Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or a staff member know. We thank you for placing your trust in us and you can expect us to deliver the highest quality of care possible. Referred by: Today s Date: Patient Name: Birth date: Address: Age: City, State, Zip: Gender: Female Male Patient SSN: Marital Status: Single Married Separated Divorced Widowed Occupation: Full time student?: Yes No Primary Care Physician: Email: Your Phone #: ( ) ( ) Home Cell Emergency Contact: ( ) Name Relationship to Patient Phone Primary Insurance Information Secondary Insurance Provider (if applicable) Insured name: Insured name: Insured SSN: Insured SSN: Insured DOB: Insured DOB: Employer: Employer: Payor/Health Plan: Payor: Relationship to Relationship to the insured: Self Spouse Dependent the insured: Self Spouse Dependent Member #: Member #: Policy/Group #: Policy/Group #:
Please describe you reason(s) for treatment at this time: Is this injury work related? Yes No Is this injury due to an auto accident? Yes No How long have you had this condition?: Does it bother your: Sleep Work Sex Life Other: What do you feel was the initial cause? (if known): Have you consulted another Doctor about these problems?: Yes No If yes, Doctor s name, and diagnosis: Please feel free to bring in any lab work, X-ray or MRI interpretation, etc. Are you experiencing any discomfort in any areas of your body?: Yes No If yes, using the models below, please indicate the appropriate location of the discomfort by using the symbol that best describes the feeling. + + + Sharp/Stabbing v v v Dull/Aching THE PAIN INDOCATED ABOVE IS: o o o Pins & Needles / / / Numbness Mild Moderate Severe
YOUR PAST MEDICAL HISTORY Aids/HIV Diabetes Pacemaker Allergies(food,drug,pollen) COPD Eczema Pleurisy Alcoholism/Drug Abuse Epilepsy Pneumonia Appendicitis Glaucoma Rheumatic Fever Anemia Gout Seizures Asthma Heart Disease Sciatica Arthritis Hepatitis (type: ) Stroke Major Trauma Depression Herpes Thyroid Disorders Birth Trauma High Blood Pressure Ulcers Cancer/Tumor Mental Disorder (type: ) Migraines List of previous illness/hospitalizations or surgeries: List of any current medicines, homeopathics, vitamins, minerals, or herbs you are taking now: Lifestyle/Nutrition Average Daily Menu Regular Exercise Alcohol a.m. Type: Frequency: Tobacco Stress Caffeinated Tea Coffee noon Soft Drinks Sugar Artificial Sweetener p.m.
General Poor Appetite Fever Disturbed Sleep Weight Gain Sweating Easily Localized Weakness Weight Loss Chills Sudden Energy Drop Strong Thirst Tremors (time of day?: ) Night Sweats Insomnia Bleeding or Bruising Easily Head, Eyes, Nose, Throat / Skin Dizziness Spots in front of eyes Sores on lips or tongue Rashes Glasses Poor Vision Migraines Hives Poor Hearing Cataracts Ringing in ears Eczema Dry Throat Earaches Blurry Vision Psoriasis Sinus Problems Dry Mouth Headaches Grinding Teeth Recurrent sore throats (Location: ) Nose Bleeds Mucus (When: ) Cardiovascular Low Blood Pressure Fainting Blood Clots Chest Pain Swelling of Hands Difficulty in Breathing Irregular Heart Beat Cold Hands/Feet High Blood Pressure Swelling of Feet Any other heart or blood vessel problems: Respiratory Cough Bronchitis Excessive phlegm or color Coughing up Blood Pain with deep inhalation Asthma Difficulty in breathing when lying down (color: ) Gastrointestinal Nausea Constipation Black Stools Bad Breath Abdominal Pain Vomiting Gas Blood in Stools Rectal Pain Chronic Laxative use Diarrhea Belching Acid Reflux Hemorrhoids Do you have daily bowel movement?: Yes No How often?: Formed Loose Hard
Urinary Pain with urination Urgency to urinate Decrease in flow Frequent urination Kidney Stones Burning with urination Blood in urine Unable to hold Urine Do you wake up to urinate? If so, how often? Any particular color to your urine? Any other genital or urinary problems? Reproductive and Gynecologic (Women) Breast Tenderness Heavy menstrual flow Premature births Menstrual clots Light menstrual flow Miscarriages Painful Menses Irregular menses Abortions Sexually Transmitted Diseases Cramps Infertility Age at first menses Age at menopause Number of live births Number of days between cycles Number of days bleeding First day of last menses Do you practice birth control? If so, what type? For how long? Any other gynecologic problems? Urogenital/Reproductive (Men) Testicular swelling/pain Dribbling urination Low sperm count Premature ejaculation Burning urination Impotence Nocturnal emissions Discharge from penis Decreased sex drive Weak or slow urine stream Rectal/anal pressure Increases sex drive Any other questions, comments or concerns:
FINANCIAL TERMS Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and your provider will be paid directly by the carrier. You will be responsible for any applicable deductions and copayments. Copayments must be paid at the time services are rendered. If you are not eligible at the time services are rendered, you are responsible for full payment. CANCELED/MISSED APPOINTMENTS A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than 24 hours notice, you will be billed directly according to the scheduled fee or according to the rules of your health plan. Your health plan does not cover payment for missed appointments; therefore, you are responsible for payment in full. A cancellation fee of $50.00 will be applied with less than 24 hours notice of scheduled appointment. I have read, or have had read to me, the above consent and other information. I have also had an opportunity to ask questions about its content, and by signing below, I agree to the above named procedures. 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 may seek treatment. Patient (or parent/guardian) name Signature Date May we contact you via text message to remind you of your upcoming appointments? Y / N Signature