Acupuncture Intake Form- General

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Transcription:

Acupuncture Intake Form- General Today s date Name: Age DOB Address Best contact phone # Email address Reason for today s visit: How long have you had this condition? What seemed to be the initial cause? Is it getting worse? (Yes / No) What seems to make it better /worse? Any other health concerns? Have you had acupuncture before? (Yes/N0) When was your last treatment? What is your Blood Type? (A, B, AB, O, or?) Other therapies you are currently receiving? Current medications and supplements? General History: Allergies Anemia Arthritis Asthma Autoimmune Disease: Cancer: Diabetes Mellitus Elevated Cholesterol Heart Disease Hepatitis Herpes HIV/ AIDS High Blood Pressure Low Blood Pressure Osteoporosis Reproductive Issues STDs Skin Conditions Thyroid Disorders Tuberculosis Urinary Incontinence Other Family History: General Symptoms Poor appetite Heavy appetite Strongly like cold drinks Strongly like hot drinks Peculiar taste Cravings Sweats easily Night sweats Poor sleep Dream disturbed sleep Heavy sleep Bodily heaviness Chills Fever Bleed or bruise easily Cold hands or feet Poor circulation Vertigo or dizziness Fatigue Lack of strength Shortness of breath Muscle cramps Head, Eyes, Ears, Nose, Throat Headaches Migraines Facial pain Glasses Poor vision Blurred vision Eye strain Red eyes Itchy eyes Spots in eyes Respiratory Difficulty breathing when lying down Shortness of breath Tight chest Cough Wet or dry? Cardiovascular High Blood Pressure Tight chest Blood clots Glaucoma Night Blindness Sores on lips or tongue Swollen glands Dry mouth Excessive saliva Recurrent sore throat Lumps in throat TMJ Teeth problems Color of phlegm Coughing blood Asthma/ wheezing Fainting Difficulty breathing Heart palpitations Grinding teeth Sinus problems Enlarged thyroid Excessive phlegm Earaches Ringing in ears Poor hearing Gum problems Pneumonia Irregular heart beat

Gastrointestinal Bowel movements: Frequency: Texture/Form Color: Odor Diarrhea Constipation Laxative use Mucous in stools Musculoskeletal Joint pain Muscle pain Neck/ shoulder pain Upper back pain Skin and Hair Rashes Eczema Dandruff Hair loss Neuropsychological Seizures Poor Memory Irritability Numbness Genito-urinary Pain when urinating Blood in urine Venereal disease Increased libido Impotence Your Diet Appetite Low Strong Too Busy to Notice Coffee (#/day) Sugar Salty food Soft Drinks Itchy anus Anal fissures Black stools Bloody stools Gas Bloating Intestinal pain or cramping Burning anus Rectal pain Lower back pain Rib pain Limited range of motion Limited use Change in hair / skin texture Hives Psoriasis Itching Depression Anxiety Easily stressed Tics Frequent urination Bedwetting Unable to hold urine Decreased libido Premature ejaculation Artificial sweeteners Processed/Packaged foods? Thirst for water # of glasses per day Hemorrhoids Nausea Vomiting Acid regurgitation Bad breath Hiccup Fungal infections Ulcerations Acne Abuse survivor Considered/ attempted suicide Wake to urinate Incomplete urination Kidney stone Nocturnal emission meat (#/wk) dairy (#/wk) Yesterday s Breakfast Lunch Dinner Snacks Is this a typical day? Y or N Your Lifestyle Alcohol Marijuana Tobacco Stress Drugs Occupational Hazards Regular Exercise: Type Frequency: WOMEN ONLY Menstrual History: Date of last menstrual period: At what age did you begin your menstruation? < 11 11 12-14 15 >15 Is your menstrual cycle regular? (i.e.: 28 days long?) (Yes/ No) What is the duration of your flow? <3 days 3-6 days >6 days How is your overall flow? Light Moderate Heavy How is your clotting during menstruation? None Few Moderate Size of your clots? Small Medium Large How are your menstrual cramps? None Moderate Severe How long do your cramps last? Hours Days Do you have irregular bleeding outside of your menstruation? (Yes / No) What are the symptoms you experience pre-menstrually? (Please check all that apply.) Anxiety Mood Swings Nervousness Fluid Retention Headaches Food Cravings Tender Breasts Difficulty Sleeping Constipation

