PATIENT INTAKE FORM Name ______________________________________ Date of Birth _______________________ ____________ ___________ NOW:
□
PREGNANT
□
Gender:
□
Date ________________________
Male
PACEMAKER □ HIV DISEASE
□
□
Female
HEPATITIS
□
BLOOD TRANSFUSION
FAMILY HISTORY: □ □ □
Abuse □ AIDS □ Alcoholism □ Allergies □ Asthma □ Cancer □ Chemical Dependency □ Diabetes Heart Disease □ High Blood Pressure □ Mental Illness □ Respiratory Diseases □ Seizures □ Stroke Other _______________________________________________ __________________________________________________ ___
YOUR PAST MEDICAL HISTORY/ILLNESSES: □ Other:_________________________________ □
Aids/HIV □ Alcoholism □ Allergies □ Anemia □ Arthritis □ Asthma □ Auto Immune Immune Disease □ Bleeding Disease □ Breast Cysts □ Bi Polar □ Bronchitis □ Cancer □ Candida (Yeast) □ Chemical Dependency Fatigue Syndrome □ Chronic Lung Disease □ Colitis □ Diabetes □ Eating Disorder □ Fracture □ Chronic Fatigue □ Glaucoma □ Gall Stones □ Gout □ Headaches □ Heart Disease □ Hepatitis □ Hernia □ Herniated disc □ High Blood Pressure □ High Cholesterol □ Kidney Disease □ Liver Disease □ Low blood pressure □ Migraine □ Mononucleosis □ Multiple Sclerosis □ Mental Illness □ Osteoporosis □ Organ Transplant □ Parkinson’s Diseases (STD) □ Pneumonia □ Prostate problems □ Rheumatic Fever □ Seizures/Epilepsy □ Sexually Transmitted Diseases □ Stroke □ Substance Abuse/Addiction □ Suicide attempt □ Thyroid Disease □ Tuberculosis □ Ulcers □ Vaccine Reaction □ Whooping Cough
SURGERIES: (Please include dates and if any complications) 1 -____________________________________ -______________________________________________ __________ 2__________________________________________ 3- ______________________________________________ 4__________________________________________
TRAUMATIC INJURY: (Please include dates and if any complications) Car accident(s) ______________________________________________________________________________ ______________________________________________________________________________ Fall(s) _______________________________________________________________________________ Other _______________________________________________________________________________
ALLERGIES / ALERGIAS Drugs/Medication ___________________________________________________________________________ Chemicals _______________________________________________________________________________ Food ____________________________ Seasonal/Environmental ____________________________
CURRENT MEDICATIONS: OCCUPATIONAL/ENVIRONMENTAL EXPOSURES OR HAZARDS: Chemical: ________________________________ Acid/Alkalines: Heavy Metals: ________________________________ Physical Labor: Electrical: ________________________________ Psychological:
____________________________ ____________________________ ____________________________
HABITS/EXCESSIVE USAGE: (Please tell us how often & how much) □ alcohol________ □ artificial
sweetener _________ □ chocolate_________ □ cigarettes ________ □ coffee ________ □ cola_________ □ drugs ________ □ exercise_________ □ food_________ □ salt ________ □ sex __________ □ sugar _________ □ tea _________ □ water _________ □ other _________
.
