Acupuncture New Patient

Remember to Breathe Health Center

4305 Gesner St. Suite 100 San Diego 92117

Clinic phone 858.291.8581 Cell (call or text) 619.887.6138

This is a CONFIDENTIAL questionnaire to help determine the best treatment plan for you.
PERSONAL INFORMATION
Full Name *
Date *

Month Day Year
Date
Home Address *
City *
State *
Zip *
Home Phone *
Cell Phone *
Occupation
E mail *
You acknowledge that I will add your information to my database and may contact you either via email, text, or phone to keep you updated on news, special offers, and events. Please initial below *
Who may I thank for referring you?
Please fill out the following personal health information: *

Male Female Other
Height
Weight
Birth date *

Month Day Year
Date
Marital Status

Married Divorced Single Widowed
Number of children
Have you received acupuncture therapy before?

Yes No
When did you last receive an acupuncture treatment?
Please indicate any significant illnesses you have had:

Cancer Hepatitis High blood pressure Diabetes Heart disease Seizures Rheumatic fever Infectious disease Tuberculosis Emotional disorder Other
Check the box next to any of the following you are currently taking:

antacids aspirin cold tablets laxatives hay fever medication diet pills ibuprofen sleeping pills oral contraceptive herbs or vitamins Other
List any medications you are currently taking and the reason:
Please indicate the frequency of the following:
Do you smoke cigarettes or cigars?

Yes No
Number per day?
Do you drink caffeinated drinks?

Yes No
Number of 8 oz. cups of coffee per day?
Number of cups of caffeinated tea per day?
Number of sodas per day?
Do you drink alcohol?

Yes No
Number of drinks per week
How often do you use any non-medical drugs such as marijuana or CBD?
What are the main health problems for which you are seeking treatment?
What other forms of treatment have you sought?
List any other health problems you now have:
List any allergies or food sensitivities
List any accidents, surgeries or hospitalizations
Five Element - Wood : Check the box next to any symptoms you experience once or more per month.

Irritability/anger Indecisive Headaches or migraines Dizziness or vertigo Tremors or restless legs Visual problems Red, dry or itching eyes Spots in front of eyes Feeling of a lump in the throat Pain or full feeling in lower ribs Clenching teeth at night Muscle cramping or twitching Cold hands or cold feet Joints feel tight and stiff Awaken between 1 and 3am Irregular menstruation Menstrual cramps Soft or brittle nails Craving sour foods
Five Element - Fire : Check the box next to any symptoms you experience once or more per month.

Heart palpitations Chest pain Insomnia Easily startled Mental restlessness Anxiety and/or panic attacks Depression Tongue sores Vivid dreams Difficulty concentrating Lack of joy in life Laughing for no reason Easily excitable Talks constantly Craving bitter foods
Five Element - Earth : Check the box next to any symptoms you experience once or more per month

Heaviness anywhere in the body Fatigue Overweight Edema (swelling) Muscles feel tired often Easy bruising and/or bleeding Bad breath Excessive hunger Poor appetite Tendency to low blood sugar Difficulty digesting greasy foods Nausea, vomiting or acid reflux Gas and belching Bloating or abdominal pain Gum or mouth sores Tired or sleepy after eating Constipation Loose stools Indigestion or heartburn Excessive worrying Craving sweets
Five Element - Metal : Check the box next to any symptoms you experience once or more per month.

Dry cough Have much phlegm Sticky sputum Asthma Sinus problems Poor sense of smell Nose bleeds Itchy or painful throat Dry mouth Skin rashes Oily skin Dry or itchy skin Grief or sadness Shortness of breath Allergies Low resistance to colds Low physical stamina Sweat easily with little exertion No desire to talk Craving spicy foods
Five Element - Water : Check the box next to any symptoms you experience once or more per month.

