Naples Valley Acupuncture

Naples Valley Acupuncture

Michelle L. Wright, L.Ac.

PO Box 302 , Naples, NY 14512 Phone: (585) 944-7447

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1. PATIENT INFORMATION

Name: ______Date:______

Age: ______Date of Birth: ______Occupation: ______

Address:______City: ______Zip: ______

Best phone # to call: ______cell home work text? yes no

Alternate phone #: ______cell home work text? yes no

Email: ______

Primary Physician: ______Phone #: ______

Emergency Contact: ______Phone #: ______

Relationship: ______

*Medical Insurance Company:______

Policy Holder Name: ______Policy #: ______

*Note: Naples Valley Acupuncture does not currently subscribe to any health insurance networks, however many insurance policies reimburse members for “out-of-network” acupuncture services. We are happy to provide you with a “superbill” that details information insurance companies require for you receive reimbursement for our fees as your policy allows. Please check with your insurance company to see what they cover.

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2. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I received a copy of Naples Valley Acupuncture’s Notice of Privacy Practices, dated 7-31-10.

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Signature of Patient or Personal Representative Date

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Printed Name of Personal Representative Relationship of Personal Representative

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3. PATIENT ADVISORY TO CONSULT A PHYSICIAN

Naples Valley Acupuncture is committed to your health and well-being. While Oriental Medicine has a great deal to offer as a health care system, it cannot totally replace the resources available through biomedical physicians. Consequently, we recommend that you consult your primary care physician regarding any condition(s) for which you are seeking acupuncture treatment.

We, the undersigned, do affirm that ______(patient) has been advised by Michelle Wright, Licensed Acupuncturist, to consult a physician regarding the condition(s) for which the patient seeks an acupuncture treatment.

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Patient SignatureDate

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Michelle Wright, L.Ac. Date

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4. INFORMED CONSENT FOR ACUPUNCTURE TREATMENT

I, ______, consent to acupuncture treatments and other procedures associated with the practice of Traditional Oriental Medicine (TCM) provided by Naples Valley Acupuncture (NVA). I have discussed the nature and purpose of my treatment with Michelle Wright, L.Ac., of NVA. I understand that methods of treatment may include but are not limited to acupuncture, moxibustion, cupping, electrical stimulation, herbal and nutritional recommendations, and bodywork therapies such as medical message and Tui Na (Chinese Massage) and Shiatsu.

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects includingbruising, numbness or tingling near the needling sites that may last a few days, and also dizziness or fainting. Infection is also a risk, although this site uses sterile, disposable needles and maintains a clean and safe environment. Very rare and unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax).

Other TCM therapies also have some side effects and risks. Bruising is a common side effect of cupping. Burns and/or scarring are a potential risk of moxibustion. Recommended herbs and nutritional supplements (from plant, animal and mineral sources) are traditionally considered safe in the practice of Chinese Medicine, however some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.

I will notify Naples Valley Acupuncture if I am, or become pregnant.

I do not expect Naples Valley Acupuncture to be able to anticipate and explain all possible risks and complications of treatment.

I understand that Naples Valley Acupuncture may review my medical records and lab reports, and that portions of my records may be used for treatment purposes only. Otherwise, all of my records will be kept confidential and will not be released to any party without my written consent.

By voluntarily signing below I show that I have read, or have had read to me, this consent to treatment, and have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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 at Naples Valley Acupuncture.

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(Patient Signature/Signature of Personal Representative)(Date)

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(Print Patient Name) Michelle Wright, L.Ac., MSAOM

Current Health Concerns/Goals
List your primary concerns/goals for coming in for treatment today? / <Practitioner Notes – leave blank>
Health History
List current medications/vitamin supplements you are currently taking (or provide a list).
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List other serious illnesses/accidents/surgeries.
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List Known Allergies:
______/ Check conditions you or a blood relative have or had in the past.
Self Blood Relative
AIDS……………….....
Anemia…………....….
Arthritis………...……..
Autoimmune disease.
Bleeding disorder...…
Cancer.……………….
Depression…...……...
Diabetes………………
High Blood pressure…
High cholesterol………
Low Blood pressure…
Mental illness…………
Thyroid disorder……….
Lifestyle
How many hours per week do you work? ______
Check what most accurately describes your job. sedentary light activity very active
Do you exercise regularly? yes no
If yes, what form(s) of exercise do you prefer? ______
How often and for how long do you exercise? ______
Do you follow a particular diet? vegan vegetarian gluten-free low carb low glycemic low fat other: ______
Do you partake in the following substances?
Coffee ______cups/day (1 serving = 8-10oz mug)
Alcohol ______servings/week (1 serving = 5oz wine, 8oz beer, 1oz liquor)
Tobacco ______cigarettes/day chew
Marijuana ______How much, how often? ______
Other drug use: ______

FIRST VISIT INTERVIEW FORM

Symptom Review
Check symptoms you have had in the last year.
BODY TEMPERATURE Tends to hot
Tends to cold Normal Excessive sweat
HEAD headaches migraine
dizziness / vertigo
MENTAL / EMOTIONAL Depression
Anxiety Easily startled Difficulty focusing Excessive worry/fear Excessive anger
Nervousness / irritability Mood swings
SLEEP Normal (7-9 hours, uninterrupted)
Wake frequently Excessive dreaming
Nightmares Wake startled
Difficulty falling asleep
EYES/EARS Itchy/irritated eyes Dry eyes
Blurred vision Eye pain glasses/contacts
Earache Ringing/tinnitus Hearing loss congestion
CARDIOVASCULAR Previous Heart attack
Poor circulation Chest pain
Hardened arteries Swelling of ankles
Rapid/irregular heart beat
High Blood pressure Low Blood pressure
RESPIRATORY Asthma/wheezing
Persistent Cough Difficulty Breathing
Shortness of Breath Sinus congestion
Frequent colds Hay fever / rhinitis
Enlarged glands Nose bleeds
Sore throat Hoarseness
DIGESTION low appetite excessive appetite Indigestion Belching/ gas/bloat
Heartburn/acid reflux Difficulty swallowing Nausea Vomiting Pain over stomach Gall Bladder trouble Constipation Diarrhea Hemorrhoids (piles)
rectal prolapse Weight gain Weight loss / GENITO / URINARY Frequent urination
Incontinence Blood/pus in urine
Frequent infection (UTI, Kidney)
SKIN Boils Bruise easily Dry skin Itchy/rash Sensitive/painful skin
Sore that won’t heal
MUSCLE / JOINT / BONES
Tremors Cramps
Pain, weakness, numbness
Neck…………………….
Arms…………………….
Shoulders………………
Elbows…………………..
Hands / fingers…………
Legs……………………..
Knees……………………
Feet / Toes ……………..
Hips……………………...
Back……………………..
FOR MEN ONLY
Erection difficulty Penis discharge Infertility Prostate trouble Genital pain lowered libido
FOR WOMEN ONLY
Age of onset of period ______years old
Length of Menstrual cycle average/normal (26-30 days
short cycle (less than 26 days)
long cycle (more than 30 days)
skipped periods unpredictable
Bleeding between periods Clots PMS
Menstrual pain/cramping lowered libido
Excessive bleeding Scanty bleeding
Menopausal symptoms
Past menopause – age at last period ______
Could you be pregnant? yes no
Number of children ______pregnancies ______