195Acupuncture Whiting Street, Hingham, &MA 02043 Homeopathy | 781.749.8088 of Hingham Megan Stewart, MEd, MAc | Licensed Acupuncturist & Homeopath

INFORMED CONSENT

I, the undersigned, hereby give consent for the administration of treatment by the method of acupuncture/magnet therapy.

I understand that acupuncture is performed by the insertion of needles, with or without the addition of an electric current, through the skin or the application of heat to the skin, or both, at certain points on the body in an attempt to improve body function and/or relieve pain.

I have been make aware that certain side effects may result. These may include, but are not limited to, some local bruising, bleeding, fainting, temporary pain or discomfort and the possible aggravation of symptoms existing prior to acupuncture treatment.

I am aware that although acupuncture is a common practice, there are no guarantees about its effects.

I understand that the results obtained from this treatment may be published, but that my identity will not be revealed.

I understand that none of the foregoing provisions shall prevent adminstration to me of more conventional medical therapy by a licensed physician.

I hereby certify that I have read the above and that I understand the provisions described therein.

Patient Signature Date 195 Whiting Street, Hingham, MAAcupuncture 02043 | 781.749.8088 | Megan & Stewart, Homeopathy MEd, MAc | Licensed Acupuncturist of Hingham & Homeopath PATIENT INFORMATION

Name: Today’s Date: Address: Employed by: Occupation: Residential Phone Number: Business Phone Number: Cell Phone Number: Age: Weight: Height: Email Address: Your Family Doctor: Date of Birth: Referred by: Place of Birth: Marital Status: Number of Children: Chief Health Concern: How long ago did this problem begin? To what extent does this problem interfere with your daily activities (work, sleep, sex, etc.)?

If you’ve been given a diagnosis for this problem, what is it? Names of all drugs, medicines or supplements that you are now taking: Therapies that you have tried in the past for this problem: If you are currently involved in any other therapies for this problem, what are they? Is this your first experience with acupuncture? J Yes J No HABITS AND LIFESTYLES

Exercise: J Yes J No What type? How often? Cigarettes? J Yes J No Amount per day: Recreational Drugs: Alcohol? J Yes J No Amount per week: Caffeinated tea, coffee, cola: J Yes J No Amount per day: Sweets? J Yes J No Amount per day: How do you unwind stress? Exposure to chemicals? J Yes J No Exposure to cigarette smoke? J Yes J No Describe your average diet (morning, afternoon evening, snacks, list what time for each):

Time you go to bed: Time you get up: Amount of sleep: Do you sleep through the night? J Yes J No FAMILY MEDICAL HISTORY

J Cancer J Heart Disease J High Blood Pressure J Diabetes J Allergies J Arthritis J Alcoholism J Cigarette Smoking Anything else not listed above? MEDICAL HISTORY

J Heart Murmur J Rheumatic Fever J Heart Attack J High Blood Pressure J Jaundice J Blood Transfusion J Emphysema J Anemia J Bleeding Disorder J Diabetes J Hepatitis J Ulcer J Arthritis J Thyroid Disorder J Surgery J Cancer J Glaucoma J Kidney Stones J Tumor J Epilepsy J Tuberculosis J Kidney/Bladder Trouble J Pneumonia

J Sexually Transmitted Disease(s): J Allergic Reactions (foods, medicines, chemicals): J Significant Trauma (date, description): J Any other disorders that were not listed above: PERSONAL MEDICAL HISTORY

Place and X beside the symptoms that you have had in the last three months. GENERAL

J Poor Appetite J Poor Sleeping J Fatigue J Food Cravings J Chills J Night Sweats J Sudden Energy Drop J Tremors J Weight Loss J Localized Weakness J Poor Balance (what time of day?) J Bleed of Bruise Easily J Constipation J Weight Gain J Sweat Easily J Peculiar Tastes or Smells J Strong Thirst (cold or hot drinks?) J Bloating J Change in Appetite J Fevers J Diarrhea

SKIN AND HAIR

J Rashes J Ulcerations J Hives J Itching J Excema J Pimples J Dandruff J Change in hair or skin texture J Recent Moles J Hair Loss Any other hair or skin problems?

HEAD, EYES, EARS, NOSE AND THROAT

J Dizziness J Poor Vision J Ringing in the ears J Grinding Teeth J Eye Pain J Earaches J Recurrent Sore Throats J Eyestrain J Blurry Vision J Nosebleeds J Sores on Lips or Tongue J Cataracts J Sinus Problems J Teeth Problems J Glasses J Spots in front of eyes J Jaw Clicks J Migraines J Color Blindness J Facial Pain J Concussions J Night Blindness J Poor Hearing Headaches (where and when?)

MUSCULOSKELETAL

J Neck Pain J Muscle Pain J Knee Pain J Back Pain J Muscle Weakness J Foot or Ankle Pain J Hand or Wrist Pain J Shoulder Pain J Hip Pain Any other joint or bone problems?

MEN

J Weak Urine Stream J Prostate Trouble J Impotency J Discharge from Penis J Painful or Swollen Testes WOMEN

J Trouble with Menstruation: Date of Last PAP smear: J Painful Period J Clots J Breast Lumps or Discharge J Vaginal Discharge J Vaginal Sores J Hot Flashes J Changes in body or psyche prior to menstruation Time between periods: Duration of periods: Usual characteristics (heavy, light, etc.): Age at time of First Period: Date of Last Period: # of Pregnancies: Abortions: Miscarriages: Are you pregnant now? J Yes J No Are you trying to become pregnant now? J Yes J No Do you practice birth control? J Yes J No If yes, what type?

NEUROPSYCHOLOGICAL

J Seizures J Bad Temper J Concussion J Depression J Anxiety J Palpitations J Poor Memory J Dizziness J Loss of Balance J Areas of Numbness J Lack of Coordination J Easily Susceptible to Stress Have you ever been treated for emotional problems? J Yes J No Have you ever considered or attempted suicide? J Yes J No Any other neurological or psychological problems? J Yes J No Any other problems not covered above you would like to discuss?