Acupuncture Initial Consultation Form PATIENT INFORMATION
Name:
Last:
First:
M.I:
Address:
Street:
City:
Phone:
Primary:
Secondary:
State:
Zip:
Email: month: D.O.B Emergency Contact/Guardian: Name:
day:
year:
Sex:
M
F
Phone:
Marital Status: Relationship:
EMPLOYMENT INFORMATION
Employer: Business Address:
Occupation: Street:
City:
State:
Zip:
State:
Zip:
HEALTH CARE INFOMATION Primary Care Physician: Physician Address: Physician Phone:
Primary Care Physician Specialty: Street:
City:
Primary:
ACUPUNCTURE HISTORY
Previous Acupuncture Treatment: Acupuncturist:
Name:
Y
N
Condition(s) Treated: Contact Info:
PRIVACY POLICY Healthworks Health Information and Privacy Policies Notice This notice describes how your medical information may be used and disclosed and how your privacy is being protected at Healthworks. The privacy of your medical information is important to us and we are committed to protecting your medical records. We create a record of the care and services you receive at our organization to provide you with quality care and to comply with certain legal requirements. In order to maintain the level of service that you expect from Healthworks, we may need to share limited personal medical and financial information. This notice will also describe your rights and certain duties we have regarding the use and disclosure of medical information. How Healthworks May Use or Disclose Your Health Information Healthworks collects health information about you and stores it in a chart and on a computer. Your medical records are the property of Healthworks, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes: Treatment: We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians, health care providers or other health care facilities that will provide services that we do not provide. We may disclose medical information to family or others who can help you when you are sick or injured. Health Care Operations & Payment: We use and disclose medical information about you to obtain payment for the services we provide and perform daily operations at Healthworks fitness centers. For example, we may use and disclose this information to review and improve quality of care, or the competence and qualifications of our professional staff. Appointment Reminders & Sign-In Sheet: We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone. We may use and disclose medical information about you by having you sign in for complimentary consultations or when you arrive at Healthworks for scheduled appointments. We may also call out your name when we are ready to see you. Notification & Communication with Family: We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or object, our health professionals will use their best judgment in communication with your family and others. Marketing: We may contact you to give you information about products or services related to your treatment, case management or care coordination, or to direct or recommend other treatments or health-related benefits and services that may be of interest to you, or to provide you with small gifts. We may also encourage you to purchase a product or service when we see you. We will not use or disclose your medical information without your written authorization. Required by Law: We will limit our use and disclosure of your health information to relevant requirements of the law. When the law requires us to report abuse, neglect, domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning those activities. Public Health: We may, and are sometimes required by law to disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm. Health Oversight Activities: We may, and are sometimes required by law to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations imposed by federal and Massachusetts law. Judicial and Administrative Proceedings: We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.
Law Enforcement: We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying of locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes. Public safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public. Specialized government functions: We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody. When Healthworks May Not Use or Disclose Your Health Information Healthworks will not use or disclose health information that identifies you without your written authorization except as described in this Notice of Privacy Polices. If you do authorize Healthworks to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time. Your Health Information Rights Right to Request Special Privacy Protections: You have the right to request restrictions on certain uses and disclosures of your health information, by a written request specifying what information you want to limit and what limitations on our use or disclosure of that information you wish to have imposed. We reserve the right to accept or reject your request, and will notify you of our decision. Right to Request Confidential Communications: You have the right to request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular email account or to your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to receive these communications. Right to Inspect and Copy: You have the right to inspect and copy your health information with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to and whether you want to inspect or copy the record. We will charge a reasonable fee, as allowed by Massachusetts law. We may deny your request under limited circumstances. If we deny your request to access your child's records because we believe allowing access would be reasonably likely to cause substantial harm to your child, you will have a right to appeal our decision. Right to Amend or Supplement: You have a right to request that we amend your health information that you believe is incorrect or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate or incomplete. We are not required to change your health information, and will provide you with information about Healthworks denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. You also have the right to request that we add to your record a statement of up to 250 words concerning any statement or item you believe to be incomplete or incorrect. Right to an Accounting of Disclosures: You have a right to receive an accounting of disclosures of your health information made by Healthworks, except that Healthworks does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in the treatment, payment, health care operations, notification and communication with family and specialized government functions paragraphs of this Notice of Privacy Practices or disclosures for purposes of public health which exclude direct patient identifiers, or which are incident to a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement official to the extent Healthworks has received notice from that agency or official that providing this accounting would be reasonably likely to impede their activities. Changes to this Notice of Privacy Practices We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with this Notice. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. Questions and Complaints Questions and complaints about this Notice of Privacy Practices or how Healthworks handles your health information should be directed to our Privacy Officer, Erin Walker, Lic. Ac., MAOM, during regular business hours. If you are not satisfied with the manner in which Healthworks handles a complaint, you may submit a formal complaint without the risk of penalization to: Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Bldg., 200 Independence Avenue, S.W., Room 509F HHH Building, Washington, DC 20201.
