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Chapel Hill Acupuncture Health History Intake Form

Chapel Hill Acupuncture | 141 Providence Rd. Suite 160, Chapel Hill, NC 27514 | Phone: 919-406-4858 |

This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill it out as completely as possible even if you do not feel certain questions pertain to your present condition. Thank you.

Personal Information

Name_______________________________________________________________Age_________ Date _____________

Home Address________________________________________________________________________________________

City________________________________________________________ State_____________________ Zip____________

Home Phone__________________________ Work Phone_______________________E-mail_________________________

Birthdate____________________ If under 18, person responsible for your account__________________________________

Emergency Contact: Name______________________________________________ Contact Phone:____________________

Whom should we thank for referring you to our office? ________________________________________________________

Have you had acupuncture therapy before? □ Yes □ No With Whom? ____________________________________

Please indicate if any of the following pertain to you: (marking “yes” does not make you ineligible for treatment, however, it may restrict some of our treatment modalities):

□ Hepatitis □ HIV □ High Blood Pressure □ Seizures □ Pacemaker □ Blood-Thinning Meds □ Pregnancy

Health History

What are the health problems for which you are seeking treatment? ______________________________________________

____________________________________________________________________________________________________

How long have you had this condition? ____________________________________________________________________

List 3 activities that you are unable to perform. ______________________________________________________________

____________________________________________________________________________________________________

_

What makes it worse? __________________________________________________________________________________

What makes it better? __________________________________________________________________________________

|What diagnostic tests have you had for this problem? |X-RAY |MRI |EMG |CT Scan |Bone Scan |

|What treatments have you had for this problem? |Physical |Chiropractic |Counseling |Injections |Massage |

| |Therapy | | | | |

|IF YES IF YES TO ANY OF BELOW, PLEASE CIRCLE SYMPTOM |

| Vision change 
 Difficulty swallowing Night pain Chest pain New Rashes Nausea/Vomiting |

|Dizziness Fevers Loss of control of urine Shortness of breath Depressed Mood |

|Low Back Pain Headaches Palpitations Double Vision |

Chapel Hill Acupuncture Health History Intake Form, Page 2

Please make a mark on the line below to indicate the level of discomfort you have today.


No Pain _______________________________________________________________________ Worst Pain Ever

0 1 2 3 4 5 6 7 8 9 10


Please describe what the pain feels like: Dull, Achy, Burning, Stabbing, Numbness, Tingling, Pulling, Cramping, Tightness

Please describe the time course of your pain: Constant, Comes and goes, Getting worse, Getting better, Staying about the same

|Medications (Current) With Doses: | | |

|ALL medications including Prescription, Over-the- Counter (ie: Advil,| | |

|Vitamins) | | |

| | | |

| | | |

| | |[pic] |

|Medical/Surgical History: | | |

|ALL Surgeries, Diabetes, Cancer, High blood pressure, Heart attack, | | |

|Pacemaker, Arthritis, Fractures, Accidents, Osteoporosis, etc. | | |

|Allergies to Medicines? | | |

|Family History: | | |

|Cancer, Heart disease, Stroke, Arthritis, Osteoporosis, etc. | | |

|What do you do for exercise? | | |

|Do you use a cane or walker? | | |

|Tobacco use (cigarette, cigar, pipe, chew): |Current |Quit |Never | |

|Illicit drug use (cocaine, marijuana, heroin, etc): |Current |Quit |Never | |

|Opioid use (hydro/oxycodone, morphine, etc): |Current |Quit |Never | |

|History of substance abuse/addiction? |Current |Quit |Never | |

|Number of alcoholic beverages per week: | | |

|Occupation: | | |

Chapel Hill Acupuncture Consent to Treatment Form

I do hereby voluntarily consent to be treated with acupuncture, Chinese medicinal herbs and Oriental medicine by a licensed acupuncturist at Chapel Hill Acupuncture.

Initial here________ Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of sterile single use needles through the skin in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. Acupuncture and Moxibustion are typically safe methods of treatment, however certain adverse side effects could occur. These could include, but are not limited to: local bruising, minor bleeding, dizziness, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.

