SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781) 925-1941
ACUPUNCTURE INITIAL INTAKE
PROGRAM INFORMATION AND POLICIES
Welcome to the SZABO FITNESS & ACUPUNCTURE acupuncture program! We are delighted that you chose us as a part of your commitment to health and fitness. Our skilled licensed acupuncturists are ready to provide you with the necessary information and motivation to help you reach and maintain your personal goals. The following information will provide you with important program policies. Before getting started, please read and sign this form so that we can be sure that you have been provided with and understand this information.
PAYMENT & RESPONSIBILITY
Payment for sessions must be made at the time of meeting with your acupuncturist, and at the time of purchasing any prepaid packages.
EXPIRATION DATE
All SZABO FITNESS & ACUPUNCTURE acupuncture sessions and packages have an expiration date of 3-months from the date of purchase. After the expiration date, any remaining sessions will be invalid. Cards can be frozen for medical purposes only and require medical documentation. Frozen cards will be held for one year after which time any remaining sessions will become invalid.
CANCELLATIONS
In order to cancel or reschedule an appointment, you must contact SZABO FITNESS & ACUPUNCTURE at least 24 hours in advance of the scheduled appointment or you will be charged for that session.
TARDINESS
All patients and practitioners are encouraged to be prompt. If a patient arrives late, this time will be deducted from the session. Please be advised that practitioners are required to wait 15 minutes for a scheduled patient, after which time the session is subject to cancellation and patients will be charged for a full session.
REFUNDS AND CREDITS
SZABO FITNESS & ACUPUNCTURE does not offer refunds or credits, so please be sure that our services will match your needs before committing through payment. If you find that your needs change once you have begun this program, please let us know; we are eager to find a way to accommodate you within this program.
I have read and will comply with the above information.
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Name (please print)
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Signature Date
SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781)925-1941
General Information and Consent for Acupuncture Treatment
General information about Acupuncture:
Acupuncture is a 2500 year old Chinese tradition performed by licensed practitioners. It is based on the premise that illness, dysfunction, pain, lack of energy, etc., are due to the improper flow of energy (Qi) in the body. There are many theories explaining Qi, some of which equate it with the electrical impulses of the nervous system or the Autonomic Nervous system. With the use of sterile, disposable needles, massage, heat therapy, cupping, electrical stimulation, diet, herbs, movement/exercise and topical applications, the acupuncture practitioner can correct the imbalance and dysfunction of energy that is causing ill-health and pain.
The powerful combination of Acupuncture and Herbs can not only treat painful conditions, but has a great degree of success in reducing the symptoms of many health problems, including, but not limited to:
Gastrointestinal problems Diabetes Female and male reproductive problems Stress-related disorders Migraines Dermatological problems
PMS/ Menstrual Problems Age-related problems
Depression/Anxiety Hypertension Immune weakness/ Frequent infections Painful conditions Chronic colds
Allergies Menopausal symptoms
Licensed acupuncturists do not make conventional diagnoses, but often require the information from you or your primary health providers in order to properly evaluate your overall health.
Potential risk: Pain, discomfort, discoloration, bruising and very occasionally, fainting and aggravation of pre-existing symptoms can occur with treatment.
Potential benefits: Restoration of health and the body’s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progression.
Facial Rejuvenation Acupuncture: Facial acupuncture can result in bruising of the face at the sight of treatment. It is important to tell your practitioner if you bruise easily or have any major illness considered contraindicated for facial treatment.
Notice to Pregnant Women: If you are pregnant, suspect you may be, or are trying to get pregnant, please alert your practitioner. Certain therapies used could present a risk to the pregnancy. No labor-stimulating acupuncture points or labor-stimulating substances will be used.
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Szabo Fitness& Acupuncture or any of its personnel regarding cure or improvement of my condition. I understand that a record will be kept of the health services provided to me. The record will be kept confidential and will not be released to others unless so directed by my representative or me or otherwise permitted or required by law.
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patient signature date
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guardian/personal representative signature date
SZABO FITNESS & ACUPUNCTURE
121 Nantasket Ave. Hull, MA 02045 (781) 925-1941
ACUPUNCTURE PERSONAL HEALTH HISTORY
Note: Information provided on this form is confidential
It is very important the information given is complete and accurate to assist you properly in your healing process.