CHIEF COMPLAINT / REASON FOR YOUR VISIT: _____________________________________ How and when did this condition begin?_____ b egin?_____________ ________________ _______________ _______________ ________________ ______________ ______ ____________________________________________________________________________________ Please list your main health concerns you would like to be free of, in order of importance: 1. _________________________________________ 2._____________________________________________ 3.__________________________________________4. _____________________________________________ GENERAL □
(Please check all that apply to you within within the last 3 months) months)
poor appetite □ change in appetite □ large appetite □ cravings □ weight gain □ weight loss □ sleep walking □ weakness □ fevers □ sweating
□ insomnia
□
□
hours of sleep _______ easy to fall asleep □ heavy sleeper □ light sleeper □ disturbing dreams □ trouble staying staying asleep □ sleep apnea □ dizziness □ Vitamins □
bleeds easily □ bruises easily □ chronic fatigue □ lethargy □ fatigue/tired □ sudden drop in energy □ vertigo □ bitter taste □ headache □ mental fog
□
diff loosing/gaining loosing/gaining weight weight □ excessive need for sleep □ chills □ trouble falling asleep □ hot flashes □ tremors/shaking □ edema □ poor coordination □ Herbs □ Supplements
□ high □ moderate □ low Thirst desires: Energy level : desires : □ hot □ cold □ room temp. □ no desire Cold sensations: sensations: □ hands □ feet □ back Heat sensations: sensations: □ hands □ feet □ solar plexus □ abdomen □ whole body Stiffness: Stiffness: □ joints □ back □ limbs Intolerance to: to: □ hot □ cold □ wind □ fan □ A/C Work odd hours: __________ Do you make time for relaxation/meditation/prayer? relaxation/meditation/prayer? □ yes □ no Are you taking: □ Aspirin □ Blood Thinners Do you follow a special diet: □ yes □ no If so, please explain: explain: __________________________________________________________________________________________
SKIN AND HAIR (Please check all that apply to you within the last 3 months) PIEL Y PELO ( indique todo lo que le apliqué en los ultimos 3 meses) □
rashes □ eczema □ sores □ ulcers □ herpes □ psoriasis
□
eruptions □ discharge □ pimples/acne □ bruises □ itching □ hives
□
change in skin texture texture □ dandruff □ loss of body hair hair □ change in hair hair □ balding □ thinning of hair
□
fungal/yeast infection skin type: type: □ dry □ moist □ other skin skin problems: problems: _____________________ □ other hair problems: problems: _____________________
HEAD, EYES, EARS, NOSE, MOUTH & THROAT(Please check all that apply within the last 3 months) Head Eyes (R/L) □ dizziness □ cataract/ □ migraine glaucoma □ eye pain Headaches: Headaches: □ frontal □ twitching □ temporal □ floaters/spots □ vertex □ poor vision □ occipital □ blurry vision □ head injury □ night blindness □ facial pain □ itchiness □ facial paralysis □ glasses/contacts □ sinus problems □ red eyes □ heaviness in head
Ears (R/L) loss of hearing □ discharge □ earaches □ poor hearing □ itchiness Ringing in ears: ears: □ loud □ soft □ high pitch □ low pitch □ inflammation □ tenderness □
Nose Mouth Throat □ grind teeth □ dry throat loss of smell smell □ good sense of smell □ drooling □ hoarseness □ nose bleeds □ excess saliva □ recurrent □ allergies □ dry mouth □ sore throat □ nasal discharge □ gum disease □ loss of voice □ bad breath □ difficulty color : □ yellow □ white □ clear □ gum bleeding □ swallowing □ green □ gum swelling □ “lump in th throat” amount : □ scanty □ frequent □ mod □ heavy □ ulcers □ tonsillitis □ thick □ thin □ sores □ freq. sore throat □ dry nose □ dry lips □ taste in mouth □
other _____________________________________________________________________________________________________
CARDIOVASCULAR (Please check all that that apply to you within the last 3 months) □
□
high blood pressure pressure pressure □ low blood pressure □ dizziness □ fainting □ palpitations
chest pain □ cold hands/feet □ swelling hands/feet □ irregular heart beat □ insomnia
□ □ □ □ □
difficulty in breathing shortness of breath dream disturbance poor memory mania/delirium
□
coma □ loss of consciousness □ heart pounding □ stifling sensation in chest other: ____________________
RESPIRATORY (Please check all that apply to you within with in the last 3 months) □ pneumonia
cough: cough: how long? ________________ □ dry □ croup □ rapid □ other phlegm: phlegm: □ thin □ thick □ clear □ white □ yellow □ green chest □ allergies □ tightness in chest □ sinus infection □ post nasal drip chest □ sinus congestion □ heaviness in chest
□
bronchitis □ asthma □ coughing blood □ wheezing □ frequent colds □ chronic cough
□
shortness of breath □ fullness in chest difficulty breathing: breathing : □ sitting □ lying down □ difficulty inhaling or exhaling □ frequent sighing chest discomfort □ other chest
GASTROINTESTINAL (Please check all that apply to you within the last 3 months) □
food allergies □ vomiting □ cramping meals □ gas after meals □ abd/stomach pain □ nausea □ overeat □ tastelessness eating □ fatigue after eating
□
taste in mouth □ belching □ bad breath □ hiccup □ constipation □ diarrhea □ "outh sores □ heart burn/reflux □ bulimia
□
loose stools □ bloody/black stools □ ulcers □ increased appetite □ poor appetite □ hungry-no desire to eat □ dry, hard stools □ “nervous stomach” □
cravings
□
difficult stools stools □ mucus in stools □ hemorrhoids □ hernia □ rectal pain □ rectal bleeding □ pain with passing stool □ flucttion ls □ gall stones
