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______