Patient Application Form- Acupuncture

Patient Application Form- Acupuncture
Welcome to our clinic!
Our purpose is to help you achieve your highest level of health by providing services
that seek to restore and maintain your body to its optimum function. Our care is based
on the scientific principles of anatomy and physiology and is focused on addressing
causes of health problems instead of simply treating symptoms.
Our initial objective is to determine if you are in the right office. We must consider
what issues you are having as well as what you are seeking. Please fill out the following
information completely so we have as much information as possible to determine if we
can accept your case.
Please feel free to ask any questions if you need assistance.
We look forward to serving you!
Patient’s Name
Patient’s Signature
Guardian Signature (if patient is under age 18)
Title: Mr./Mrs./Ms./Dr./Rev./Rank____________
Last Name____________________________ First Name________________________ M.I_______ Nickname_______________
Address_____________________________________________________ City__________________ State_____ Zip_________
Mobile Phone______________________ Home Phone____________________ E-Mail__________________________________
Date of Birth____________________________ Age___________
Gender: M
Marital Status:
Employer Name___________________________________________ Occupation______________________________________
Spouse Name________________________ Phone_________________ Spouse Employer/Occupation_____________________
Children (names, ages) ____________________________________________________________________________________
Most of our patients are referred by a family member or friend, what made you decide to visit our office?
□ Friend or Family Member Name______________________________________________________________________
□ Website
□ Internet search
□ Facebook
□ Sign/Drive-by
□ Presentation
□ Other______________
Have you, your spouse or children ever received Acupuncture? ____________________________________________________
Primary Physician _________________________________________________________________________________________
Reason for this visit:_______________________________________________________________________________________
Approximately, when did this condition begin?___________________________________
Did it begin: Gradually Suddenly
What makes your symptoms worse?__________________________________________________________________________
What makes your symptoms better?__________________________________________________________________________
Symptom characteristics:
Does it radiate into your arms or legs? Yes No
Is the condition getting worse? Yes No
How often do you experience these symptoms throughout the day? 100% 75% 50% 25% 10% Only with activity
Does your complaint interfere with: ___Work ___Sleep ___Hobbies ___Daily Routine
Have you experienced this condition before? Yes No If yes, please explain _______________________________________
Have you been evaluated/treated for this? Yes No If yes, by whom?_____________________________________________
What did they do? _________________________________________________________________________________
How did you respond? ______________________________________________________________________________
On a scale of 1-10, please rate your pain level.
( )0
Low Pain
( )1
( )2
( )3
Moderate Pain
( )4
( )5
( )6
Intense Pain
( )7
( )8
( )9
Please place “X’s” where you feel your pain.
( ) 10
Please mark all that apply:
___Bleed Easily
___Heart Disease
___Kidney Disease
___Thyroid Disorder
___Birth Trauma
___Lyme Disease
___Varicose Veins
___Alcoholism/Substance Abuse
___Hepatitis A / B / C
___Irritable Bowel Syndrome
___High Blood Pressure
___Multiple Sclerosis
Please list any health conditions not mentioned:_________________________________________________________________
Are you pregnant?
If so, how many weeks? ___________________________________________________
Please list all past surgeries, major illnesses or diseases, hospitalizations, injuries or accidents (with approximate date):
Current medications:
For what symptoms:
For how long?
Side effects you have experienced:
______________________________ _________________
______________________________ _________________
______________________________ _________________
______________________________ _________________
______________________________ _________________
Are you taking or have you recently taken:
Coumadin, Warfarin or any other blood thinner? Yes No
Lithium, Zoloft, Prozac or any anti-depressant/Anti-anxiety medication? Yes No
Sleeping Pills? Yes No
Do you drink alcohol? Yes No What and how much?__________________________________________________________
Do you drink coffee/tea? Yes No How many cups per day?_____________________________________________________
Do you drink soda? Yes No How many per 12 oz. servings per day?______________________________________________
Do you drink water? Yes No How much per day?____________________________________________________________
Do you eat vegetables and fruits? Yes No How many servings per day?____________________________________________
Do you eat meat? Yes No
How much?____________________________________________________________________
Do you eat sweets? Yes No How much?___________________________________________________________________
Do you eat dairy products? Yes No How much?_____________________________________________________________
How often do you eat processed foods?
