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Document 6422382
Ferndale Location Grandview Business Center 7056 Portal Way R7 Ferndale, WA 98248 360-366-4216 F)360-366-4241 Bellingham Bellwether Location Bayview Center 12 Bellwether Way, Suite 219 Bellingham, WA 98225 360-366-4216 F)360-366-4241 Acupuncture Health History Form Patient Information Name Address City Home Phone Height Weight Date State Sex: Date of Birth Occupation Have you had acupuncture before? Major Complaint Primary reason for your visit today? Cell Phone Male Female Zip Marital Status Age Employer No Yes, Name of Acupuncturist Has this condition been diagnosed by a physician, or other provider? No Yes, Diagnoses Are you being treated for this condition by anyone else? Yes No If yes, what is the treatment? Have these treatments helped? Yes Somewhat Not Much How does this condition affect you? How long have you had this condition? Personal Health History Your general health as a child was? Excellent Good Average Poor Did you feel safe and nurtured as a child? Always Usually Sometimes Not At All Never Check all the illnesses or conditions which you currently have or have had in the past: AIDs / HIV Eating Disorders Kidney Disease Rheumatic Fever Alcoholism Epilepsy Measles Scarlet Fever Allergies Glaucoma Meningitis Sexually Transmitted Antibiotic Use Heart Disease Mental Illness Disease Asthma Hepatitis Multiple Sclerosis Stroke Bleed Easily High Blood Mumps Tuberculosis Pressure Cancer High Fevers Obesity Typhoid Fever Chicken Pox Hyperthyroid Pneumonia Ulcers Diabetes Hypothyroid Polio Vascular Disease Drug Abuse Jaundice Other Are you taking Coumadin or Warfarin? Yes No Do you have a pacemaker? Do you have seizures? Yes No Do you currently have any infectious diseases? Yes No Possibly If yes, please identify: HIV / AIDs Hepatitis B Hepatitis C Flu / Cold Mononucleosis Tuberculosis Other Known or suspected allergies: Yes No Streptococcus A BETTER WAY MASAGE, LLC | 1.2014|SF Personal Health Inventory Please put a check mark ( )by the symptoms that you have now. Place a star () next to the ones you have noticed within the last three months. Qi, Blood, Yin, Yang anxiety catches colds easily or frequently chest pain traveling to shoulder cold feet cold hands difficult to concentrate dizziness dream disturbed sleep dry skin fatigue feverish in the afternoon or flushes general weakness heat sensations in hands, feet, chest insomnia mental confusion night sweats palpitations restlessness sores on tip of tongue speech problems sweats easily thirst, at night you feel worse after exercise you see floating black spots LU allergies chills alternating with fever cough difficulty breathing dry mouth, throat, nose feeling achy headaches nasal discharge nose bleeds shortness of breath sinus congestion sneezing sore throat stiff neck/ shoulders SP abdominal bloating and / or gas after eating belching chest congestion constipation diarrhea eating disorders fatigue after eating gas general feeling of heaviness in your body hemorrhoids loose stools low appetite mental heaviness, sluggishness or fogginess nausea prolapsed organs (previously diagnosed) swollen feet swollen hands you bruise easily ST bad breath belching bleeding, swollen or painful gums burning sensation after eating constipation heartburn large appetite mouth sores (canker or cold sores) stomach pain vomiting HT / PC chest pain edema high blood pressure insomnia low blood pressure palpitations stroke varicose veins LR / GB bitter taste in mouth blood shot eyes blurred vision chest pain convulsions diarrhea alternating with constipation difficulty swallowing dry eyes feeling of a lump in your throat headache at the top of your head hot flashes muscle spasms, twitching, cramping numbness of hands and feet pain in rib cage red, sore or irritated eyes seizures skin rashes tight feeling in chest TMJ or locked jaw you anger easily you feel better after exercise KI / BL frequent urination hair loss joint pain lack of bladder control loose teeth low back pain memory problems night blindness or low vision ringing in your ears sore, cold or weak knees you get up more than one time at night to urinate Other A BETTER WAY MASAGE, LLC | 1.2014|SF Family History How do you feel about the following areas of your life in the past month. Significant Other Great Good Fair Poor N/A Comments Family Great Good Fair Poor N/A Comments Self Great Good Fair Poor Comments Check illnesses which have occurred in any of your blood relatives: Alcoholism Cancer Heart Disease Allergies Diabetes High Blood Pressure Bleed Easily Epilepsy Kidney Disease Other Mental Illness Obesity Stroke Women Only Are you pregnant? Yes, How many months? No Trying Maybe Method of birth control? Age of First Menses Date of Last Menses Age of Menopause Typical Length of Menses (Days You Bleed) Typical Length of Cycle (From the 1st Day of One Cycle to 1st Day of the Next) Number of: Pregnancies Births Abortions Miscarriages Hysterectomy Yes Partial Complete Date No Check all that apply to you: Scanty Flow Heavy Flow Clotting Vaginal Discharge Abnormal Pap Smear Menopausal Symptoms Premenstrual Problems Other Painful Periods Breast Tenderness Breast Lumps Nipple Discharge Fibrocystic Breasts Bleeding Between Cycles Irregular Cycles Low Libido Excessive Libido Painful Intercourse Infertility Fibroids Endometriosis Ovarian Cysts Men Only Check all that apply to you: Low Libido Excessive Libido Impotence Vasectomy, Date Seminal Emissions Premature Ejaculation Painful Intercourse Prostate Problems Testicular Pain Testicular Redness Testicular Swelling Other A BETTER WAY MASAGE, LLC | 1.2014|SF Medications Please list medications, herbal supplements and vitamins you are currently taking: Drug / Supplement / Vitamin Reason For Taking For How Long Dosage Frequency Lifestyle How would you rate the following areas of your health in the past month. Digestion