New Patinet Form for Acupuncture Treatment GENERAL INFORMATION Name: Date of Birth: First Name M.I Last Name MM/DD/YYYY Age: Sex: F M Phone Number: Email: Cell Number: Emergency Contact: Relationship to patient: Phone: Email: OPTIONAL INFORMATION Marital Status: Occupation: Employer: MAIN COMPLAINT Reason(s) for seeking medical treatment? (Chief Complaint) 1. 2. 3. When did these issue begin? 1. 2. 3. Have you been given a diagnosis? if so, what? Does anything make it better or worse? (like heat, cold, rest, activity etc.)
MEDICAL HISTORY Medications: (list all prescription, OTC, vitamins, supplements, and what they are taken for) 1. 2. 3. 4. 5. Allergies: (list all known allergies) Check all that apply - Medical Checklist Yes No Family Diabetes Chest Pain/Angina High Blood Pressure Heart Attack High Cholesterol Pacemaker Headaches Kidney Stones Kidney Disease Cancer Osteoporosis Asthma Stroke Seizure HIV/AIDS Hepatitis Stomach Ulcer Liver Disease Heart Palpitations Arthritis Heart Surgery Blood Clots Tuberculosis Depression Congestive Heart Failure Thyroid Disease List any Additional Conditions
PAIN Please mark all locations where you are feeling pain or discomfort below Please rate your pain from a scale of 1-10 No pain 1 2 3 4 5 6 7 8 9 10 Intolerable pain Does anything make the pain better? Does anything make the pain worse? What is the quality of the pain? (dull, sharp, aching, electric, moving, etc.)
Prostate problems Seminal emissions Decreased urine flow MEN S HEALTH Erecle dysfuncon Genital pain Painful urinaon History of tescular cancer Reduced sex drive Burning urinaon Other: WOMAN S HEALTH Age of 1st menses: Age at menopause: Period between menses: Days. Duraon of menses: Days Number of pregnancies: Births: Miscarriages: Aborons: Last period: Pregnant: Yes / No Form of birth control: Menstrual pain Mood changes Clots Low backache Hot flashes Heavy bleeding Irregular menses Painful breasts Scanty bleeding Vaginal dryness Vaginal discharge Ferlity problems Other:
HIPPA NOTICE OF PRIVACY PRACTICES Your protected health informaon may be used and disclosed by Lee's Acupuncture for the purpose of providing health care services to you, to support the health care operaon, and as required by law. Treatment: to provide, coordinate, or manage your health care and related services. This includes the coordinaon of your health care with a third party. For example, to another health care professional to whom you have been referred to ensure that the provider has the necessary informaon to diagnose or treat you. Healthcare operaons: In order to support the business acvies of Lee's Acupuncture. These acvies include, but are not limited to, quality assessment and review of acvies, licensing, and conducng or arranging for other business acvies. For example, to contact you to remind you of your appointment or review your case to determine a connued course of treatment. You have the right to inspect and copy your protected health informaon. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; informaon compiled in reasonable ancipaon of, or use in, a civil, criminal, or administrave acon or proceeding; and protected health informaon that is subject to law that prohibits access to protected health informaon. You have the right to request a restricon of your protected health informaon. You may ask Lee s Acupuncture not to use or disclose any part of your protected health informaon for the purposes of treatment, payment, or healthcare operaons. You may also request that any part of your protected health informaon not be disclosed to family or friends who may be involved in your care. Your request must state the specific restricon and to whom the restricon will apply. You have the right to request confidenal communicaons by alternave means or at an alternave locaon You may have the right to amend your protected health informaon. If denied, you have the right to file a statement of disagreement with Lee s Acupuncture You have the right to receive an accounng of certain disclosures made, if any, of your protected health informaon. You have the right to obtain a paper copy of this noce, upon request, even if you have agreed to accept this noces electronically. Complaints: You may complain to Lee's Acupuncture or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. Lee s Acupuncture is required by law to maintain the privacy of, and provide individuals with, this noce of our legal dues and privacy pracces with respect to protected health informaon. I acknowledge that I have received the HIPPA Noce of Privacy Pracces. Paent Signature Date
ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the pracce of acupuncture on me (or on the paent named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibuson, electro-smulaon, cupping, electrical smulaon, tui-na (medical massage), Herbal medicine, and nutrional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instrucons provided orally and/or in wring. The herbs may have an unpleasant smell or taste. I will immediately nofy a member of the clinical staff of any unancipated or unpleasant effects associated with the consumpon of herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or ngling near the needling sites that may last a few days, and dizziness or fainng. Burns and/or scarring are a potenal risk of moxibuson and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infecon is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutrional supplements (which are from plant, animal and mineral sources) that have been recommended are tradionally considered safe in the pracces of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, voming, headache, diarrhea, rashes, hives, and ngling of the tongue. I will nofy a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to ancipate and explain all possible risks and complicaons of treatment, I wish to rely on the clinical staff to exercise judgment during the course of the treatment which the clinical staff thinks at the me, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrave staff may review my paent records and lab reports, but all my records will be kept confidenal and will not be released without my wrieen consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask quesons. I intend to this consent form to cover the enre course of treatment for my present condion and for any future condion(s) for which i seek treatment. ACUPUNCTURIST NAME: PATIENT SIGNATURE x (or Paent Representave) Andrew J. Lee, MSTCM, DACM, LA.c. Date: (Indicate relaonship if signing for paent) Representave relaonship to paent:
PAYMENT POLICY All payments are due at or before the me of service. Appointments that are canceled or missed with less than 24 hours advance noce may be charged a $35 fee. Paents which arrive late for their appointment may have a shorter treatment, as to respect the appointment mes of other paents. Paents who arrive too late to have a treatment of any value (as decided by the judgment of the treang acupuncturist), may either be (1) charged the $35 missed appointment fee, or (2) pending availability, be pushed into a different me slot on the same day. Thank you for understanding. I have read, fully understand, and agree to all the above-menoned financial policies and terms of service. Paent signature Date This secon intenonally len blank Lee s Acupuncture (510) 730-0340 Email: Dr.Lee@Lee-Acupuncture.com www.lee-acupuncture.com