Do you take any supplements (i.e. vitamins, minerals, herbs)?_____________________________________________________
Do you have any food cravings? Yes No If yes, explain: _______________________________________________________
Do you have any food intolerances? Yes No If yes, explain: ____________________________________________________
Are you excessively thirsty? Yes No
Do you exercise? Yes No
What kind of exercise? ________________________________
How is your general energy level?
Very Low
How often?_______________
Very High
Are you sedentary or active? ________________________________________________________________________________
_____Panic Attacks _____Depression
_____Poor Memory
_____Difficulty Concentrating
How many hours do you sleep each night? __________________
Do you perspire while you sleep? Yes No
_____Difficulty Falling Asleep
Do you perspire during the day without cause? Yes No
_____Restless Sleep
_____Disturbed Sleep
_____Waking at Night
Do you currently have or have you had a major incidence in the past with any of the following?
____Acid Reflux
How often do you have a bowel movement? ______ times per day/week
How many times do you urinate per day (average)? _________________
_____Bladder Infections
_____Frequent Urination
Light or Dark in Color? ________________________
_____Pain During Urination
Do you wake up at night to urinate? Yes No
GYNECOLOGY (females only)
Age Menses Began: ______
Days of Menstrual Flow: ______
Number of Pregnancies: _____ Number of Live Births: _____
____Heavy Flow
____Light Flow
____Uterine Fibroids
____No Flow
Length of Cycle (day 1 to day 1): ______
Date of Last PAP: ___________ Age at Menopause: _______
____Blood Clots
Cystic Breasts
____Vaginal Discharge
____Painful Periods
____Irregular Periods
PROSTATE (males only)
Last Prostate Check-Up:________________ Results/PSA Count:___________________
How Is Your Sex Life? ______________________________________________________________________________________
How Is Your Libido? _______________________________________________________________________________________
Do You Smoke? Yes No
____Frequent Colds
____Ear Pain
______Erectile Dysfunction
_____ Cigarettes/Day for _____Years
____Cold Sores
____Ringing in Ears
____Bleeding Gums
____Dry Mouth
____Excessive Phlegm
_____Chest Pain
_____Varicose Veins
_____Cold Hands/Feet
_____Irregular Heart Beat
____Dry Skin ____Skin Rashes
_____Poor Circulation
_____High Blood Pressure
_____Low Blood Pressure
_____Blood Clots
____Hair Loss
____Joint Pain ____Arthritis ____Muscle Tightness ____Numbness ____Tendonitis ____Osteoporosis ____Swelling
FAMILY HEALTH HISTORY (indicate if a blood relative has had any of the following)
___High Blood Pressure
___Vascular Disease
___Heart Disease
I attest that all of the above information is correct to the best of my knowledge.
Patient/Guardian Signature
Please eat a moderate amount of food 1 to 1½ hours before your appointment.
Please dress comfortably or wear loose clothing so that your arms and legs may be accessible. If we need to have access
to your back or other areas that require the removal of clothes, we will drape you appropriately with a sheet.
Whenever possible, please arrange your schedule so you do not have to rush to or away from the clinic.
Please tell us if you are uncomfortable with physical touch or with discussing certain activities or parts of the body.
Feel free to ask any questions that may arise during your treatment. It is important that you feel informed and
understand your own health!
Cancellation must be done via phone and at least twenty-four (24) hours prior to your appointment time, or you may be
charged for the appointment and/or released from care.
