Initial Intake Form: Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212 ( 3 0 3 ) 3 5 1-1 2 2 8 Name: Phone: Address: City: State: Zip: E-mail: Would you like to be added to our E-Mail newsletter to find out about news, events and specials: Yes No Sex: Age: DOB: Height: Weight: Marital Status: Number of Children Personal Physician: Emergency Contact: Phone: Phone: Occupation: Referred By: Insurance Information: Company name Address Phone Patient ID# Group# Acupuncture coverage? Please describe the problem(s) you would like addressed: 1. When did this begin? What helps it? What makes it worse? What other types of treatments have you tried? Secondary complaints Have you been given a diagnosis for the problem by a Physician? Please explain:
Patient Name Date Habits / Lifestyle: Do you smoke? Yes No (cigarettes/day ) Do you consume alcohol? Yes No (drinks/day ) Do you drink coffee? Yes No (cups/day ) Do you drink soda? Yes No (cups/day ) Do you exercise? Yes No (days/week ) Current Activities Rate your sleep, hours per night: 4-6 6-8 8-10 12+ Do you wake rested: Yes No Sometimes On a scale from 1-10, how is your energy level in general? When is it at it s peak? When is it at it s lowest? Would you consider you stress to be? Mild Moderate Severe Stress Source How would you describe your emotional state? How would you rate your digestion? Poor Fair Medium Good Excellent How would you rate your appetite? Poor Fair Medium Good Excellent Describe your diet on a typical day: Breakfast Lunch Dinner Snacks Pain / Discomfort Diagram Pain Intensity Pharmaceuticals: Please list prescription drugs you have taken the past two months:
Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212 (303) 351-1228 Permission to Call or E-mail Occasionally situations arise in which I may need to call you. For instance if a cancellation must occur of if an opening should come up and you asked to be notified. To protect your privacy, the patient, if any of these situations were to occur that I have authorization to contact you by phone and where the best number to reach you may be. Please check the appropriate line: Contact me at any of my numbers or e-mail address listed on my intake form Contact me only at my work number - - Contact me only at my home number - - Contact me only at my cell - - Only contact me at this email Do not contact me at any of my phone numbers or email Signature Date
COLORADO MANDATORY DISCLOSRE AND INFORMED CONSENT Tiffany Schiedt 4022 Tennyson Ave. Phone: (303) 351-1228 Andrew Young Denver, CO 80212 www.berkeleycommunityacu.com This disclosure statement is in compliance with the State of Colorado, Department of Regulatory Agencies, Colorado Statute Title 12 Article 29.5. All rules and regulations set forth by the Department of Health are strictly adhered to, including proper cleaning, sterilization, and sanitation of equipment and office. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have any comments, questions, or complaints, contact the Acupuncturists Registrations Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303 894-2440. The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. 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 Registration in the Department of Regulatory Agencies. Clinic Fee Schedule (due at time of service) All our Fees are on a Sliding Scale. No Proof of Income Required Initial Private Treatment Sliding Scale of $65-$85 Follow-up Treatments Sliding scale of $50-$85 Herbal Consultation only: Sliding Scale of $25-$45 (plus herbs) Auriculotherapy only: Sliding scale of $25-$45 Packages: 8 Private treatments $360 24 hour notice is required for all cancellations. Without 24 hour cancellation notice the full minimum treatment fee will be charged. Practitioner Certification, Education and Experience: Tiffany Schiedt, MS, L.Ac., Dipl OM- Master of Science in Traditional Chinese Medicine from Colorado School of Traditional Chinese Medicine in 2012. NCCAOM Diplomat in Acupuncture and Oriental Medicine issued in 2012. Colorado licensed acupuncturist. Andrew Young, MS, L.Ac., Dipl OM- Master of Science in Traditional Chinese Medicine from Colorado School of Traditional Chinese Medicine in 2006. NCCAOM Diplomat in Acupuncture and Oriental Medicine issued in 2006. Colorado licensed acupuncturist. Informed Consent I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or on the patient names below, for whom I am legally responsible) by the acupuncturist named 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 Denver Community Wellness. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-na, Chinese herbal medicine, and nutritional counseling. I understand that herbs need to be prepared and consumed according to the instructions provided. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects possibly associated with the consumption of the 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 tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture. Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxabustion and cupping. I understand that while this document describes the major risks of treatment, other side effects may occur. The herbs and nutritional supplements that have been recommended are traditionally considered safe in the practice of
Chinese 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, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. If I suspect that I am pregnant, I will immediately inform the acupuncturist. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture practitioner or other healthcare provider who may be more qualified to treat me outside of these facilities. I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand the results are not guaranteed. I understand that I have the choice to accept or reject treatment at any time. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written 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 questions. 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 see treatment. Signature of Patient or Person authorized to consent Relationship or Authority of Representative Date Signature Acknowledging the Receipt of Privacy Policy Relationship or Authority of Representative Date