<p> SUMMERVILLE COMMUNITY ACUPUNCTURE Today’s Date . Health History and Registration Please fill out both sides Name Preferred name/nickname Address Best Phone Email Birthdate Gender Occupation Emergency Contact Primary Physician Name When was your last complete physical exam? Phone How did you hear about us? Have you had acupuncture before? HEALTH HISTORY What is your reason for treatment? How long have you had these problems? 1. 2.</p><p>3. Check symptoms you have now or have had in the What medications are you taking? last year:  Depression  Difficulty Focusing Do you sleep well?  Dizziness  Easily Startled  Excessive Worry  Excessive anger  Excessive fear  Fatigue/Tiredness How is your digestion (indigestion, heartburn,  Headaches  Loss of sleep constipation, diarrhea, etc)?  Weight loss/gain  Nervous/Irritable  Overwhelmed by life Do you have Please list any serious illnesses, accidents or  Bleeding Disorders  Allergies surgeries with approximate year  Hepatitis  Arthritis  Seizure  Diabetes  High Blood  Cancer (at this time) Pressure  Palpitations  Pacemaker  Blackouts  Vertigo/Dizziness  Could you be  PTSD pregnant? NOTES/DID WE MISS ANYTHING?</p><p>We are a POCA clinic PEOPLES ORGANIZATION OF COMMUNITY ACUPUNCTURE Find a Clinic like this for someone you love at www.pocacoop.com/clinics. Financial Policy Summerville Community Acupuncture is a low-cost, high-volume Community Acupuncture Clinic. Our fees are $15-35 per treatment (with an additional $10 paperwork fee for the first visit). You decide what you can pay at each visit. We will never ask for income verification and trust that you will know best what you can afford to pay for your treatment. We make every attempt to make acupuncture available to as many people as possible at the most affordable rates. This is our mission.</p><p>Payment is expected at the time of your visit. We accept cash, checks, credit cards and HAS/FSA cards. We ask that you be prepared to pay for your treatment each time you come in. At any time you may change the amount that you pay on the sliding scale up or down. If you need a receipt to submit to your insurance, please let us know. We’d also be happy to give you a cash receipt as well. Just ask.</p><p>I agree to the above policy:</p><p>Print Name .</p><p>Signature . Date . .</p><p>Informed Consent Acupuncture involves the insertion of special needles into particular points on the body. The purpose of the treatment is to prevent or reduce pain and to help your body function better. There are some risks to treatment, which may include bruising of the skin and/or slight bleeding, weakness, fainting and aggravation of symptoms existing prior to acupuncture treatment. There is little or no risk of infection when all needles are sterile. We use only one-time use, sterile disposable needles. We do not reuse needles, even at different areas of the body for the same person.</p><p>We do not provide primary care, nor Western (allopathic) medical care. Please see your medical doctor for those services and for routine checkups. If you are pregnant, have a bleeding disorder, pacemaker, high blood pressure, local infection or have been prescribed anticoagulant/blood thinning medication like Coumadin, Heparin or Warfarin, by signing below you state that you have informed your acupuncturist of such conditions.</p><p>With this knowledge, I voluntarily consent to the above procedures.</p><p>Print Name .</p><p>Signature . Date . . SUMMERVILLE COMMUNITY ACUPUNCTURE 1731 N. Main St., Ste. H 843.810.1225 Summerville, SC 29483 www.SummervilleCommunityAcupuncture.com</p><p>Welcome to Summerville Community Acupuncture! We are one of the many member clinics of the Peoples Organization of Community Acupuncture (POCA). POCA is a multi-stakeholder cooperative whose mission is to make acupuncture affordable for nearly everyone, while promoting a sustainable business model that works for both patients and practitioners. To jump on board, learn more about the cooperative, find a clinic like this one for someone you love, and to support us by becoming a member, visit www.pocacoop.com.</p><p>Acupuncture is a PROCESS. It is very rare for any person to be able to resolve a problem completely with just one treatment. Frequent treatment is much more likely to lead to relief. Your acupuncturist will suggest a course of treatment based on the intensity and duration of your health concern. Twice a week is usually the minimum needed to get some momentum moving ahead with a health issue – though more frequent visits are common for short periods of time if the problem is quite intense. If you don’t come in often enough or for enough treatments, acupuncture may not work as well for you.