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Becky LaPlante MSTOM, Dipl. AC, L.Ac Address of Service:15 Hartford Ave STE G, Granby CT 06035 Phone: 860.709.1131 www.elementaltransformation.com New Patient Information Name Today s Date Street Address Unit City State Zip Preferred Phone Email Birth Date (include year) Age Gender Height Weight Occupation Employer Marital Status Referred by Emergency Contact: Name Phone Primary Care Physician: Name Phone Other Practitioners Involved In Your Care: Name Phone Name Phone Cancellation Policy: If you need to change or cancel your appointment please notify us within a minimum of 24 hours notice. Failure to do so will result in being charged the equivalent of the cash rate of the missed appointment to your account. I understand the cancellation policy. Signature: Date: / / Health History: Have you had acupuncture before? If so, for what reason? Main issue(s) you are seeking treatment for and length of time experiencing each: Diagnoses from medical professional and approximate dates of diagnosis (if applicable):

Please mark any areas of pain or discomfort: Please list areas of pain or discomfort below with the 1-10 pain scale and a brief history: (1: barely noticeable pain, 10: excruciating pain) Please check any symptoms that you have experienced in the past or currently experience: sweating easily during the day loss of appetite weight loss/gain increase in appetite brain fog or confusion trouble falling asleep dizziness/vertigo trouble staying asleep fatigue during the day swollen/sore lymph nodes fevers bleed or bruise easily chills autoimmune disease Please elaborate: Skin & Hair rashes/hives psoriasis eczema itchy skin dry skin acne oily skin loss of hair/thinning hair

Head, Ears, Eyes, Nose & Throat earaches/pressure in the ears headaches/migraines ringing in the ears sinus pressure hearing loss nose bleeds eye floaters dizziness/vertigo itchy eyes teeth/jaw clenching blurry vision sore throat vision loss swollen throat Cardiovascular/Circulatory chest pain swelling/edema fainting high blood pressure lightheadedness low blood pressure cold hands & feet palpitations heart arrhythmia heart murmur shortness of breath Respiratory pain on inhaling sneezing chest tightness seasonal/other allergies cough phlegm production asthma nasal congestion wheezing difficulty swallowing pain behind the eyes Genito-Urinary difficulty urinating urgent/frequent urination blood in urine sores on genitals pain upon urination genital pain STD yeast infections/vaginosis

Neurological/Psychological anxiety poor memory depression quick temper loss of balance/coordination easily susceptible to stress areas of numbness/paralysis mood swings irritability ADD/ADHD Parkinsons Multiple Sclerosis Digestive heartburn gas belching diarrhea bloating constipation nausea abdominal pain/cramps vomiting mucus in stool chronic bad breath blood in stool sores on lips/tongue hemorrhoids For Women Only: irregular periods breast pain painful periods vaginal discharge bleeding between periods vaginal sores period clots hot flashes menstrual cramping night sweating age of first menses duration of typical period duration of typical cycle date of last PAP # of pregnancies # of live births (+ years) # of miscarriages # of abortions

Are you currently pregnant or breastfeeding? Have you been through menopause? Age? Did you experience a difficult menopause? Have you ever taken birth control pills? When and for how long? Other premenstrual & menstrual symptoms (bloating, breast tenderness, irritability, mood swings, fatigue, loose stools, acne, etc.) For Men Only: erectile dysfunction/impotence ejaculatory pain varicocele BPH Please elaborate: Lifestyle: Current medications/herbs/supplements (please list dosages and how long you have been taking each): Do you follow any certain diet or way of eating? (vegetarian, gluten-free, paleo, etc.) How much water do you drink per day? Is it filtered and if so, which type of filter do you use? Have you used antibiotics in the past? If so, when and how often? Current exercise routine: Do you or have you ever used tobacco? If so, how often?

Do you or have you ever drank alcohol heavily? If so, how many drinks/week? Do you or have you ever taken recreational drugs? If so, how often? Are you currently taking any of the following medications? (circle if yes and indicate how often) Advil/Motrin/Ibuprofen Aleve/Naproxen Prednisone/Prednisolone Celebrex/Celecoxib Bayer/Aspirin Acetaminophen/Tylenol Allergies (medications/foods/chemicals/etc.): Have you ever had a seizure? If yes, indicate date of last: Please circle any significant illnesses and indicate date: Cancer Hepatitis Diabetes High blood pressure Epilepsy Heart Attack Stroke Ulcer Disease Liver Disease Colon Polyps Other Please list any major surgeries/hospitalizations and approximate dates: Family Medical History: Cancer Seizures High blood pressure Stroke Diabetes Heart Attack Hepatitis Asthma Other What are your goals for your health? Please list any other relevant information or issues you would like to discuss:

Informed Consent for Acupuncture Treatment and Care Your treatment may include acupuncture, moxibustion, cupping, electric or magnetic stimulation, acupressure, gua-sha, infra-red heat lamp, Chinese herbs/supplements, therapeutic exercises and dietary counseling based on the principles of Chinese Medicine. The potential risks may include, but are not limited to: Discomfort or minor pain at the site of needle insertion during treatment. Localized, minor bleeding, bruising, or swelling Minor burns with the use of moxa Needle sickness (dizziness, fainting, nausea) Possible, temporary aggravation of symptoms that existed prior to treatment, then rapid recovery (known as a healing crisis) Infection and the risks from needling in the vicinity of an infection Please notify the acupuncturist if you have any adverse effect from treatment. Some herbs and acupuncture points are contraindicated for certain conditions. Please inform your practitioner if you have any of the following conditions: If you are pregnant If you have ever experienced fits, faints, or panic attacks If you have a pacemaker or any other electrical implants If you have HIV/AIDS, Hepatitis, or other infectious disease Acupuncture is performed by the insertion of sterile, disposable acupuncture needles through the skin, and/or the application of heat or electrical stimulation to the skin at the certain points on the body. After each treatment the needles are disposed of as medical waste, and are never reused. Additionally, the acupuncturist has been trained in Clean Needle Technique and Universal Precautions. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been suggested are traditionally considered safe in the practice of Chinese Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastrointestinal upset or allergic reactions to the herbs, I will inform the acupuncturist. I have been advised to consult a physician regarding the condition for which I am undergoing acupuncture treatment. The benefits and risks of receiving acupuncture and Oriental medical treatment have been explained to me. I understand that my signature in this form indicates that I have read and understand the preceding the information regarding my treatment. I understand that if I have any questions about this information I should ask Becky La Plante, L.Ac. I hereby release Becky La Plante, L.Ac. from any and all liability that may occur in connection with the above mentioned procedures, except for the failure to perform the procedures with appropriate medical care. Patient's Name Patient's/Patient Representative's Signature Today's Date / /

HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent. May we phone, email, or send a text to you to confirm appointments? YES NO May we leave a message on your answering machine at home or on your cell phone? YES NO May we discuss your medical condition with any member of your family? YES NO If YES, please name the members allowed: This consent was signed by: (PRINT NAME) Signature: Date: Witness: Date:

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