TO THE NEW PATIENT:OUTLINE OF PROCEDURES FOR CARE

STEP 1: All new patients are requested to carefully read the included materials and fill out the generalinformation and Health History questions.

STEP 2: A one-on-one consultation will be done to discuss your health problems.

STEP 3: An Oriental Medical examination - including classical pulse diagnosis and tongue diagnosis ­will be given to determine the precise cause of your problem

STEP 4:The Acupuncturist will advise you if additional tests are needed.

STEP 5:You will be given an initial Report of Findings at which time the cause of your problem will

be discusse(;L It includes a through explanation of our treatment recommendations and what results canbe obtained .

.STEP 6: If you are accepted as a Patient, care will begin. Additional explanations will be given on thedifferent types of treatments that are available in the office.

STE? 7: An estimate of the future care that is needed will be given and upon your acceptance, carewill continue until the personal maximum correction of your problem has been obtained.

STEP 8: After maximum correction has been obtained, a schedule of care will be recommended to

help prevent future problems and maintain good health.

STEP 9: Cancellation Policy: If you cannot make an appointment, please notifY us by calling305-446-3009 as soon as possible. Recording machines are available 24 hours a day. Because we donot double-book patients, when you fail to arrive for an appointment, a hole is created in our schedule.Patients who have acute problems or need to be seen the same day may be inconvenienced or deniedtreatment. We ask that you provide 24 hours notice of a change or cancellation of a scheduledappointment. A charge applies to appointments that are not cancelled, or are cancelled less than 24

hours before the appointment. We understand that there are unavoidable emergencies and

inconveniences in everyone's life, but repeated problems keeping appointments will result in dismissalfrom the practice.

A cancellation fee of an appointment cancelled without 24 hour prior notice is $15.No shows are chan!ed $25.

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* Most patients that come to our office have one or two objectives in mind concerning their healthcare. Some patients come for only symptomatic relief of pain or discomfort relief care. Others areinterested in having the cause of the problem and the symptoms corrected. This is called correctivecare. Whether your goal is Relief Care or Corrective Care, or both, your Acupuncturist will weigh

your needs and desires when recommending your treament pro~am.

Relief Care Corrective Care Check here if you want theAcupuncturist to select the typeof care appropriate for yourcondition.

Date: __________ Patient' Signature:

PAYMENT RESPONSIBILITY..AGREEMENT

I understand and agree that health and accident insurance policies are an arrangement between an

insurance carrier and myself. Furthermore, I understand that Coral Gables Acupuncture & HerbalMedicine, Inc. will prepare any necessary reports and forms to assist me in making collection from theinsurance company and that any amount authorized to be paid directly to Coral Gables Acupunctureand Herbal Medicine, Inc. or Green Healthcare, LLC. will be credited to my account on receipt.

However, I clearly understand and agree that services rendered me are charged directly to me and that Iam personally responsible for payment. I also understand that if I should receive payment for clinicservices from my healthcare insurance company, I will submit all original information, documents,checks, explanation of benefits directly and immediately to this office.

I hereby authorize the Acupuncturist to treat my condition as he/she d----------appropriate and I also agree that I am responsible for all bills incurred at this office.

Patient's Signature:

For Minors:

Guardian or Spouse:

Date: .

Date:

I

r H:eaLth H:i.storyb.

" , ,QUestLo nnaLre

Infrn'rruuiorafrr your.d~Important: Complete this document as thoroughly as possible. Some of the questions thatfollow may seem unrelated to your condition, but they may playa major rolc in diagnosis andtreatment.

All inffn'11Ulhtm is sftictiy confidential.

I. General Patient Information

Date: __ /__ /__ Name: ~ _

Address; City. _

State Zip: Cell Phone: ( ), _

, Home Phone: () Work Phone: (..... ),_, _Age: Date of Birth: __ /--1__ Place of Birth: _Email (for appt reminders): ,-------------------------Gender. [ ] M ( ] F Height: __ '__ " Weight: __ lbs. '

Social Security Number: - - _

Driver's License Number: _

Occupation: Employer:. _Employer.Ad.dress: City _State .Zip _

Docs anything limit you ttom care? [ ] y [ ]N If yes, cxplain: _

How did you hear about our oftic:e? ~ _

Otbcr ph}'liM2n!t/thcrapists seen for this c:ondition., _Medications (ifany): _Prcscribcdby: _

Treatment:

Results:

Supplemcnts(if any vihf'l'\;M, herbs, ~ etc..): _

1

Patient 'nita's -----

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List Major Complaint(s), in order of significance to you:

(

1

2

3

4

5

6

7

Severeooooooo

Moderateooooooo

Slightoooo.0oo

Normalooooooo

How do these conditions impair your daily activities?

