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) _____________________ Date PATIENT REGISTRATION Title: Mr./Mrs./Ms./Dr./Rev./Rank____________ Date______________________ Last Name____________________________ First Name________________________ M.I_______ Nickname_______________ Address_____________________________________________________ City__________________ State_____ Zip_________ Mobile Phone______________________ Home Phone____________________ E-Mail__________________________________ Date of Birth____________________________ Age___________ Gender: M F Marital Status: S M W D 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 _________________________________________________________________________________________ CURRENT HEALTH COMPLAINT 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: Sharp Dull Ache Does it radiate into your arms or legs? Yes No Burning Throbbing Spasm Numbness Tingling Shooting 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 Explain:__________________________________________________________________________________________ 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? ______________________________________________________________________________ NAME:____________________________________________________________DATE__________________ BORG PAIN SCALE On a scale of 1-10, please rate your pain level. Normal ( )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. Emergency ( ) 10 HEALTH HISTORY Please mark all that apply: ___Asthma ___Migraines ___Bleed Easily ___Heart Disease ___Jaundice ___Kidney Disease ___Thyroid Disorder ___Tuberculosis ___Allergies ___Emphysema ___Birth Trauma ___Lyme Disease ___Colitis ___Epilepsy ___Varicose Veins ___Pacemaker ___Diabetes ___Aids/HIV ___Polio ___Cancer ___Seizures ___Herpes ___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? Yes No 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 NUTURITION 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? Never Rarely Occasionally Often Exclusively 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 ENERGY AND EXERCISE Do you exercise? Yes No What kind of exercise? ________________________________ How is your general energy level? Very Low Low Moderate High How often?_______________ Very High Are you sedentary or active? ________________________________________________________________________________ EMOTIONS AND SLEEP _____Panic Attacks _____Depression _____Anxiety _____Nervousness _____Poor Memory _____Fearful _____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 _____Dreams _____Waking at Night GASTROINTESTINAL Do you currently have or have you had a major incidence in the past with any of the following? ____Belching ____Indigestion ____Ulcers ____Hernia ____Hemorrhoids ____Nausea ____Vomiting ____Bloating ____Acid Reflux How often do you have a bowel movement? ______ times per day/week ____Irregularity ____Constipation ____Diarrhea ____Gas URINATION How many times do you urinate per day (average)? _________________ _____Bladder Infections _____Incontinence _____Frequent Urination ____Pain Light or Dark in Color? ________________________ _____Burning _____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 ____PMS ____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:___________________ SEXUAL HEALTH How Is Your Sex Life? ______________________________________________________________________________________ How Is Your Libido? _______________________________________________________________________________________ ______Dryness ______Impotence RESPIRATORY Do You Smoke? Yes No ____Frequent Colds ____Ear Pain ______Erectile Dysfunction _____ Cigarettes/Day for _____Years ____Asthma ____Migraines ____Cough ____Cold Sores ____Ringing in Ears ____Sinusitis ____Bleeding Gums ____Dry Mouth ____Excessive Phlegm CARDIOVASCULAR _____Palpitations _____Chest Pain _____Varicose Veins _____Cold Hands/Feet _____Irregular Heart Beat SKIN AND HAIR ____Dry Skin ____Skin Rashes ____Itching _____Poor Circulation _____High Blood Pressure ____Acne ____Eczema _____Dizziness _____Low Blood Pressure _____Blood Clots ____Hair Loss MUSCULOSKELETAL ____Joint Pain ____Arthritis ____Muscle Tightness ____Numbness ____Tendonitis ____Osteoporosis ____Swelling FAMILY HEALTH HISTORY (indicate if a blood relative has had any of the following) ___Alcoholism ___Asthma ___Diabetes ___Seizures ___High Blood Pressure ___Allergies ___Vascular Disease ___Cancer ___Heart Disease ___Stroke I attest that all of the above information is correct to the best of my knowledge. ______________________________________________ ____________________ Patient/Guardian Signature Date GENERAL GUIDELINES      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! PAYMENT AND CANCELATION POLICY    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) NOTICE OF PRIVACY PRACTICES 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 radiologist. 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) ________________________ DATE INFORMED CONSENT FOR ACUPUNCTURE AND CHINESE MEDICINE 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 (NCCAOM). 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 counseling. 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) ______________ Date