Patient Information General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth: Age: Gender: M F Relationship Status: Physician: Physician Phone: Employer: Occupation: Hrs/Wk: Who may we thank for referring you? Have you ever had acupuncture before? Y N If so, where? Emergency contact: Phone: Relationship: If patient is a minor or under legal guardianship: Guarantor Name: Relationship to Patient: Guarantor Address: Guarantor Phone: Insurance Information Primary Insurance Company: Subscriber ID#: Group #: Subscriber Name: Relationship to Patient: Birthdate: Secondary Insurance Company: Subscriber ID#: Group #: Subscriber Name: Relationship to Patient: Birthdate: Revised 7/2014 Page 1
Patient Health History Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this to the best of your ability. What is the main reason you are seeking treatment today? (Please mark any areas of pain on diagram) 1. Chief Complaint Date of onset 2. 3. Please list any major accidents, surgeries, or hospitalizations and include approximate dates. Chronic Illnesses: Allergies/Sensitivities (seasonal, chemical, environmental, food, drugs, etc.): Medications (prescribed/over-the-counter) and supplements you are currently taking. (Continue on back if you require more space). Medication/Supplement Reason Dosage How Long Prescribed by Revised 7/2014 Page 2
Family Medical History: (M=mother, F=father, GP = grandparent, S =sister, B=brother) YOU RELATIVE WHO YOU RELATIVE WHO Allergies Alcoholism Alzheimer s Disease Arthritis Asthma Autoimmune Disease Cancer Diabetes Heart Disease Hepatitis High Blood Pressure High Cholesterol Infectious Diseases Mental Illness Osteoporosis Seizures Stroke Thyroid Disease Lifestyle Caffeine Tobacco Alcohol Soda Water intake Exercise (describe) Nutrition YES NO AMOUNT Meals/day Snacks/day Food cravings Special Diet? Y N Breakfast: Dinner: General Lunch: Snacks: Height: Weight: Maximum Weight: When? Interests & Hobbies: Spiritual Practice: Are you in a supportive relationship? Y N If not, what about it is not supportive? Have you experienced any major traumas? (Whatever you consider to be a traumatic event in your life) Y N Explain: Revised 7/2014 Page 3
Wellness Rating Health and wellness is a balance of many factors. Using the scale below, choose your level of satisfaction in each area of your life on a scale from 1-10 (1 = not happy, 10 = very satisfied). Physical Health 1 2 3 4 5 6 7 8 9 10 Financial Health 1 2 3 4 5 6 7 8 9 10 Spiritual Health 1 2 3 4 5 6 7 8 9 10 Family Health 1 2 3 4 5 6 7 8 9 10 Social Health 1 2 3 4 5 6 7 8 9 10 Career Health 1 2 3 4 5 6 7 8 9 10 Sexual Health 1 2 3 4 5 6 7 8 9 10 Mental Health 1 2 3 4 5 6 7 8 9 10 Please check any symptoms you have had in the past 3 months. General Poor appetite Poor sleeping Night sweats Localized weakness Fevers Chills Cravings Poor balance Sweat easily Tremors Change in appetite Weight gain Bleed or bruise easily Weight loss Strong thirst Peculiar taste/smell Sudden energy drop Fatigue Skin & Hair Rashes Eczema Recent moles Itching Hair loss Dandruff Hives Ulcerations Change in skin/hair texture Acne Head, Eyes, Ears, Nose & Throat Dizziness Concussions Migraines Glasses Eye strain Eye pain Poor vision Night blindness Color blindness Cataracts Blurry vision Ear aches Ringing in ears Poor hearing Spots in front of eyes Sinus problems Nosebleeds Grinding teeth Recurrent sore throats Facial pain Teeth problems Jaw clicks Headaches Cardiovascular High blood pressure Low blood pressure Chest pain Phlebitis Fainting Cold hands or feet Swelling of hands Swelling of feet Blood clots Irregular heartbeat Palpitations Respiratory Cough Pneumonia Bronchitis Difficulty breathing Asthma Coughing blood Pain with deep breath Phlegm Revised 7/2014 Page 4
Gastrointestinal Nausea Chronic laxative use Diarrhea Constipation Vomiting Belching Black Stools Indigestion Bad breath Blood in stools Hemorrhoids Abdominal cramps Gas Acid reflux Genitourinary Nighttime urination Frequent urination Blood in urine Urgent urination Incontinence Kidney stones Decreased flow Genital sores Strong smelling urine Dark urine Painful urination Female Reproductive Pregnant Trying to get pregnant Breast self-exams Menopause Hysterectomy Fibrocystic breasts Breast tenderness Fibroids Endometriosis Irregular periods Decreased libido PMS Yeast infections Bleeding between periods Painful periods Ovarian Cysts Age at first period # of pregnancies Last gynecological exam # days between periods # of live births Last mammogram Date of last menstrual period # of miscarriages Last bone density exam # Days of flow # of abortions Last colonoscopy Male Reproductive Prostate problems Premature ejaculation Testicular pain Urination problems Erectile dysfunction Decreased libido Date of last prostate exam Date of last colonoscopy Musculoskeletal Neck pain Muscle pain Knee pain Back pain Muscle weakness Foot/ankle pain Hand/wrist pain Shoulder pain Hip pain Numbness Tingling Neuropsychological Seizures Loss of balance Poor memory Lack of coordination Anxiety Depression Bad temper Easily susceptible to stress Is there anything else you would like me to know? Revised 7/2014 Page 5
