On Point Acupuncture, LLC
12 Coulter Street, Old Saybrook, CT 06475 • 860-598-0459
Health History Questionnaire and Registration
P A TIENT I N FO RM ATION
CONTACT I N FORMATION
Date
Home phone
Name
Work phone
Address
Other/cell phone
City, State, Zip
Email
Age
Birth date
Gender
_
Pronoun
Emergency Contact:
Name
Occupation
Relationship
Company name
Phone
Primary physician
How did you hear about us?
Physician phone number
HEAL TH HIST O RY
What are your primary concerns for coming in for
treatment?
123-
How long has it been since you have had a complete
medical exam?
Check illnesses that have occurred in blood relatives.
 Diabetes High blood pressure Stroke
 Cancer
Heart disease Kidney disease
Check symptoms you have or have had in the last year:
□ Depression
□ Difficulty in focusing
□ Dizziness
How is your digestion?
□ Easily startled
□ Excessive worry or fear
□ Excessive anger or irritability
Are you currently taking pain medication or blood
□ Fatigue/tiredness
thinners? (including aspirin)
Yes
No
□ Headaches or Migraines
□ Loss of sleep/poor sleep
List medications or food supplements you are taking.
□ Loss or gain of weight
□ Overwhelmed by life
How is your sleep?
List serious illnesses, accidents, or surgeries.
List any known allergies.
Check conditions you have or have had in the past:
□ Allergies
Head trauma
□ Anemia
□ Arthritis
HIV/AIDS
□ Bleeding disorder
Hypo/hyper thyroid
□ Breast lump
Pacemaker
□ Cancer
Seizure
□ Diabetes
Stroke
HEALTH HIST ORY… C ONTIN U ED
Check symptoms you have or have had in the last
year:
M USC UL O SK E L E T A L
□ Tremors
Muscle cramps
□ Swollen joints
Pain, weakness, numbness in: (indicate side of
body)
Back
□ Arm
Hip
□ Wrist
Leg
□ Hand
Knee
□ Elbow
Ankle
□ Shoulder
□ Neck
Foot
EYES/E AR/N OSE/T HRO AT/R ESPIR ATO RY
□ Asthma/wheezing
□ Blurred or failing vision
□ Difficulty breathing
□ Earache
□ Enlarged glands
□ Eye pain
□ Frequent colds
□ Hay fever
□ Hoarseness
□ Gum trouble
□ Nose bleeds
□ Loss of hearing
□ Persistent cough
□ Ringing in ears
□ Sinus problems
C ARDI O V ASC UL A R
□ Chest pain
□ Hardening of arteries
□ High or low blood pressure
□ Pain over heart
□ Poor circulation
□ Previous heart attack
□ Rapid/irregular heart beat
□ Swelling of ankles
SK IN
□
□
□
□
□
□
□
Boils, acne
Bruise easily
Dry skin
Itching/rash
Sensitive skin
Sore won't heal
Sweats
URIN ARY
□ Bladder or urinary tract infection
□ Blood/pus in urine
□ Frequent urination
□ Inability to control urine
□ Kidney infection/stones
REP R O DU C TIV E
□ Lowered libido
□ Erection difficulties
□ Penis discharge
□ Prostate trouble
□ Infertility
□ Bleeding between periods
□ PMS, symptoms
□ Severe menstrual pain
□ Clots in menses
□ Excessive menstrual flow
□ Scanty menstrual flow
□ Irregular menstrual cycle
□ Menopausal symptoms
□ Previous miscarriage (#
)
□ Pregnancies to term (#
)
GAST ROIN TEST IN AL
□ Belching, gas or bloating
□ Colon trouble
□ Constipation
□ Diarrhea
□ Difficulty swallowing
□ Excessive hunger
□ Gall bladder trouble
□ Hemorrhoids
□ Indigestion
□ Nausea
□ Pain over stomach
Could you be pregnant?
□ Poor appetite
SIGN□ATUR
E
Vomiting
The information on this form is correct to the best of my knowledge.
