Disclosure Form. Memberships: National Certification Commission for Acupuncture and Oriental Medicine (Dipl. Acup.)
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- Lesley Houston
- 8 years ago
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1 Consent Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental materia medica Matt Hillman, L.Ac. I understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended. 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 by 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 have been made aware that certain adverse side effects may results. 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 or 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 have been made aware that certain adverse side effects 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 that I associate with these substances, I should suspend taking them and call HealthMark as soon as possible. Tui Na/Acupressure-Massage: I understand that I shall also be given acupressure-massage as part of my treatment to modify or prevent pain perception and to normalize the body s physiological functions. I have been made aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: muscle soreness or achiness and the possible aggravation of symptoms existing prior to the treatment. I understand that I may stop this therapy if it is uncomfortable. Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I have been made aware that certain adverse side effects may result which 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 therapy. I understand that there may be other treatment alternatives, including treatment that might be offered by a licensed physician. I have carefully read and understand all of the above information and am fully aware of what I am signing. I have also been asked if I want a more detailed explanation given to me and do not want more information. I give my permission and consent to treatment. Signature: Printed Name: Complete Address: Phone Number: Date: Date of Birth: SIGN BELOW ONLY IF YOU REQUESTED AND RECEIVED MORE DETAILED INFORMATION. I requested and received, in substantial detail, further explanation of the procedure or treatment, other alternative procedures or methods of treatment, and information about the material risks of the procedure or treatment. I give my permission and consent to the procedure or treatment. X Patient s Signature Date Explained by me and signed in my presence: X Practitioner s Signature Date
2 Disclosure Form Patient Name: Date: Date of Birth: Age: Mailing Address: Physical Address: Home Phone: Work Phone: Cell Phone: Main Reason For Visit: Name: Matthew James Hillman Address: HealthMark, 4700 East Iliff Avenue, Denver, Colorado, Business Phone: (303) Fee Schedule: Cancellation Policy: $ For First Set of Needles and $40.00 for each additional set of Needles. $85.00 for electro acupuncture and $45.00 for each additional set of electro acupuncture needles. Please call twenty-four (24) hours ahead of time to change or cancel your appointment. If you fail to call ahead of time you will be charged $50.00 for the missed appointment. Education: Oregon College of Oriental Medicine (09/98-09/01) Apprenticeship in Oriental Medicine under Vince Black, O.M.D. (07/95-06/98) University of Arizona (08/93-05/95) Washington University in St. Louis (08/90-05/93) Lafayette College (08/89-05/90) Degrees: Master of Acupuncture and Oriental Medicine Diplomate of Acupuncture Master of Science in Exercise Science Bachelor of Arts in Psychology Licenses: Licensed Acupuncturist in Colorado (#733) Memberships: National Certification Commission for Acupuncture and Oriental Medicine (Dipl. Acup.) I have never had any license, certificate, or registration revoked. This Acupuncture Practice states that it is complying with any rules and regulations promulgated by the Department of Health with respect to this article. Proper cleaning, sanitation, and sterilization are always practiced and only sterile, one-use only, disposable needles are used in this practice. This Acupuncture Practice is regulated by the Department of Regulatory Agencies at the address 1560 Broadway, Suite 1545, Denver, Colorado, The Director of the Division of Registrations telephone number is (303) This Acupuncture Practice states that the patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy if known. This Acupuncture Practice states that a patient may seek a second opinion from another health care provider or terminate therapy at any time. This Acupuncture Practice states that in a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies. I, Matthew James Hillman, state that my training and experience in the application of adjunctive therapies and herbs are defined by the traditional Oriental medical concepts. Patient Signature: Date:
3 Patient Health History for Acupuncture Have you tried acupuncture or Chinese herbal medicine before? Please complete this questionnaire as thoroughly as possible. Please PRINT all information and indicate areas of confusion with a question mark. Thank you. 1. Are you currently receiving health care? Y N If yes, where and from whom? If no, when and where did you last receive health care? For what reason? 2. Has your case been referred to an attorney? Y N 3. Please identify the health concerns that have brought you in to seek treatment. Condition Past Treatment a. b. c. d. 4. What are your most important health problems? Please list in order of importance. a. c. b. d. 5. Do you have any reason to believe that you are pregnant? Y N 6. Do you have any chronic infectious diseases? Y N If yes, please explain: 7. Are you currently suffering from any chronic illness? Y N If yes, please explain: 8. If applicable, please list any foods, drugs, or medications you are hypersensitive or allergic to (please include the type of reaction):
