CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
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1 CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your home phone, work phone, and cell phone numbers List your address Occupation Referred by whom WHAT ARE YOUR COMPLAINTS? #1 How long? #2 How long? #3 How long? #4 How long? #5 How long? #6 How long? #7 How long? #8 How long? #9 How long? #10 How long? #11 How long? #12 How long? #13 How long? #14 How long? #15 How long?
2 CONSULTATION & CONSENT FORMS p. 2 OF 5 Please check the appropriate descriptions and fill in the necessary information: Emotions: depress sad panic attack anger anxiety Energy: low exhausted hyperactive Sleep Pattern: have difficulty falling asleep wake up times per night wake up too early cannot go back to sleep after waking up Menstrual Cycle: average days from the last cycle days of menstruation period clots menstrual pain Color: pale red bright red dark red Emotion around period: depression irritability anger crying anxiety others: Emotions occur: before period during period after period Temperature: fever cold hands cold feet hot flash Sweating: too little too much night sweats Sensitivity and Allergy: cold hot dampness food dust hay pollen others Appetite and Digestion: poor appetite rapid hungering craving nausea bloating gas Bowel Movement: constipation diarrhea loose watery incomplete hard and dry strong smell with mucous with blood Time of day when BM occurs: Body Weight: Overweight Underweight How many pounds would you like to gain or lose?
3 CONSULTATION & CONSENT FORMS p. 3 OF 5 Liquid Intake: dry mouth thirsty drink a lot of water Not thirsty, but drink a lot of water anyway Urination: frequent urgent burning painful cloudy dark color foul smell retention bloody Number of times per day: Number of times per night: Pain - Degree of Pain: (0-10) Location of Pain: Chronic, Acute ; How long Dull, Sharp, Burning, Spasm, Ache Palm Moisture: Right Left Habits: smoking drink coffee drink alcohol eat chocolate eat cinnamon powder eat spicy food Exercise: light medium vigorous Medication: Antacids Antibiotics Blood pressure Blood thinning Hormones Insulin Laxatives Sleeping Pills Thyroid Medications Family History(F=father, M=mother; circle your answers): Asthma ( F ) ( M ); Arthritis ( F ) ( M ); Allergies ( F ) ( M ) Anemia ( F ) ( M ); Cancer ( F ) ( M ); Colitis ( F ) ( M ) Diabetes ( F ) ( M ); Epilepsy ( F ) ( M ); Goiter ( F ) ( M ) Hypertension ( F ) ( M ); Heart Disease ( F ) ( M ); Migraine ( F ) ( M ) Overweight ( F ) ( M ); Stroke (Clots) ( F ) ( M ); Stroke (Bleeding) ( F ) ( M )
4 Consultation and Consent Forms p. 4 of 5 ************************************************************************************ ACUPUNCTURE CONSENT FORM C J Herbal Remedies Inc Legacy Circle, Suite 102 Naperville, IL (630) ACUPUNCTURE INFORMATION AND INFORMED CONSENT Acupuncture is performed by the insertion of PRE-STERILIZED, DISPOSABLE acupuncture needles through the skin, and / or the application of heat stimulation to skin, or both, at certain points on the body. The benefits and risks of receiving acupuncture procedures and Chinese herbal consultation have been explained to me. Although rare, certain side effects may result from Acupuncture, I understand that each procedure has specific risks and benefits. I understand that the practice of Acupuncture and Herbal consultation is not an exact science, and I acknowledge that no guarantees have been made to me. I understand that licensed Acupuncturists perform these procedures. I have been informed of the risk and benefits of the procedures and products listed below that apply to my case: Acupuncture needles to stimulate points and meridians, including the specific risks of needling certain points, and the use of mechanical stimulation of acupuncture points or acupressure. I have been informed and understand the risks and side effects listed below: 1) Needle reaction symptoms: pale face, dizziness, palpitation shortness of breath, cold sweat, nausea, even fainting, reactions similar like low blood sugar condition, 2) Minor burning, 3) Broken needles, 4) Some pain at the site of needle insertion, 5) Infection, 6) The risks from needling in the vicinity of an infection, and 7) Potential side effects of Chinese herbs. I understand that when I have needle reaction symptoms, and emergency care is necessary, I authorize CJ Herbal Remedies Inc. to call 911. I am responsible for payment of the full amount of emergency care cost. I have been advised to visit medical doctor regularly, and in emergency situations, I have to seek emergency medical service immediately. I understand that C J Herbal Remedies Inc. may record information concerning my case in electronic and in other physical form. Such information may be released by C J Herbal Remedies Inc. for the purposes authorized on this form. I understand that portions of my records may be disclosed to other personnel for the purpose of management, financial audits, and licensure and program evaluation without my express consent. I understand that I am responsible for all consequences should I choose to purchase herbal products from sources other than C J Herbal Remedies.
5 Consultation and Consent Forms p. 5 of 5 CJ Herbal Remedies, INC. RECORDS RELEASE AUTHORIZATION I understand that I am responsible for my bill. I authorize payment directly to C J Herbal Remedies Inc. I authorize the use of this form for all of my insurance submissions. I authorize release of information to all my insurance companies. I permit a copy of this authorization to be used in place of the original. I authorize C J Herbal Remedies Inc. to make another copy of my previous medical information which I have provided. I authorize the use of my previous medical information to be the basis of acupuncture procedures and herbal consultation. This authorization is not intended to allow the release of records regarding my case for services requiring a restricted release under State of Federal Law. Client s Name (print) Client s Signature Date NOTICE OF PRIVACY PRACTICES I have received a copy of C J Herbal Remedies Inc. Notice of Privacy Practices. I understand this information defines my rights under 45 CFR of the federal regulations and is intended to comply with federal patient privacy rights. Client s Signature Date: CONSENT FOR A MINOR CLIENT I authorize C J Herbal Remedies Inc. and whomever it designates as assistants to administer Acupuncture procedures and Chinese herbal consultation as deemed necessary to my (relationship). Minor Client s Name Custodian Signature Date
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