CONTACT INFO Legal Last Name: Legal First Name: Preferred Name: Gender: [ ] Female [ ] Male [ ] MTF [ ] FTM Address: City: State: Zip: Mobile#: Other#: E-mail: Date of Birth: Age: Emergency Contact: Relationship: Emergency Mobile #: Other Emergency #: INSURANCE INFORMATION Primary Insurance Carrier: Member ID#: Group ID#: Provider Services Phone #: Secondary Insurance Carrier: Member ID#: Group ID#: Provider Services Phone #: Please bring a copy of your insurance card to the first visit. HOW DID YOU FIND THE OFFICE? (Check All That Apply): [ ] Insurance Website [ ] Google Search [ ] Yelp [ ] Neighborhood Walk-by [ ] Solano Stroll [ ] Public Class or Speaking Event [ ] Referral from: [ ] Other: EMPLOYMENT [ ] Full-time [ ] Part-time [ ] Self-employed [ ] Retired [ ] Unemployed [ ] Student Occupation: OTHER CAREGIVERS Are you currently under the regular care of?: [ ] Primary M.D. Name: Practice Group Name: [ ] Psychotherapist, Psychologist, Psychiatrist : [ ] Chiropractor: [ ] Physical Therapist: [ ] Other Medical Specialist: Page 1 of 9
AGREEMENTS - By signing below I understand and agree to the following: Privacy I understand that my patient records and information will be kept strictly confidential and will only be shared when necessary to provide care, under my written authorization, or when required by law. A detailed health privacy policy will be provided to me at the time of the visit. _ Appointment Reminders I understand that return patient appointment reminders are provided via online scheduling software and that these reminders are offered as a courtesy. Patients are responsible for keeping track of their appointments in case of a failure on the part of the software or patient email. Cancellation Policy I understand that due to the individualized nature of this medicine, having adequate time to check-in is critical. For this reason and for the respect of other patients appointments, I understand that arriving more than 15 minutes after my scheduled appointment start time is too late to receive an acupuncture treatment. If I arrive more than 15 minutes after my scheduled appointment I understand that I will not be able to have an acupuncture treatment. I understand that if I do not receive care my insurance cannot be billed. I understand that a late arrival is the same as a late cancellation and I agree to pay A LATE CANCELLATION FEE which is the same as the CASH VISIT RATE, $100. I agree to provide 48-hours advance notice if I need to cancel or reschedule my appointments. I understand that if I do not receive care my insurance cannot be billed. If I fail to provide 48-hours notice I agree to pay A LATE CANCELLATION FEE which is the same as the CASH VISIT RATE, $100. Exceptions for late cancellation include emergencies such as accidents, hospitalizations or extreme illness. I understand that work deadlines and family functions do not qualify as emergencies for these purposes. Communication I understand that communication with the office should be via phone call or email and that text message is not an effective means of communicating with Marie or with office administration. Responsibility I accept full responsibility for taking charge of my physical and emotional health. I understand that making shifts in my health will require me to commit to appointment times, to make changes to my nutrition and lifestyle and I am willing to make these changes. My signature below indicates that I understand and agree to the policies and intentions outlined on page 8 of this intake form. Patient Signature: Date: Page 2 of 9
MARIE BOWSER ACUPUNCTURE HEALTH INFORMATION PRIVACY POLICY This notice describes the office s policy for how medical information about you may be used and disclosed and how your privacy is being protected. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information in the following cases: Payment: In order to secure payment we may disclose health care information to your insurance company or with Worker s Compensation (and your employer as well in this instance). Treatment: Your health care information may be disclosed to other healthcare professionals within the practice or other medical practitioners that you authorize Emergencies: In the event of an emergency, we may need to notify a family member or other person responsible for your care that you have been in an emergency situation. Public Health: As required by law, we may disclose your health information to public health authorities for the purpose of preventing or controlling disease, reporting child or elder abuse or neglect, reporting domestic violence or reporting disease or infectious exposure, for example Judicial and Administrative Proceedings or Law Enforcement: For example in the case of complying with a court order or subpoena. Other Communication: For example, we may call your home to remind you of an appointment. No protected health information will be provided on this call except for the date and time of your scheduled appointment. Safeguards in place at our office include: Limited access to facilities where information is stored including locked files. Policies and procedures for handling information. Requirements for third parties to contractually comply with privacy laws. Please also note, some of my clinical locations are in a communal setting which creates potential for personal medical information to be overheard by others. In administering your health care, we gather and maintain information that may include: Non-public personal information Information about your financial transactions with us (billing transactions) Medical history, treatment notes, medical test results, and any letters, faxes, emails or telephone conversations to or from this office, to or from other health care practitioners, from health care providers, insurance companies, workman s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information). By signing this document, I acknowledge that I have received a copy of Marie Bowser Acupuncture Privacy Policy. Signature: Printed Name: Date: Page 3 of 9
