Initial Patient Form

Initial Patient Information Form
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:
How did you hear about us?

Google SearchFriend / FamilyInsurance WebsiteYelpSocial Media (FB, Instagram, Twitter)
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?
Please Indicate if you have any of the following:

Believe that you may be pregnantCardiac PacemakerSeizure DisorderFainting DisorderBleeding DisorderTuberculosis (TB)HIVHepatitisOther
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?
Do you take any of the following medications more than once a week?

Blood Pressure MedicationBlood Thinner MedicationDiabetesPain Relievers (Aspirin, Ibuprofen)Thyroid MedicationAntibioticsSleeping MedicationCortisone (Cream or Pills)Diet Pills, Appetite SuppressantsOther
Please list any prescription medications you are regularly taking, including dosage and frequency, if possible:
Family Medical History (Do you have a family history of any of the following ?)

AnemiaArthritisAsthmaCancerDiabetesEpilepsyGall bladder diseaseHeart diseaseHigh blood pressureKidney diseaseLiver diseaseMental illnessStrokeTuberculosisThyroid diseaseOther
Female Reproductive
Age of first Menses
Age of last Menses
Length of Cycles
Duration of Menses
Numbers of Pregnancy
Numbers of Children
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
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Signature (or Patient's Representative)*

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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*

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Signature (or Patient's Representative)*

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Date*

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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*

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Signature (or Patient's Representative)*

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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 for a Late Cancellation/Missed Appointment Fee of Forty ($40) dollars. You may or may not be charged this fee depending upon the circumstances and/or number of occurrences. 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:*

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Date:*

MonthDayYear
Insurance Payment Difference Agreement
By initialing 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 refunded to me on a quarterly basis.

Agreed by signing below
Signature*

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Medical Insurance Information
Medical Insurance Name
Member ID Number
Group No#
Copy of ID Card Front Side

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Initial Patient Information Form

Patient Information

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

Acupuncture Informed Consent to Treat

Late Cancellation/ Missed Appointments Notices

Insurance Payment Difference Agreement

Medical Insurance Information