Initial Acupuncture Form Questions

Confidential Acupuncture Intake Form for a Follow up
We look forward to helping you achieve your health goals. Please help us learn more about you so that we may provide you with the most effective care. On this questionnaire, you will find many in-depth questions; each answer provides important information that allows us to optimize your health care results. Thank you for your thorough responses.
1. Please fill below *
2. Height (ft/in) *
3. Weight (lbs) *
4. Blood Type (if known)
5. Marital/Partnership Status *
6. Emergency Contact *
7. Employer and Occupation *
8. How did you hear about us? *
9. Are you currently under a Medical Doctor's care? *
10. MD's Name
11. MD's Phone
12. List your reasons for today's visit, in order of importance *
13. What type of treatments have you already done for your condition(s)
14. Check if you have a FAMILY history of the following
15. Please identify current gastrointestinal symptoms *
16. Please identify current blood-related symptoms *
17. Please identify current respiratory system related symptoms *
18. Please identify current energy related symptoms *
19. Please identify current temperature regulation related symptoms *
20. Please identify current ear, nose and throat related symptoms *
21. Please identify current urine related symptoms *
22. Please identify current mental/emotional state(s) *
23. Please identify current skin, hair, and nail related symptoms *
24. Please identify past trauma that may currently be impacting you *
25. Please identify current neurological related symptoms *
26. Please identify current sleep related symptoms *
27. Please identify current lifestyle and diet conditions *
28. Amount of caffeine consumed on a daily basis *
29. Amount of alcohol consumed on a weekly basis *
30. Amount of fast food consumed on a weekly basis *
31. Exercise (describe) *
32. Herbs/Supplements (list) *
33. For MEN
34. For WOMEN
35. Are you currently pregnant or trying to become pregnant? *
36. Full length of menstrual cycle (onset to onset)
37. Duration of menstrual periods
38. Date last period began (day 1)
39. Number of pregnancies you have had
40. Number of births you have had
41. Current birth control method
42. Check any conditions that apply (or have applied in the past) *
43. Surgeries, hospitalizations & dates *
44. Accidents, injuries & dates *
45. Medications, reasons & dosages *
46. Rate your Pain Level
1 2 3 4 5 6 7 8 9 10
47. Check all areas of pain that apply *
48. Please DESCRIBE your pain/discomfort
Consent to Treatment by Awaken Integrative Health
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me by the acupuncturist named above and/or other licensed acupuncturists who may now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named above, including those working at the clinic or office listed above 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, moxabustion, cupping, electrical stimulation, tui-na (Oriental massage), oriental herbal medicine, homeopathy, and nutritional counseling. I understand that the herbs may need to be prepared and consumed according to the instructions provided orally and in writing. 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 generally a 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. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve  damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the  clinic uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential  risk of moxabustion and cupping. 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 Oriental 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.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and 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 the 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 clicking the agreement 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.
I have read and agree to the terms above *
Notice of Privacy Practices
Uses and Disclosures
Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of Awaken LLC. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections to facilitate law-enforcement investigations and to comply with government mandated reporting.Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state?s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that had occurred before you notified us of your decision to revoke your authorization.Appointment Reminders: Your contact information will be used by our staff to send you appointment reminders.
Individual Rights. You have certain rights under the federal privacy standards. These include:? The right to request restrictions on the use and disclosure of your protected health information? The right to receive confidential communications concerning your medical condition and treatment? The right to inspect and copy your protected health information? The right to amend or submit corrections to your protected health information? The right to receive an accounting of how and to whom your protected health information has been disclosed? The right to receive a printed copy of this notice
Awaken Integrative Wellness Centers LLC Duties. We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.Right to Revise Privacy Practices. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in the federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.Requests to Inspect Protected Health Information. You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Office Director or your physician directly. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.Complaints. If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns
I have read and agree to the terms above *
51. Would you like to be added to our monthly mailing list with current promotions? *
Financial Policy
There are two billing options available for you.  If at any time you choose to change your billing option, you are required to let us know immediately, and click to consent a new Financial Policy form. 
Insurance Billing I understand that I must pay all co-payments and/or co-insurances not covered by my insurance company at the time of check out for all visits. Awaken LLC will submit my claim for me to my insurance company. Although Awaken LLC verifies my insurance; I understand that this verification is not a guarantee of payment. I understand that any and all charges incurred at this office including co-payment, co-insurance, percentage due and/or deductibles or any other fees or services not covered by my insurance company are my responsibility. I understand that if these patient portions due are unpaid for over 90 days, the balance can and will be sent to collections for recovery unless prior arrangements have been made. I authorize my insurance benefits to be paid directly to Unveiling Wellness LLC. I also authorize the doctor to release any information and medical records required by my insurance company. I understand that I may revoke this consent by written request, at any time. No other records shall be released without my signed consent.  
Private Pay Private pay patients are patients that do not bill insurance. This discounted cash rate is only applied to the published rate if you pay at the time of service.
Payment Methods Accepted:  Cash, Check, Visa, Mastercard, Discover and Debit Cards are accepted.
Returned Checks:  Each returned check will incur a fee of $30.
Cancellations or Missed Appointments: I understand that I can cancel or reschedule my appointment without being charged any time until 24 hours preceding my appointment time. For any changes I make to my appointment within 24 hours of the appointment start time, I will be charged 50% of my scheduled service price. If I do not CALL or TEXT to cancel or reschedule my appointment and I do not show up for my scheduled appointment, I will be charged full price for the scheduled service.
Paying in full at the time of service frees our office from the administrative costs that would be required in medical billing. We have adjusted our ?usual and customary? fees. Your superbill/receipt form will show exam and treatment procedures that occurred during your visit. Depending on the visit and the nature of your treatment, certain procedure codes and/or exam codes may modify appointment fees and you will only be responsible for certain other fees.Your out-of- pocket fees will be as follows:
Initial Consultation and Acupuncture:  $95Acupuncture Follow-up session:  $85Youth Acupuncture 6-12 years old: $65Initial Consultation and Vitamin B12/Homeopathic Injection Therapy: $65Follow-up Vitamin B12/Homeopathic Injection Therapy: $30Food Therapy Program/Herbal Consultation: $45Cupping only session: $45Additional Modality add-ons:  $10 
I have read and agree to the terms above *
Cancellation policy
Please arrive at least ten minutes before your scheduled appointment time. You may cancel your appointment without charge up to 24 hours preceding your appointment. Same day cancellations will be charged 50% of the scheduled service price. If you do not call to cancel your appointment and do not show up for your scheduled appointment, you will be charged full price for the scheduled service. 
I have read and agree to the terms & conditions and cancellation policy. I authorize Radiant and/or Awaken to charge my card on file for missed or late canceled appointments. *