Great Good Fair Poor Comments Stools Great Good Fair Poor Comments How many times per day? Do they feel complete? Yes No Stool consistency? Loose Formed Hard to Pass Other What is the color of your stools? Is there blood in your stools? Yes No How Often? Urination Great Good Fair Poor Comments How many times per day? What color is your urine? After you've gone to sleep do you get up to urinate? Yes No How Often? Is your urination painful? Yes No Appetite Great Good Fair Poor Comments Diet Great Good Fair Poor Comments Are you vegetarian or vegan? Yes No For how long? Food / Drink: Foods You Crave When? Daily Water Intake Coffee Intake Daily Soda Intake Caffeine? Yes No _ Daily Tea Intake Do you drink alcohol? How Much? Do you use tobacco? Yes Do you use recreational drugs? Caffeine? Caffeine? How Often? No Yes No Yes No Daily Yes No What kinds? Past Use? Yes No Date Stopped Past Use? Yes No Date Stopped Past Use? Yes No Date Stopped How do you feel about the following areas of your life in the past month. Energy Sleep Great Good Fair Poor Comments On a scale of 1 to 10? (10 is high energy) Great Good Fair Poor Comments Hours per night? Do you wake feeling rested? Great Good Fair Poor Comments Great Good Fair Poor Comments Great Good Fair Poor Comments How often? What kind? How would you rate your stress level on a scale of 1 to 10? (10 is high stress) How well do you feel you handle your stress? Great Good Fair Yes No Sex Life School Exercise Poor A BETTER WAY MASAGE, LLC | 1.2014|SF Pain Please answer the following questions if you have pain. Indicate on the diagram your areas of pain How long have you had this pain? Describe the onset of your pain? On a scale of 1-10 (10 being worst) how strong is your pain? What does your pain feel like? (check all that apply) Dull Sharp Stabbing Constant Comes and Goes Does the pain radiate? What helps the pain? Moisture No Ice Massage What aggravates the pain? Moisture Massage Sore Fixed Achy Cramping Moves About Yes Where? Heat Rest Nothing Movement Burning Pressure Other Ice Heat Rest Nothing Other Movement Pressure Does anything relieve this pain? (i.e.; medications, over the counter drugs, liniments) Other treatments you have had for this pain? Anything you wish to add? The above information is true to the best of my knowledge. X Patient's Signature DateofBirth: Today’sDate: A BETTER WAY MASAGE, LLC | 1.2014|SF PATIENT INFORMED CONSENT The law requires patients receiving acupuncture to give their informed consent prior to receiving treatment. Informed consent is for the patient to be advised of the credentials of the practitioner(s) and the scope of the practice of acupuncture in the State of Washington. The practitioner, Shannon Freeman, L.Ac., EAMP, LAC is licensed in the State of Washington. He has over 20 years of experience in the medical field, and was a Licensed Certified Nursing Aide and Licensed Massage Practitioner prior to graduating from Middle Way Acupuncture Institute with a Masters degree in Acupuncture in 2012. The practitioner, Heather Falkenbury, L.Ac., EAMP is licensed in the State of Washington. She graduated from Bastyr University with a Masters degree in Acupuncture and Oriental Medicine and Chinese Herbal Medicine in 2006. Heather has also completed an intensive course study of Chinese Herbal medicine at Chengdu’s College of Traditional Medicine in China. Heather is also a Certified Holistic Doula. As stated by law, therapy acupuncturists in the State of Washington are allowed to use the methods listed below. This in no way means that all these methods will actually be used for your treatment. You will be advised before any one of these methods is to be applied, and you always have the right to decline. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. use of acupuncture needles to stimulate acupuncture points use of electrical, magnetic, or mechanical devices to stimulate acupuncture points moxibustion (direct or indirect application of heat on acupuncture points using herbal materials) Tui Na (acupressure) cupping Gua Sha (dermal friction) infra-red light sono-puncture (ultrasound) laser puncture dietary advice based on traditional Chinese medical theory Patients with the following conditions must inform the practitioner(s) prior to receiving acupuncture treatments. Please check the following that applies. pregnancy pacemaker severe bleeding disorders hepatitis AIDS or HIV positive I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the above named practitioner(s), or other licensed practitioners who now or in the future treat me while employed by, working or associated with or serving as back-up for the practitioner(s) above, including those working at the clinic or office listed above. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Oriental massage), 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. 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. Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes the major risks of treatment, other side effect 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 Oriental 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 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. 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. I, the undersigned, have read and understood the foregoing information and voluntarily consent to the use of the above procedures for treatments. I understand that there is no guarantee implied or expressed regarding the success or effectiveness of a treatment or a series of treatments. I hereby release Shannon Freeman, L.Ac., EAMP, LMP and Heather Falkenbury L.Ac., and the assistant(s) under the supervision of him or her, from all liability in connection with these treatments. I understand that I am free to withdraw my consent and stop treatment at any time. Patient Signature: Guardian signature if under age 18 Patient Name (please print): Date:
