Head:



Dragon’s Lair Acupuncture

Patient Health History

Name: _______________________________________________Phone: _____-__________ Date: __/___/___

(first) (middle) (last)

Date of Birth: _____/_____/_____ Age: _______ Gender: ___ Marital status: S M D W

Occupation ________________ Email__________________@___________________

Mailing Address ___________________________________________________

___________________________________________________________________

city zip code

Emergency Contact:___________________ Phone: _____________________Relationship_______________

How did you hear about us? ___________________________________________________

Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you.

Please note that Acupuncture is NOT Primary Care Medicine. It is complementary and supplemental. If you have acute symptoms please follow up with your primary care physician. It is recommended to consistently meet with your primary care physician and review medications and dosages on each visit with ongoing complementary care.

There is a 24 hour cancellation policy. Late cancellations will be charged $50.

Currently, An Shen: Peaceful Spirit Acupuncture does not bill insurance directly. If you would like to apply for reimbursement, please request a Superbill.

Chief Complaint:

Meds & Supplements:

Allergies:

Surgeries/ Scars:

Head: Knees:

Torso: GB:

Back: HT:

Legs: Other:

Ankle:

Feet:

Head:

• Headaches:

o Vertex

o Temporal

o Frontal

o Occipital

o Band around occipital to forehead

• Balance

o Dizzy

▪ Room Spins

▪ I Spin

o Faint

▪ When I stand up

▪ Anytime

▪ Regularly Occasionally

• Eyes

o Burning, Red, Itchy

o Floaters

o Dry Wet

o Pressure

▪ Sucked into head

▪ Pushed out of head

• Ears

o Ringing

▪ Hi Lo

▪ Wind rushing

o Itchy

o Congestion

o Hx of Ear Infections

• Nose & Sinus

o Take Decongestant Regularly

▪ Type:

o Congestion

o Drainage

▪ Post-nasal drip -- tastes Salty Sweet Bland

▪ Color – clear, watery clear thick

• White Thick

• Yellow moist dry

• Grey Brown

• Blood

o Upper or Lower Sinus

• Mouth

o Dry

o Plum Pit

o Scratchy throat, esp in morning

Back:

• Neck and Shoulders

• Between shoulder-blades

o Cold sensation?

o Left Right

• Mid-back

• Low Back

o Sharp

o Achy

o Radiates down Legs GB ST BL

• Improves with Heat Ice

Skin:

• Rash Eczema Psoriasis Acne

Arms & Legs Wrists & Hands Ankles & feet

• Muscles: Cramps Achy

• Heavy Crawling Sensation

• Sharp pains Tingling Numbness

o Cramping Freezing Pain

o Colder or Hotter than rest of body?

Chest:

• Spontaneous Sweating

• Palpitations Shortness of Breath

• Constriction Fullness Emptiness (vacuity)

• Are you, or were you, a smoker? How Long?

o Quit: When? How?

• Are you thirsty?

o Do you prefer Hot , Cool, or COLD drinks?

▪ Soda Juice EmergenC Water

• General Temperature

o Hands & Feet Hotter Colder Just at Night

• Do you bruise easily?

• Do you heal quickly?

• Do you sweat? Head Back Chest Palms and Feet

•

• Pee:

o Can you hold it?

o Stress Incontinence (the sneeze and pee)

o Is it warm to your own sensation? Any pain, tingling, or odd sensation?

o Are there bubbles, or foam that does not dissipate?

▪ Suspended bubbles?

▪ Cloudy

Abdomen:

• Do you have an Appetite?

• Are you satisfied when you eat?

• Cravings? Salt Sweet Spicy Burnt Sour Bitter

• Reflux Heartburn Belching Hiccups

o Medicated? (Prilosec)

• Bloating, Gas

• Referred Pain

o Do you have your GB?

• Hx of Abdominal Surgeries?

• Poop:

o How often?

o Solid, Soft, Hard Logs

o Rabbit Pellets, Soft Serve puddle

o Watery, Explosive, Falls Apart

o Is the food digested?

o Do you wake up to poo?

o Do you poo 1st thing in morning?

o Do you poo when you are stressed, nervous, or angry?

o Mucus in your poo? White Yellow

Sleep:

• Do you fall asleep easily? Restless Thinking

• Do you stay asleep?

o Wake to Pee? Times?

o Wake to noise or disturbance? Back down easily not easily

o Wake randomly and need to get up? How long are you up for?