Initial here________ Pregnancy: I will notify Chapel Hill Acupuncture should I become pregnant or if I am in the process of trying to become pregnant so that my practitioner can avoid points and herbs that could induce miscarriage. Otherwise, Chinese medicine treatment can be very beneficial in the pregnancy and birthing process.

Initial here________ Chinese Herbs: I understand that Chinese medicinal herbs may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effects could result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, nausea & vomiting, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call Chapel Hill Acupuncture as soon as possible.

Initial here________ Acupressure/Tui-Na Massage, Qi Gong: I understand that I may also be given acupressure/tui-na massage and/or Qi Gong as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.

Initial here________ Cupping / Gua Sha: I understand that I may also be given cupping (the application of glass cups that create suction Chapel to the skin) and Gua Sha (rubbing of the skin with a smooth object such as a porcelain spoon) as part of my treatment to modify or prevent pain perceptions and to normalize the body’s physiological functions. I am aware that these treatments are intended to cause minor bruising and through unsightly are not normally painful. However, certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse the treatment or stop the treatment at anytime for any reason.

Initial here________ Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.

Initial here________ I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.

I do not expect Chapel Hill Acupuncture to be able to anticipate and explain all possible risks and complications of treatment. I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation of anything regarding my treatment. I understand that my records will be kept confidential and will not be released without my written consent (unless in an emergency or by legal demand). I give my permission and consent to treatment.

Signature: _____________________________________________Date: _______________________

Printed Name: _________________________________________ Date of Birth: _________________

HIPAA NOTICE OF PRIVACY PRACTICES

Chapel Hill Acupuncture | 141 Providence Rd. Suite 160, Chapel Hill, NC 27514 | Phone: 919-406-4858 |

This notice explains how your medical information may be used, disclosed, and your access to this information.

Please review it carefully before your first visit.

Under the Health Insurance Portability and Accountability Act (HIPAA) of July 1, 1997, it is our legal duty to make sure your protected information (PHI) is safe.

Our office respects your right to privacy. Information regarding your therapy is strictly confidential and is only used to communicate with your doctor, case worker and claims representative for payment or for pre-authorization. Should any other official party request information about you, we would need to see a signed authorization request to release information. All other uses of this protected health information will be made only with your authorization which you have the right to revoke at any time. If a claim is unpaid due to the unavailability of the requested information, you will be responsible for payment to us.

Evaluation reports, treatment plans and copies of prescriptions for the therapy and progress notes are sometimes mailed to the insurer (case worker) to carry out treatment and receive payment for our services. In settlement cases, your attorney can request copies of your file with a written request from you. A subpoena would be issuesdby the other party’s attorney. A subpoena is a legal demand for information which we must comply.

Marketing:

Chapel Hill Acupuncture will not use or disclose your PHI for marketing communication without your written authorization. This office may send birthday cards, thank you cards, newsletters, email, notice of events and/or appointment reminders to you.

Disclosure:

Chapel Hill Acupuncture may use or disclose your PHI without your consent or authorization when required by law.

Patient Rights of Privacy Policy:

• A patient may request restrictions on certain uses and disclosure of protected information.

• You have the right to receive confidential communication of protected health information

• You have the right to inspect and request a copy of protected health information and medical records.

• You have the right to an accounting of disclosures of protected health information.

• You have the right to amend protected information (there is an appeal process).

Chapel Hill Acupuncture reserves the right to change our Privacy Policy in accordance with HIPAA and would send such notices to your last known address. This is in compliance with HIPAA following April 13, 2003 except for emergency treatment situations.

If you have any questions about this notice or any complaints about our privacy practices please contact our office.

I have read and understood my rights regarding privacy of information.

I acknowledge that I have received the HIPAA notice and I will ____ will not ____ take a copy with me. _____initials

Print Name: _________________________________________________Date:____________________

Patient or Authorized Person

Signature: ___________________________________________________

Patient or Authorized Person

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