Patient Health History Form

Patient Health History Form

Common Way Acupuncture
Name*

First NameLast Name
Current Date*

MonthDayYear
Date of Birth*

MonthDayYear
Cell Phone*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person*

First NameLast Name
Phone Number*
Relationship*
Have you received acupuncture before?*

YesNo
When did you last receive acupuncture?*
What is your primary reason for your acupuncture visit?*
What treatments have you had for this condition?
Have you had any major accidents?*

YesNo
Please provide a few details to help me understand any impact on your treatment.*
Have you had any surgeries?*

YesNo
Please provide a few details about the surgery to help us understand any impact on your treatment.*
List any major medical conditions that exist in your family (parents and siblings):
If you are taking medications, please list them and which of their side effects you experience. (See drugs.com to see lists of side effects)
Authorization & Consent
HIPAA

Federal laws effective April 14, 2003, require patients to be given a notice of privacy policy formulated in accordance with HIPAA (the Health Insurance Portability and Accountability Act) and to sign a consent form and payment agreement. At Common Way Acupuncture, your health records will never be shared with anyone without your personal consent. They are held privately and securely, according to the regulations stated by the California Acupuncture Board.

Consent
- In signing this form, I voluntarily consent to treatment with acupuncture and other modalities (cupping, gua sha, moxa) that may be required for a complete treatment of my health issue.
- I understand that acupuncture is a minimally invasive technique in which sterile, stainless steel, disposable needles are inserted into specific points on the body to cause a desired healing effect via regulating the flow of qi (vital energy) in the body.
- I understand that the techniques may include manual stimulation of the needles and that the benefits of this modality may include the alleviation of pain or other symptoms, an overall sense of well-being, improved sleep, and increased energy levels.
- Likewise, I understand that the risks may include feeling weak, nauseated or faint and that occasionally there may be a worsening of symptoms.
- I also understand that bruising might occur at the site of the needle insertion and that blood might exit from these sites.
- I have been informed that moxibustion is a heat treatment using the herb mugwort placed on or near the body and that there is a possible risk of burning due to fallen ashes.
- I also understand that bruising and tenderness can occur with gua sha or cupping.
Financial Policy

I have been informed of the fees for payment for this service and I agree to render it at the time of treatment. I also agree to pay for any appointment canceled or missed for which I did not give 24 hours' notice.

By signing below, I acknowledge and agree to the policies and provide consent as outlined above.
Patient Signature:*

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Patient Health History Form

Authorization & Consent