Food Therapeutics and Nutrition Intake

Food Therapeutics & Nutrition Intake

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*
Chief Complaint
What would you like help with?*
When did it begin?
What makes it better?
What makes it worse?
Are you currently receiving medical treatment?*

YesNo
Is it helping?
Does there appear to be a connection to stress?
Does there appear to be a connection to diet?
Are symptoms affected by season, weather, or time of day?
Dietary Information
How do you usually feel before you eat?
How do you usually feel after you eat?
Do you take any vitamins or supplements? How much and how often?
List any medications you take & their side effects (see drugs.com for this information):
Past Illnesses & Family History
List any major illnesses and surgeries:
List a detailed family history of illnesses and health conditions (include mother, father, siblings, and grandparents):
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 Food Therapeutics & Nutrition treatment.

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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Food Therapeutics & Nutrition Intake

Chief Complaint

Dietary Information

Past Illnesses & Family History

Authorization & Consent