Document 2437

Ferndale Location
Grandview Business Center
7056 Portal Way R7
Ferndale, WA 98248
360-366-4216 F)360-366-4241
Bellingham Bellwether Location
Bayview Center
12 Bellwether Way, Suite 219
Bellingham, WA 98225
360-366-4216 F)360-366-4241
Acupuncture Health History Form
Patient Information
Name
Address
City
Home Phone
Height
Weight
Date
State
Sex:
Date of Birth
Occupation
Have you had acupuncture before?
Major Complaint
Primary reason for your visit today?
Cell Phone
Male
Female
Zip
Marital Status
Age
Employer
No
Yes, Name of Acupuncturist
Has this condition been diagnosed by a physician, or other provider?
No
Yes, Diagnoses
Are you being treated for this condition by anyone else?  Yes
No
If yes, what is the treatment?
Have these treatments helped?
Yes
Somewhat
Not Much
How does this condition affect you?
How long have you had this condition?
Personal Health History
Your general health as a child was?
Excellent
Good
Average
Poor
Did you feel safe and nurtured as a child?
Always
Usually
Sometimes
Not At All
Never
Check all the illnesses or conditions which you currently have or have had in the past:
AIDs / HIV
Eating Disorders
Kidney Disease
Rheumatic Fever
Alcoholism
Epilepsy
Measles
Scarlet Fever
Allergies
Glaucoma
Meningitis
Sexually
Transmitted
Antibiotic Use
Heart Disease
Mental Illness
Disease
Asthma
Hepatitis
Multiple Sclerosis
Stroke
Bleed Easily
High Blood
Mumps
Tuberculosis
Pressure
Cancer
High Fevers
Obesity
Typhoid Fever
Chicken Pox
Hyperthyroid
Pneumonia
Ulcers
Diabetes
Hypothyroid
Polio
Vascular Disease
Drug Abuse
Jaundice
Other
Are you taking Coumadin or Warfarin?
Yes
No Do you have a pacemaker?
Do you have seizures?
Yes
No
Do you currently have any infectious diseases?
Yes
No
Possibly
If yes, please identify:
HIV / AIDs
Hepatitis B
Hepatitis C
Flu / Cold
Mononucleosis
Tuberculosis
Other
Known or suspected allergies:
Yes
No
Streptococcus
A BETTER WAY MASAGE, LLC | 1.2014|SF
Personal Health Inventory
Please put a check mark (  )by the symptoms that you have now.
Place a star () next to the ones you have noticed within the last three months.
Qi, Blood, Yin, Yang
anxiety
catches colds easily
or frequently
chest pain traveling to shoulder
cold feet
cold hands
difficult to concentrate
dizziness
dream disturbed sleep
dry skin
fatigue
feverish in the afternoon
or flushes
general weakness
heat sensations in hands,
feet, chest
insomnia
mental confusion
night sweats
palpitations
restlessness
sores on tip of tongue
speech problems
sweats easily
thirst, at night
you feel worse after exercise
you see floating black spots
LU
allergies
chills alternating with fever
cough
difficulty breathing
dry mouth, throat, nose
feeling achy
headaches
nasal discharge
nose bleeds
shortness of breath
sinus congestion
sneezing
sore throat
stiff neck/ shoulders
SP
abdominal bloating and / or
gas after eating
belching
chest congestion
constipation
diarrhea
eating disorders
fatigue after eating
gas
general feeling of
heaviness in your body
hemorrhoids
loose stools
low appetite
mental heaviness,
sluggishness or fogginess
nausea
prolapsed organs
(previously diagnosed)
swollen feet
swollen hands
you bruise easily
ST
bad breath
belching
bleeding, swollen or
painful gums
burning sensation after eating
constipation
heartburn
large appetite
mouth sores
(canker or cold sores)
stomach pain
vomiting
HT / PC
chest pain
edema
high blood pressure
insomnia
low blood pressure
palpitations
stroke
varicose veins
LR / GB
bitter taste in mouth
blood shot eyes
blurred vision
chest pain
convulsions
diarrhea
alternating with
constipation
difficulty swallowing
dry eyes
feeling of a lump
in your throat
headache at the top
of your head
hot flashes
muscle spasms,
twitching, cramping
numbness of hands and feet
pain in rib cage
red, sore or irritated eyes
seizures
skin rashes
tight feeling in chest
TMJ or locked jaw
you anger easily
you feel better after exercise
KI / BL
frequent urination
hair loss
joint pain
lack of bladder control
loose teeth
low back pain
memory problems
night blindness or low vision
ringing in your ears
sore, cold or weak knees
you get up more than
one time at night to
urinate
Other
A BETTER WAY MASAGE, LLC | 1.2014|SF
Family History
How do you feel about the following areas of your life in the past month.
Significant Other
Great
Good
Fair
Poor
N/A Comments
Family
Great
Good
Fair
Poor
N/A Comments
Self
Great
Good
Fair
Poor
Comments
Check illnesses which have occurred in any of your blood relatives:
Alcoholism
Cancer
Heart Disease
Allergies
Diabetes
High Blood Pressure
Bleed Easily
Epilepsy
Kidney Disease
Other
Mental
Illness
Obesity
Stroke
Women Only
Are you pregnant?
Yes, How many months?
No
Trying
Maybe
Method of birth control?
Age of First Menses
Date of Last Menses
Age of Menopause
Typical Length of Menses (Days You Bleed)
Typical Length of Cycle (From the 1st Day of One Cycle to 1st Day of the Next)
Number of: Pregnancies
Births
Abortions
Miscarriages
Hysterectomy
Yes
Partial
Complete Date
No
Check all that apply to you:
Scanty Flow
Heavy Flow
Clotting
Vaginal Discharge
Abnormal Pap Smear
Menopausal Symptoms
Premenstrual Problems
Other
Painful Periods
Breast Tenderness
Breast Lumps
Nipple Discharge
Fibrocystic Breasts
Bleeding Between Cycles
Irregular Cycles
Low Libido
Excessive Libido
Painful
Intercourse
Infertility
Fibroids
Endometriosis
Ovarian Cysts
Men Only
Check all that apply to you:
Low Libido
Excessive Libido
Impotence
Vasectomy, Date
Seminal Emissions
Premature Ejaculation
Painful Intercourse
Prostate Problems
Testicular Pain
Testicular Redness
Testicular Swelling
Other
A BETTER WAY MASAGE, LLC | 1.2014|SF
Medications Please list medications, herbal supplements and vitamins you are currently taking:
Drug / Supplement / Vitamin
Reason For Taking
For How Long
Dosage
Frequency
Lifestyle
How would you rate the following areas of your health in the past month.
Digestion
Great
Good
Fair
Poor Comments
Stools
Great
Good
Fair
Poor Comments
How many times per day?
Do they feel complete?
Yes
No
Stool consistency?
Loose
Formed
Hard to Pass
Other
What is the color of your stools?
Is there blood in your stools?
Yes
No How Often?
Urination
Great
Good
Fair
Poor Comments
How many times per day?
What color is your urine?
After you've gone to sleep do you get up to urinate?
Yes
No How Often?
Is your urination painful?
Yes
No
Appetite
Great
Good
Fair
Poor Comments
Diet
Great
Good
Fair
Poor Comments
Are you vegetarian or vegan?
Yes
No For how long?
Food / Drink:
Foods You Crave
When?
Daily Water Intake
Coffee Intake
Daily Soda Intake
Caffeine?
Yes
No _ Daily Tea Intake
Do you drink alcohol? How Much?
Do you use tobacco?
Yes
Do you use recreational drugs?
Caffeine?
Caffeine?
How Often?
No
Yes
No
Yes
No Daily
Yes
No
What kinds?
Past Use?
Yes
No Date Stopped
Past Use?
Yes
No Date Stopped
Past Use?
Yes
No Date Stopped
How do you feel about the following areas of your life in the past month.
Energy
Sleep
Great
Good
Fair
Poor Comments
On a scale of 1 to 10? (10 is high energy)
Great
Good
Fair
Poor Comments
Hours per night?
Do you wake feeling rested?
Great
Good
Fair
Poor Comments
Great
Good
Fair
Poor Comments
Great
Good
Fair
Poor Comments
How often?
What kind?
How would you rate your stress level on a scale of 1 to 10? (10 is high stress)
How well do you feel you handle your stress?
Great
Good
Fair
Yes
No
Sex Life
School
Exercise
Poor
A BETTER WAY MASAGE, LLC | 1.2014|SF
Pain
Please answer the following questions if you have pain.
