Healing Point Acupuncture

Transcription

1 PATIENT INFORMATION Name Date Home Address City State Zip Phone Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex Marital Status (Single, Married, Life Partner, Divorced, Widowed) In Case of Emergency Notify How did you hear of this office? Have you ever before tried acupuncture or Chinese herbal medicine? CHIEF COMPLAINT What are the main health problems for which you are seeking treatment? Please rate the extent to which your current complaint affects your daily life (1 = minor; 10 = major) Please rate your commitment to resolving this problem (1 = minor; 10 = major) What other forms of treatment have you sought? PAST MEDICAL HISTORY (check all which apply) Allergies Cancer Diabetes Hepatitis High Blood Pressure Heart Disease Seizures Rheumatic Fever Surgeries Venereal Disease Thyroid Disease Birth Trauma Vaccinations Childhood Illnesses Accidents Significant Trauma Medications FAMILY MEDICAL HISTORY (check all which apply and specify which blood relative) Cancer High Blood Pressure Hepatitis Rheumatic Fever Infectious Disease Diabetes Heart Disease Seizures Emotional Disorder Tuberculosis LIFESTYLE (please indicate the use and frequency of the following) Coffee Black Tea Tobacco Alcohol Caffeinated Beverages Recreational Drug Exercise (please specify type) FORMS/CLINIC page 1

2 MEDICATIONS Please list any medications and/or supplements you are currently taking GENERAL HEALTH (please check all that apply) Poor Appetite Disturbed Sleep Insomnia Fatigue Poor Coordination Weight Gain Cold Hands and Feet Night Sweats Cold Abdomen Tremors Large Appetite Localized Weakness Strong Thirst Weight Loss Fevers Poor Balance Bruise/Bleed Easily Sweat Easily Cravings Chills Sudden Energy Drop Soft/Brittle Nails Catch Colds Easily SKIN AND HAIR Rashes Itching Dandruff Ulcerations Redness Eczema Psoriasis Hair Loss Hives Pimples Recent Moles HEAD, EYES, EARS, NOSE, THROAT Dizziness Eye Pain Blurred Vision Floaters Spots in Eyes Night Blindness Ringing in Ears Poor Hearing Earaches Headaches Migraines Recurrent Sore Throats Sores on Lips/Tongue Dry Mouth/Throat Bleeding Gums Nosebleeds Facial Pain Jaw Clicking Toothaches CARDIOVASCULAR Dizziness Low Blood Pressure High Blood Pressure Irregular Heart Beat Fainting Cold Hands/Feet Chest Pain Swelling of Hands/Feet Blood Clots Difficulty Breathing Palpitations RESPIRATORY Cough Coughing Blood Asthma Bronchitis Pneumonia Coughing Phlegm Pain with deep breath Shortness of Breath Nasal Congestion Difficulty breathing when lying down FORMS/CLINIC page 2

3 GASTROINTESTINAL Nausea Vomiting Diarrhea Constipation Gas Bloating Belching Abdominal Pain/Cramps Indigestion Heartburn/Reflux Retention of Food in Stomach Lack of Appetite Excessive Appetite Rectal Pain Black Stools Blood in Stool Hemorrhoids Bad Breath Sensitive Abdomen Chronic Laxative Use GENITO-URINARY Pain on Urination Frequent Urination Blood in Urine Urgency to Urinate Unable to Hold Urine Kidney Stones Decrease in Urine Flow Impotence Sores on Genitals Waking at Night to Urinate REPRODUCTIVE/GYNECOLOGICAL Age of 1 st Period Age at menopause # Pregnancies # Live Births # Premature Births # Miscarriages/Abortions # days between periods # days of flow Color of blood Clots (Color ) Painful Menses Irregular Menses Premenstrual Symptoms Strong Menstrual Odor Vaginal Discharge Vaginal Odor Vaginal Dryness Fibroids Breast Lumps/Swellings Endometriosis Ovarian Cysts Sexually Transmitted Disease Urinary Tract Infection Hot Flashes Decreased Sex Drive Positive Mammogram/Pap Smear MUSCULO-SKELETAL Neck Pain Back Pain Knee Pain Muscle Pain Foot/Ankle Pain Shoulder Pain Hip Pain Hand/Wrist Pain Sciatica Muscle Weakness Other Joint/Bone Problems (please specify) NEURO-PSYCHOLOGICAL Seizures Dizziness Loss of Balance Areas of Numbness Poor Memory Lack of Coordination Concussion Depression Anxiety Bad Temper Easily Stressed Attempted Suicide Treated for Emotional Problems FORMS/CLINIC page 3