</p><p>We treat in a community room. We believe a group setting has many benefits: it’s easier for friends and family to come in together, and it allows patients to keep their needles in as long as they want. Most people learn after a few treatments when they feel “done” or “cooked”. This can take anywhere from twenty minutes to an hour or two.</p><p>The treatment room is meant to remain a quiet space for you and others to rest, sleep and sort it all out. Its atmosphere exists through our patients relaxing together. We appreciate everyone’s presence. We find this kind of collective stillness a rare and valuable thing in our rushed and isolating society. Maintaining this reservoir of calm requires very little talking in the clinic space – including us. If you would like to speak to your acupuncturist one-on-one at great length, please let us know and we can arrange for some sit-down time.</p><p>So please grab your blankets and pillows, turn off your phone, take off your shoes and socks, roll up sleeves and pant legs and you’ll be ready for treatment.</p><p>Our commitment to you. We want our community to be welcoming to all different kinds of people. We want to give you the tools to take care of your own health in a safe environment with skilled, experienced practitioners. We will always be available to listen to any advice and/or feedback you may have about SCA. We will do all of this with a sense of humor and help from you as well. Please enjoy the space and time to do your work. We’re happy you’re here. After your first treatment….</p><p>At the needle site… You may notice a tingling, aching, soreness or numbness around the area. Occasionally, a point may bruise. These feelings are most often minor and short lived. If you are concerned about anything, please let us know. What to expect… Depending on the condition for which you are being treated for, its severity and whether its acute or chronic, you may experience some immediate relief or notice no change. Relief may be dramatic or subtle and it may be short-lived or last several days. Change is rarely permanent following just one treatment. Occasionally (in about 5-10% of cases), the issue may get worse the following 24 hours after treatment, followed by great relief. A general rule is that any change is a good sign, but don’t be discouraged if you feel no change at all after just one treatment. Remember, your body did not get this way overnight and will not heal itself overnight.</p><p>Pay attention to how you feel… Particularly in the 24-48 hours after your treatment. Because acupuncture is holistic and most acupuncture points can be used to treat a multitude of conditions, benefits may occur such as better spirits, relaxation, increased energy, improved digestion and more restful sleep.</p><p>Your treatment plan… You will get the best results from acupuncture the more you have it. The benefits will increase and the results will last longer over time. It’s like exercise; your body gets stronger the more you do it. People come in anywhere from a few weeks to several months, depending on the length and severity of their health issue. Stick with your recommended treatment plan and give acupuncture enough time to “kick-in” and create lasting change for you. If you are unable to be treated as frequently as we suggest, it is still beneficial to receive acupuncture spaced further apart; however it may take longer to notice improvement.</p><p>We look forward to working with you in achieving your health goals!</p><p>Summerville Community Acupuncture 843-810-1225</p><p> www.summervillecommunityacupuncture.com</p><p>Hours: Tues / Th 10-3, Wed / Fri 3-7 and Sat. 10-2 How often should I get acupuncture?</p><p>Being Example of condition: Treatment frequency: For how long: treated for: Extreme Acute back sprain, Daily until change in For several days discomfort daily migraines condition Serious Sprained ankle, acute Every other day until A week or two discomfort digestive distress change in condition Moderate Knee pain while Twice weekly until Over several discomfort running, poor sleep change in condition weeks Working on a Trying to get pregnant, Twice weekly until Over several health overcoming allergies change in condition weeks milestone Ongoing Occasional insomnia; Weekly + as-needed for Over a few episodic PMS acute episodes months condition Support for Stress, work-related Weekly Ongoing/as chronic issues, chronic illness needed issues General Life! Weekly or bi-monthly Ongoing/as health needed</p>