Acupuncture Pain Relief Clinic Wellness Starts Here827-A N Bloodworth St, Raleigh, nc 27604 // 919-283-8784 www.ApRclinic.com

GENERAL INFORMATION

Date:

Occupation:

Name:

Date of Birth: / /

Age:

Address:

Height: Weight:

City/State/Zip:

Sex: □ Male □ Female

Phone: home

work

cell (text reminders sent to this number)

Email address:

Emergency contact (name and number):

How did you hear about us? □ Healthprofs □ Google □ Facebook □ Yelp □Sign □ Referred by : □ Other : Insurance Plan(s): Physician name: Names of other health professionals you are currently seeing: Have you ever had acupuncture before? □ Yes □ No

PATIENT HISTORY

Reason for visit today: __________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ How long have you had this condition? ______________________________________________________ How often are symptoms present?__________________________________________________________ What treatments have you been taking for the above condition(s)? (surgery, medications, chiropractic, injections,etc) _____________________________________________________________________________________________ Other current health problems: ____________________________________________________________________ List any medications, over the counter drugs, supplements, or herbs you are currently taking: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Is there a history of injuries or surgeries? If so, please include date: ______________________________________ __________________________________________________________________________________________________________________________________________________________________________________________ Do you have any allergies? (environmental, food, drug) _________________________________________________ _____________________________________________________________________________________________

Indicate any significant illnesses you have: □ Cancer □ Diabetes □ High Blood Pressure □ Bleeding Disorder □ Heart Disease □ Hepatitis □ Seizures □ Thyroid Disease □ Rheumatic Fever □ Emotional Disturbances □ Sexually Transmitted Disease: ___________________________ □ Other: __________________________________________________________________________ Are you wearing an electronic device? (pacemaker, hearing aid, etc.) □ Yes □ No Do you have any artificial joints? □ Yes □ No If yes, which joint(s)? _________________________ Current or recent use of antibiotics? □ Yes □ No Do you faint easily? □ Yes □ No

Patient Lifestyle

Please indicate the use and frequency of the following: □ Tobacco ______________ □ Caffeine _______________ □ Alcohol _____________ □ Recreational Drugs _____________ Do you follow an exercise program? Please explain: ________________________________________________ _____________________________________________________________________________________________ Do you have any food cravings? If so, please explain: _________________________________________________

Family Medical History

□Allergies________________ □ Asthma □ Alcoholism □ Arthritis □ Diabetes □ Heart Disease □ Cancer ___________________________________ □ High Blood Pressure □ Seizures □ Stroke □ Other(s):_______________________________________________________________________

For Women Only: Are you currently pregnant? □ yes □ no Age at menopause: _________ Are you currently breastfeeding? □ yes □ no Age menses began: __________ Length of cycle (day 1 to day 1): _______________ Duration of flow: __________________ Color of menstrual blood: □ light red □ red □ dark red □ purple □ brown Date of last period: ________________ Do you have: (check all that apply) □ Irregular periods □ Painful periods □ PMS □ Heavy bleeding □ Clots □ Vaginal discharge (color: _______________) □ Vaginal odor

For Men Only: Do you have: (check all that apply) □ Prostate problems (please explain: ______________________________________) □ Painful or burning urination □ Impotence □ Premature ejaculation □ Pain or coldness in genital area

Acupuncture Pain Relief Clinic Wellness Starts Here827-A N Bloodworth St, Raleigh, nc 27604 // 919-283-8784 www.ApRclinic.com

Additional Patient Symptoms

SOMETIMES/ OFTEN □ □ poor appetite □ □ excessive appetite □ □ loose stool or diarrhea □ □ acid reflux □ □ nausea □ □ vomiting □ □ bad breath □ □ gas □ □ burping □ □ fatigue □ □ edema □ □ difficulty breathing when lying down □ □ shortness of breath □ □ cough □ □ asthma □ □ tight feeling in chest □ □ catch colds easily □ □ dry skin □ □ other skin problems □ □ constipation □ □ intestinal problems (colitis,diverticulitis, IBS)

SOMETIMES/ OFTEN □ □ eye problems □ □ jaundice □ □ gallstones □ □ muscle spasms □ □ dizziness □ □ easily angered □ □ high blood pressure □ □ high cholesterol □ □ low back pain □ □ knee problems □ □ hearing impairment □ □ kidney stones □ □ decreased sex drive □ □ hair loss □ □ urinary disturbances □ □ insomnia □ □ heart palpitations □ □ cold hands and feet □ □ nightmares □ □ low blood pressure □ □ chest pain

---End of patient portion of intake form

Acupuncture Pain Relief Clinic Wellness Starts Here827-A N Bloodworth St, Raleigh, nc 27604 // 919-283-8784 www.ApRclinic.com

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Cancellation and Fee Policy I understand that I am financially responsible for all charges and services rendered on my behalf or my dependents, and that a fee schedule containing priced services is available at the front desk upon request. I agree to pay in full for all charges when services are rendered. Signature____________________________________________ Date____________________________ Request and Consent for Treatment I hereby request the Acupuncturist (Jacob Lee) to treat me. I authorize him to perform on me the treatment within the Acupuncturist’s scope of practice that he sees fit. I have read and understood the possible risks involved as outlined below. I understand that I have been given no guarantee as to the results that may be obtained.

