoo Natural Awakenings Other Phone Book Emergency Contact name Emergency Contact phone Radio Drive By Referral: (name?) Physician(name?) Other

NAME: DATE: ENERGY: Low Medium High Best time of day? Low time of day? FATIGUE: Lethargic Feels Heavy What makes it better or worse? STRESS: None Moderate Severe Cause: THIRST: Low Medium High Daily water intake? Do you drink ice water? Nauseous after water intake? HOT/ COLD: SWEAT: Night Day Excessive Hot flashes? How often? With Sweat? HEADACHES: Mild Severe Chronic Occasional Date began: What makes them better? Worse? Are they Sharp Dull Diffuse Bandlike Fixed Borring Location: ST LI/ Frontal SJ GB/ Temporal one sided UB SI/ Occipital LIV UB SI/ Parietal DO YOU EXPERIENCE MEMORY LOSS? Long term Short term DO YOU SUFFER FROM BALANCE LOSS/ PROBLEMS? EARS: Hearing Loss Ringing Infections Pain Discharge Other Issues: EYES: Loss of sight Blurring Infections Dryness Floaters Photophobia Night Blindness Other Issues: NOSE/ SINUSES: Allergies Sinusitis Phlegm/ Congestion Postnasal drip Sputum Nosebleeds Other Issues: HAIR: Loss Brittle Oily Other Issues: TEETH: TMJ Gingivitis Loss Other Issues: MOUTH/ TONGUE/ GUMS: Sores Swelling Location Other Issues: THROAT/ LYMPH GLANDS: Sore Swollen Hoarseness Difficulty Swallowing Chronic Infections Object Sensations in Throat Other Issues: LUNGS: Cough Wheezing Phlegm Voice Loss Mucus Rattles Coughing Blood Sputum Color? Consistency? Do you experience difficulty breathing?

CHEST: Pain Tightness Pressure Side Pain Other Issues: HEART: Do you experience heart palpations? BREAST: Pain Lumps Cysts Tumors Other: ABDOMEN/ STOMACH: Tightness Pressure Bloating Ulcers Nausea Gas Heart burn Burning Belching Bitter Taste Bad Breath Lumps ABDOMEN PAIN: Dull Sharp Fixed Diffused Likes pressure Hot/Cold Dislikes Pressure Hot/Cold APPETITE: Normal High Low Favorite Tastes: Unusual Tastes in Mouth? Food Cravings? Tired or weak if missed meal? Do you skip breakfast? Any Snacks? How many meals a day do you eat? Biggest meal? STOOL: Normal Diarrhea Constipation Hemorrhoids Blood in stool Pain Formed Unformed Undigested food Mucus in stool Alternating Burning Odor Other: URINATION: Difficulty Urinating Burning Pain Infections Blood in urine Odor Dribbling Color?: Amount? Water Retention? Location: Urinary Tract Infection? EDEMA: Face Arms Legs Upper Mid Lower jiao pitting hot SKIN: Dry Itchy Moist/Clammy Oily Melanoma Acne Moles Boils Lumps Other: BONE/JOINT: Do you experience pain in any of the following? Neck Shoulder Lower Back Mid Thoracic Elbow Wrist Knee Leg Weakness Ankles Feet Arthritis Other SLEEP: Trouble falling asleep? Trouble staying asleep? Excessive Dreams Restful On average, how many hours do you sleep a night? Waking time? (Continue on next page ) NEUROLOGICAL: Seizures Irritabilty Frequent Crying Shingles Alzheimer s Worry/ Anxiety Mood Swings Confusion Depression Poor Concentration Tremors Easily Angered Poor Coordination Numbness/ Tingling in Limbs Neuralgia Suicidal Muscle Weakness

MEDICAL HISTORY: - Please indicate if you have a history of the following: Arthritis Heart Trouble Asthma Hepatitis Anemia Jaundice Cancer: Kidney/ Urinary/ Bladder issues Chronic Fatigue Lupus Chronic Fevers Osteoporosis Chronic Swollen Lymph Stroke Diabetes Sudden Weight Loss or Gain Epilepsy Ulcers Gallstones FAMILY HISTORY: Any member affected by problems listed above? Yes No Family Member(s): Illness(es): FEMALES MENSTRUATION & GYNECOLOGY: Last period: Length of Monthly Cycle: Do you have problems w/ regularity? How many days does period last? Color Heavy/ Light flow Clots? Clot Size Cramping: Before During After PMS: Water Retention Irritability Breast Soreness Tearfulness Food Cravings Missed Periods Age Period Started: Age Period Ended: PREGNANCY: # of Miscarriages: # of Deliveries: # of Cesareans: # of Abortions: OPERATIONS: Cervix Uterus Ovaries Other : SEX DRIVE: None Low Med High Painful DISCHARGES: Yellow White Thick Thin Itching Burning Chronic Time in Cycle: Vaginal Dryness: PID: Cysts Tumors Endometriosis Herpes Other Infections: LAST PAP: BIRTH CONTROL: MALES OPERATIONS: Vasectomy Prostate Other:

SEX DRIVE: None Low Med High Painful CONCERNS: Lumps Tumors Impotence Infertility Prostate Trouble Premature Ejaculation Discharges Burning Urination Herpes Testes Ejaculation UTI

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