ACUPUNCTUREVISITINITIALINTAKEFORMName________________________________________Date________________________________________DateofBirth________________________________(M/D/Y)SexMF(pleasecircle)Address:________________________________________________________________________________________________E-mailAddress_______________________________________________________________________________HomeTelephoneNumber_________________________Work__________________________________EmergencyContact:_________________________________Phone:_________________________________Whatareyourhealthgoalsorconcerns,inorderofimportancetoyou?1.______________________________________2.______________________________________3.______________________________________4.______________________________________MEDICALHISTORYIfyouarefemale,areyoucurrentlypregnant?YESNO(Pleasecircle)Doyouhaveanyallergies(medicines,environmental,etc.)?_________________________________________________________________________________________________Pleaselistallcurrentmedications(prescription,over-the-counter,vitamins,herbs,homeopathic,etc.)_________________________________________________________________________________________________Doyoufrequentlyuseanyofthefollowing(circle):Aspirin/Laxatives/Antacids/Dietpills/Alcohol/Caffeine/RecreationalDrugs.BirthControl:Pills/Implants/InjectionsPleaselistallHospitalizations,Surgeries,Scars,X-rays,CATScan,MRI,etc.:_________________________________________________________________________________________________ENVIRONMENTOccupation____________________________________________________________________________________Areyouexposedtosignificanttobaccosmoke(work,homeetc.)YESNOAreyoufrequentlyexposedtoanimals(work,pets,etc.)YESNO

INFORMEDCONSENTANDPRIVACYPOLICY

AcupunctureandTraditionalChineseMedicine(TCM)arethetreatmentandpreventionofdisease with the use of natural tools. Acupuncture and TCM assess and treat the wholepersonusinggentleandnon-invasivetechniquesthatstimulatethebody’sinherentabilitytoheal.Anumberofdifferenttreatmentmodalitiescanbeusedtotargetaspectsofmental,physical,emotionalandspiritualwellbeing.Treatmentmodalitiescanincludeacupuncture,acupressure,cuppingtherapy,guasha,moxibustion,TDP(heatlamp),electro-acupuncture,auricular acupuncture, dietary modification, lifestyle counseling, nutritionalsupplementation,BotanicalMedicine,Chineseherbs,andhydrotherapy.Yourfirstvisitwillinvolveathoroughcasehistory,acomplaint-orientedphysicalexamanda treatmentsession.At times,even thegentlest therapiescancausecomplications inverysensitiveindividuals.Sometherapiesshouldbeusedcautiouslyinthosewithdiseasesor conditions involving the heart, liver, or kidneys, those taking medications, andthosepreparing forpregnancyor lactation. It isofutmost importancethatyou informyourDoctorassoonaspossibleifyoushouldhaveoneofthesecautions.IunderstandthatmyDoctorwillanswermyquestionsandgivemetreatmentandadvicetothebestofherability.Iunderstandthatresultsarenotguaranteed,andIdonotexpectthedoctor to anticipate all risks and complications of treatment. With this knowledge, Ivoluntarilyconsenttodiagnosticandtherapeuticproceduresmentionedabove.HealthrisksassociatedwithAcupunctureandTCMinclude,butarenotlimitedto:

• Aggravationofpre-existingsymptomsduringthehealingprocess.• Allergicreactionstosupplementsorherbs.• Pain,localbruisingorminorbleedingfromacupunctureneedles.• Faintingorpuncturingofanorganwithacupunctureneedles.• Rednessorblisteringfromcupping,TDP(heatlamp)ormoxibustion.

TheDoctormayprescribesupplementsthatcanbepurchasedattheclinicoratotherlocaloptionsi.e.healthfoodstores.Mostinsurancecompaniesdonotcoverthesupplementsthatweprescribeanddispense.Iunderstandthatfeesandsupplementsaretobepaidforatthetimeofconsultation.Asthepatient,Iamresponsibleforthelocalchargesincurredforeachvisit.Iunderstandthatafeeequivalenttohalfthetreatmentpricewillbechargedforanymissedappointmentsorcancellationswithlessthan24hoursnotice.Signature:_____________________________________Date:_____________________________________________