Acupuncture Intake Survey Kindly complete this form prior to your first acupuncture treatment. Member InformationFirst Name(Required)Last Name(Required)Date of Birth(Required)Preferred Email Address(Required)1. Age(Required)18 to 2425 to 3435 to 4445 to 5455 to 6465 or over2. Gender(Required) Male Female Non-binary Transgender Other 3. Home Zip Code(Required)4. Work Zip Code(Required)5. Height6. Weight7. Blood Pressure at time of last examinationHealth Background8. Please select your chief complaints. Select all that apply.(Required) Chronic pain (e.g., back pain, neck pain) Stress or anxiety Insomnia or sleep disturbances Headaches or migraines Digestive issues (e.g., bloating, constipation) Fatigue or low energy Menstrual irregularities or menstrual pain Allergies or sinus issues Joint pain or arthritis Emotional imbalances (e.g., depression, irritability) Please list any other chief complaints at this time.9. Current Medications/Supplements10. Allergies (Food, Medication, Other) None Yes Please list:11. Current Health Concerns/Diagnoses/ROS (check all that apply) Metal implants/pacemaker Alcohol or drug dependence Joint pain, back, neck, shoulder pain, migraines, headaches, eye pain, ear pain Sleep issues, fatigue, low energy High blood pressure, diabetes, high cholesterol Heart disease, palpitation, angina, congestive heart failure, peripheral vascular disease, heart murmur   Seizure disorder, stroke/CVA/TIA/double vision Gastrointestinal disease, gas, bloating, constipation, diarrhea, nausea Mental illness, depression, anxiety Kidney, liver, thyroid, disease (frequent UTI’s, fatty liver, hyper/hypothyroid) Hepatitis, HIV/AIDS, tuberculosis Cancer Menstrual cycle issues, PMS, PCOS, endometriosis, fibroids, hot flashes Recent surgery/hospitalizations/injury Select AllPlease list any clarifications for the above points:12. Risk Screening/Health History(Required) Recent hospitalization or ER visit New or changed medications, especially blood thinners Currently undergoing chemotherapy or radiation Sudden onset of high blood pressure, severe headache, dizziness, fainting, vision changes, or calf swelling or pain especially when walking Sudden onset chest pain, pressure, or shortness of breath Unusual bruising or bleeding (i.e. stool, urin. etc), bleeding disorder, blood clotting disease Open wounds, active infections or fever Pregnancy or recent Postpartum changes None of the above Select AllIf any of the below are checked, please alert your practitioner before treatment.13. Family History (Please list any known medical problems)14. I have a Primary Care Physician.(Required) Yes No Lifestyle15. I do muscle strengthening exercises 2 or more times a week.(Required) Yes No Sometimes 16. I do moderate-intensity aerobic exercise at least 150 minutes (2 hr and 30 minutes) per week.(Required) Yes No Sometimes 17. Please select all that apply. Drink 1-2 glasses of alcohol per night Smoke/vape tobacco Smoke/vape marijuana Select AllInformed Consent and Privacy Practices for Acupuncture Services(Required) By checking this box, I hereby consent to the following:I certify that the above health information is correct to my knowledge. The information provided in this form contains protected health information (PHI), which is safeguarded under federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically using encryption and access controls to safeguard it during transmission and storage. Your PHI will be maintained in compliance with applicable federal and California privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) and the California Confidentiality of Medical Information Act (CMIA). I hereby request and consent to acupuncture treatment. I understand that results are not guaranteed, and I have the right to refuse or discontinue any treatment at any time and understand that this refusal may affect the expected results. I agree to inform the acupuncturist of any changes in my health condition or medications prior to each treatment session. I understand that acupuncture is generally safe and effective. However, I understand that there are risks involved with my consent to acupuncture treatment including side effects such as dizziness, fainting, bruising, numbness and/or tingling near the needling sites that may last a few days. I understand that though unusual, additional risks of acupuncture include spontaneous miscarriage, nerve damage, and/or organ puncture, including lung puncture (pneumothorax). I understand that although the acupuncturist(s) use sterile disposable needles and always maintain a clean and safe environment, infection is another possible risk. 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 judgement during treatment. I understand that if I experience any adverse reaction during or after treatment, I should promptly inform the acupuncturist and/or seek emergency medical attention if appropriate. I hereby request and consent to the performance of acupuncture treatments (or on the patient named below, for whom I am legally responsible) by the acupuncturist(s) administering treatment at any time. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to acupuncture treatment and have been told about the risks. I intend this consent form to cover all acupuncture treatments at any time. I understand this includes the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.Signature(Required)Today's Date(Required) MM slash DD slash YYYY