Please PRINT Today’s Date ___/___/___
Name ______Date of Birth ___/___/___ Sex: Male � Female �
Address______
City/ State/ Zip ______email______
Telephone (home)______(work)______Occupation______
Emergency Contact Person /Relationship______Tel:______
Physician______
Physician’s phone #______
How did you hear of us?______
What do want treated with acupuncture?______
How long have you had this condition?______The onset was sudden � gradual �
Symptoms relieved by______
Symptoms worsened by______
What medical diagnosis have you received for this condition?______
What other treatments have you received for this condition?______
What medications are you taking?______
Is this your first experience in Oriental Medicine and acupuncture?______
How do you feel about acupuncture?______
Are you currently pregnant? Yes � No �
Are you presently trying to get pregnant? Yes � No �
Do you drink coffee? ____ How much/ day? ______
Do you drink alcohol?____ How much?______How often?______
Past Medical History:
Have you had any of this condition(s)? Circle all that apply:
AIDS/HIV Alcoholism Allergies (food, latex) Asthma Birth Trauma
Cancer Diabetes Drug Addictions Emphysema Fibromyalgia
Heart Disease Hepatitis A/B/C Herpes Joint Replacements
Lyme Disease Lymph Nodes removed Multiple Sclerosis Pacemaker
Polio Rheumatic Fever Scarlet Fever Seasonal Allergies
Seizures Sinus Infections Tuberculosis
Operations______Other______
Family Medical History: (Please list any significant family illnesses, e.g. diabetes, heart disease,
respiratory conditions, blood pressure, neurological disorders, psychological disorders, arthritis)
Mother:______
Father:______
Siblings:______
Grandparents:______
Exercise & Energy:
How is your energy?______
What time of day is your energy: Highest?______Lowest?______
Do you fatigue easily?______
What do you do for weight management?______
Are you interested in nutritional recommendations for weight management?______
What kind of exercise do you do?______
How often do you exercise?______
Emotions & Sleep:
How do you feel emotionally?______
Do you have (circle all that apply): Panic attacks Depression Anxiety Bad temper
Nervousness Fear attacks Poor memory Difficult concentration
Are you in a relationship? Yes � No �
How do you feel about your relationship?______
How do you hold stress?______
How do you relax?______
How do you feel about your work?______
How long do you normally sleep? ______hours per night______
I have difficulties with (circle all that apply): Falling asleep Staying asleep
Dream-disturbed sleep Waking up at about _____am/pm and not being able to fall asleep again
Gastrointestinal:
I have (circle all that apply): Belching Nausea Vomiting Vomitting of blood Ulcers
Bloating Acid regurgitation Heartburn Hernia Indigestion Severe stomach pain
Bowel movements: How often? ______time(s)/day ______days/week
I have (circle all that apply): Irregular Constipation Diarrhea Gas Burning sensation
Hemorrhoids Undigested food in stool Loose stool Hard stool Blood in stool Itchiness
Painful bowel movements
Urinary:
Urination: How often?______/day Color: Pale yellow Dark yellow/orange
I have or had (circle all that apply): Trouble starting stream Frequent urination
Incontinence Pain Burning Dribbling when sneezing Blood in urine Kidney stones
Urinary tract infections Other______
Women:
At what age did you start menstruating? ______Number of days between cycles:______
Number of days of flow:____Color: ______Number of pregnancies______
I have or had (circle all that apply): Irregular menstruation Heavy flow Light flow No flow
Clots Vaginal itching/burning Spotting between periods Discomfort/pain before period Discomfort/pain during period Other______
Any vaginal discharge? No � Yes � Color______
Men:
I have (check all that apply): Prostatitis� Impotence � Penis blood/mucous discharge �
Other:______
Muscles, Joints & Bones:
Do you have pain or tightness? No � Yes � Where?______
The pain is (check all that apply): Sharp � Dull � Aching � Numb � Superficial Pain �
Deep Pain � Burning � Tingling � Shooting � Pain worse/better with heat �
Pain worse/better with cold � Pain worse/better with pressure � Pain worse in am/pm �
I have (check all that apply): Swollen joints � Arthritis/joint pain � Tendonitis � Bone pain � Muscle cramping � Muscle pain � Repetitive Strain Injury � Fractured Bone(s) �
Where?______Other______
Eyes, Ears, Nose, Throat, & Head:
Do you smoke? No � Yes � ______per day, for ______years
I have (check all that apply): Frequent colds � Chronic runny nose � Frequent sore throat � Chronic cough � Coughing blood � Cough up mucous � Pain inhaling �
Shortness of breath on exertion/at rest � Asthma � Nose bleeds � Painful/red eyes �
Poor vision � See spots/floaters � Dizziness � Cold sores � Bleeding gums � Dry mouth � Ear pain � Ringing in ears � Clogged/popping in ears � Frequent headaches/migraines � describe:______
Cardiovascular:
I have (check all that apply): Chest pain � Palpitation � Varicose veins � Phlebitis � Cold hands and feet � Irregular heart beat � Poor circulation � Other:______
Skin & Hair:
I have or often have (check all that apply): Dry skin � Skin rashes � Itching � Acne �
Eczema � Hives � Hair loss � Premature graying � Other:______
INSURANCE INFORMATION
Name______Birthday______
Address______
Insurance claim number ______
Insurance company ______Group #______
Subscriber’s Name ______
Referring Doctor______Date of injury______
Social security number ______Email address ______
(only if you are using personal health insurance)
By signing below I authorize all insurance payments to be made directly to Szabo Fitness & Acupuncture. I understand that my signature explicitly allows the release of my medical record to my “first party” payer identified above as necessary to have my bill paid. Chart note copies and billing information to a “third party” will only be processed with my valid written authorization. All record requests require payment of appropriate fee. I further give permission to this provider to consult with my primary care and or referring doctors as it pertains to the heath concerns at hand. I understand that my primary insurance company will be billed directly on my behalf for these acupuncture sessions as a courtesy. I agree to take full responsibility for any remaining balance not paid by my insurance company or related companies, including co-pays, deductibles, and non-covered services and denied services. If the treatment is for injures sustained in an auto accident where payment is pending form a “third party” I understand that my full cooperation will be necessary to secure payment from that party. In the event no payment is made, I will be held fully responsible for the charges incurred. I understand my insurance will not cover missed appointments therefore payment for cancellations without 24-hour notice is my responsibility.
Signed______Date______