Paitient Medical History:

1. How was your childhood health_? _

2. Hospital Visits/Stays:

3. Recent Tests:

o Physical 0o HIV / STD 0

4. Test Results & Date:

Cholesterol

Pap smear

2

o Prostateo Blood

o Mammographyo Other

Patient Initals _

..-- /' "'\, (

'''-..-

Check any you have had in the past:

(7'-"\. (

o D~abetes 0 Allergies 0 Glaucoma . 0 Rheumatic Fevero Heart Disease 0 ~VA (stroke) 0 Vein condition 0 Thyroid disordero Asthma 0 Pneumonia 0 'Juberculosis 0 Emphysemao Jaundice 0 Gonorrhea 0 Mumps 0 Bleeding tendencyo Syphilis 0 Measles 0 Chicken. pox 0 ,Nervous disordero Meni~gitis 0 HIV 0 Polio 0 Mononucleosis

o Epilepsy 0 High fever 0 Hepatitis 0 'Multiple Sclerosiso Paralysis 0 Cancer 0 Migraines 0 High blood pressureo other lung illnesses 0 other li~er illnessesO other heart illnesses 0 other kidney illnesseso othe~ spleen illnesses 0 other stomach illnesseso other:, _

Immunizations: _

Surgeries:. _

III. Family History

Family member

AliveDeceasedPresent health or cause of deathFather

00

Mother

00

Spouse

00

Children

00

Brother

00

Brother

00

Brother·

0O'

Sister

00

Sister

00

Sister

00

3

Patient Initals -----

(-'----- (

Where areyou in the birth order? 0 first 0 last 0 middle 0 onlyCheck the following that have occurred in your blood relatives:

o Diabetes

o Allergieso Kidney diseaseo Stroke

a Cancero Tuberculosiso Alcoholismo Other

o Heart disease

o Obesiryo Nervous Illness

o High blood pressUrca Bleeding tendencya Mental illness

Please clearly mark any areas of PAIN and any SCARS:

~

. )h.. i

Do the following worsen the pain? • 8o Pressure 0 Cold 0 Heat J~~

o Other:

Please cheek the following that pertain to you:, A' . (\ \Overall Temperature (Kidney function): I I I lo Cold hands

o Cold feet

o Sweaty h4Ulds

a Sweaty feet J

o Hot body temperature (sensation)

o Afternoon flushes \

o Night sweats \

o Heat in the hands, feet, and chest IJ'o Hot flashes any time of the day ,.1

o Thirsty C-O Perspire easilyo Lack of perspiration

a Aching

o Moving

o Burningo Dullo Other:

Do the following lessen the pain?o Pressure 0 Cold 0 Heato Exercise 0 Other:

Is the pain:a Sharpo Cn.mpingo Fixed

Patient 'nita's ------------------- -

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o Take water to bed

o Difficulty keeping eyes open in the daytime

Overall Energy (Lung, Kidney function):o Shortness of breath

o Difficulty keeping eyes open in the daytimeo General weakness

o Easily catch coldso Low energyo Feel worse after exercise

Blood (Liver, Spleen, Heart function):o Dizziness

o See floating black spots

Heart function:

o Palpitationso Anxiety

o Sores on the tip of the tongueo Restlessnesso Mental confusion

·0 Chest pain traveling to shouldero Frequent dreamso Wake unrefreshed

o Drink coffee (# of cups per week:--~)

f(

o Overall achy feeling in the bodyo Stiff necko Stiff shoulderso Sore throat

o Difficulty breathingo Smoke cigarettes (# of cigarettes per day:

)o Sadness

o Melancholy

.Spleen function:o Low appetiteo Abrupt weight gaino Abrupt weight losso Abd6nunal bloatingo Abdominal gaso Gurgling'noise in the stomacho Fatigue after eatingo Prolapsed organs (previously diagnosed,

which organ? )o Easily bruisedo Hemorrhoidso Pensive

DOver-thinkingo Worry

)

Spleen, Stomach, Large Intestine, SmallLung function: Intestine function:o Nasal Discharge (Color: ) 0 Loose

o Cough 0 Constipatedo Nose Bleeds 0 Incompleteo Sinus Congestion 0 Diarrheao Dry mouth 0 Blood in stoolso Dry throat 0 MucoUs in stools

o Dry Nose 0 Undigested food in stoolso Dry Skino Allergies (To what? ) Dampness trapped in the body:o Alternating fever and chills 0 General sensation of heaviness in the bodyo Sneezing 0 Mental heavinesso Headache (Location: 0 Mental sluggishness

o Mental fogginess

5Patient Initals _

------~_..- .._-----_ .. -.. -

(.~

o Swollen hands

.0 Swollen feet

o Swollen joints

o Chest congestiono Nausea

o Snoring

Stomach function:

o Burning sensation after eatingo Large appetiteo Bad breath

o Mouth (canker) sores

o Bleeding, swollen or painful gumso Heartburn

o Acid regurgitationo Ulcer (diagnosed)

o Belchingo Hiccoughs

. 0 Stomach pain

. 0 Vomiting

Liver~ Gall BI3.dder function:

o Alternating diarrhea and constipationo Chest pain

o Tight sensation in the chesto Bitter taste in the mouth

o Anger easilyo Frustration

o Depression

o Irritability

o Frequendy unable to adapt to stress (Whatcauses the stress?