4 9. Please circle any of the following medications that you are currently taking: Laxatives Pain Relievers Antacids Thyroid Medication Appetite Suppressants Antibiotics Tranquilizers Sleeping Pills Cortisone Blood Pressure Medication 10. Please list any prescription medications, over-the-counter medications, vitamins, and supplements that you are currently taking: Height: Weight: Currently: Past Maximum Weight: When: 12. What is your most recent blood pressure reading? When was this taken? 13. Childhood Illnesses (please circle any that you have had): Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Chicken Pox 14. Immunizations (please circle any that you have had): Polio Tetanus Pertussis Diphtheria Measles / Mumps / Rubella Other: 15. Hospitalizations and Surgeries: Reason When Reason When 16. X-Rays / CAT Scans / MRI s / NMR s / Special Studies: Reason When Reason When 17. Family History Mother Father Brothers Sisters Spouse Children Age (If Living): Health (G = Good, P = Poor): Age at Death (If Deceased): Cause of Death: Check below any conditions that members of your family have had: Cancer: Diabetes: Heart Disease: High Blood Pressure: Stroke: Mental Illness:
5 18. Emotional (please circle any that you experience now and underline any that you have experienced in the Mood Swings Nervousness Mental Tension 19. Energy and Immunity (please circle any that you experience now and underline any that you have experienced in the Fatigue Slow Wound Healing Chronic Infections Chronic Fatigue Syndrome 20. Head, Eye, Ear, Nose, and Throat (please circle any that you experience now and underline any that you have experienced in the Impaired Vision Eye Pain / Strain Glaucoma Glasses / Contacts Tearing / Dryness Impaired Hearing Ear Ringing Earaches Headaches Sinus Problems Nose Bleeds Frequent Sore Throat Teeth Grinding TMJ / Jaw Problems Hay Fever 21. Respiratory (please circle any that you experience now and underline any that you have experienced in the Pneumonia Frequent Common Colds Difficulty Breathing Emphysema Persistent Cough Pleurisy Asthma Tuberculosis Shortness of Breath Other Respiratory Problems: 22. Cardiovascular (please circle any that you experience now and underline any that you have experienced in the Heart Disease Chest Pain Ankle Swelling Palpitations / Fluttering High Blood Pressure Stroke Heart Murmurs Rheumatic Fever Varicose Veins 23. Gastrointestinal (please circle any that you experience now and underline any that you have experienced in the Ulcers Changes in Appetite Nausea / Vomiting Epigastric Pain Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hepatitis B or C Hemorrhoids Abdominal Pain Stool: Diarrhea Constipation Undigested Food Mucous Blood in Stool 24. Genito-Urinary Tract (please circle any that you experience now and underline any that you have experienced in the Kidney Disease Painful Urination Frequent Urination Impaired Urination Blood in Urine Kidney Stones Venereal Disease Frequent Urinary Tract Infections Frequent Urination at Night 25. Female Reproductive / Breasts (please circle any that you experience now and underline any that you have experienced in the Irregular Cycles Breast Lumps / Tenderness Nipple Discharge Heavy Flow Bleeding Between Cycles Vaginal Discharge Clotting Premenstrual Problems Menopausal Symptoms Difficulty Conceiving 26. Menstrual / Birthing History: 1. Age of First Menses 4. Birth Control 7. # of Abortions 2. # of Days of Menses 5. # of Pregnancies 8. # of Live Births 3. Length of Cycle 6. # of Miscarriages
6 27. Male Reproductive (please circle any that you experience now and underline any that you have experienced in the Sexual Difficulties Prostate Problems Testicular Pain / Swelling Penile Discharge 28. Musculoskeletal (please circle any that you experience now and underline any that you have experienced in the Neck / Shoulder Pain Muscle Spasm / Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain (If So, Where?) 29. Neurologic (please circle any that you experience now and underline any that you have experienced in the Vertigo / Dizziness Paralysis Numbness / Tingling Loss of Balance Seizures / Epilepsy 30. Endocrine (please circle any that you experience now and underline any that you have experienced in the Hypothyroid Hypoglycemia Hyperthyroid Diabetes Mellitus Night Sweats Feeling Hot or Cold 31. Other (please circle any that you experience now and underline any that you have experienced in the Anemia Cancer Rashes Eczema / Hives Cold Hands / Feet Is there anything else we should know? 32. Lifestyle: a. Please indicate typical food intake: Breakfast: Lunch: Dinner: Snacks: b. Daily Exercise: c. Spiritual Practice: d. Sleep Habits: e. Education: f. Occupation: Employer: Hours per Week: Do you enjoy work? Y N Why / Why Not? g. Nicotine / Alcohol / Caffeine Use: h. Have you experienced any major traumas? Y N Explain: i. Consumption of Liquids: j. Television Habits: k. Reading Habits: l. Interests and Hobbies:
7 Indicate Painful or Distressed Areas: Symbol Reaction Pain or Pressure X XX XXX Little Strong Swelling Slight Severe Tension / Weakness Weak # Tense Spontaneous Pain Slight Severe Pulsing Slight Temperature Strong Colder + Hotter Physical Sores Rashes Spasms
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PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
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PATIENT REGISTRATION FORM
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How To Get A Medical Checkup From A Doctor
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Interventional Spine Pain Consultants, P.A. Initial Consultation Information
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A photocopy of this document shall be considered as effective and valid as the original.
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Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.
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Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
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PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
Patient Registration Form
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NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
New Patient Evaluation
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NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
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Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If