□ □ □ □ □ □ □
tenderness in abdomen abdomen fullness in abdomen abdomen burning in abdomen abdomen like/dislike pressure like/dislike cold like/dislike warmth difficulty swallowing
GENITO-URINARY (Please (Please check all that apply to you within the last 3 months) □
burning /painful urine stream/scanty urine □ poor stream/scanty □ diminished sex drive color : □ cloudy □ pale □ dribbling urine □ increased sex drive □ dk yellow □ pink/red □ unable to urinate □ impotency □ unable to hold urine □ frequent urination □ genital itching □ urgency to urinate □ sexually active ? □ genital sores/pain up to urinate more more than once per night How many many times?__________ □ wakes up
□
discharge □ history of kidney stones □ history of bladder infections □ history of prostate problems □ history of STD
NEUROPHYSIOLOGICAL (Please check all that that apply to you within the last 3 months) □
history of mental illness illness □ depression □ anxiety □ easily stressed □ confusion/foggy □ lack of clarity □ moody □ fear/fright □ hyper □ sadness □ frustration
□ melancholy □
grieving easy to anger anger □ irritability □ restlessness □ emotional □ frequent sighing □ over-worried □ bad-tempered □ tics □ hopelessness □
□
joyful □ giddy □ over-thinking □ talkative □ silent □ extrovert □ introvert □ poor memory □ seizures □ panic □ feeling stuck
□ tremors/shaking □ convulsions □
coma □ concussion □ paralysis □ trauma at birth □ vaginal delivery □ cesarean □ considered/attempted suicide focus □ unable to focus □ phobia □ seeing therapist
MEN’S HEALTH (Please check all that apply to you within the last 3 months) □ prostate
problems □ decreased libido □ hernia □ infertility □ history of STD
□
swellings, lumps and pain in testicles □ discharge from penis genitals □ cold feeling in genitals □ difficult achieving and maintaining erection □ difficult ejaculation □ injury to reproductive organs sexually active □ painful erections □ currently sexually □ other:___________________________________________________________
MUSCULO-SKELETAL (Please check all that apply to you within the last 3 months)
Area:: Area::
□
face □ jaw □ chest □ epigastric area □ rib cage □ low abdominal □ pelvic □ genitals □ neck □ shoulder □ fingers □ upper back □ mid back □ knee □ lower back □ sacrum/tailbone □ sciatica □ upper limbs □ lower limbs □ feet □ whole body □ bone □ muscle □ joint Rate the pain: pain: Scale 1-10 (10 worst) 1 2 3 4 5 6 7 8 9 10 Please indicate which side is affected: _____ ______________________________________ ________ How often is the pain present □ 0-25% □ 26-50% □ 51-75% □ 76-100% of the time Do you often carry heavy objects? □ not often □ often Is/does your pain? pain? : □ fixed □ moves around □ radiates □ sharp □ dull □ aggravated by □ alleviated by: □ sitting □ standing □ movement □ pressure □ warmth Is the pain □ cold □ other:_____________ other:___________________________ ____________________________ ___________________________ ___________________________ ___________________________ ________________________ ___________ Do you have? □ pain □ swelling □ burning □ weakness □ numbness □ tingling □ arthritis □ clicking □ stiffness □ spasms □ twitching □ shaking □ soreness □ tenderness □ unsteadiness □ tension □ heaviness □ better with movement □ worse with □ hernia with movement movement
GYNECOLOGY AND PREGNANCY (Please (Please check all that apply to you within the last 3 months) Date of last PAP:_______ Last Menstrual Menstrual Period:_________________ □ light red □ red □ dark red □ red/purple □ purple □ dk purple □ brown color : □ pale red □ pelvic pain □ currently sexually active □ pregnant currently □ # of pregnancies __________ □ # of live births __________ □ no. of miscarriages _________ □ # of abortions__________ □ # of premature birth ______ □ age at first menses menses □ fibroids □ endometriosis □ length of period________ □ abd. Bloating/fullness □ spotting between periods clots: □ large □ small □ early menstrual menstrual cycle(less 21 days) □ mood change change before before period □ body change change before before period □ late menstrual cycle (less than than 35 days) days) Menstrual pain/cramps: pain/cramps: □ before □ during □ after Vaginal discharge: □ odor □ no odor □ watery □ thick □ curdy □ itchy color : □ clear □ white □ yellow □ bloody □ infertility □ pain during during intercourse □ irregular menstrual menstrual cycle cycle □ days of heavy flow ______ □ uterine prolapsed □ menopause: □ endometriosis menopause: □ pre □ post birth control pills: pills: type ______________ how long? _________
□
age at menopause ______ flow: flow: □ thick □ thin □ history of ovarian cysts amount : □ scanty □ mod □ history of uterine problems □ heavy □ very heavy □ hormone replacement □ decreased libido
□ □ □ □
vaginal burning/itching vaginal pain genital eruptions absent menstruation
BREAST (Please check all that apply to you within the last 3 months) months) □ □ □
history of breast disease breast lumps/masses history of breast cancer
□ □ □
breast tenderness breast discharge: discharge: □ clear □ white □ yellow □ green □ black □ blood □ watery □ thin □ thick breast fullness/swelling breast pain other: ____________________________________ _____
