412 Holistic Health, LLC Maura Schuster, L.OM Practitioner of Oriental Medicine NEW PATIENT INTAKE

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1 412 Holistic Health, LLC Maura Schuster, L.OM Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name Primary physician Physician phone How did you hear about us? When was your last complete medical exam? Relationship status: Single Married Partnered Divorced Separated Widowed CONTACT INFORMATION Cell phone Home phone Work phone Another person we may contact if needed: Name Relationship Phone Have you been treated with acupuncture in the past? yes no Do you have any concerns about the needles? yes no What is the reason for your visit today? 1

2 HEALTH HISTORY List serious illnesses, accidents or surgeries. List medications, vitamins, and supplements that you are taking. CONDITONS AND SYMPTOMS Check conditions or symptoms you have or have experienced in the past: Adverse reaction to medical treatment AIDS / HIV Alcoholism Allergies Anemia Arthritis Artificial heart Asthma Bleeding disorder Cancer Chronic fatigue syndrome Depression / anxiety Diabetes Dizziness Drug addiction Eating disorder Fainting Fatigue Fibromyalgia Gout Headaches / migraines Heart attack Heart disease Hepatitis or liver disorder High blood pressure Irritable bowel syndrome (IBS) Insomnia Kidney disorder Low blood pressure Mental disorder Organ transplant Pacemaker Respiratory disorder Sciatica Seasonal affective disorder Seizures / epilepsy Skin disorders Spinal problems Stomach or intestinal disorder Stroke Thyroid disease Ulcer Urinary tract infection Weight gain or loss 2

3 BODY SYSTEMS Check symptoms you have or have experienced in the past year: EYES / NOSE / THROAT / RESPIRATORY Asthma / wheezing Blurred or failing vision Change in smell Change in taste Difficulty swallowing Difficulty breathing Earache Enlarged glands Eye pain / inflammation Frequent colds Hay fever Hearing loss Hoarseness Gum problems Nosebleeds Oral ulcers Persistent cough Poor night vision Ringing in ears Sinus congestion / infections Spots in vision Sore throat Visual changes FOR MEN ONLY Erection difficulties Fertility difficulties Low sex drive Lumps in testicles Penis discharge Prostate problem Weak urinary strength SKIN Acne Bruise easily Changes in mole / lump Dry skin / eczema Eczema Itching / rash / hives Sensitive skin Sore won t heal Sweating excessively CARDIOVASCULAR Chest pain or tightness Edema / swollen ankles Hardening of arteries Heart attack High / low blood pressure Poor circulation Palpitations Rapid / irregular heartbeat GASTROINTESTINAL Acid reflux Belching Blood in stool / black stool Colon problem Constipation Diarrhea Excessive hunger Food cravings Gallbladder problem Gas / bloating Hemorrhoids Indigestion Nausea Poor appetite Stomach pain Vomiting Weight gain / loss 3

4 FOR WOMEN ONLY Abnormal PAP smear Bleeding between periods Breast lumps Clots in menses Cramps Endometriosis Extreme menstrual pain Frequent UTIs Frequent vaginal infections Heavy menstrual flow Infertility Irregular cycle Light menstrual flow Menopausal symptoms Ovarian cysts Pelvic inflammatory disease PMS Previous miscarriage Could you be pregnant? yes no Are you trying to become pregnant? yes no MUSCULOSKELETAL / NEUROLOGICAL Difficulty walking Poor balance Seizures Sprain or strain Swollen joints Tendonitis Tremors or cramps Pain, weakness or numbness in: Arms Back Feet Hands Hips Knees Legs Neck Shoulders Other Please indicate location of pain or injury: Describe type of pain. Sharp Burning Fixed Aching Other 4

5 LIFESTYLE Please indicate frequency and how much: Alcohol Caffeine Recreational drugs Tobacco use Other EXERCISE Please list type of activity and frequency. DIET Standard American Low carbohydrate Low fat Paleo Whole foods Gluten-free Vegetarian Vegan Other What did you eat yesterday? Breakfast Lunch Dinner Snacks 5

