Significant Trauma (Physical Or Emotional)

Main Complaint (Please briefly summarize your symptoms, western medical diagnosis, duration, etc.)

Significant Trauma (physical or emotional)

Birth History (prolonged labor, forceps delivery, complications, etc.)

Surgeries (please include date of procedure)

Allergies (chemical, environmental, food, drugs, etc.)

Medications (names & dosages) Please attach an additional page if necessary.

Vitamins/Supplements/Herbs

Exercise

Days per week Length of workout Type of Activity

Diet

Meals per day Snacks Caffeinated Drinks Alcohol per week

What makes your condition better? (Rest, movement, heat, cold, fresh air, eating, crying, etc.)

What makes your condition worse? (stress, fatigue, hunger, heat, certain foods, damp days etc.)

Personal History Please check any conditions or symptoms you have now.

ArthritisLiver/Gall Bladder DiseaseStrokeHeart Disease

High/Low Blood PressureHypo/HyperglycemiaKidney DiseaseElevated Blood Cholesterol

CancerDiabetesFood Allergies/IntoleranceDiverticulitis/IBS

UlcerSeizuresHepatitisRaynaud’s Disease

Chronic FatigueAnemiaThyroid ImbalanceRespiratory Allergies

AlcoholismLyme DiseaseChronic Pain ConditionImpotence

Gastritis/PancreatitisAsthmaInfertilityEmphysema

Family Medical History Please check any condition that applies to your immediate family. Put an F (father),

M (mother), S (sister), B (brother), GM (grandmother), GF (grandfather) next to choice.

Diabetes ___Seizures ___Heart Disease ___Stroke ___

High Blood Pressure ___Allergies ___Cancer ___Asthma ___

Other______

Please check if you have had any of these items listed below in the lastyear

Put a star on the box if you had this in the past but do not any longer.

General

Poor AppetitePoor SleepingFatigueFevers

ChillsNight SweatsSweats EasilyTremors

CravingsLocalized WeaknessPoor BalanceChange in appetite

Bleed/Bruise easilyWeight loss/gainPeculiar tastes/smellsDental/gum problems

Muscle weakness/fatigueSudden energy drop Strong thirst (hot or cold drinks)

Skin and Hair

RashesUlcerationsHives/Allergic DermatitisItching

Eczema/PsoriasisDandruffLoss of hairRecent moles

Skin discolorationAcneChange in skin/hair textureFace flushing

DermatitisWartsFungal InfectionWeak or ridged nails

Head, Eyes, Ears, Nose and Throat

DizzinessDifficulty swallowingMigrainesGlasses

Eye StrainEye painPoor visionNight Blindness

Color BlindnessCataractsBlurred visionEaraches

Ringing in earsPoor hearingSpots in front of eyesSinus problems

Nose bleedsRecurrent sore throats/coldsGrinding teethFacial pain

Sores on lips/tongueDental problemsJaw clicks/locksHeadaches

Cardiovascular

Chest pain or pressureIrregular heart beatPalpitations at restFainting

Cold hands/feetSwelling of hands/feetBlood clotsPhlebitis

Shortness of breathVaricose/spider veinsPressure in chestHigh blood pressure

Low blood pressureSpontaneous sweatingDizziness

Respiratory

Cough/WheezingCoughing bloodAsthmaBronchitis

PneumoniaPain with deep inhalationTight sensation in chestDifficult inhale/exhale

