Angela Filsinger LLC

Angela Read LLC

Angela Read

Licensed Acupuncturist

Patient Health History

---Please note that all information is kept confidential---

Name ______Date ______

Age _____ DOB ______Sex M F Social Security # ______

Marital Status: single married divorced partnership # of children ______

Address ______

Phone (home)______Phone (cell)______

Email ______Employer ______

Is it all right to leave a message about your care at these numbers? Yes No

Emergency Contact______

Relationship & Phone #______

Physician ______Phone #______

How did you hear about my services?______

Thank you for taking the time to fill out this form as completely as possible.

To provide quality and effective healthcare, it is essential for me to

have a th0rough understanding of your past and present health.

Please list the primary health concerns you would like to address in order of importance:

1.______

2.______

When did these conditions begin? Was anything of significance happening at the time?

1.______

2.______

What types of treatments have you tried? How have they helped?

1.______

2.______

How do these conditions affect your daily activities/work/relationships/emotions?

1.______

2.______

Please list all medications/supplements/vitamins you are currently taking:

Name/Dosage Reason For how long

______

Please list all major accidents, illnesses, surgeries or hospitalizations and when they occurred:

______

Please list all diseases or conditions that your are currently diagnosed with or believe you may have:______

Please list any allergies you have and your response to them (medications, foods, animals, environmental, etc.) ______
______

Please list any significant family medical history (diseases, conditions, tendencies, genetic predispositions, mental health and premature deaths including age and reason).

______

Are you or might you currently be pregnant? Y / N

Do you have a pacemaker? Y / N Heart Murmur? Y / N

Do you have a history of seizures? Y / N Fainting? Y / N

Have you had any cosmetic procedures? Y / N

Lifestyle & Fundamental Aspects of Good Health

Do you sleep well? Y / N Explain:______

Time to Bed:______Time to rise:______Average hours of sleep:______

Do you exercise? Y / N How often and what type? ______

Do you feel you drink enough water each day? Y / N How much? ______

What other beverages do you consume regularly and how much? ______

Do you feel like you have a generally healthy diet? Y / N

What types of foods /meals do you commonly eat? ______

Do you tend to have cravings? Y / N What are they? ______

Do you consume / use alcohol, caffeine, tobacco or any other drug / substance? If so, which ones and how much per week? ______

What is your current occupation? ______How many hours/week? _____

Do you enjoy your work? Y / N Why? ______

Do you have someone you can really talk to or confide in? Y / N

Do you have activities that allow you to relax or rejuvenate? Y / N

If yes, what are they? ______

The following is a list of symptoms, please circle those that you are currently experiencing and underline those that you have experienced in the past.

General Mental & Emotional Tendencies

fatigue / low energy anxiety / excess worry

feel better with exercise panic attacks

feel worse with exercise nightmares

heavy sensation of the body easy to anger

unclear or foggy thinking irritability

experience high stress feelings of hopelessness

“lump in the throat” sensation indecisiveness

symptoms are worse with stress feelings of grief / sadness

difficulty falling asleep feelings of worthlessness

hands & feet feel cold frequent crying

hands & feet feel hot manic episodes / behaviors

pale face, nails or inside eyelids difficulty concentrating / focusing

excess fear

Musculo-Skeletal feel generally positive and capable

low back pain other______

pain between shoulders

neck pain Cardiovascular

arm pain shortness of breath

jaw pain irregular heart beat

joint pain / stiffness heart palpitations

frequent sprain / strains chest tightness or pain

other______heart problems

ankle / low body swelling

Neurological varicose veins

muscle weakness / atrophy high blood pressure

numbness / tingling low blood pressure

loss of sensation or functions other ______

paralysis

balance problems Respiratory

forgetfulness catch colds easily (>3x/year)

fainting or dizziness cough (dry or productive)

poor memory cough up phlegm

other______cough up blood

asthma, type:______

Head, Eyes, Ears, Nose & Throat shallow or difficulty breathing

headaches chest tightness or pain

sinus congestion / pressure hoarseness

floaters in vision lung problems

excess tearing or dryness

blurry vision / poor night vision

dental problems Gastro-Intestinal

bleeding or swollen gums mouth sores

earaches belching

ear ringing nausea or vomiting

hearing difficulties acid reflux / heartburn

dry nose / mouth / throat stomach pain

nasal discharge gas or bloating after meals

nose bleeds fatigue after meals

chapped lips digestive problems

sore throat big appetite

low appetite

Genito-Urinary gallbladder stones

excess or frequent urination intolerance of fatty foods

urinary tract or bladder infections tend towards constipation

kidney stones tend toward loose stools or diarrhea

waking to urinate at night blood in stools

pain or burning with urination mucus in stools

difficulty passing urine undigested food in stools

blood in the urine hemorrhoids

cloudy urine Have you traveled outside of the U.S.? Y / N

dribbling or incontinence Have you ever had a parasite? Y / N

Women’s Health Men’s Health

vaginal/labial pain or swelling testicular pain / swelling

excess vaginal discharge penile discharge

yeast infections low libido

nipple discharge sexual difficulties

breast lumps Types of protection/birth control used?

