Mountain Acupuncture and Massage
Jaime Levy, EAMP, LMP~Ph.509.881.7905~Fax 509.888.6694
Location: Lynn Chadd Natural Healthcare~10090 Main Street, Suite H, Peshastin, WA 98847
email:
Confidential Patient Health Record
Name Date
Address
CityStateZip
Phone Numbers: HomeWorkCell
EmailDate of Birth
Marital StatusNumber of Children and Ages
Employer Name
Employer Address
How did you hear about us?
Emergency Contact
NameRelationship
Home PhoneCell Phone
Patient Condition
Primary Reason for Care
Secondary Reason for Care
Date symptoms started
What are your main treatment goals?
Frequency of symptoms: Constant 100%Frequent 75%Occasional 25%Rarely 10%
Symptom Trend: ImprovingProgressively worseRemaining the same
Describe any recent related accident or injury
What makes symptoms increase?
What makes symptoms decrease?
Type of Pain: SharpDullAchingBurningThrobbingNumb
Other:
Where does the pain radiate?
How severe is your pain (indicate 0-no pain to 10-unbearable pain)
Health History
What treatment have you received and what additional practitioners are you seeing?
Medication
Surgery
Physical Therapy
Acupuncture
Massage
Chiropractor
Other
Please mark C for current condition; P for past condition; Leave blank if not applicable
___ADD/ADHD
___AIDS/HIV
___Anemia
___Anorexia
___Anxiety
___Appendicitis
___Arm Pain
___Arthritis
___Asthma
___Bronchitis
___Bulimia
___Cancer
___Carpal Tunnel
___Celiac Disease
___Chest Pain
___Chicken Pox
___Chronic Fatigue
___Cold Sores
___Concussions
___Cough
___Crohn’s Disease
___Depression
___Diabetes
___Dizziness
___Epilepsy
___Fainting
___Fibromyalgia
___Gall Stones
___Goiter
___Gout
___Headaches
___Heart Disease
___Hepatitis
___Hernia
___Herniated Disc
___Herpes
___High Cholesterol
___Hypertension
___Irritable Bowel Syndrome
___Infertility
___Jaw Pain
___Kidney Infections
___Kidney Stone
___Knee Pain
___Leg Pain
___Liver Disease
___Low Back Pain
___Mid Back Pain
___Migraine Headaches
___Miscarriage
___Mononucleosis
___Multiple Sclerosis
___Mumps
___Neck Pain
___Night Sweats
___Numbness or Tingling
___Osteoporosis
___Pacemaker
___Parkinson’s Disease
___Pinched Nerve
___Pneumonia
___Polio
___Prostate Problems
___Psoriasis
___Psychiatric Care
___Rheumatoid Arthritis
___Sciatica
___Seizures
___Shingles
___Shoulder Pain
___Sinus Congestion
___STD’s
___Stroke
___Thyroid Condition
___Tonsilitis
___Tuberculosis
___Tumors/Growths
___Ulcerative Colitis
___Ulcers
___Upper Back Pain
___Urinary Tract Infection
___Vaginal Infection
___Whooping Cough
___Other:
Allergies:
__Dust
__Mold
__Trees
__Weeds
__Grass
__Animal
__Perfume
__Smoke
__Foods (list on next page)
Description and Dates on the following:
Hospitalizations/Surgeries
Recent Infections (Cold, Flu, etc)
Falls/Injuries
Fracture/Dislocation
Medications
Vitamins/Supplements
Please list family history of any diseases or conditions
Social and Occupational History
Diet:
Food Cravings: __Sweets __Salt__Sour__Bitter__Spicy
__Alcohol (type/drinks per week)
__Sugar (type/amount per week)
__Caffeine (type/drinks per day)
__Tobacco (type/amount per day)
__Marijuana (method and frequency)
Typical Diet: (Breakfast, Lunch, Dinner, Snacks, Beverages)
Gastrointestinal: __Excess Hunger __Poor Appetite __Nausea __Hemorrhoids __Diarrhea __Constipation __Heartburn __Gas __Bloating __Strong Smell # of Bowel Movements/Day______
Sleep: Hours per night______Quality: __Poor __Fair __Good __Trouble Falling Asleep
__Trouble Staying Asleep __Insomnia
What time do you wake up? How many times do you wake up?
