Katie Robinette, Lac., MSTOM

Robinette Acupuncture

Katie Robinette, LAc., MSTOM

3470 S. Sherman St., #3, Englewood, CO 80113

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New Patient Intake Form

PATIENT INFORMATION

Name: Last______First ______Middle______Sex: M/F

Address: ______City ______State______Zip______Phone: ______Home /Work /Cell (circle)

Is it okay to leave detailed messages on voicemail? YES/NO (circle) _____Initial

Date of Birth ______Age______E-mail: ______

Is it okay to send health related correspondence to this email address? YES/NO (circle) ____ Initial

Appointment reminders by: ____e-mail ___text ___none

Maritial Status: (Circle) Single Married Partnered Widowed Separated Divorced

Employment: (Circle) Employed Unemployed Disabled Retired Student

Patient’s Occupation: ______Employer ______

Responsible Party (if dependent): ______Relationship to Patient: ______

In Case of Emergency, Contact: Name: ______Relationship to Patient: ______

Phone: ______

How Did You Hear About Our Clinic?

Internet (specify Google/Yelp/Facebook/Map/etc)______Referral______Other ______

Today’s Date ______

Main Complaint______

How long has this been occurring? ______

Have you been given a diagnosis by a physician? Please describe. ______

What other therapies have you tried?

______How would you rate the severity of this issue, from 0-10, with 10 being most severe? ______

Are there other symptoms or complaints you would like to address? Please explain:

______

HEALTH HISTORY

Please check all conditions or previous diagnoses that apply.

AllergiesCancerDiabetesHepatitisSeizuresStrokeThyroid DiseaseHeart DiseaseOther diagnosed disease (please list): ______

Any accidents or significant trauma?

______

Any surgeries or scars?

______

Please list all prescription medications (current or within last 2 months).

______

Please list any vitamins, supplements or herbs you are currently taking.

______

LIFESTYLE

Do you exercise?

RarelySometimes (2 days/week or less)Often (3 days/week or more)

What types of exercise?

______

How is your sleep? ______

Any dietary restrictions? (vegetarian, vegan, etc.)

______

Habits

CigarettesAlcoholCaffeine Cannabis

Any foods or flavors that you crave? ______

Any foods that make you feel bad? ______

What are your symptoms when you eat these foods? ______

______

RECENT CONDITIONS AND SYMPTOMS

General Health

InsomniaDisturbed SleepNight SweatsSweating EasilyGeneralized WeaknessNoticeable FatigueWeight GainWeight LossEdemaNumbness or TinglingCold HandsCold FeetGenerally ColdGenerally HotStrong ThirstLack of AppetiteExcessive HungerFood CravingsTremors/TremblingDizziness/Vertigo

Other abnormal symptoms or changes in your general health?

______

Musculoskeletal

Neck PainBack PainShoulder PainKnee PainHip PainArthritisHand/Wrist PainFoot/Ankle PainMuscle WeaknessOverall Pain

Other musculoskeletal symptoms?

______

Psychological and Mental

DepressionAnxietyStressIrritability/FrustrationPoor MemoryLack of ConcentrationLack of MotivationAddiction

Other emotional symptoms?

______

Skin and Hair

RashEczema or PsoriasisUlcerationsPimplesHivesDry Skin/ScalpItchingHair Loss

Other skin and hair symptoms?

______

Digestion

Lack of appetiteFeeling of retention of food in stomachLoose stools or diarrheaConstipationVomitingHeartburn/refluxBloating or fatigue after meals

Other digestive symptoms?

______

Face and Head

Migraines/HeadachesEye Pain/StrainEye Floaters/SpotsPoor VisionRinging/Sound in EarsPoor HearingEarachesRecurrent Sore ThroatsSinus CongestionNose BleedsSinus/Facial PainJaw Clicks/PainLip/Mouth SoresDry Mouth

Other face and head symptoms?

______

Cardiovascular

High Blood PressureLow Blood PressureIrregular HeartbeatChest Pain

Other problems with respiratory tract?

______

Urination

Pain on UrinationFrequent UrinationUrgency to UrinateIncontinence/LeakageDecreased UrinationWaking Often to UrinateKidney StonesBlood in Urine

Other urinary symptoms?

______

Men's Health

Genital Sores/RashErectile DysfunctionDecreased LibidoExcess Libido

Other men's health symptoms?

______

Women's Health

PMSPainful PeriodsHeavy FlowLight FlowIrregular PeriodsAbsent PeriodsMenstrual CrampsPast Miscarriage

Other women's health symptoms?

______

Have you been pregnant or given birth in the past 3 years?

YesNoMaybe / Not Sure

Age at menopause (if applicable) ______

Is there anything else you would like to share about your health history, allergies, or care preferences?

______

Please Sign the Below Statement if you Agree:

I take responsibility for alerting my practitioner to any physical, mental, or emotional changes that occur with my health. The above information is accurate and true to the best of my knowledge. I will not hold my acupuncturist responsible for any errors or omissions I may have made in the completion of this form.

Signature: ______Date:______

CLINIC POLICIES
1. You are ultimately responsible for all fees charged.
2. If you need to cancel an appointment, please notify us at least 24 hours in advance. Failing to do so will result in a $50.00 cancellation fee.
3. We are required by law to maintain the privacy and confidentiality of your protected health. You may request a copy of the HIPPA privacy guidelines from your health care practitioner, or find it in your Patient Portal.
4. We have a right to contact you by phone, mail, or email if you gave permission in your consent form. This contact could be regarding scheduling, promotions, or other pertinent reasons of the clinic, but we will not give Personal Health Information to anyone else as a result of these types of contact.
5. You have access to a copy of the Colorado State Disclosure Form through the website, the Patient Portal, or you may request a copy.
6. If you are under 18, please have your parent/guardian sign below.
I consent to receive acupuncture and adjunctive therapies at Robinette Acupuncture, LLC. I have read and agree to the terms of the preceding paragraphs. All of the required information is true to the best of my knowledge.

Sign if you understand and agree the above statements.

Signature:

______Date:______

CONSENT TO TREATMENT-PLEASE READ AND SIGN BELOW IF YOU UNDERSTAND AND AGREE
By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist. I understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic’s practitioners.
Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.
Chinese Herbs: I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call the Chinese Medical Clinic as soon as possible.
Cupping, Gua Sha, Acupressure: I understand that I may also be given acupressure as part of my treatment to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.
Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.
I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.
I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment.

Signature:

______Date:______