)o Skin rashes

o Headache at the top of the head

o Tmgling sensationo Numbness

o Muscle spasms

o Muscle twitching

o Muscle crampingo Seizures

6

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o Convulsions

o Lump in the throato Neck tension

o Limited Range-of-Motion, Necko Shoulder tension

o Limited Range-of-Motion, Shouldero Drink alcohol

o Recreational drugs (Which?_________ .,How much perweek? )

o High-pitched ringing in the earso Gall stones (history or current)a Sexually transmitted clisease (Which?

)

Eyes (Liver function):o Itchy .a Bloodshot

a Hot

o Dryo Watery

o Gritty '..o Blurry vision

o Decreased night visiono Near-sighted

o Far-sighted

Kidney, Urinary Bladder function:

o Freq';lcnt cavitieso Easily broken boneso Sore knees .

o Weak kneeso Cold sensation in the knees

O· Low back pain

o Memory problemso Excessive hair loss

o Low-pitched ringing in the ears

o Kidney stoneSo Bladder infections

a Wake during the night twice' or more tourinate

Patient Initals _

( (

0Lack of bladder controll0

Fear

Easily startledUrination:

0Normal 0Scanty 0Discharge

0Dark Yellow0Profuse 0Difficult

0Clear 0Strong Odor 0Urgent

0Reddish 0Burning 0Frequent

0Cloudy 0Painful 0Other

Sleep Profile:

0Trouble going to Sleep 0Trouble waking up

0Trouble Staying Asleep 0Disturbed Sleep

Explain:

Women Onlv:

Regular Menstrua.~Cycle:

0Yes 0No

Number of Children:

Pregnant?0Yes0No

Age of First Menstruation:

Age of Menopause:(if applicable)Average # of days of flow:

Average # of Days:

Cycle:

."

Severe

ModerateSlightNormal

Vaginal Discharge:

0000

Bleeding:

0000

Do you experience any of the following pre-menstrual syndromes?

0Nausea 0Vomitting 0Depression

0Headaches0Migraines '0Water Retention

0Anxiety 0Breast Swelling0Dull Pain, where?

0Food Cravings0Breast Tenderness0Sharp Pain, where?

0Irritability0Water Retention

Other:

7

Patient Initals _

.'

Please fill in the following menstrUal chart:(Put in a number and what color it is)

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Day 1Day 2Day 3Day 4Day 5Day"6Day 7

Color (normal, bright red, pale, brown, rust, dark, purple, other)Amount of flow (normal, heavy,light)Pain/cramps (location, dull,sharp, other)ClotS (large, small, black, purple,red, other)Vomiting (checkif yes)Nausea (check if yes)Other

~en only:Severe

ModerateSlightNormal. "

o Swollen testes0000

o Testicular pain

0000o Impotence

0000o Premature ejaculation

0000.0 Feeling of coldness or numbness in external genitalia

0000o Other

.."0000All please fill out:

Other Comments:

Patient Signature:

Acupuncturist Signature:

8Patient Initals -----

(I ('

To be completed by the patient's representativeif necessary, if the patient is a minor or is

Physically or legally incapacitated.

INFORMED CONSENT FORACUPUNCTURE TREATMENT AND CARE

I hereby request and consent to the performance of acupuncture treatments and other OrientalMedicine procedures, including various modes of physio-therapy on me (or on the patient namedbelow, for whom am legally responsible) by the below named licensed acupuncturist and/or otherlicensed acupuncturist who now or in the future treat me while employed by, working or associatedwith or serving as a back-up for the treating acupuncturist named below, including those working atthis office clinic or any other office or clinic.

I understand that methods or treatment may include, but are not limited to acupuncture,moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese or WesternHerbal Medicine, or Nutrional counseling, Manual Therapy, Myofascial Release, Trigger PointTherapy, Mobilization, Gliding, Therapeutic Stretching. I have had the opportunity to discuss withthe acupuncturist named below and/or with other office or clinic personnel the nature and purposeof acupuncture treatment and other procedures.

Acupuncture has the effect to normalize physiological functions, to modify the perception of pain,and to treat certain diseases of dysfunctions of the body. I have been informed that acupuncture is asafe method of treatment, but occasionally there may be some bruising or tingling near the needlingsites that last a few days. There have been very rare instances reported of fainting, infections andscarring. There have been extremely rare instances reported of spontaneous miscarriage andpheumthorax. There may be some bruising after cupping.