Do you sleep on your: __Back __Side __Stomach __AllNight Urination: Frequency:
Urination: __Excess Urination __Frequent Urination __Painful Urination
FEMALE ONLY: Total length of cycleLength of menses Menses: __Heavy __Moderate __Light
__PMS __Mood Swings __Cramping __Breast Tenderness __Pregnant __Post Menopausal
Occupational History:
Job activities include:
Work Activity Level: __Sedentary ___Light Manual Labor ___Moderate Manual Labor ___Heavy Manual Labor
How long do you sit at a desk and work on a computer or speak on a telephone each day?
Do any of your work activities aggravate your present main complaints? Please Describe:
Stress Level: ___Mild ___Medium ___Severe
Reason:
How do you handle stress: ___Exercise ___Sleep ___Eat ___Therapy ___Other:
Energy Level (10=high energy): 012345678910
Time during the day when you experience regular low energy
Exercise: 1. TypeFrequency
Exercise: 2. TypeFrequency
Exercise: 3. TypeFrequency
Do you have any questions for me?
Consent for Care, Financial Policy Agreement and Privacy Practices Acknowledgement for Mountain Acupuncture and Massage
Consent for Care: I, the undersigned, in consideration of Mountain Acupuncture and Massage’s services, agree to the following terms:
I hereby grant permission to Mountain Acupuncture and Massage and Jaime Levy, LMP, EAMP to perform examinations and therapeutic treatments as are considered necessary or advised for my diagnosis and treatment plan. My signature on this document serves as my consent for treatment.
The practice of East Asian medicine in the state of Washington includes the following:
The use of acupuncture needles or lancets to directly and indirectly stimulate acupuncture points and meridians may be expected. Other modalities include the use of electrical mechanical, or magnetic devices to stimulate acupuncture points and meridians;
Peizoelectric pen;
Moxibustion (Artemisia Mugwort);
Acupressure;
Cupping;
Dermal friction technique or GuaSha;
Infrared therapy or TDP lamp;
Sonopuncture including tuning forks;
Laserpuncture;
Point injection therapy or aquapuncture;
Dietary advice and health education based on East Asian medical theory, including the recommendation and sale of herbs, vitamins, minerals, and dietary and nutritional supplements;
Breathing, relaxation and East Asian exercise techniques;
Qi gong;
East Asian massage and Tuina (a method of East Asian bodywork);
Superficial heat and cold therapies.
Side effects of treatments listed above may include the following: Pain following treatment; Minor bruising; Infection; Needle sickness; and Broken needle
Patients must inform the East Asian medicine practitioner if they have a severe bleeding disorder or pacemaker prior to any treatment.
Authorization to Release Information for Insurance clients: I authorize Mountain Acupuncture and Massage to release any information required to process a claim to any insurance company or attorney. I also authorize any insurance company or medical provider to release my medical records to Mountain Acupuncture and Massage for the purpose of processing my claim for benefits due. I hereby agree that a photocopy of this document is as valid and effective as the original copy.
Personal Responsibility and Charges: I understand that I remain personally responsible for my charges, and that at any time I can request a copy of my total charges from the office. I agree to pay the full amount of my charges to the office upon their demand. Any partial payments toward my charges shall not be acceptance of any installment payment plan, and shall not constitute a waiver of Mountain Acupuncture and Massage’s right to receive payment in full upon demand. In the event that any payer denies payment or claim by an insurance company or second party, I agree that I am personally, fully, and immediately responsible for the portion of my charges denied or likely to be denied. In no event shell I hold Mountain Acupuncture and Massage liable in any of the above named instances.
HIPAA Notice of Privacy Practices: I understand and I have access to the Notice of Privacy Practices and am able to review it and obtain a copy at my request.
Liability Agreement: I have read, understood and agree to the terms of this agreement.
____(Initial Please) Cancellation Policy: I agree to give 24 hours notice of cancellation and will be charged $45 for services allotted if I do not arrive for an appointment or have a late cancellation.
Patient Signature______Date: ______
Patient Name (print)______
Name of Custodial Parent/Legal Guardian______
Parent/Guardian Signature______Date: ______