Difficulty breathing when lying downProduction of phlegm… what color? ______

Gastrointestinal

NauseaVomitingDiarrheaConstipation

GasBelchingBlack stoolsBlood in stool

IndigestionBad breathRectal painHemorrhoids

Bloating/EdemaChronic laxative useLoose stools (>2 per day)Abdominal pain/cramps

Changes in appetiteAcid reflux/GERDHerniaPoor appetite

Excessive appetiteSignificant thirstIBS/Crohn’s Disease

Genito-Urinary

Pain on urinationFrequent urinationBlood in urineUrgent urination

Unable to hold urineKidney stonesScanty flowCopious flow

ImpotenceSores on genitalsUrinary tract infectionBurning urination

Premature ejaculationDecreased libidoProstatitisDribbling after urination

Nocturnal emissionPain in testiclesHerpesInfections

Night urination… What time?______How often?______Excessive libido

Gynecological/Reproductive

Difficult/Painful intercourseOvarian cystsAge of first menses______

Vaginal drynessEndometriosisDate of last menses______

Vaginal soresUterine FibroidsDate of last PAP/Pelvic______

Vaginal dischargeFibrocystic breast tissueNumber of pregnancies____

InfertilityPolycystic Ovarian DiseaseNumber of ectopic pregancies______

Irregular menstruationPMSNumber of live births______

Painful menstruationNumber of miscarriages______

Do you practice birth control?______Number of abortions______

What type?______How long?______

Musculoskeletal

Neck painShoulder painHand/wrist painCarpal Tunnel

Knee painSprains/StrainsSciaticaFoot/ankle pain

Hip painMuscle painMuscle weaknessTendonitis

Back pain Low___ Middle___ Upper___BursitisRotator Cuff

Soreness/weakness in lower body (back, knee, hip, ankle, foot)

Neuropsychological

SeizuresLoss of balanceVertigo/DizzinessAreas of numbness

Lack of coordinationPoor memoryConcussionDepression

Anxiety/Panic attacksBad temper/irritableEasily susceptible to stressSeasonal Affective Disorder

NervousnessADD/ADHD Manic Depression

Have you ever been treated for emotional problems? Yes No

Have you ever considered or attempted suicide? Yes No

Have you ever been treated for substance abuse? Yes No

Please list the medications, supplements and herbs you are currently taking.

Acupuncture Consent to Treatment

I hereby request and consent to the performance of acupuncture treatments and other Oriental medicine procedures on me (or on the patient named below, for which I am legally responsible) by the below name licensed acupuncturist.

I understand that methods or treatments may include but are not limited to acupuncture, moxibustion, cupping, bloodletting, electrical stimulation, Tui Na (Chinese massage), Gua Sha, Chinese or Western herbal medicine, and nutritional counseling.

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 Chinese Medicine. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status. If I experience any gastro-intestinal reactions to the herbs I will inform the acupuncturist immediately.

I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. 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. ______

initials

I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to share appropriate medical information. My signature gives my practitioner permission to release my medical records for the reasons listed above. ______

initials

I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation. ______

initials

I agree to pay all charges incurred for services rendered, over and above insurance coverage. ______

initials

To be completed by the patient’s representative, if the patient is a minor, or physically/legally incapacitated.

Name of Patient______

Patient’s Representative______

Relationship or Authority of Patient______

Witness______

Patient’s Name

Patient’s Signature

Date Signed

Are you Pregnant?

Name of Licensed Acupuncturist

Charles Chace

2600 30th St.

Boulder Co.

303-545-5792 X106

wwwcharleschace.com

Colorado Mandatory Disclosure Form

Charles Chace, Lic. Ac

2600 30th st., Suite 200

Boulder Co. 80301

This clinic complies with all rules and regulations promulgated by the Colorado Department of Public Health and Environment, including the proper disposal, cleaning and sterilization of acupuncture needles and sanitization of acupuncture offices. Only single-use, disposable, factory- sterilized needles are used. No licenses, certificates, or registrations has ever been suspended or revoked.

Patient’s Rights

1The patient is entitled to receive information about the methods of therapy, the techniques used, and the suggested duration of therapy.

2The patient may seek a second opinion from another health care professional and may terminate treatment at any time.

3In a professional relationship, sexual intimacy is never appropriate and should be immediately reported to the Director of the Division of Registrations at the Department of Regulatory Agencies.

The practice of acupuncture is regulated by the Director of Regulations, Colorado Department of Regulatory Agencies. If you have questions, comments or complaints, you can contact the Acupuncture Registration Office, 1650 Broadway, Suite 1340, Denver, Colorado 80202. (303) 894- 7851.

Fee Schedule

Initial 90 minute office visit $200

Regular 45 office visit $100

I have read and understand this document

Signature: ______Date: ______