Acupuncture: I understand that acupuncture is performed by the insertion of needles through the skin in an attempt to treat bodily dysfunction or disease, to modify or prevent pain perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment.

Moxibustion: I understand that moxibustion is the application of heat to the skin at certain points on the body. I am aware that there is a risk of burning of the skin involved with moxibustion.

Cupping: I understand that cupping is the application of glass cups to the skin through suction and that there is a risk of bruising involved.

Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture treatment. I am aware that if I am wearing any type of electronic device (pacemaker, hearing aid, etc.) that I must make the acupuncturist aware of my electronic device and that I am forbidden from receiving electro-acupuncture. The risks may include, but are not limited to: electrical shock, pain or discomfort and the possible aggravation of symptoms existing prior to treatment.

Herbal Medicine: I understand that Chinese herbs as listed in the Chinese Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception and to normalize the body’s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain side effects may result from taking these substances. These could include, but are not limited to: changes in bowel movements, abdominal pain or discomfort, skin rash, and the possible aggravation of symptoms existing prior to treatment. Should I experience any problems which I associate with my herbs I should suspend taking them and contact the clinic as soon as possible.

I understand that I may refuse any of the above listed treatments.

Signature____________________________________________ Date____________________________

Acupuncture Pain Relief Clinic Wellness Starts Here827-A N Bloodworth St, Raleigh, nc 27604 // 919-283-8784 www.ApRclinic.com

NOTICE OF PRIVACY POLICIES Acupuncture Pain Relief Clinic is dedicated to providing services with respect for human dignity. Protecting your privacy and healthcare information is fundamental in the course of our relationship. This notice will remain in effect until it is replaced or amended by changes in law. We gather personal information and health information in several ways: ● Information we receive from you ● Information we receive from other healthcare providers ● Information we receive from third-party payors This information is used for treatment, payment and healthcare operations. You should be aware that during the course of our relationship with you we will likely use and disclose health information about you for the treatment, payment and healthcare operations. You may specifically authorize us to use protected health information for any purpose or to disclose your health information by submitting the authorization in writing. Such disclosures will be made to any personal representative you choose to have your protected health information. MARKETING: Acupuncture Pain Relief Clinic will not use your health information for marketing communications without your written authorization. This clinic may send birthday cards, newsletters, and appointment reminders, by calls, postcards or letters. This clinic may send you information to support your health care, information about alternative treatments, and health-related services that may be of interest to you. Please advise this office if you do not wish to receive such communications, and we will not use or disclose your information for such purposes. DISCLOSURE: Acupuncture Pain Relief Clinic may use or disclose your Protected Health Information when required by law. Without your consent or authorization, this clinic may disclose information about you only for the following purposes: ● To a public health agency, for the purpose such as controlling disease ● In case of suspected child abuse, to the appropriate governmental authority.

● In other cases of suspected abuse, neglect or domestic violence, to the appropriate governmental authority, with your agreement or if required by law, or if you are incapacitated or it appears necessary to prevent serious harm to you or others.

● To health oversight authorities, for regulatory, licensing and other legal purposes ● In litigation, subject to certain requirements controlling the terms of the disclosure ● To law enforcement agencies, subject to applicable legal requirements and limitations.

● For medical research purposes, subject to your authorization or approval by an institutional review board. ● If you are in the United States military, national security or intelligence, or Foreign Service, to your authorized superiors or other

authorized federal officials. We may not use or disclose information about you for any other purpose without your written authorization, provided separately from your written consent. PATIENT RIGHTS 1. Upon written request you have the right to access, review or receive copies of your healthcare records 2. Upon written request you have the right to receive a list of items this office disclosed about your healthcare information. 3. You have the right to request that this office place additional restrictions on disclosure of your Protected Health information. 4. You have the right to request that we amend your Protected Health Information; the request must be in writing 5. You have a right to receive all notices in writing If you have questions, complaints or want more information, please contact this office. Contact: Acupuncture Pain Relief Clinic, 827A N Bloodworth St., Raleigh, NC 27604 COMPLAINTS: Complaints about your privacy right or how your privacy is handled at this office can be directed to the privacy officer by calling this office or directing a letter to his or her attention. If you are not satisfied with how this office handles your complaint you may submit a formal complaint to: DHHS (Office of Civil Rights), 200 Independence Ave., S. W., Room 509F HHH Building, Washington, DC 20201

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, ___________________________________________ (printed name) have read, reviewed, understand and agree to the Notice of Privacy Policies for healthcare services in this office. This practice has attempted to provide each patient with a Notice of Privacy Policies. ___________________________________________________________________________ Patient Signature Date

Acupuncture Pain Relief Clinic Wellness Starts Here827-A N Bloodworth St, Raleigh, nc 27604 // 919-283-8784 www.ApRclinic.com