The herbs and nutritional supplements (which are from plant, animal and mineral sources) that havebeen recommended are traditionally considered safe in the practice of Chinese Medicine. Iunderstand 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 do not expect the acupuncturist to be able to anticipate and explain all risks and complications,and wish to rely on the acupuncturist to exercise judgment during the course of the procedure whichthe acupuncturist feels at the time, based upon the facts then known, is in my best interests. Iunderstand the clinical and administrative staff may review my medical records and lab reports, butall me records will be kept confidential and will not be released without my written consent.

I have read, or have had read to me, the above consent, I have also had an opportunity to askquestions about its content, and by signing below I agree to the above-named procedures. I intendthis consent form to cover the entire course of treatment for my present condition and for any futurecondition(s) for which I seek treatment.

To be completed by the patient:I have read and understand the above information.

PATIENT'S NAME _

PATIENT'S SIGNATURE _

DA TE SIGHNED

Are you pregnant? YES NO

NAME OF THE PATIENT _

PATINET'S REPRESENT ATIVE _

RELATIONSHIP OR AUTHORITY OFPATIENT

WITNESS

NAME OF CUNICIOFFICE: Coral Gables Acupuncture and Herbal Medicine or Green HealthCare, LLC

NAME OF TREATING ACUPUNCTURIST: STEVE A. CHASENS A.P., PAT BARBEE A.P., ROBERTBARROCAS A.P., JEAN-PIERRE CHACON A.P., DOREEN COTT A.P., CHRISTINE ROBAINA A.P.

(New patient consent to the Use and disclosure of Health Information for Treatment,

Payment, of Healthcare Operation

I, , understand that as a part of my health care, Coral GablesAcupuncture and Herbal Medicine or Green Healthcare, LLC originates and maintains paper and/orelectronic describing my health history, symptoms, examination and test results, diagnosis,treatments, and any plans for the future care or treatment. Iunderstand that thIS information servesas:

• A basis for planning my care and treatment.• A means of communication among the main health professionals who contributes to my care.• A source of information for applying my diagnosis and surgical information to my bill.• A means by which a third-party payer can verify that services billed were actually provided,

and

• A tool for routine healthcare operations such as assessing quality and reviewing thecompetence of health care professionals.

I understand and have been provided with a Notice of Information Practices that provides a more completedescription of information uses disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent.• The right to object to the use of my health information of directory purpose, and• The right to request restrictions as to how my health infOl:mation may be used or disclosed to

carry out treatment, payments, or health care options.

I understand that Coral Gables Acupuncture and Herbal Medicine or Green Healthcare, LLC is not requiredto agree to the restrictions requested. lunderstand that I may revoke this consent in writing, except to theextent that the organization has already take action in reliance thereon. I also understand that by refusing tosign consent or revoking this consent, this organization may refuse to treat me as permitted by section164.506 of the code of Federal Regulation:

I further understand that Coral Gables Acupuncture and Herbal Medicine or Green Healthcare, LLCreserves the right to change their notice and practices and prior to implementation, in accordance withsection 164.520 of the code of Federal Regulations. Should Coral Gables and Herbal Medicine or GreenHealthcare, LLC change their notice, they will send a copy of any revised notice to the address I'veprovided (whether U. S. mail or if! agree, email).I wish to have the following restrictions to the use or disclosure of my health information:

I understand that as part of this organization's treatment, payment, or health care operations, it may becomenecessary to disclose my protected health information to another entity, and I consent to such disclosure forthese permitted uses, including via fax.

I fully understand and accept/decline the terms of this consent and acknowledge the receipt of privacynotice.

Patient Signature _

Date _

For office use only

{ } Consent received by on _{ } Refused by Patient and Treatment refused as permitted.{ } Consent added to the patients medical records on _

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Acknowledgement of Receipt of Privacy Notice

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I have been presented with a copy of My Practice's Notice of Privacy Policies,anddetailing how my information may be used and disclosed as permitted under federal andstate law. I understand that the contents of the Notice,and I request the followingrestriction(s) concerning the use of my persona; medical information:

Further, I permit a copy of the authorization to be used in place of the original andrequest payment of medical insurance benefits either to myself or to the party whoaccepts assignments. Regulations pertaining to medical assignment of benefits apply.

Signed: _ Date:

If not signed by, please indicate relationship to patient (e.g., spouse)

Relationship: _' _

Internal Use Only:

Witnesses by: ~ __

If a patient representive refuses to sign acknowledgement of receipt of notice, pleasedocument the date and time the notice was presented to patient and sign below.

Presented on (date and time): _

By: (name and title): _