Initial Patient Form

Initial Patient Information Form
YOUR PRIVACY IS OUR PRIORATY, this form is under HIPPA Compliance.
Welcome Information
Welcome to RUYI Acupuncture Integrative Medicine Clinic. We are thoroughly committed to working with you to enhance your health and wellness. We value your time and realize that office visits may be an interruption to an otherwise very busy schedule for you, and we commit to ensuring that your time at our clinic is as focused and efficient as possible. Effective medical health care is only possible when the practitioner completely understands the patient’s physical, mental and emotional condition. Oriental medicine is based largely on pattern recognition. Even the smallest details can relate to your overall constitutional picture, so no detail is too small. With that in mind, your thoughtful and honest responses will help to determine an appropriate course of treatment specific to you and allow us to use time in the clinic most effectively. All responses are of course bound to the strict rules of doctor-patient confidentiality. For your first visit please bring: 1. An updated list of all medications & supplements you are taking. (space provided on intake form) 2. Any lab results or relevant imaging received within the last year. In general, if you are receiving acupuncture, to receive the most benefit, and to avoid side effects, please adhere to the following: 1. Wear loose clothing. 2. Have a light meal or snack before the visit, as heavy meals can cause nausea and an empty stomach can be the cause of dizziness or light headache after the treatment. 3. Do not drink coffee and/or any drink that will stain the tongue several hours prior to your appointment and make sure to drink enough water on the day of treatment. 4. After your visit, it is preferable that you make the rest of your day as easy as possible. Please avoid heavy exertion. Moderate exercise is okay. 5. Do not drink alcohol or use other intoxicating drugs, eat greasy or spicy food, or exercise excessively before or after your appointment. We are looking forward to working with you, Stay Rejuvenate, Revitalize and Relax!
Patient Information
First Name:*
Last Name:*
Date of Birth*

MonthDayYear
Age:
Gender:*
Contact Phone:*

Area CodePhone Number
Home Phone:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email:*
Occupation:
Emergency Contact:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Relationship with Emergency Contact:*
How did you hear about us?

Google / Yelp SearchFriends & FamilyInsurance WebsiteSocial Media (FB, Instagram, Twitter)Other
Chief Complain. Please describe your current health concerns?*
Severity of the condition / Pain Scale

0 - No Pain1 - Minimal2 - Mild3 - Uncomfortable4 - Moderate5 - Distracting6 - Distressing7 - Unmanageable8 - Intense9 - Severe10 - Unable to Move
Are you aware of any allergies to food, drugs, or other environmental allergens?
Do you take any of the following medications more than once a week?*

Blood Pressure MedicationBlood Thinner MedicationDiabetic MedicationPain Relievers (Tylenol, Ibuprofen)Thyroid MedicationAntibioticsSleeping MedicationCortisone (Cream or Pills)Diet Pills, Appetite SuppressantsNone of theseOther
Please list all Prescribed Medications you are regularly taking, including dosage and frequency, if possible:
Please Indicate if you have any of the following:

Believe that you may be pregnantCardiac PacemakerSeizure DisorderFainting DisorderBleeding DisorderTuberculosis (TB)HIV / HPVHepatitisNone of these
The reason you visit a doctor's office, clinic or hospital, ER recently?
What diagnostic imaging studies have you had?

X-raysCT ScanPET ScanMRIMammogramBone Densities ScanElectrocardiogramElectroencephalogramOther
Do You currently have a primary care doctor?

YESNO
Primary Doctor's Name:
Phone Number:

Area CodePhone Number
Are you currently under the care of any other physician/healthcare providers ?

YESNO
Doctor's Name:
Phone Number:

Area CodePhone Number
What hospitalizations or surgeries have you had?
Family Medical History (Do you have a family history of any of the following ?)