Self Brest Exam (SBE) monthly? Y / N ______

Have you had a mammogram? Y / N Have you had your prostate checked? Y / N

When?______When? ______

low libido

sexual difficulties Chronic infections, Please check all that apply:

Types of protection/birth control used? ______Tuberculosis ______Hepatitis A/B/C

______HIV ______AIDS ______STD Other______

Menstrual History and Patterns

Age of first period______Endocrine & Immune Function

Age of menopause ______body tends to feel warm/hot

Date of last annual exam ______body tends to feel cool/cold

Is your cycle regular? Y / N spontaneous day sweats

Do you bleed between periods? Y / N night sweats

# of bleeding days ______excess thirst

Total length of cycle (# of days) ______brittle or soft nails

Is your bleeding heavy / moderate / light? hair loss or thinning

Do you have clots? Y / N unusual hair growth

Do you have cramping? Y / N slow wound healing

Cramping before / during / after menses? easy bruising

Vaginal discharge skin problems

Do you have PMS symptoms? Y / N (itch, rash, dryness, acne, other)

*Breast tenderness? Y / N

*Emotional instability / mood swings Y / N Pregnancy

*Other______# of pregnancies ______

hysterectomy # of live births______

# of miscarriages______# of abortions______

Complications? Explain

Angela Read LLC

Angela Read

Licensed Acupuncturist

HIPPA

Consent for Purposes of Treatment, Payment and Health Care Operation

I consent to the use or disclosure of my identifiable health information by Angela Read LLC for the purposes of diagnosis or providing treatment to, obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or treatment of me at Blooming Moon Wellness Spa may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my identifiable health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Angela Read LLC is not required to agree to the restrictions that I may request. However, if Angela Read LLC agrees to a restriction that I request, the restriction is binding upon Angela Read LLC.

I have the right to revoke this consent, in writing, at any time.

My identifiable health information means health information, including my demographic information, collected from me and created or received by my practitioner, another health care provider, a health plan, my employer or a health care clearinghouse. This identifiable health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have the right to review Angela Read LLC’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my identifiable health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Angela Read LLC. The Notice of Privacy Practices is also provided at the front desk of the clinic. This Notice of Privacy Practices also describes my rights and the duties of my practitioners and Blooming Moon Wellness Spa with respect to my identifiable health information.

Angela Read LLC reserves the right to change information contained in the Notice of Privacy Practices at any time. I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office visit.

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Signature of Patient or Authorized Representative Date

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Angela Read LLC

Angela Read, Licensed Acupuncturist

Consent Form

I, the undersigned, understand that methods of treatment used in this practice may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, herbal therapy, massage and nutritional counseling.

I understand that acupuncture, moxibustion, electrical stimulation and cupping are all safe methods of treatment. Potential risks include temporary bruising, swelling, bleeding, numbness and tingling and soreness at the needling side that may last a few days. Unusual risk of acupuncture include dizziness, fainting or nerve damage. Infection is possible, although the clinic used alcohol and sterile disposable needles and maintains a safe and clean environment. Potential risks of moxibustion are burns, blistering or scarring. Temporary bruising or redness lasting a few days is a common side effect of cupping and gua sha. I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments.

I will notify the acupuncturist should I become pregnant or if I am in the process of trying to get pregnant so that my practitioner can avoid points and herbs that could induce miscarriage. Other wise, Chinese medicine treatment can be very beneficial in the pregnancy and birthing process.

I understand that herbal and nutritional supplements recommended to me by my acupuncturist are safe in the recommended doses. Large doses of herbs taken without my practitioner’s recommendation may be toxic, and some herbs are inappropriate during pregnancy. Some possible side effects of herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I understand that I must stop taking any herbs and notify my acupuncturist as soon as I experience any discomfort or adverse reactions.

I understand that I can discuss risk and benefits further with my practitioner before signing if I so choose. However, I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on the practitioner to exercise his or her best judgment in my interest during the course of treatment, based upon the facts then known.

I recognize that scheduling an appointment involves the reservation of time specifically for me, and that consequently, a minimum of 24 hours notice is required to reschedule or cancel an appointment. Unless otherwise agreed to in advance, the full fee will be charged for sessions missed without such advance notification. I understand that most insurance companies do not reimburse for missed sessions.

I understand the financial policy, which states that payment is due at time of service. Payment is accepted in cash or check. If your treatment is covered by insurance, we must first verify your benefits. If we are unable to verify your benefits at your first visit, you are required to pay for your office visit in full at the time services are rendered.

In signing this form, I acknowledge any inherent risks, and give my consent for treatment, payment and healthcare operations received, incurred or carried out at this practice.

Print name______

Signature______Date______