Indicate on the diagram your areas of pain
How long have you had this pain?
Describe the onset of your pain?
On a scale of 1-10 (10 being worst) how
strong is your pain?
What does your pain feel like? (check all that apply)
Dull
Sharp
Stabbing
Constant
Comes and Goes
Does the pain radiate?
What helps the pain?
Moisture
No
Ice
Massage
What aggravates the pain?
Moisture
Massage
Sore
Fixed
Achy
Cramping
Moves About
Yes
Where?
Heat
Rest
Nothing
Movement
Burning
Pressure
Other
Ice
Heat
Rest
Nothing
Other
Movement
Pressure
Does anything relieve this pain? (i.e.; medications, over the counter drugs, liniments)
Other treatments you have had for this pain?
Anything you wish to add?
The above information is true to the best of my knowledge.
X Patient's Signature
DateofBirth:
Today’sDate:
A BETTER WAY MASAGE, LLC | 1.2014|SF
PATIENT INFORMED CONSENT
The law requires patients receiving acupuncture to give their informed consent prior to receiving treatment. Informed consent is for the
patient to be advised of the credentials of the practitioner(s) and the scope of the practice of acupuncture in the State of Washington.
The practitioner, Shannon Freeman, L.Ac., EAMP, LAC is licensed in the State of Washington. He has over 20 years of experience in
the medical field, and was a Licensed Certified Nursing Aide and Licensed Massage Practitioner prior to graduating from Middle
Way Acupuncture Institute with a Masters degree in Acupuncture in 2012.
The practitioner, Heather Falkenbury, L.Ac., EAMP is licensed in the State of Washington. She graduated from Bastyr University
with a Masters degree in Acupuncture and Oriental Medicine and Chinese Herbal Medicine in 2006. Heather has also completed an
intensive course study of Chinese Herbal medicine at Chengdu’s College of Traditional Medicine in China. Heather is also a Certified
Holistic Doula.
As stated by law, therapy acupuncturists in the State of Washington are allowed to use the methods listed below. This in no way means
that all these methods will actually be used for your treatment. You will be advised before any one of these methods is to be applied, and
you always have the right to decline.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
use of acupuncture needles to stimulate acupuncture points
use of electrical, magnetic, or mechanical devices to stimulate acupuncture points
moxibustion (direct or indirect application of heat on acupuncture points using herbal materials)
Tui Na (acupressure)
cupping
Gua Sha (dermal friction)
infra-red light
sono-puncture (ultrasound)
laser puncture
dietary advice based on traditional Chinese medical theory
Patients with the following conditions must inform the practitioner(s) prior to receiving acupuncture treatments. Please check
the following that applies.
pregnancy
pacemaker
severe bleeding disorders
hepatitis
AIDS or HIV positive
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of practice of
acupuncture on me (or on the patient named below, for whom I am legally responsible) by the above named practitioner(s), or other
licensed practitioners who now or in the future treat me while employed by, working or associated with or serving as back-up for
the practitioner(s) above, including those working at the clinic or office listed above.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation,
Tui Na (Oriental massage), herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the
teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell or taste. I will
immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the
herbs.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising,
numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of
cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture
(pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe
environment. Burns and/or scarring are a potential risk of moxibustion and cupping. I understand that while this document describes
the major risks of treatment, other side effect and risks may occur. The herbs and nutritional supplements (which are from plant, animal
and mineral sources) that have been recommended are traditionally considered safe in the practice of Oriental Medicine, although 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, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff
member who is caring for me if I am or become pregnant.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely
on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts
then known is in my best interest.
I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept
confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the
risks and benefits of acupuncture and other procedures. 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.
I, the undersigned, have read and understood the foregoing information and voluntarily consent to the use
of the above procedures for treatments. I understand that there is no guarantee implied or expressed regarding the success or effectiveness
of a treatment or a series of treatments. I hereby release Shannon Freeman, L.Ac., EAMP, LMP and Heather Falkenbury L.Ac.,
and the assistant(s) under the supervision of him or her, from all liability in connection with these treatments. I understand that I am
free to withdraw my consent and stop treatment at any time.
Patient Signature:
Guardian signature if under age 18
Patient Name (please print):
Date:
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