AnemiaArthritisAsthmaCancerDiabetesEpilepsyGall bladder diseaseHeart diseaseHigh blood pressureKidney diseaseLiver diseaseMental illnessStrokeTuberculosisThyroid diseaseNone of theseOther
Review of Systems

(Check any symptoms that you have)
General

FeverChillsWeight LossWeight GainNight SweatsFatigueWeakness
Psychology

DepressionAnxiety/Panic AttacksInsomnia or Disturbed sleepWake up unrefreshedHigh-stress level
Endocrine

Cold intoleranceHeat intoleranceExcessive thirstExcessive urinationExcessive sweatingFlushing
Skin

Sun sensitivityHivesThickening or tightening of the skinCalcium depositsFingers/toes turn colors in the coldNodulesPsoriasisNail problemsDry skinRash/purple or red spots/pigment change
Neurologic

MigrainesHeadachesNumbness/tinglingMuscle weaknessIncontinenceSeizuresMuscle crampsDifficulty thinking or remembering
Scalp/Head

Hair lossScalp tendernessHeadacheJaw pain with chewing
Eyes

Vision problemsDouble VisionRed-eye or pink-eyeEye PainDry eyesSandy, gritty sensation in eyes
Ears

Ringing in earsHearing lossEar painSwollen earRed earDrainage from earVertigo
Nose

Runny noseNasal congestionNose bleedsDeformity of noseSwelling of the noseRed noseDry noseNose soresLoss of sense of smellSinusitis
Mouth

Sores in the mouthDry mouthDental problemsLoss of tasteDifficulty swallowingBleeding gumsSore throatHoarseness/change in voice
Allergy

Frequent sneezingSeasonal allergiesIncreased infections
Lungs

Shortness of breathCoughCoughing up bloodWheezingChest pain with breathing/pleurisy
Heart

Chest painStabbing chest pain/pericarditisIrregular or rapid heart rateLightheadedness/Passing outShortness of breathAwakened by shortness of breathLeg/ankle swellingColor changes in legs/feetLeg cramps with walkingHeart murmur
GI/Abdomen

Abdominal painHeartburnBloatingNauseaVomitingDifficulty swallowingDiarrheaConstipationBlood in stoolsBlack, sticky stoolsMucous in stoolsJaundice
Genitourinary/Urology

Pain/burning with urinationDifficulty urinatingFrequent urinationUrinary incontinenceCloudy urineBlood in urineHistory of STDs
Blood/Lymph

Blood clotsBleeding tendencyBruisingTransfusionsSwollen lymph nodes (status post biopsy)
Women Only

InfertilityEndometriosisDysmenorrheaMenopausePCOS.PMS.OsteoporosisHistory of miscarriageVaginal dischargeVaginal ulcersBreast cancerOvarian cancerPre-eclampsia or high blood pressure during pregnancy
Men Only

Low libidoErectile dysfunctionPremature ejaculationProstate enlargementProstatitisProstate cancerPenile dischargePenile ulcers
Female Reproductive
Age of first Menstruation
Age of last Menstruation
Period every
Number of days of flow
Number of Pregnancy
Number of Live Births
Are you Pregnant or Breastfeeding?
Other Concerns
I feel that I have answered the above questions to the best of my ability and understand that if I choose to omit any health information I do so at my own risk and that in no way will the healthcare provider be responsible for any omitted information.

Agreed by signing below
Print Name*
Signature (or Patient's Representative)*
Date*

MonthDayYear
HIPAA Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTHCARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, paying your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose and treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital administration. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to quality assessment activities, employee review activities, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. Use Required by Law: We may use or disclose your protected health information in the following situations without your authorization. These situations include as Required by Law; Public Health issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Funeral Directors; Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; or for Inmates. Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500 Other Permitted and Required Uses and Disclosures will Be made only with your consent, authorization, or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.Agreed by signing below
Print Name*
Signature (or Patient's Representative)*
Date*