Informed Consent for Acupuncture Treatment & Qigong Classes I hereby request and consent to the performance of acupuncture treatments and/or other procedures associated with Traditional Chinese Medicine, including various modes of physiotherapy on me (or the patient named 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 working or associated with, or serving as a back-up for the acupuncturist named below, including those working at this or any other office, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion (holding smoldering mugwort herb in proximity to the skin to stimulate an acupuncture point with heat), cupping (using glass cups under suction on the skin), gua sha (scraping the skin with a special tool), acupuncture with electrical stimulation, breathing techniques, exercise therapy, qigong exercises, qigong therapy, acupressure, Tui-Na (Traditional Chinese medical massage), herbal medicine, nutritional and lifestyle counseling. 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. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Bruising is a common side effect of cupping and gua sha. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist below 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 (which are from plant, mineral, and animal sources) 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. I understand that the herbs need to be consumed according to the instructions provided verbally and in writing. I understand that some herbs may have an unpleasant taste or smell. I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbs. I will notify the acupuncturist who is caring for me if I am or become pregnant. I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the acupuncturist to exercise judgment during the course of treatment based upon the facts known at the time to be in my best interest. I understand that results are not guaranteed. 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. Signature of Patient (or Representative) Print Name Date Page 4 of 9
CHIEF COMPLAINTS Health Goal / Chief Complaint Severity (1-10) 1 is least severe 10 is most severe 1. 2. 3. How Long? PAIN Describe any pain that you are experiencing not listed above Location Severity (1-10) 1 is least severe 10 is most severe 1. 2. 3. How Long? What are three criteria that will help us know when we have met each of your health goal(s)? (Include 3 criteria for each Chief Complaint). 1. 1. 1. 2. 2. 2. 3. 3. 3. What is your present level of commitment to make nutrition and lifestyle changes to address the causes of your signs and symptoms? 1 2 3 4 5 6 7 8 9 10 (10 = 100% Commitment) Page 5 of 9
What behaviors or lifestyle habits do you engage in that you believe contribute to your chief complaint or get in the way of your health? What obstacles do you foresee in eliminating unhelpful nutrition or lifestyle factors or incorporating nutrition and lifestyle suggestions? What behaviors or lifestyle habits do you engage in that you believe support your health? Who do you know that will support you in making suggested lifestyle and nutritional changes? How do you manage stress and unpleasant emotions? What things are most important to you? When do you feel most happy and in the flow of life? How satisfied are you in the different areas of your life? (10 = 100% Satisfied) Relationships 1 2 3 4 5 6 7 8 9 10 Home 1 2 3 4 5 6 7 8 9 10 Financial 1 2 3 4 5 6 7 8 9 10 Career 1 2 3 4 5 6 7 8 9 10 Fun & Recreation 1 2 3 4 5 6 7 8 9 10 Rest and Relaxation 1 2 3 4 5 6 7 8 9 10 Page 6 of 9
FREQUENCY OF USE Sugar Coffee Tobacco Alcohol Marijuana Other Substances (Specify): Age Started Age Quit Amount Per Day TYPICAL DAY OF FOOD Breakfast: Lunch: Dinner: MEDICAL CONDITIONS AND SURGERIES List conditions & surgeries you have or have had and year diagnosed, including noteworthy illnesses of childhood: Condition or Surgery Year MEDICATIONS List all prescription or non-prescription medications you use, including vitamins, supplements, inhalers and drops. Continue on the back side if necessary. Pharmaceutical Dose Frequency Purpose ALLERGIES List all allergies including Medications, Seasonal, Environmental & Food. Continue on Back Side if necessary. Page 7 of 9
DETAILED SIGNS AND SYPTOMS Condition Past Current Condition Past Current Fatigue Unquenchable Thirst Insomnia Never Thirsty Nervousness Food Cravings Worry/Anxiety Crave Warm Drinks Depression Crave Cold Drinks Anger Feels Hot Irritability Feels Cold Crying Cold Hands &/or Feet Mood Swings Frequent Urination Grief Infrequent Urination Manic Depression Difficulty with Urination Eating Disorder Pain with Urination Body Image Blood in Urine Stress Mucous in Urine Digestive Gas Urinary Tract Infections Heartburn Dry Skin Belching Itchy Skin Stomach pain Boils or skin infections Intestinal Cramps Cysts or Lipomas Stomach Cramps Changing Moles Nausea Frequent Rashes Vomiting Acne Mouth sores Scalp Issues Weight Gain/Loss Dry Hair Bitter/Sour Taste Easy to Bruise Bloating Easy to bleed Diarrhea Numbness or Tingling Loose Stools Dizzyness or Vertigo Watery Stools Balance Issues Undigested Food Headaches Bloody Stools Migraines Black Stools Memory Loss Mucous in Stools Poor Memory Constipation Confusion Hemorrhoids Poor Concentration Lower Bowel Gas Poor Coordination Urgent Bowel Movement Seizures High Appetite Tremors Low Appetite Parkinsons Page 8 of 9
DETAILED SIGNS AND SYPTOMS (Cont d) Condition Past Current Condition Past Current Shingles Persistent cough Multiple Sclerosis Coughing Blood Neuralgia (Nerve Pain) Coughing Phlegm Eye Pain Painful Sore Throat Dry Eyes Mild sore throat Blurred Vision Dry throat Visual Obstructions Scratchy throat Flashing Lights in eyes Difficulty swallowing Sensitive to Ligiht Hoarseness Hearing Loss Jaw pain Earaches Teeth problems Ear Infections Gum problems Ringing in Ears Swollen tongue Sinus Congestion Mouth sores Frequent Colds Low or No Sex Drive Shortness of Breath Impotence Wheezing Painful Ejaculation Coughing Premature Ejaculation Mucous Production Diagnosed Prostate Issue Difficult Night Breathing Chest Pain or Pressure Palpitations Discharge STI HIV, HEPB, HEPC, Other Female Body Systems Pregnant? [ ] Yes [ ] No Form of birth control [ ] None [ ] Pill [ ] Other (Condom, Vasectomy, ) Last monthly period Number of Days Between Periods Bleeding Days Age started menstrual cycle Age stopped Menstrual pain Low backache Irregular bleeding Heavy bleeding Light bleeding Clotting Water retention Mood changes Missed periods Low or no sex drive painful breasts Hot flashes Menstrual Blood Color: History of or Current Infections: Discharge: Yellow White Clear Odor Itching # of Pregnancies # of Deliveries # of Miscarriages # of Abortions # of Cesareans Ages of Children: Page 9 of 9