Informed Consent for Treatment Patients who are pregnant, trying to become pregnant, have a pacemaker or heart condition, have a seizure or bleeding disorder, or those taking blood thinning medications should discuss these conditions with the acupuncturist prior to proceeding with any treatments. By signing below, I do hereby voluntarily consent to the services rendered by, Inc. using treatment methods within the scope of practice for an East Asian Medicine Practitioner as outlined by the Washington State Department of Health (see attached). I understand that acupuncturists practicing in the state of Washington are not primary care providers and that regular care by a licensed physician is strongly recommended by this clinic. I understand that any procedure (acupuncture, electro-acupuncture, moxibustion, cupping, guasha, infrared heat lamp, massage, nutritional counseling and herbal medicine) intended to help may have complications. While the chances of experiencing side effects are small, it is the practice of this clinic to inform patients about them. These complications may include, but are not limited to: pain, discomfort, dizziness, local bruising, minor bleeding, burns, electric shock, changes in bowel movements, temporary abdominal discomfort and temporary worsening of symptoms. There is a low incidence of unusual risks such as nerve damage and organ puncture. Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. It is also our policy to explain each procedure, including possible risks and alternative treatments. If your practitioner does not explain a procedure to your satisfaction, please ask for more information. I do not expect the practitioner to be able to anticipate and explain all the risks and complications, and I wish to rely on her to exercise judgment during the course of the procedure which she feels at the time is in my best interest. By signing below I acknowledge that: I have carefully read and understand the above information and am fully aware of what I am signing I have been told about the risks and complications of acupuncture and other procedures. I have had the opportunity to ask questions I understand there are no guarantees concerning treatment and that I may refuse or stop treatment at any time. I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I give my permission and consent to treatment. Signature: Date: Print Name: DOB: Revised 7/2014 Page 6
Patient Signature Form FINANCIAL POLICY As a courtesy, we will bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill, including deductibles, co-payments, co-insurance and non-covered services as determined by your contract with your insurance carrier. This office cannot guarantee payment of your claim, nor accept responsibility for collecting or negotiating settlement on disputed claims. Co-pays/coinsurance are due at the time of service. You will receive a monthly statement showing the activity and balances due on your account. We accept cash, checks, MasterCard, Visa and Discover. Unless payment arrangements have been made in advance, any remaining balance owed by you is due in full when you receive your statement. A $35 bank fee will be charged for NSF checks. Balances not paid within 30 days may be subject to finance charges at 1.5% per month. There is a 30-day return policy on unopened supplements or herbs. Granule herb formulas are non-refundable. SELF PAY PATIENTS Patients without insurance are required to pay in full at the time of the service unless prior arrangements have been made. Self pay patients are offered a 20% discount on services if paid in full at time of service. CANCELLATION POLICY As a courtesy, we request 24 hours notice for an appointment you will not be able to keep. Failure to provide timely notice, or neglecting to show up for your scheduled appointment, may result in a $35 missed appointment fee. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT AND CONSENT I understand that, Inc. (CAN) will use and disclose health information about me. I understand that my health information may include information both created and received by CAN, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that CAN may use and disclose my health information in order to: make decisions about and plan for my care and treatment; refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support my physician s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care. I also understand that I have the right to review a written description of how CAN will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the staff and other office personnel of CAN, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revision. I also understand that I can request a copy of the most current version of the Notice of Privacy Practices at any time. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that CAN is not required by law to agree to such requests. BENEFIT ASSIGNMENT I authorize to bill my insurance on my behalf, and assign all benefits, if any, directly to CAN, that otherwise would be payable to me for services rendered. I authorize the use of my signature on all insurance submissions. This consent will continue indefinitely unless revoked by me in writing. PATIENT SIGNATURE I agree that I have reviewed and understand the information above and that I have been offered a copy of the Notice of Privacy Practices. By signing below, I acknowledge that I have read and understand all the information included on this form. Patient/Patient Representative Signature Relationship (if not patient) Date Revised 7/2014 Page 7