scential cupuncture LLC A A New Patient Form

GENERAL INFORMATION

Name: Date of Birth: / /

Age: Sex: F / M SSN: Email: Recieve or monthly newsletter? Yes No

Address: City: State: Zip: Phone: Home: Work: Cell: Marital Status: Occupation: Employer:

Emergency Contact: Relationship: Phone: Primary Physician: Phone:

How did you hear about us? Internet -search engine or key term:

Recommend by Friend/Family: Who?

Other:

INSURANCE INFORMATION

MAIN COMPLAINT Reason for seeking acupuncture? When did it begin, or what is the initial cause? Have you been given a diagnosis? If so, what? What makes your symptoms better? What makes your symptoms worse?

MEDICAL HISTORY

Surgeries: Significant Trauma (auto accidents, falls, emotional, etc): Allergies: Have you ever had an infectious disease? (HIV, TB, etc.) □ Yes □ No If so, please describe:

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 Medications: (Please list all OTC, prescription, vitamins, and supplements, and what they are taken for)

FAMILY MEDICAL HISTORY (Please check if any of the following applies to you or any family members) □ Alcoholism □ Asthma □ Hypertension □ Mental Illness □ Seizures □ Allergies □ Cancer □ Hypotension □ Multuple Sclerosis □ Strokes □ Alzheimer’s □ Diabetes □ HIV/AIDS □ Pulmonary Disease □ Other: □ Arthritis □ Heart Disease □ Kidney □ Obesity

If mother, father, or siblings are deceased what was the cause?

SOCIAL & LIFESTYLE Do you have a regular exercise program? □ Yes □ No If so, describe:

Hours of sleep per night? Do you wake rested? □ Yes □ No □ Awake Easily □ Have Difficulty Falling Asleep □ Have Restless Sleep □ Have Vivid Dreams □ Sleep Too Much □ Nightmares □ Disturbing Dreams □ Other:

What is your stress level on a scale from 1-10?

□ Caffeine How often? □ Alcohol # drinks per week: □ Tobacco How often? □ Former alcohol use # years quit: □ Recreational Drugs How often? □ Former tobacco use # years quit:

DIET (Please describe your typical daily diet) Breakfast: Snack:

Lunch: Snack:

Dinner: Snack:

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 Current Symptoms (Check all that apply) General Overview Kidney/Urinary Bladder Heart □ High blood pressure □ Urinary problems □ Palpitations □ Low blood pressure □ Frequent urination □ Anxiety □ High cholesterol □ Wake during night to urinate □ Mental confusion □ Hyperthyroid □ Incontinence □ Chest pain □ Hypothyroid □ Weakness/pain in lower back □ Frequent dreams □ History of blood clots □ Aching bones □ Insomnia □ Migraines □ Feel cold easily (hands/feet) □ Restlessness/agitation □ Pace Maker □ Low sexual energy □ Breathlessness □ Metal implants □ Excess sexual desire □ Craving or avoiding bitter foods If so where ______□ Low pitched ringing in ears □ Poor memory Spleen/Stomah □ Hair loss Liver/Gall Bladder

□ Low appetite □ Early Greying of hair □ Sigh often

□ Large appetite □ Hearing problems □ Bitter taste in mouth

□ Abrupt weight gain □ Fearful □ Anger easily

□ Abrupt weight loss □ Easily startled □ Vertigo

□ Fatigue □ Craving or avoiding salty foods □ Depression

□ Easily bruised □ Irritability

□ Hemorrhoids □ Stress

□ Over-thinking Lung □ Muscle twitching

□ Worry often □ Nasal discharge □ Muscle cramping

□ Bad Breath □ Dry cough □ High pitched ringing in ears

□ Abdominal pain □ Cough with sputum □ Soft brittle nails

□ Vomiting □ Nose bleeds □ Dizziness

□ Gas/belching □ Sinus congestion □ Feeling of lump in throat

□ Bloating □ Dry mouth □ Joint tightness/stiffness

□ Edema (swelling) □ Dry throat □ Headaches/migraines

□ Heartburn □ Dry nose □ Visual problems

□ Acid regurgitation □ Dry skin □ Red eyes

□ Ulcer □ Skin rashes □ Dry/itching eyes

□ Belching □ Itchy skin □ Spots in front of eyes

□ Craving or avoiding sweets □ Alternating chills and fever □ Blurred vision

Digestion (SP, ST, LI, SI) □ Low resistance to colds or flu □ Craving or avoiding sour foods

□ Constipation □ Sore throat

□ Diarrhea □ Difficulty breathing

□ Blood in stool □ Shortness of breath

□ Mucous in stool □ Sadness

□ Undigested food in stool □ Craving or avoiding spicy foods

MEN’S HEALTH

□ Prostate Problems □ Erectile Dysfunction □ Impotence □ Reduced Sex Drive □ Seminal Emissions □ Genital Pain □ History of Testicular Cancer □ Pain or Burning During Urination □ Decreased Urine Flow □ Other:

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 WOMEN’S

PAIN AREAS

Please clearly mark any areas of pain.

Is the pain: Sharp Cramping Fixed Burning Dull Aching Moving Other:

Do the following lessen the pain? Pressure Exercise Cold Heat Other:

Do the following worsen the pain? Pressure Cold Heat Other:

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 Ascential Acupuncture LLC

Financial Policy

Ascential Acupuncture makes every attempt to make acupuncture available at affordable rates:

All payments are due at time of service.

• Follow-up visit: $60 • We do offer treatment packages. - 5 treatment sessions $270 - 10 treatment sessions $500

Ascential Acupuncture understand that it is not always possible to keep scheduled appointments. We do ask that you allow 24 hours notice should you need to cancel or reschedule your appointment. Appointments that are cancelled or missed with less than 24 hour advance notice will be charged a $45 fee. The payment is due at the time of the next scheduled appointment. If appointments have been purchased in a package, the missed or cancelled appointment will be deducted from the remaining appointments in that package.

Thank you for your understanding.

service.

Patient Signature Date

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 Ascential Acupuncture LLC

For Patient Review Regarding Diagnostic Exam

Please choose one option below:

Option 1:

I have received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment.

Patient Signature Date

Option 2:

I have NOT received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturist recommend that you receive a diagnostic examination from a physician or chiropractor regarding the condition for which you are seeking treatment.

I understand this recommendation.

Patient Signature Date

Licensed Practitioner (L.Ac) Signature Date

Ascential Acupuncture LLC • www.ascentialacupuncture.com • 614.526.4164 ACUPUNGTURE INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturisl named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include. but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage apd organ puncture, including lung puncture (pneumothorax). lnfection is another possible risk, although the clinic uses sterile disposable needlds and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine. although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent.

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 risks and benefits of acupuncture 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.

ACUPUNCTURIST NAME:

PATIENTSIGNATURE X (Or Patient Representative) (lndicate relationship if signing for patient)

ALso SIGN THE ARBITRATION AGREEMENT OI.I REVERSE spe

AAC.FED