INFORMED CONSENT 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 this or any Licensed Acupuncturist employed by Healthworks on this day and on any future dates. I understand that methods of treatment may include, but are not limited to, acupuncture, cupping and Tui-Na. 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 cupping or when treatment involves heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture. Infection is another possible risk, although the clinic uses sterile disposable needles 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. While I do not expect the Acupuncturist 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 there are no guaranteed results and that I am free to stop acupuncture treatment at any time. I understand the Acupuncturist will not be providing Western Medical Care and I should look to my Western Primary Care Physician for those services. It is recommended that you seek outside advice from qualified medical authorities and obtain clearance from your physician prior to beginning any supplemental program. I understand it is my responsibility to seek the proper medical attention should I develop an injury or if mu medical condition changes, and to inform Healthworks and its Acupuncture Therapists of any change in my health or medical status. I understand that any information provided to my Acupuncturist is confidential and will not be shared with any other Healthworks employee. I have received, read and understood the Notice of Privacy Policies of Healthworks. I understand how Healthworks may use or disclose my health information. I understand when Healthworks may not use or disclose my health information. I understand my health information rights and understand that Healthworks reserves the right to change their Notice of Privacy Practices. I also understand how to place a complaint regarding this Notice and have also been provided the opportunity to review and question the privacy policies Healthworks. By voluntarily signing below, I show 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 the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
Patient Signature: ____________________________________________
Date: __________________________________
NAME: ________________________________________________________________ CHIEF COMPLAINT Describe chief complaint or health concern. If office visit is concerning a specific health condition or illness, describe concern in as much detail as possible.
Has there been a diagnosis for this condition?
____________________________________________________
List any additional physicians, healthcare practitioners or treatments sought for this condition.
Physician Name
Office Address
City
State
Treatment Received
Zip
Office Phone
Dates of Care
Treatment Results
Physician Name
Office Address
City
State
Treatment Received
Zip
Office Phone
Dates of Care
Treatment Results List any other important health concerns or conditions. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ENERGY Describe your energy: (circle one) excellent
good
average
tired
exhausted
Experienced any significant change in your energy level? If yes, please explain: ___________________________________________ Does your energy fluctuate during the day? ________________________________________________________________________ If yes, when is your energy at its highest and lowest? _________________________________________________________________ GOALS Goals for acupuncture treatment? _______________________________________________________________________________ __________________________________________________________________________________________________________ Current health goals? ______________________________________________________________________________________ ____________________________________________________________________________________________________________
Potential obstacles do you have in the achieving these goals? _________________________________________________________ ____________________________________________________________________________________________________________
CURRENT MEDICATIONS List all physician prescribed medication, over-the-counter medication, nutritional supplements, vitamins, minerals, herbal or homeopathic remedies that have been taken within the last three months. NAME
DATE BEGAN
DOSAGE
REASON FOR TAKING
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. SURGERIES Indicate reason and date of any surgeries ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ OTHER HOSPITALIZATIONS Indicate reason and date of admission ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ OTHER SIGNIFICANT TRAUMA ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ALLERGIES List all known allergies. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ALLERGEN Animal hair/dander Chemicals Drugs/medications Dust Food
