PATIENT INFORMATION PATIENT INFORMATION Date Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner s Name Birthdate SS# Occupation Spouse/Partner s Employer Whom may we thank for referring you? PHONE NUMBERS H W Cell Best time & place to reach you INSURANCE Who is responsible for this account? Relationship to Patient Insurance Co. Group # Is patient covered by additional insurance? Yes No Subscriber s Name Birthdate SS# Relationship to Patient Insurance Co. Group # ASSIGNMENT AND RELEASE I, the undersigned, certify that I(or my dependent) have insurance coverage with and assign directly to all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature Relationship Date ACCIDENT INFORMATION Is condition due to an accident? Yes No Date Type of accident Auto Work Home Other IN CASE OF EMERGENCY, CONTACT Name Relationship Home phone Work phone To whom have you made a report of your accident? Auto Insurance Employer Worker Comp. Other Attorney Name (if applicable) GENERAL INFORMATION Have you had acupuncture before? Yes No Have you used Chinese herbal medicine? Yes No Are you currently under the care of a physician? Yes No If Yes, for what? Physician s name: Physician s phone:
ORIENTAL MEDICINE INTAKE FORM Name: Date: PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: Does it interfere with your: Work Sleep Daily Routine Recreation Other therapies tried: Medications Surgery Chiropractic Phys. Therapy Other 2. Approx. Date of Onset: Does it interfere with your: Work Sleep Daily Routine Recreation Other therapies tried: Medications Surgery Chiropractic Phys. Therapy Other 3. Approx. Date of Onset: Does it interfere with your: Work Sleep Daily Routine Recreation Other therapies tried: Medications Surgery Chiropractic Phys. Therapy Other Please list all medications that you are currently taking (or have used in the past two months), with dosages: 1. 2. 3. 4. 5. 6. Please list any vitamins, minerals, herbs, or homeopathic remedies that you are presently taking: 1. 2. 3. Please list allergies that you have to any of the following: 4. 5. 6. Drugs: Foods: Other (i.e. pollen, paint, etc.): HEALTH HISTORY Past Medical History: Please list past injuries, broken bones, surgeries and hospitalizations, with approx. dates. Personal Habits: Tobacco Alcohol Coffee/tea/cola Recreational drugs packs/day drinks/wk cups/day times/wk Work Activity: Sitting Standing Light labor Heavy labor High Stress Level Reason Do you follow any diet regimens/restrictions? Yes No If Yes, describe: Exercise: Do you exercise regularly? Yes No If Yes, describe & tell how often: FAMILY INFORMATION Do you have children? Yes No If Yes, how many? Ages Are you, or could you be currently pregnant? Yes No Due date
Please check if you have had (in the last three months) GENERAL! Poor appetite! Heavy appetite! Changes in appetite! Weight loss/gain! Cravings! Peculiar tastes! Strong thirst SKIN AND HAIR! Rashes/Hives! Itching! Dry skin! Dandruff Other hair or skin concerns:! Fevers/Chills! Sweat easily! Localized weakness! Bleed / bruise easily! Sudden energy drop (time?)! Fatigue! Ulcerations! Eczema/Psoriasis! Loss of hair! Pimples/Acne! Tremors! Poor sleeping! Heavy sleeping! Dream disturbed sleep! Night sweats! Dizziness! Fungal infections! Recent moles! Change in hair or skin texture HEAD, EYES, EARS, NOSE, AND THROAT! Concussions! Spots in front of eyes! Glasses/Contacts! Earaches/Infections! Eye strain/pain! Ringing in ears! Red eyes! Poor hearing! Itchy eyes! Sinus problems! Dry eyes! Post nasal drip! Excessive tearing! Excessive phlegm! Poor/blurry vision color! Night blindness! Nose bleeds! Cataracts/Glaucoma! Recurrent sore throats! Headaches (location, triggers, severity)?! Swollen glands! Sores on lips/tongue! Dry mouth! Excessive saliva! Teeth problems! Gum problems! TMJ disorder! Grinding teeth Other head & neck concerns: CARDIOVASCULAR! High blood pressure! Low blood pressure! Chest pain! Irregular heartbeat! Palpitations! Fainting! Cold hands/feet! Swelling of hands! Swelling of feet! Blood clots! Phlebitis Other heart or blood vessel concerns: RESPIRATORY! Cough! Coughing blood! Wheezing! Asthma! Bronchitis! Pneumonia! Pain with deep breath! Shortness of breath! Tight chest! Production of phlegm - color? Is it thick or thin Other lung related concerns:
GASTROINTESTINAL! Nausea! Vomiting! Diarrhea! Constipation! Gas/Bloating! Hiccups History of chronic laxative use?! Belching! Bad breath! Blood in stools! Black stools! Mucus in stools! Acid Regurgitation! Abdominal pain! Itchy anus! Burning anus! Hemorrhoids/fissures Other concerns with your general digestion: GENTIO-URINARY! Pain on urination! Frequent urination! Blood in urine! Urgency to urinate! Unable to hold urine! Decrease in flow If you wake to urinate, how often?! Bedwetting! Kidney stones! Impotency! Increased libido! Decreased libido! Premature ejaculation! Nocturnal emissions! Sores on genitals! Frequent urinary tract infections! Chronic yeast infection Other concerns with genitals or urinary system: MUSCULOSKELETAL! Neck pain! Upper back pain! Lower back pain! Hand/wrist pains! Muscle pains! Muscle weakness! Cramps/spasms! General joint pain/stiffness! Shoulder pain! Knee pain! Foot/ankle pain! Hip pain! Joint with limited range of motion Other muscle, joint or bone concerns: NEUROPSYCHOLOGICAL! Seizures! Loss of balance! Areas of numbness! Tics! Lack of coordination! Memory loss! Concussion! Depression! Anxiety! Irritability! Easily susceptible to stress! History of emotional/physical abuse Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Other neurological or psychological concerns: GYNECOLOGY Age of first menses If no longer menstruating, approximate date ceased First day of last menses Length between menses: days Duration of period: days! Unusual flow ( heavy! Clots in flow! Vaginal dryness or light)! Vaginal discharge! Vaginal sores! Painful periods color! Hot flashes! Irregular periods! Vaginal odor! Breast lumps/soreness