6 FAMILY HISTORY Complete for each family member by placing an x in the corresponding box. Condition Self Mom Dad Sister Brother Spouse Child Addiction Allergies Arthritis Anemia Cancer Diabetes Eating disorder Heart disease High BP Kidney disease Seizures Stomach disorders Stroke Other AGE OF DEATH PLEASE RATE ON A SCALE OF 1 (low) to 10 (high). Stress Energy level Hydration / water intake Sleep quality

7 ACUPUNCTURE TREATMENT What are your goals for your acupuncture treatments? Please list any other health concerns you would like to discuss. SIGNATURE The information in this form is correct to the best of my knowledge. I will update the office with any significant changes. Signature Date PLEASE MAKE SURE YOU EAT A LIGHT MEAL AND ARE HYDRATED BEFORE YOUR TREATMENT. PLEASE DO NOT MOVE AROUND ONCE NEEDLES HAVE BEEN INSERTED. Thank you for your time and effort. I look forward to providing you with the best possible care! 7

8 412 Holistic Health, LLC INFORMED CONSENT TO TREATMENT I consent to acupuncture treatments and other procedures associated with Oriental Medicine by Maura Schuster, L.OM. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, massage, Chinese herbal remedies, and nutritional counseling. ACUPUNCTURE I have been informed that acupuncture is a safe method of treatment, but that it may have side effects including bruising, dizziness or fainting, and numbness or tingling near the needle sites that may last a few days. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although this clinic uses sterile disposable single use needles, and maintains a clean and safe environment. MOXIBUSTION Moxibustion involves burning an herb on or near an acupuncture point in order to improve physiological function or treat pain. Burns and / or scarring are a potential risk of moxibustion. CUPPING Cupping involves using cups to suction the skin, in order to improve physiological function, reduce blood stagnation and relieve pain. Bruising is a common side effect of cupping. ACUPRESSURE / TUI-NA MASSAGE Massage may occasionally cause bruising or soreness. Some oils or liniments may cause allergic reactions in people with sensitive skin. HERBAL REMEDIES AND NUTRITIONAL SUPPLEMENTS The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that may be recommended are traditionally considered safe in the practice of Oriental Medicine. I understand that the herbs need to be prepared and consumed according to the instructions provided orally and in writing. Some possible side effects of taking herbs are nausea, gas, stomachache, headache, change in bowel movements, or dizziness. Should I experience any unanticipated effect I will immediately notify Maura Schuster, L.OM. Also, I will keep her informed of my current medications. I understand that some herbs and acupuncture treatments are contraindicated during pregnancy. I will notify Maura Schuster, L.OM if I am or intend to become pregnant. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I also understand that results are not guaranteed. I do not expect Maura Schuster, L.OM to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the above named practitioner to exercise judgment during the course of treatment which she thinks at that time, based upon facts then known, is in my best interests. I understand that I may refuse or stop any treatment. By voluntarily signing below, I show that I have read, or have had read to me, this 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. X Signature of Patient X Printed Name of Patient Date 8

9 412 Holistic Health, LLC We look forward to providing for your health needs and encourage your questions and participation in all aspects of your health care. Please initial the following lines: Payment for all services and products is due at the time of the visit. We do not currently accept insurance. You will be charged the full cost of your appointment for any missed appointments or late cancellations (less than 24-hours notice). I give permission for Maura Schuster, L.OM to contact me via telephone or and leave a message that may contain appointment or medical information if I am not available. I have read and agree to the Privacy Practices of Maura Schuster, L.OM (found on the website or in the office). FEES Acupuncture Initial Visit $125 Acupuncture Follow up Visit $80 As the patient, you are responsible for the total charges incurred for each visit. We accept cash, checks, and credit cards. I have read and understand the above-stated policies and will comply with them in all respects. X Patient Name Signature Date X Signature acknowledging receipt of HIPAA privacy policy Date 9

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