TYPICAL REACTION
ALLERGEN Grass Pollen Mold Tree Pollen Other
TYPICAL REACTION
HEALTH SCREENING HISTORY Complete the following chart. EXAM/TEST Blood Panel Chest X-ray Cholesterol Colonoscopy Complete Physical Exam
DATE
RESULTS
EXAM/TEST Eye Exam Mammogram Pap Smear Prostate Exam PSA
DATE
RESULTS
Other (please specify) Other (please specify) PAST MEDICAL HISTORY Complete the following chart for patient and each family member by placing an X in the appropriate box. Use the blank columns for additional family members. Health History Age Allergies Alzheimer’s Asthma Blood Disorder Cancer Chemical Dependency Chronic Fatigue Syndrome Congenital Disorders Diabetes Epilepsy Fibromyalgia Gastrointestinal Disorder Heart Disease High Blood Pressure Kidney or Bladder Disorder Mental Illness Multiple Sclerosis Epilepsy Fibromyalgia Osteoporosis Parkinson’s Disease Seizures Stroke Thyroid Disorder Tuberculosis Other (please specify) Age at Death
SELF
MOTHER
FATHER
SISTER
BROTHER
REVIEW OF SYSTEMS: Please indicate all symptoms that you have experienced by placing an X in the appropriate box. GENERAL Chills Excessive Sweats
Fever General Body Aches
Severe Fatigue Weight Loss
HEAD, EYES, EARS, NOSE & THROAT
Blurred Vision Cataracts Color Blindness Concussions Conjunctivitis Contacts Dental Problems Difficulty Chewing Difficulty Opening Mouth Dizziness Dry Eyes Ear Infections
Ear Ringing Excessive Tearing Eye Pain Facial Pain Floaters Frequent Colds Glasses Glaucoma Grinding Teeth Headaches Hearing Aid Hearing Loss
Itchy Eyes Jaw Clicks Loss of Smell Loss of Taste Migraines Mouth Sores Nose Bleeds Poor Vision Post Nasal Drip Red Eyes Sneezing Sore Throats
Other head, eyes, ears, nose or throat problems? Describe: ___________________________________________________________ RESPIRATORY Asthma Blood Streaked Sputem Bronchitis
Cough Difficulty Breathing Difficulty Swallowing
Pneumonia Shortness of Breath Wheezing
Other respiratory problems? Describe: ____________________________________________________________________________ DERMATOLOGY Dry Skin Eczema Hair Loss
Itchy Skin Pimples Rash
Scars Ulcerations Unusual Bleeding
Other hair or skin problems? Describe: ____________________________________________________________________________ CARDIOVASCULAR
Bleed Easily Bruise Easily Chest Pain Chest Pressure Cold Hands & Feet Dizziness
Edema Fainting Feet/legs Swelling Hand Swelling High Blood Pressure Irregular Heart Beat
Leg Cramps Low Blood Pressure Murmur Pacemaker Palpitations Shortness of Breath
Other heart or circulation problems? Describe: _____________________________________________________________________ GASTROINTESTINAL
Abdominal Cramping Abdominal Pain Acid Reflux Bad Breath Belching Black Stools Blood in the Stool Clay colored Stools Colitis Constipation
Decreased Appetite Diarrhea Difficult Bowel Movements Diverticulitis Eating Disorders Excessive Appetite Excessive Thirst Gall Stones Gas Heartburn
Hemorrhoids Jaundice Mucus in Stools Nausea Painful Bowel Movements Rectal Pain Rectal Spasms Ulcers Vomiting
Other digestive problems? Describe: _____________________________________________________________________________
GENITOURINARY
Blood in the urine Burning Urination Cloudy Urine Decreased urination Dribbling
Frequent Urination Hesitancy Kidney infection Kidney stones Painful Urination
Urinary Incontinence Urinary Tract Infection Urination at Night
Other genitourinary problems? Describe: __________________________________________________________________________
WOMEN’S HEALTH
Amenorrhea Bleeding between periods Decreased Sex Drive Heavy bleeding Hot Flashes/Nightsweats
Infertility Irregular menstrual cycle Light bleeding Menstrual clots Menstrual pain
Swelling or pain of breasts Vaginal discharge Vaginal dryness Vaginal itching Vaginal pain
Other gynecological problems? Describe: __________________________________________________________________________ _______Age Menstruation Began _______Number of days cycle lasts _______Number of days between cycles
_______Date of Last Cycle _______Age of Menopause
_______Births _______Children _______C-sections _______Ectopic Pregnancies
_______Elective Abortions _______Miscarriages _______Pregnancies _______Premature Births
Other labor or delivery complications?
_______________________________________________________________________
Currently pregnant?
YES
NO
Currently trying to conceive?
YES
NO
Currently nursing?
YES
NO
SEXUALLY TRANSMITTED DISEASE SCREENING & HEALTH HISTORY Chlamydia Genital Herpes Genital Warts
Gonorrhea Hepatitis B Hepatitis C
HIV Oral Herpes Syphillis
Currently have a partner?