Signature
Date
Office & Financial Policy
We require your signature on this form prior to treatment. Please read the following and then sign and date the
bottom of the page. Thank you.
Fee Schedule:
First Treatment
Follow-up Treatments and Herbal Consults
Chinese Herbs
$35-$55 sliding scale (includes $15 intake fee)
$20-$40 sliding scale
prices vary
Privacy Policies:
Patient has reviewed and acknowledges the Notice of Privacy Policies, HIPPA form. You can request a copy of our
privacy policies at any time.
General Policies:
Patient is responsible for payment of all fees. Payment is expected at the time services are rendered. We accept
personal checks, cash, Mastercard, Visa, Discover, and American Express.
Returned checks will incur a $25 fee, due and payable immediately.
Payment in full is due at time of service. We do not bill insurance companies directly. We are happy to submit a form
to your insurance for out-of-network reimbursement depending on your plan. You are responsible for verifying
coverage with your insurance company.
Cancellation Policy:
Your treatment time is reserved specifically for you. Please provide a minimum of 24 hours notice to cancel an
appointment.
Last minute cancellations or no-shows will incur a $40 fee.
Late Policy:
If the patient is late and treated, the appointment will be shortened and end according to the original start time of the
appointment.
Late patients will be charged the full treatment fee.
Gift Certificates:
Gift certificates may only be redeemed for services provided by On Point Acupuncture. Cash refunds will not be given
for any gift certificate.
By signing this form, I give permission to On Point Acupuncture, LLC to send cards, newsletters or other clinic
documents to the mailing address and email address on my health history questionnaire. I understand that I can
remove myself from such mailing lists and that On Point Acupuncture, LLC will keep my contact information
confidential.
Acknowledgement of Policies
I have reviewed and understood On Point Acupuncture, LLC’s Office & Financial Policy handout. I understand that
paper copies of the handout are available for my files and I may request a copy at any time.
Patient Signature:_________________________________________________________________________________________
Date:_________________________________________________________________________________________________________
12 Coulter Street
Old Saybrook, CT 06475
860-598-0459
[email protected]
Consent to Treatment
www.ctonpoint.com
Consent to Treatment
Consent to Treat
I hereby request and consent to the performance of Acupuncture treatments and other Chinese Medicine
procedures on me (or on the patient named below, for which I am legally responsible) by the Licensed
Acupuncturists of On Point Acupuncture, LLC. I understand that methods or treatments may include, but are
not limited to, acupuncture, moxibustion, cupping, bloodletting, electrical stimulation, Tui Na massage, Gua
Sha, Chinese Herbal Medicine, nutritional counseling, non‐insertive acupoint stimulation, and/or magnets.
Acupuncture attempts to normalize physiological functions, to modify the perception of pain and to treat
certain diseases of dysfunction of the body. I have been informed that Acupuncture is a safe method of
treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few
days. There have been very rare instances reported of fainting, infection and scarring. There may be some
bruising after cupping or Gua Sha. I wish to rely on the Acupuncturist to exercise judgment during the course
of the procedure which the Acupuncturist feels at the time, based on the facts then known, is in my best
interests
The herbs (which are from plant, animal and mineral sources) that have been recommended are traditionally
considered safe in the practice of Chinese Medicine. I understand the same herbs may be inappropriate
during pregnancy and will inform my practitioner immediately of pregnancy status. If I experience any
gastrointestinal reactions to the herbs I will inform the Acupuncturist immediately
I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me,
the above consent. I have also had an opportunity to ask questions about its consent, and by signing below I
agree to the above named procedures. 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.
I agree to pay all charges incurred for services rendered. I agree to pay a $40 charge for any missed or
forgotten appointments without 24‐hour notice of cancellation
By signing below, I agree to the above‐named procedures.
Patient Name (or Guardian if patient is under 18 yrs of age): ________________________________________________________
Signature:_________________________________________________________________________________________________________________
Print Name:________________________________________________________________________Date:_________________________________
Practitioner Signature:___________________________________________________________________________________________________
Updated March 24, 2015