INFERTILITY (Please explain with as much detail as possible) How long have you been trying to get pregnant? pregnant? _____________________________________________________________ Have you tried any method of assisted reproduction? ________________________________________ __________________ Any long term exposure to chemicals? chemicals? _____________________________________________________________________ Do you keep track of you menstrual cycle? cycle? __________________________________________________________________ Do you keep your BBT(Basal Body Temperature? Temperature? ____________________________________________________________ Do you test yourself for ovulation? ______________________________________ ___________________________________ Has your partner been evaluated for infertility? _________________________________________ ______________________ Anything else you would like to tell us? ________________________________________ ______________________________
ACUPUNCTURE INFORMED CONSENT TO TREAT I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according according to the instructions instructions provided orally orally and in writing. The herbs may have have an unpleasant smell smell or taste. I will immediately immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, cupping, or when treatment involves involves the use of heat lamps. lamps. Bruising is a common common side effect of cupping. cupping. Unusual risks of acupuncture include spontaneous spontaneous miscarriage, nerve damage damage and organ puncture, including lung puncture (pneumothorax). (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes describes the major risks of treatment, other side effects effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal a nd mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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.
ACUPUNCTU ACUPUNCTURIST RIST NAME: NAME:
(Date)
PATIENT SIGNATURE
X
(Or Patient Representative) Representative)
(Indicate relationship if signing for patient)
ALSO
AAC-FED
SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE
A2004
PATIENT NAME:
ARBITRATION AGREEMENT malpractice, including whether any medical services services Article 1: Agreement to Arbitrate: Arbitrate: It is understood that any dispute as to medical malpractice, rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration arbitration proceedings. Both parties to this contract, contract, by entering into it, are giving up their constitutional constitutional right to have any such dispute decided in a court of la w before a jury, and instead are accepting the use of arbitration. does not relate to medical malpractice, malpractice, including Article 2: All Claims Claims Must be Arbitrated: It is also understood that any dispute that does disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims claims arising out of or relating to treatment or services provided by the health care provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence occurrence giving rise to any claim. This agreement is intended intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not. All claims claims for monetary monetary damage damages s exceed exceeding ing the the jurisdi jurisdictio ctional nal limit limit of the the small small claims claims court against against the health health care care provider, provider, and/or and/or the health health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including , without limitation, claims claims for loss of consortium, wrongful death, emotional distress, distress, injunctive injunctive relief, or punitive damages. This agreement is intended to create an open book a ccount unless and until revoked. arbitration must be communicated communicated in writing to all all parties. Each party shall shall Article 3: Procedures and Applicable Applicable Law: A demand for arbitration select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days days thereafter. The neutral arbitrator shall then then be the sole arbitrator and shall decide the arbitration. arbitration. Each party to the arbitration shall pay such party’s pro rata share of the e xpenses and fees of the neutral arbitrator, together with ot her expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. transaction, or related circumstances circumstances shall be arbitrated in one Article 4: General Provision: All claims based upon the same incident, transaction, proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. written notice delivered to the health care provider within within 30 days of signature Article 5: Revocation: This agreement may be revoked by written and, if not revoked, will govern all professional services services received by the patient and all other disputes between the parties. this agreement to cover cover services rendered rendered before the date it is signed (for example, example, Article 6: Retroactive Effect: If patient intends this emergency treatment), treatment), patient should should initial here. _______. Effective Effective as of the date of first professional professional services. services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity invalidity of any other other provision. I understand that I have have the right to receive a copy copy of this Arbitration Agreement. Agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS THIS CONTRACT, YOU ARE AGREEING AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. (Date)
PATIENT SIGNATURE
X
(Or Patient Representative) Representative)
(Indicate relationship if signing for patient) (Date)
OFFICE SIGNATURE
X
.
ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE
AAC-FED
A2004