Urinary problems Frequent urination Incontinence Low back pain or weakness Arthritis, degenerative bones Weakness or pain in knees Feel cold easily Low sexual energy Excess sexual desire Little desire to drink Fearful or easily frightened Poor memory Mental confusion Loss of hair Hearing problems Ringing in ears Prefers heat to cold Craving salty foods
WOMEN ONLY
Age at onset of menses?
Date of first day of last period:
Are you pregnant?

Yes No
Number of Premature births?
Number of miscarriages?
Number of caesarian sections?
Number of abortions?
List any infertility problems:
Type of birth control:
Last OB/GYN exam and results:
MEN ONLY
Any decrease in urinary flow?
Any issues with erectile dysfunction?
Infertility issues?
Any issues with impotence?
Experiencing pain or itching in genital area?
Any issues with the prostate?
ACUPUNCTURE INFORMED CONSENT TO TREAT
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bums and/or scarring are a potential risk of and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax Infection is another possible risk), although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above 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.

Acupuncturist Name: Nicole Stone, MS, LAc
Patient Signature (If signing for patient, please state you relationship to patient) *

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Date

Month Day Year
Date
Arbitration Agreement
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties
as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This
agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the
arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability
and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here. _______. Effective as of the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Patient Signature (If signing for patient, please state your relationship to patient) *

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Print name
Date

Month Day Year
Date
Acknowledgment of Receipt of Privacy Practices
Our office is dedicated to providing service with respect for human dignity. Protecting your privacy and your Healthcare information is fundamental in the course of our relationship.

This notice will remain in effect until it is replaced or amended by changes in law.

We gather personal information and health information in several ways:
- Information we receive from you
- Information we receive from other healthcare providers
- Information we receive from third party payers
This information is used for treatment, payment and healthcare operations. You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for treatment, payment, and healthcare operations.

You may specifically authorize us to use your protected healthcare information for any purpose or to disclose your health information by submitting the authorization in writing. Such disclosures will be made to any personal representation you choose to have your protected health information.

Marketing

This office will not use your health information for marketing communications without your written authorization. This office may send birthday cards, newsletters and appointment reminders, by calls, post cards or letters.

Disclosure

This office may use or disclose your Protected Health Information when required by law.

Patient Rights

1. Upon written request you have the right to access, review or receive copies of your healthcare records.

2. Upon written request you have the right to receive a list of items this office disclosed of your healthcare information.

3. You have the right to request that this office place additional restrictions on disclosure of our Protected Health Information.

4. You have the right to request that we amend your Protected Health Information. The request must be in writing.

5. You have the right to receive all notices in writing.

If you have any questions, complaints or want more information contact this office.

Nicole Stone, MS, LAc 4305 Gesner St. Suite 100, San Diego 92117

You may submit a written complaint to the U.S.A. Department of Health and Human Services
I have read, reviewed, understand and agree to the statement of the Privacy Policy for healthcare services in this office. This practice has attempted to provide each patient with a statement of Privacy Policies.
Patient Signature (If signing for patient, please state you relationship to patient) *

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Late Cancellations and No Shows
To better accommodate those patients on my waiting list I am initiating the following policy.

If you find it necessary to cancel or change an appointment, please allow at least 24 hours notice. Any changes or cancelations (or missed appointments) less than 24 hours in advance will obligate you to pay for the originally scheduled time.

Should a substitute be found to fill your appointment, no charge will be made for the missed appointment. I will go out of my way to be fair and hope that you will do the same.

I agree to give a minimum of 24 hours notice if I need to reschedule or cancel a scheduled acupuncture appointment.

I understand that if I cancel my appointment or do not show up I will be charged a fee of $50 for the missed appointment.
Patient Signature (If signing for patient, please state your relationship to patient) *

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Should be Empty:

PERSONAL INFORMATION

WOMEN ONLY

MEN ONLY

ACUPUNCTURE INFORMED CONSENT TO TREAT

Arbitration Agreement

Acknowledgment of Receipt of Privacy Practices

Late Cancellations and No Shows