YES
NO
Sexually active?
YES
NO
Experiencing any sexual difficulties?
YES
NO
Current methods of contraception? ______________________________________________________________________________ Past or other pertinent contraception history? _____________________________________________________________________ NEUROLOGICAL Change in Gait Lack of Coordination Loss of Balance
Loss of Sensation Numbness Seizures
Slow or slurred speech Tremors Vertigo
other neurological problem? Describe: ____________________________________________________________________________
MUSCULOSKELETAL
Ankle Pain Arthritis Back Pain Change in Gait Difficulty Lifting Difficulty Sitting Difficulty Standing Difficulty Walking
Foot Pain Hand Pain Hip Pain Knee Pain Limited Range of Motion Loss of Grip Strength Loss of Sensation Muscle Spasm
Muscle Weakness Neck Clicks/Pops Neck Pain Numbness Shoulder Pain Swelling Tingling Wrist pain
Chief musculoskeletal complaint? ____________________________________________________________________________ When did this condition begin?
____________________________________________________________________________
How frequent and for how long was the pain experienced? __________________________________________________________ What is the intensity of the pain from a scale of 1-10?
1
2
3
4
5
6
7
8
9
10
What is the quality of the pain?
Achy Burning Cramping Deep
Dull Electric Loss of Sensation Numb
Does pain radiate or travel to any other area of the body?
Pins & Needles Sharp Stabbing Throbbing
_________________________________________________________
Has there been injury to this area before or any other related problems? ________________________________________________ What alleviates or worsens the condition? ________________________________________________________________________ Is pain worse or better with specific types of weather ________________________________________________________________ Have there been any recent X-rays, MRIs, CTscans, or other special tests performed? YES NO ____________________________________________________________________________________________________________ MENTAL HEALTH
Anger Anxiety Apathy Confusion Crying Depression Difficulty Making Decisions
On a scale from 1-10, what is stress level:
1
2
Fear Grief Hyperactivity Irritability Lethargy Memory Loss Mood Swings
3
On a scale from 1-10, what is stress handling ability: 1
4 2
3
5
6
7
8
4
5
6
7
9 8
Nervousness Poor Concentration Restlessness Stress Suicidal Thoughts
10 9
10
What are major stress factors?
_______________________________________________________________________________
Rate your emotional health:
excellent
good
fair
poor
unstable crisis
Currently in psychotherapy, counseling or involved in a support group?
YES
NO
If yes, describe: _____________________________________________________________________________________________ LIFESTYLE Indicate any of the following substances which apply now or in the past. Alcohol Crack/cocaine Heroin Marijuana Tobacco (chewing) Tobacco (cigarettes) Other Recreational Drugs If yes, what drug of choice?
Yes No _____amount per day/week ______age began ______age quit Yes No _____use per day/week ______age began ______age quit Yes No _____use per day/week ______age began ______age quit Yes No _____use per day/week ______age began ______age quit Yes No _____use per day/week ______age began ______age quit Yes No _____cigarettes per day/week ______age began ______age quit Yes No _____use per day/week ______age began ______age quit _________________________________________________________________
Have there ever been treated for substance abuse? YES
NO
If yes, explain: ________________________________________________________________________________________________ NUTRITION Describe typical diet in the chart below: BREAKFAST
SNACK
LUNCH
SNACK
DINNER
SNACK
What are favorite foods? _______________________________________________________________________________________ What type of foods are craved or disliked strongly? _________________________________________________________________ Any other diet restrictions? _____________________________________________________________________________________ Currently dieting? If yes, specify: _________________________________________________________________________________ Increase or decrease your current weight? _________________________________________________________________________
EXERCISE Currently physically active?
YES
NO
What type of exercise? _________________________________________________________________________________________ How frequent and for how long? _________________________________________________________________________________ Training for any specific event or have specific exercise goals? _________________________________________________________ Favorite recreational activities? __________________________________________________________________________________
SLEEP How many hours per night of sleep?
________________________________________________________________________
Feel rested when you wake up?
YES
NO
Experienced insomnia?
YES
NO
Difficulty falling asleep?
YES
NO
Difficulty staying asleep?
YES
NO
Dream excessively?
YES
NO
Nightmares?
YES
NO
Other difficulties sleeping?
____________________________________________________
ADDITIONAL COMMENTS ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