▪ What do you do with yourself in mid of night?

o Sleep Apnea? Snoring? Wheezing? SOB?

o Nite Sweats?

▪ Back Front Head Feet

o Burning Feet?

• Do you dream? Recurring themes or components?

o People, memories, elements:

• Are you rested in the morning?

Sex:

o Painful How? Where?

o Dry

o Libido?

o Difficulties?

MEN

• Feeling of coldness or numbness in genitalia?

• Pain or swelling of testicles?

• Premature ejaculation?

• Impotence?

• Number of children? _________

• Prostate problems

o Sexually Transmitted Dz or Infectious Illness?

Menses:

o Onset/ menarche:

o Age of Menopause: Last period?

o Do you bleed between periods?

o Do you have vaginal discharge between periods?

o Color Consistency Odor

o Itchy

o How many days bleeding?

o Clots Heavy/ Light Color: Bright Purple Brown

o How many days between?

o Regular

o PMS?

o Irritability Focus: Me Partner Work Other

o Water retention Bloating Breast tenderness Breast swelling

o Weeping Depression Indecision

o Food cravings Insatiable appetite Constipation Diarrhea

o Migraines Low back pain

o Cramps?

o Before During After

o Front Back

o Radiate down leg (s) L R

o Nausea, vomiting Chills and Fever? Other systemic Rx?

o Birth Control of choice: How long have you been using it?

o Pregnancies:

o Miscarriage Abortions Plan B

o Still Birth Ectopic Adoption

o Are you, or could you be pregnant now?

o Do you take hormone replacements?

Emotional Landscape

Which emotions do you struggle with?

Anger/ Temper Depression/ Melancholy Anxiety/ Grief

Worry/ Contemplation Fear/ Willpower

Self Doubt/ self esteem Self Loathing / self worth

o What does Depression look like for you?

o Hiding in a closet/ closed room? Cutting off the world?

o Ice cream on the couch with TV/ Movies?

o Sleeping?

o How do you deal with stress?

o Current Stressors:

o Work

o Home

• Partner

• Kids

• Pets

o Partner: History: Past Divorce, Widow ( Rx:

o Current: Health Issues?

What was your experience of:

o Parents’ Relationship while you were growing up?

o Family dynamic (sibs, stresses, attention, support, role)

Mom: Relationship, Stability, Health, Death? Age (mom) (pt)

Dad: Relationship, Stability, Health, Death? Age (dad) (pt)

Siblings: Relationship, Stability, Health, Death? Ages (pt)

Kids: Relationship, Stability, Health, Death? Ages (pt)

PAR Consent to Treatment Form

By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at the An Shen: Peaceful Spirit Acupuncture. I understand that acupuncturists practicing in the state of Arizona are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.

Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, 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.

Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy.

Chinese Herbs: I understand that substances from the Oriental Materia Medica 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 effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, 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 the An Shen: Peaceful Spirit Acupuncture as soon as possible.

Acupressure/Tui-Na Massage: I understand that I may also be given acupressure/tui-na massage 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.

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.

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

I have carefully read and understand all of the above information and am fully aware of risks associated with acupuncture treatment and what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.

Signature: _____________________________________________Date: __________________

Printed Name: _________________________________________ Date of Birth: ___________

Address: _______________________________________________________________________

City: _______________ State: ____________ Zip Code: _____________ Phone: _________

HIPAA forms

Our Clinic Protects Your Health Information and Privacy

This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.

In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company¸ with Worker’s Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.

Safeguards in place at our office include:

• Limited access to facilities where information is stored.

• Policies and procedures for handling information.

• Requirements for third parties to contractually comply with privacy laws.

• All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.

Types of information that we gather and use:

In administering your health care, we gather and maintain information that may include nonpublic personal information:

• About your financial transactions with us (billing transactions).

• From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.

• From health care providers, insurance companies, workman’s comp and your employer, and other third part administrators (e.g. requests for medical records, claim payment information).

In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you - e.g. your name, address, Social Security number, etc.).

We value our relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please call us at 520-839-9071.

I have been presented with HIPPA protection guides, and understand that my information is secure.

Signature ____________________________________________Date: ______________________

Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way or try to or actually have oral, anal, or vaginal sex with you?

4. Did you often feel that … No one in your family loved you or thought you were important or special? Do you feel that your family didn’t look out for each other, feel close to each other, or support each other?

5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?

7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her; sometimes or often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

9. Was a household member depressed or mentally ill or did a household member attempt suicide?

10. Did a household member go to prison?

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