4 Birth/Infancy/Early Childhood History: (Please fill out as best you can. It s ok if you don t know and have to leave some blank.) Age of mother at conception? Age of father at conception? Mother exposed to toxins? If so, what? Did your mother have prior history of miscarriages? Did mother/father drink excessive amounts of alcohol three months prior to conception? Did your mother have illnesses during pregnancy? (Describe) Did she have adequate nutrition? Did she experience shocks or emotional stress? Did your mother use alcohol during pregnancy? Use alcohol/nicotine/other drugs? Did your mother spend significant time in the presence of a smoker during pregnancy? Was your delivery Early Late On time Vaginal Caesarean Traumatic Was labor natural onset induced Long Fast Was your mother medicated? Unusual circumstances at birth? (breech, cord around neck, placenta previa, etc.) Birth weight Length APGAR? Placed in an incubator? How long? Were you/mother kept in hospital beyond usual post-delivery period? Why? Your health first few months after birth? Fair Poor(describe) Breastfed Bottle fed (How long? ) Combination Trauma in infancy? Colic Other illnesses or hospitalization? (What?) Emotional trauma in infancy/early childhood? (What?) Any recurring health problems in childhood, major illnesses? Earaches Colds/sore throats Digestive problems Musculoskeletal problems Developmental problems Other (describe) Did you experience any physical/emotional trauma or abuse? Physical Emotional Sexual Were you able to engage in normal physical activities commensurate with your age? Any learning disabilities? (What?) Describe your relationship with other children. How many siblings? Were you oldest/youngest/other? Oldest/Youngest/Middle child? FORMS/CLINIC page 4

5 Consent For Use And Disclosure Of Health Information By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices at anytime. You will have the right to revoke this consent at any time by giving us written notice of your revocation. Please understand that revocation of this consent will not affect any action that we took in reliance on this consent before we received your revocation, and we may decline to treat you or to continue treating you if you revoke this consent. I authorize you to disclose health information to: No person at this time. Spouse: NAME ADDRESS PHONE Family member: NAME ADDRESS PHONE Friend: NAME ADDRESS PHONE I, have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. Signature Date Social Security Number REVOCATION OF CONSENT I revoke my consent for your use and disclosure of my protected health information, payment activities, and healthcare operations. I understand that revocation of my consent will not affect action you took in reliance on my consent before you received this written notice of revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my consent. Signature: Date: FORMS/CLINIC page 5

6 Privacy Practices Policy Policy: It is the policy of to protect the health information of its patients as required by federal and state law. Procedures: USES AND DISCLOSURES OF HEALTH INFORMATION Treatment: We may use or disclose health information to a physician or healthcare professionals providing treatment to our patients. This may include but is not limited to the primary physician, PA, nurse, physical therapist, nutritionist or dentist. Healthcare Operations: We may use or disclose health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualification of health care professionals, evaluation of practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Patient Authorization: In addition to our use of health information for treatment, payment or healthcare operations, the patient may give us written authorization to release their health information or to disclose it to anyone for any purpose. If the patient gives us authorization, they may revoke it in writing at any time. Their revocation will not affect any use or disclosures permitted by their authorization while it was in effect. Family and Persons Involved in their Care: We must disclose health information to the patient. With their authorization, we may disclose their health information to a family member, or other person to the extent necessary to help with their healthcare or with payment for their healthcare. We may use or disclose health information to communicate, notify, or assist in the notification to the patient. We will also use our professional judgment and our experience with common practice to make reasonable inferences of the patient's best interest in allowing a person to pick up filled herbal prescriptions, medical supplies, or other similar forms of health information. Required by law: We may use or disclose health information when we are required to do so by law. Public Health Activities: We may disclose vital statistics, diseases, information related to recalls of dangerous products, and similar information to public authorities. Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for government programs, and similar activities. Law Enforcement: Subject to certain restrictions, we may disclose information required by law enforcement officials.. Serious Threat to Health and Safety: We may use and disclose information when necessary to prevent a serious threat to the patient's health and safety or the health and safety of the public or another person. Workers Compensation: We may release information about the patient for FORMS/CLINIC page 6

7 workers compensation or similar programs providing benefits for work-related injuries or illness. Abuse or Neglect: We may disclose health information to appropriate authorities if we reasonably believe that the patient is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose health information to the extent necessary to avert a serious threat to the patient's health or safety or the health and safety of others. Appointment Reminders or Changes: We may use or disclose health information to provide the patient with appointment reminders, make appointment changes, suggest treatment alternatives or return patient phone calls. We will request written notice of how the patient would like all telephone contact to be made. PATIENT RIGHTS Access: Patients have the right to look at or get copies of their health information. The patient must make a request in writing to obtain access to their health information. We will charge the patient at least $25 or a reasonable cost-based fee for expenses such as copies and staff time. Disclosure Accounting: Patients have the right to receive a list of instances in which we or our business associates disclosed their health information for purposes, other than treatment, payment, or healthcare operations. If the patient requests this accounting more than once every 12 month period, we may charge them a reasonable, cost-based fee for responding to these additional requests. Restrictions: Patients have the right to request that we place additional restrictions on our use or disclosure of their health information. We are not required to agree to these restrictions, but if we do, we will abide by our agreement (except in an emergency). Amendment: Patients have the right to request that we amend their health information their request must be in writing, and it must explain why the information should be amended. We may deny their request under certain circumstances. Revocation of consent: Patients have the right to revoke their consent at any time. They must give written notice of their revocation of consent. This revocation will not affect any action taken in reliance on this consent prior to receiving the written revocation of consent. We have the right to decline to treat the patient or to continue to treat the patient, if they revoke this consent. COMPLAINTS Patients have the right to complain if they feel that may have violated their privacy rights or if they disagree with a decision we made about access to their health information or our response to a request made to amend or restrict the use or disclosure of their health information. Phone: (850) They also have the right to submit a written complaint to: US Department of Health and Human Services Attention: Office of Civil Rights Sam NUTUJ Atlanta Federal Center, Suite Forsyth Street SW Atlanta, GA FORMS/CLINIC page 7