Payment is due at the time of service & may be paid in cash, check, or credit card
There will be a $25 charge on any returned checks (plus the original amount of the check)
We keep a record of the health care services provided to you. You may ask to see a copy of that record. We will not disclose
your records to others unless you direct us to, or unless the law authorizes or compels us to. You may see your record or get
more information about it by contacting Dr. Jason Degenhardt, D.C.
We may share your health information to run our office, collect payment, treat you, thank you for referring others,
discuss your case with your family, include you in health care classes, help you collect from your insurance company,
inform you about other services, or provide assistance with your diagnosis or treatment from another provider or
We may use your health information for health and safety reasons, court hearings and filings, reporting to law
officials and for reporting victims of abuse.
We may call you by name in the reception area when the doctor is ready to see you.
A postcard may be mailed to you at the address provided by you.
When telephoning your home we may leave a message with whomever answers or on your answering machine.
We may include a photo of you on our referral wall.
You have the right to request a copy of your records, ask to limit the information we share, amend your health information,
request a list of whom we share your records with, advise our management if you believe your privacy rights have been violated.
Our Notice of Privacy Practices, which you can request to view at any time, describes in more detail how your health information
may be used and disclosed, and how you can access your information.
By my signature below, I acknowledge that I have read, understand and agree to NOTICE OF PRIVACY PRACTICES.
PATIENT SIGNATURE (or Parent/Guardian)
I hereby request and consent to the performance of acupuncture, and other procedures within the scope of the practice of
Oriental Medicine, on me (or the patient named below for whom I am legally responsible) by Jesse Gilliam, MAcOM, Dipl. OM
I understand that methods of treatment may include, but are not limited to: acupuncture; moxibustion; cupping; gua’sha
(scraping therapy); needle retention; tuina (Chinese manipulation); electrical, laser, and/or magnetic stimulation; micropuncture
(mild bleeding therapy); diagnostic palpation on various areas of my body; herbal medicine; and nutritional and/or lifestyle
I understand and am informed that in the practice of Oriental Medicine, as in the practice of allopathic medicine, there are some
side effects and/or risks of treatment. I understand that although these are unlikely to occur, they are possible. Some of these
effects include, but are not limited to: bleeding; bruising, numbness, tingling, pain or other strong sensation at the location
where a needle is inserted or radiating from that location; aggravation of current symptoms; appearance of new symptoms;
general aches or dizziness. Bruising is a common side effect of gua'sha and cupping. Burns and/or scarring are a potential risk of
moxibustion and cupping. Unusual risks of acupuncture include infection or nerve pain, although the acupuncturist uses sterile,
single-use, disposable needles and maintains a clean and safe environment. Highly unusual risks include organ puncture,
including pneumothorax (punctured lung), and spontaneous miscarriage. I understand that while this document describes the
major risks of treatment, other side effects and risks may occur.
I understand that I have the choice to accept or reject the proposed diagnostic procedure or treatment, or any part of it, at any
time before or during the diagnosis or treatment.
The Chinese and Western herbs (which are derived from plant, animal and mineral sources) that are recommended are
traditionally considered safe in the practice of herbal medicine, although some may be toxic in large doses. Some possible side
effects of taking herbs are nausea, gas, stomachache, diarrhea, headache, rashes and tingling of the tongue; some possible side
effects of applying topical creams, liniments, ointments and plasters are rashes, hives and tingling of the skin. I understand that
some herbs may be inappropriate during pregnancy and will immediately notify the acupuncturist(s) if I know or suspect that I
am pregnant. Further, I will immediately notify the acupuncturist of any unanticipated or unpleasant effects associated with the
consumption or application of any Chinese herbs.
I do not expect the acupuncturist(s) to be able to anticipate and explain all possible risks and complications of treatment, and I
wish to rely on the acupuncturist(s) to exercise such judgment based on the known facts, during the course of my treatment, to
be in my best interest. I understand that results are not guaranteed.
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 benefits and risks of acupuncture treatments and other procedures, and have had an opportunity to ask 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 from this clinic.
Patient name (please print)
Patient Signature (or Parent/Guardian)