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: ______/______/______