Office Policies and Procedures 12655 Washington Blvd., Suite 106 Los Angeles, CA 90066 310.943.9044 Patient s Name: Informed Consent Acupuncture is an ancient healing art, recognized and relied on its simplicity and effectiveness for thousands of years. The statements listed below will assist your understanding and participation in the treatment process. Acupuncture is a technique utilizing tiny stainless steel needles inserted at specific points in the body in order to correct various ailments and stimulate the flow of vital energy. The location and depth of their insertion is determined by the nature of the patient s condition. I understand that the application of these needles may be accompanied by some painful sensations, and the rare possibility of bruising. From the standpoint of Oriental Medicine, these indications are not incompatible with effective treatment. Acupuncture therapy also includes the use of indirectly applying heat supplied by the burning of the herb Folium Artimesiae Vulgaris, commonly known as Mugwort. This process is known as moxibustion. On rare occasions, patients have experienced faintness or nausea during an acupuncture treatment. This can be easily remedied and I will advise the Acupuncturist of these sensations. Acupuncture is not advised when the patient is too hungry, too full, or under the influence of drugs and/or alcohol. I understand that it is my responsibility to advise the Acupuncturist of these circumstances. Payment and Insurance Payment for treatment is expected after services are rendered. Payment and/or pre-payment of service is non-refundable regardless of treatment outcome. I will be provided with a super bill upon my request; it is my responsibility to submit this to my insurance, and complete any necessary follow-up with the insurance company for reimbursement. Cancellation Policy I understand that I am expected to keep all my appointments as scheduled in order to ensure maximum progress in my, or my child s, treatment. I understand that the practitioner s time is reserved exclusively for my, or my child s, care for the duration of all scheduled visits, and that if I am late for my visit, the visit will end at the scheduled time and I will still be charged for the full visit time. If for some reason I cannot make an appointment, I will call at least 2 business days in advance to cancel or reschedule that visit. I understand that if I cancel an appointment less than 2 business days prior to the scheduled time, I will be charged a fee that represents 50% of the cost of my scheduled appointment. I further understand that if I cancel less than 1 business day before my appointment, or fail to show for my appointment, I will be charged a fee that represents the full cost of my scheduled appointment.

Authorization for Payment I hereby authorize Emily Bartlett/Holistic Kid to charge my account balance to the credit card indicated below. I authorize this credit card to be used as a guarantee against late cancellations and missed appointments, and for any and all balances including those relating to office visits, telephone/e-mail consultations, missed/late appointments, miscellaneous fees, and charges for nutritional supplements. I agree that if my credit card does not accept the charge, I will immediately make payment to Emily Bartlett for the amount due. I understand that I may cancel this authorization in writing at any time. Visa/MC (circle type) #: Exp Date: Security Code: Authorized signature: Telephone/E-mail Policy I understand that extended telephone consultations over 10 minutes, will be billed at the same consultation rate as in-person visits and charged to my credit card on file. I further understand that e-mails which take over 10 minutes to read and reply will be billed at the in-person consultation rate and charged to my credit card on file. By sending an e-mail, I acknowledge and agree that a prompt reply is NOT required, expected, or contemplated. I acknowledge that I will not use e-mail communication to deal with emergencies or other time-sensitive issues. I understand that e-mail communications may not be secure and that there is some possibility that confidentiality of such communications may be breached by a third party. I understand that Emily Bartlett/Holistic Kid may keep copies of e-mail communications and that such messages may be included in your, or your child s, medical record. Initial Notice of Privacy Practices Questions and Complaints If you have any questions about the Notice of Privacy Practices, please contact: Holistic Kid: Privacy Officer, 12114 Venice Blvd. Los Angeles, CA 90066 If you think that we may have violated your privacy rights, contact the person named above. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way should you choose to file a complaint. Initial Please initial here and sign the last page to acknowledge that you have received, reviewed, and agree to the Notice of Privacy Practices. I have read and understand all of the contents in this document and agree to all of the terms listed above. Printed Name: Date: Signature Date:

Directions and Parking Our office is located at 12655 Washington Blvd 90066 Suite 106, near the intersection of Washington Blvd and Washington Place. PARKING: Please park in a space marked 106 or 104. If there are no spots open, there is ample street parking on Washington Place. If lost or late, please call us: 310-943-9044. From the beach taking 10E - Exit Centinela, Turn left onto Pico Blvd, Take 3rd right onto S. Bundy Drive which turns into Centinela Ave. (2.6 miles) to W. Washington Blvd. Turn right on W. Washington Blvd. The office a a dark brown building on your right. Taking 10W - Exit Bundy Drive South, continue on S. Centinela Ave (2.6 miles) to W. Washington Blvd. Turn right on W. Washington Blvd. The office is a dark brown building on your right. Taking 405S - Exit Venice Blvd. Turn left on Sawtelle - go 0.2 miles, Right onto Washington Place - go about one mile. The office is a dark brown building on your left.. Taking 405N - Exit CA-90W toward Marina del Rey. Go 1.1 miles and take the Centinela exit. Turn right on S. Centinela Ave. Go 1.1 miles and then turn left onto W. Washington Blvd. The office is a dark brown building on your left. PARKING: Please park in a space marked 106 or 104. If there are no spots open, there is ample street parking on Washington Place. If lost or late, please call us: 310-943-9044.

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