MonthDayYear
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 binds 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 backup 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 the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initial below. 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. Agreed by signing below
Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), the patient should initial here.initial. Effective as of the date of first professional services.
Print Name*
Signature (or Patient's Representative)*
ACUPUNCTURE INFORMED CONSENT TO TREAT
I hereby request and consent to acupuncture and associated treatments and procedures having to do with holistic medical care within the scope of practice of acupuncture for myself, (or for the patient named below for whom I am legally responsible) by Dr. Louie Lu, DAIM. L.Ac. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, gua-sha, electro-acupuncture, tui-na (Chinese manual therapy), herbal medicine, exercise and/or nutritional and lifestyle counseling and coaching. I understand that herbs may need to be prepared and that teas be consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will immediately notify my practitioner or a member of the clinical staff of any unanticipated or unpleasant effects associated with the treatment and/or consumption of herbs. I understand that acupuncture is a generally safe method of treatment that involves the insertion of subcutaneous needles at various points in the body. I acknowledge that acupuncture may occasionally have some side effects including bruising, numbness, tingling, or pain near the needle site that may last a few days, as well as dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps or hot packs. 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 Oriental manual therapy (including all bodywork procedures, cupping, gua-sha, and qigong therapy/energy work) could constitute a wide range of manually applied techniques that could include, but are not limited to, light touch, deep pressure, and joint mobilization through stretching and passive range of motion. I understand that any or all aspects of Oriental manual therapy may result in fatigue, nausea, malaise, soreness, bruising, and aching for multiple days after treatment and that bruising is a common side effect of cupping and gua-sha. Emotional release and regression to past traumatic events may also result from any or all aspects of treatment. The herbs and nutritional supplements (which are from plant, animal, and mineral sources) that I have been recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. I understand that some herbs and other treatment methods 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 my practitioner if I am now or become pregnant or if any of these side effects occur. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. As with any medical or health-related treatment, I understand that it is impossible to accurately predict how any one person may respond to treatment and I acknowledge that, in extreme and very rare circumstances, adverse side effects may even result in blindness, disability, and/or death. I understand that acupuncture and Oriental medicine treatment is not a replacement for diagnostic medical procedures. I understand that an acupuncturist does not diagnose according to standard medical practice, nor should an “Oriental Diagnosis” be considered a replacement for standard medical evaluation or testing. I acknowledge that my practitioner is not a Primary Care Doctor, Medical Doctor, Naturopathic Doctor, Doctor of Osteopath, Doctor of Chiropractic, nor Doctor of Physical Therapy and does not claim to practice within the scope thereof. By 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 and release form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I hereby agree to indemnify and hold harmless Dr. Louie Lu, DAIM. L.Ac from any loss, liability, damage, judgment awards, or costs, including court costs and attorneys’ fees that may incur due to my participation in said treatment or subrogation suits or claims, whether caused by the negligence of Releases or otherwise. I have carefully read this form and fully understand its contents. All information I have provided in any and all intake forms is true. I am aware this is a release of liability, a waiver of claims, an agreement not to sue, an indemnity, and a contract between myself and the Releases described herein. I sign it of my own free will. PARENT OR GUARDIAN OR LIAISON OF SUCH, OF A MINOR: I, as parent or guardian or liaison of the below-named minor, hereby give my permission for this child or ward to participate as a patient in the above-named treatment(s), and further agree, individually and on behalf of this child or ward, to the terms as outlined herein.Agreed by signing below
Print Name*
Signature (or Patient's Representative)*
Date*

MonthDayYear
Late Cancellation/ Missed Appointments Notices
We respect the fact that you may, on occasion, need to cancel an appointment. However, we do request 24 hours' notice. Should you cancel or reschedule an appointment without 24 hours' notice, we reserve the right to charge a Late Cancellation Fee of Forty-Eight ($48) dollars. Missed Appointment (No Show) Fee of Eighty-Eight ($88) dollars.

You may or may not be charged this fee depending upon the circumstances and/or number of occurrences. The patient also acknowledges that repeated Late/Same Day Cancellations or No-Shows for scheduled appointments may result in my discharge from the practice or I may be required to pay upfront for the cost of my services at the time of pre-scheduling.Agreed by signing below
Signature:*
Date:*

MonthDayYear
Insurance Disclaimer
Insurance Disclaimer
A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits is subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service. Insurance Liability for Payment: Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Every effort will be made by this office to have all services and procedures preauthorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service.
Beneficiary Agreement:
I understand that my health insurance company may deny payment for the services identified above, for the reasons stated. If my health insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies. Agreed by signing below
By signing below, I confirm the amount of payment made by me, and I understand that the payment (or no payment) is an estimate of my financial responsibility for the service rendered today. My final responsibility is based on the Explanation of Benefits. Any under-collection will be billed to me. Over-collection is refunded to me quarterly.

Agreed by signing below
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Medical Insurance Information
Medical Insurance Name
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Copy of Insurance Card Front & Back

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Initial Patient Information Form

YOUR PRIVACY IS OUR PRIORATY, this form is under HIPPA Compliance.

Patient Information

Review of Systems

Female Reproductive

I feel that I have answered the above questions to the best of my ability and understand that if I choose to omit any health information I do so at my own risk and that in no way will the healthcare provider be responsible for any omitted information.

HIPAA Notice of Privacy Practices

ARBITRATION AGREEMENT

ACUPUNCTURE INFORMED CONSENT TO TREAT

Late Cancellation/ Missed Appointments Notices

Insurance Disclaimer

Medical Insurance Information