REGISTRATION Chunlin Gao, M.Ac., L.Ac.

(Please print) 509 Olive Way, Suite 831

Seattle, WA 98101

206-621-1896

PATIENT INFORMATION

Name: Phone: Home ______Work/Cell______

Address: ______City: ______State: ____ ZIP: ______

Email: ______Age: ______Date of Birth: ______Gender: M / F

Social Security #: ______Family Physician: ______Referred by: ______

Employer Name & Address: ______Occupation: ______

In emergency, notify: ______Relation to Patient: ______

Marital Status:______How did you hear about us? ______

INSURANCE INFORMATION

Person responsible for account: ______Relation to Patient: ______Birth date: ____

Address (if different from patient’s): ______City: ______State: ______ZIP: ______

Social Security #: ______Phone: H ______W ______

Insurance Company: ______Policy #: ______

Contract #: ______Group #: ______Subscriber #: ______

Is your condition related to employment? Yes No Is your condition related to an auto accident? Yes No

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have (has) insurance coverage with ______and assign directly to Chunlin Gao, L.Ac. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I hereby authorize Chunlin Gao, L.Ac. to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature Relationship Date

ACUPUNCTURE CONSENT FORM

I, ______hereby authorize Chunlin Gao, L.Ac. to perform acupuncture and other specific procedures deemed necessary to facilitate my diagnosis and treatment. I recognize the potential risks and benefits of these procedures. I also understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments. I hereby release Chunlin Gao, L.Ac. from any and all liability which may occur in connection with acupuncture treatment, except for failure to perform the procedures with appropriate medical care.

Signature Date


HEALTH HISTORY

Have you ever received acupuncture or oriental medicine treatments before? Yes No

What are your main health concerns you would like help with at this time? ______

______

How long ago did this problem begin? ______

To what extent does this problem interfere with your daily activities? (work, sleep, sex) ______

______

Have you been given a diagnosis for this problem? If so, what? ______

______

What kinds of treatments have you tried? ______

______

PAST MEDICAL HISTORY

Cancer _____ Diabetes ______Hepatitis ______High Blood Pressure _____ Heart Disease _____

Rheumatic Fever ____ Thyroid Disease ____ Seizures ______Other______

Surgeries (Type and date) ______

Significant trauma (auto accident, falls, etc.) ______

FAMILY HISTORY

Cancer _____ Diabetes _____ High Blood Pressure _____ Heart Disease _____ Stroke _____ Seizures _____ Asthma _____ Allergies _____ Arthritis _____ Migraines _____ Other ______

MEDICATIONS

Drugs

Vitamins

Herbs

ALLERGIES

Drugs

Foods

Chemicals

HEALTH HABITS

Caffeine ______Tobacco ______Drugs ______Cigarettes ______


GENERAL:

q Chills

q Fevers

q Hot Flashes

q Sweat easily

q Night sweats

q Fatigue

q Sudden energy drop?

What time of day ____

q Cravings

q Poor sleeping

SKIN AND HAIR:

q Rashes

q Itching

q Pimples

q Eczema

q Herpes

q Loss of hair

q Other hair or skin

problems ______

HEAD, EYES, EARS, NOSE, AND THROAT:

q Dizziness

q Migraines

q Headaches, where and

when ______

q Poor vision

q Eye strain

q Blurry vision

q Eye pain

q Spots in front of eyes

q Ringing in ears

q Poor hearing

q Earaches

q Sinus problems

q Nosebleeds

q Grinding teeth

q Jaw clicks

q Facial pain

q Sore throat

q Sores on lips or tongue

q Other head problems:

______

CARDIOVASCULAR:

q High blood pressure

q Low blood pressure

q Irregular heartbeat

q Rapid heartbeat

q Cold hands or feet

q Swelling of hands or

ankles

q Chest pain

q Other heart or

circulatory problems:

______

RESPIRATORY:

q Cough

q Coughing blood

q Production of phlegm

q Difficulty in breathing

q Bronchitis

q Pneumonia

q Asthma

GASTROINTESTINAL:

q Poor appetite

q Excessive hunger

q Excessive thirst

q Thirst, no desire to

drink

q Nausea or vomiting

q Belching

q Abdominal pain or

cramps

q Bloating

q Gas

q Constipation

q Chronic laxative use

q Black stools

q Blood in stools

q Hemorrhoids

q Other stomach or

intestinal problems:

______

GENITO-URINARY:

q Pain on urination

q Urgency to urinate

q Frequent urination

q Unable to hold urine

q Blood in urine

q Impotency

q Sores on genitals

q Do you wake up to

urinate? Yes No

How often? ______

q Any particular color to

your urine? ______

GYNECOLOGICAL:

q Number of pregnancies

q Number of births _____

q Premature births _____

q Miscarriages ______

q Abortions ______

q Age at first menses ___

q Period between

menses ______

q Duration ______

q First date of last

menses ______

q Irregular periods

q Changes in

body/psyche prior to

menstruation

q Vaginal discharge

q Vaginal sores

q Breast lumps

Do you practice birth

control?

What type and for how

long? ______

MUSCULO-SKELETAL:

q Neck pain

q Back pain

q Hand/wrist pain

q Shoulder pain

q Knee pain

q Foot/ankle pain

q Hip pain

q Muscle pains

q Muscle weakness

q Muscle numbness

NEUROPSYCHOLOGICAL:

q Bad temper

q Depression

q Anxiety

q Easily susceptible to

stress

q Poor memory

q Loss of balance

q Seizures

Have you ever been treated

for emotional problems?

Please note the degree of severity of your problem now:

| |

No problem Worst pain imaginable

COMMENTS: (Please tell us any other problems you would like to discuss) ______

Signature Date

NOTICE OF PRIVACY PRACTICES — ACKNOWLEDGEMENTS

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so, or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting the receptionist or office manager.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

Printed name of patient

Signature of patient or legally authorized individual Date

Printed name if signed on behalf of the patient Relationship

Notation (if any) by staff

This form will be retained in your medical record.

Last update: ______/______/______