GYNECOLOGY (continued) Changes in body or psyche prior to menstruation ( PMS ): Date of last PAP: Results were: normal abnormal unsure If you use birth control, what type & for how long? Have you ever used hormonal methods for contraception or period regulation? (i.e. the pill, Depo-Provera, etc.) Other gynecological concerns: PREGNANCY HISTORY Number of pregnancies Births Miscarriages Abortions Were your births relatively normal? Explain: Other related concerns: COMMENTS Please let us know of any other concerns you would like to address: Family History: Please fill in the boxes for each condition that applies to one of your family members. Addiction (alcohol/drugs) Cancer Cardiac disorders (heart disease, high blood pressure, stroke) Diabetes Digestive/Gastrointestinal disorders Immune disorders (hepatitis, HIV, etc.) Mental illness Respiratory disorders (asthma, allergies, etc) Skin disorders (eczema, psoriasis, etc.) Yes Who Comments Seizure disorders Signature: Date:
I. PATIENT ADVISORY TO CONSULT A PHYSICIAN Victor Acupuncture, PLLC 669 Route 31 Macedon, New York 14502 315.310.5538 Victor Acupuncture is committed to your health and well being. I believe that while Oriental Medicine has a great deal to offer as a health care system, it cannot totally replace the resources available through biomedical physicians. Consequently, I recommend that you consult a physician regarding any condition or conditions for which you are seeking acupuncture treatment. To comply with Article 160, Section 821 1.1 (b) of NYS Education law, we request that you read and sign the following statement: WE, THE UNDERSIGNED, DO AFFIRM THAT(patient) HAS BEEN ADVISED BY Adrienne J. Goodman, L.Ac. (licensed acupuncturist) TO CONSULT A PHYSICIAN REGARDING THE CONDITION(S) FOR WHICH SUCH PATIENT SEEKS ACUPUNTURE TREATMENT. Patient Signature Licensed Acupuncturist Signature Date Date II. INFORMED CONSENT TO ACUPUNCTURE TREATMENT I consent to acupuncture treatments and other procedures associated with the practice of traditional Oriental Medicine provided by Victor Acupuncture. I have discussed the nature and purpose of my treatment with Adrienne Goodman L.Ac. I understand that methods of treatment may include but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, and bodywork therapies such as Medical Massage, Tui Na (Chinese Massage) and Shiatsu. I have been informed that acupuncture is a safe method of treatment, but that it may have 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. Rare and unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this site uses sterile, disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (from plant, animal and mineral sources) which may be 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, diarrhea, rashes, hives and tingling of the tongue. I will notify Adrienne Goodman L.Ac. if I am, or become pregnant. I do not expect Adrienne Goodman L.Ac. to be able to anticipate and explain all possible risks and complications of treatment. I understand that Adrienne Goodman L.Ac. may review my medical records and lab reports and that portions of my records may be used for teaching or research purposes, however my name and identifying information will not be disclosed. Otherwise all of my records will be kept confidential and will not be released to any party without my written consent. By voluntarily signing below I show that I have read, or have had read to me, this 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 seek treatment. To be completed by patient (or patient's representative if the patient is a minor or is physically or legally incapacitated). Date Consent Completed Print Name of Patient Signature of Patient or Representative Print Name of Patient Representative (if applicable) To be completed by the member of the Clinical Staff providing information and obtaining consent. Print Name of Licensed Acupuncturist Signature of Licensed Acupuncturist
Victor Acupuncture, PLLC 669 State Route 31 Macedon, New York 14502 315.310.5538 PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY POLICIES By signing below, I acknowledge receiving a copy of the Notice of Privacy Practices, dated 5/01/2011. PATIENT FULL NAME PATIENT DATE OF BIRTH (MM/DD/YYYY) SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE* DATE *If signed by a Personal Representative, the following information must also be included: NAME OF PERSONAL REPRESENTATIVE DESCRIPTION OF THE PERSONAL REPRESENTATIVE S AUTHORITY TO ACT ON BEHALF OF THE PATIENT