Acupuncture Intake Form

ACUPUNCTURE - NEW PATIENT FORM

All information is held in strictest confidence. At no given point is information disclosed or shared with outside parties without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Patient Information and History
Full Name

First Name Middle Name Last Name
Today's Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date (Type Date or Click on Calendar)

Month Day Year
Date
Phone Number
E-mail
Medications - please include doses
Allergies - seasonal, food and/or cravings
Please indicate use if frequency is more than twice a week:

coffee alcohol diet soda regular soda tobacco recreational drugs
Please indicate if you consider yourself addicted to any of these substances: (Note: Acupuncture is often used and helpful to overcome addicitions.

coffee alcohol dIet or regular soda tobacco recreational drugs
List the top three things you would like to work on.
List any accidents, surgeries, or hospitalizations (include dates when possible)
Symptom Survey

Blank = Not Experienced
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

lack of appetite excessive appetite loose stool/diarrhea indigestion bloating after eating vomiting belching and/or burping heartburn/reflux hemorrhoids abdominal pain constipation
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

cough shortness of breath sinus problems asthma difficulty inhaling bronchitis hay fever/runny nose
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

arthritis insomnia heart palpitations cold hands and feet chest pain sleep too much hand swelling ankle swelling low blood pressure high blood pressure bleed easily numbness/tingling in extremities
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

back pain sciatic nerve joint pain mouth sores muscle spasms shingles knee problems kidney stones headaches/migraines dizziness poor balance poor memory facial nerve pain
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

failing vision cataracts glaucoma other eye problem pimples/acne eczema/psoriasis moles/warts bruise easily varicose veins skin cancer hair loss toenail fungus brittle nails
Please indicate if you are experiencing these symptoms now, or have experienced them within the last year:

frequent colds hypo or hyperthyroid lump in throat grind teeth fatigue perspire easily ear ringing sudden weight loss decreased sex drive urinary infections incontinence
Which emotions most closely describe you?

happy depressed easily irritable easily angered stressed periodic anxiety fearful difficulty making decisions sad numb
How often do you exercise and what type?
Are you pregnant?
How many pregnancies have you had?
How many live births have you had?
Please indicate any of the following PMS symptoms that apply to you:

irregular menses painful menses heavy flow scanty flow water retention breast lumps clots emotional changes spotting between periods constipation/diarrhea migraines backache abnormal vaginal discharge
Late Arrival and Missed Appointment Policies:
Our clinic exists for one purpose: To help you, your family and your neighbors have access to quality, affordable, convenient, and effective Traditional Chinese Medicine health care.

In order to best serve you and your neighbors, we have important policies that we need you to understand:

Any appointment that is missed or cancelled with less than 24 hours notice will be charged the full service amount. We appreciate your understanding our need to consistently apply this policy, which helps us serve you and your neighbors with high quality, affordable acupuncture. We ask that this fee be paid the same day by phone.

It is important that you check in for your appointment 10 minutes before your appointment time. We will do our very best to accommodate you if you arrive late for your appointment, however, if you arrive late and we are unable to accommodate you because our schedule is full, we will consider it a missed appointment and will need to charge you accordingly.

We cannot guarantee you will be seeing a specific acupuncturist nor be able to reserve a table or chair at any time. We will try to accommodate these needs to the best of our ability!

We thank you for understanding the need for these policies!

Your signature below confirms that you have read and agree to these policies.
Colorado Mandatory Disclosure and Informed Consent Form:
Each patient has the following rights:
- The patient is allowed to receive information about the methods of therapy, the techniqus used, and the duration of treatment.
- The patient is allowed to seek a second opinion from another healthcare professional or may terminate therapy at any time
- In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Professions and Occupations immediately
The practice of acupuncture is regulated by the Deprtment of Regulatory Agencies. The Director of theDivision of Professions & Occupations may be contacted at:

Division of Professions & Occupations Acupuncturist Licensure

1560 Broadway, Suite 1350, Denver, CO 80202, (303) 894-7800

dora_acupunctureboard@state.co.us

I confirm that I have carefully read and understand all of the above information and am fully aware of what I am signing at the end of this form. I understand that Thrive Community Acupuncture does not provide primary care, or Western (allopathic) medical care.

I hearby release Thrive Community Acupuncture and its employees and subcontractors from any and all liability that may occur in connection with the acupuncture, body work or herbal treatment I receive, except for failure to perform with appropriate medical care. I hereby give me consent to acupuncture, cupping, e-stim, and acupressure and any herbal/homeopathic treatment for my present condition and for any future condition(s) for which I seek treatment.

My signature at the end of this form indicates that I understand and agree to the above.

Our Practitioner's Education, Certification and Experience:

David Gorski, L.Ac., is licensed in the state of Colorado having graduated from Southwest Acupuncture College in Boulder, CO with their Masters Degree in Acupuncture.

Informed Consent:

I hereby request and consent to the performance of acupuncture by the acupuncturist as your clinic has on staff.

I have been informed that acupuncture is a safe method of treatment but that it may have side effects incuding discomfort, pain, dizziness, bruising, or numbness at the site of procedure.

Unusual and are risks may include nerve damage, organ puncture, infection, and spontaneous miscarriage. Other side effects may occur. If I suspect that I am pregnant, I will immeidately inform the acupuncturist.

During my appointment I will discuss the nature and purpose of my treatment with one of the acupuncturist(s) named above.

I understand that there are no guarantees regarding cure or improvement of my condition. I understand that there may be limitations to the care provided and that in my best interest I may be referred to another acupuncture proactitioner or other healthcare provider who may be more qualified to treat me outside of these facilities.

I do not expect the acupuncturist to anticipate and explain all possible risks and complications, and I permit the acupuncturist to determine and/or alter the course of treatment as they judge to be in my best interests based upon the facts then known. I understand that I have the choice to accept or reject treatment at any time.

I understand that it is always possible that a needle may accidentally be left in place or fall on my clothing after my tretment, and I understand that I am responsible for double-checking that all needles have been removed.

I have read or have had read to me the above consent. I have also had the opportunity to ask questions about its content, by calling (970) 282-8300 and by signing below, I agree to all terms and conditions stipulated by this document. I intend this form to cover the entire course of treatment for my condition and for any future conditions for which I seek treatment.

I have futhermore been informed that Thrive Community Acupuoncture clinic's acupuncturists are not medical doctors and do not provide primary care medicine or diagnostic medical procedures. I understand, too, that if I think there is any possibility that I may be experiencing a serious health concern, or if I want someone knowledgeable to review my medical history with me, I need to see a primary care physician prior to acupncture treatment. I understand that, as a complementary care provider, Thrive Community acupouncture is pleased to communicate with my physician at my request.

I understand, acknowledge, and volunarily accept the risk associated with acupuncure services, use of your facilities, and I hereby release you (incuding, without limitation, personal, bodily or mental injury, property damage or economic loss), which may result form your acupuncture, cupping, or from taking herbs ordered by or recommended by the acupuncturist, my failure to disclose any pre-existing condition, limitation or sensitivity, or my famiure to inform my therapistof discomfort during my session.

My signature below indicates that I have given accurate information on this form and that I have read and agreed to the Colorado Mandatory Disclosure and Informed Consent form.
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Patient Information and History

Symptom Survey

Late Arrival and Missed Appointment Policies:

Colorado Mandatory Disclosure and Informed Consent Form: