Ascential Intake Form With Insurance

8/12/2019 Ascential Intake Form With Insurance

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Name: Date of Birth: / /

Age: Sex: F / M SSN: Email:

Address: City: State: Zip:

Phone: Home: Work: Cell:

Marital Status: Occupation: Employer:

Emergency Contact: Relationship: Phone:

How did you hear about us?

Primary Physician: Phone:

Internet -search engine or key term:Recommend by Friend/Family: Who?

Other:

GENERAL INFORMATION

Ascential Acupuncture LLC www.ascentialacupuncture.com 614.526.4164

Ascential Acupuncture LLCNew Patient Form

INFORMATION

MEDICAL HISTORY

Surgeries:

Significant Trauma (auto accidents, falls, emotional, etc ):

Allergies:

Have you ever had an infectious disease? (HIV, TB, etc.) Yes No If so, please describe:

Recieve or monthly newsletter? Yes No

Reason for seeking acupuncture?

When did it begin, or what is the initial cause?

Have you been given a diagnosis? If so, what?

What makes your symptoms better?

What makes your symptoms worse?


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Alcoholism Allergies Alzheimers Arthritis

Mental Illness Multuple Sclerosis Pulmonary Disease Obesity

Hypertension Hypotension HIV/AIDS Kidney

Seizures Strokes Other:

Asthma Cancer Diabetes Heart Disease

FAMILY MEDICAL HISTORY(Please check if any of the following applies to you or any family members)

If mother, father, or siblings are deceased what was the cause?

Medications: (Please list all OTC, prescription, vitamins, and supplements, and what they are taken for)

Do you have a regular exercise program? Yes No If so, describe:

Hours of sleep per night? Do you wake rested? Yes No

Awake Easily Have Difficulty Falling Asleep Have Restless Sleep Have Vivid Dreams Sleep Too Much Nightmares Disturbing Dreams Other:

What is your stress level on a scale from 1-10?

Caffeine How often? Alcohol # drinks per week: Tobacco Former alcohol use # years quit: Recreational Drugs How often? Former tobacco use # years quit:

DIET (Please describe your typical daily diet)

Breakfast: Snack:

Lunch: Snack:

Dinner: Snack:

SOCIAL & LIFESTYLE

How of ten?


Do you drink water? How many glasses per day? _____


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Spleen/Stomah Low appetite Large appetite Abrupt weight gain Abrupt weight loss Fatigue Easily bruised Hemorrhoids Over-thinking Worry often Bad Breath Abdominal pain Vomiting Gas/belching Bloating Edema (swelling) Heartburn Acid regurgitation Ulcer Belching Craving or avoiding sweets

Heart Palpitations Anxiety Mental confusion Chest pain Frequent dreams

Insomnia

Restlessness/agitation

Breathlessness

Craving or avoiding bitter foods

Lung Nasal discharge Dry cough Cough with sputum Nose bleeds Sinus congestion Dry mouth Dry throat Dry nose Dry skin Skin rashes I tchy skin Alternating chills and fever Low resistance to colds or flu Sore throat Difficulty breathing Shortness of breath Sadness

Craving or avoiding spicy foods

Digestion (SP, ST, LI, SI) Constipation Diarrhea Blood in stool Mucous in stool Undigested food in stool

Liver/Gall Bladder Sigh often Bitter taste in mouth Anger easily Vertigo Depression Irritability Stress Muscle twitching Muscle cramping High pitched ringing in ears Soft brittle nails Dizziness Feeling of lump in throat Joint tightness/stiffness

Headaches/migraines Visual problems Red eyes Dry/itching eyes Spots in front of eyes Blurred vision Craving or avoiding sour foods

Kidney/Urinary Bladder Urinary problems Frequent urination Wake during night to urinate Incontinence Weakness/pain in lower back

Aching bones Feel cold easily (hands/feet)

Low sexual energy Excess sexual desire Low pitched ringing in ears Poor memory Hair loss Early Greying of hair Hearing problems

Fearful

Easily startled

Craving or avoiding salty foods

General Overview High blood pressure Low blood pressure High cholesterol Hyperthyroid Hypothyroid

History of blood clots Migraines

Pace Maker Metal implantsIf so where _____________

Current Symptoms (Check all that apply)

Prostate Problems Erectile Dysfunction Impotence Reduced Sex Drive Seminal Emissions Genital Pain History of Testicular Cancer Pain or Burning During Urinatio Decreased Urine Flow Other:

MENS HEALTH



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WOMENS

Please clearly mark any areas of pain.

Is the pain: Sharp Cramping Fixed Burning Dull Aching Moving Other:

Do the following lessen the pain? Pressure Exercise Cold Heat Other:

Do the following worsen the pain? Pressure Cold Heat Other:

PAIN AREAS


Age at First Menses: ______ Age at Menopause: ______ Period between Menses: ______ Duration of Menses: ___

Number of Pregnancies: ______ Number of Births: ______ Miscarriages: ______ Abortions: ______

Last period: ________ Last PAP Smear: ________ Pregnant: Yes No Form of birth control: __________

Menstrual pain

Mood ChangesClots

Low backache

Hot flashes

Irregular menses Vaginal dryness

Painful breast Vaginal discharge

Fertility problem

Heavy bleeding

How long have you been trying to conceive? __________________________Have you had fertility treatments? If yes, when, where, types, and by whom? __________________________________

Have you ever taken DepoProvera? Yes No When?__________ How long?_____________________________

Have you taken medication for ovulation? Yes No When?__________ How long?Have you had any hormone laboratory tests performed? Yes No Results? _______________________________Have your fallopian tubes been evaluated medically? Yes No Results? __________________________________

Has your spouse/partner had a fertility workup? Yes No If yes, what were his results?_______________________

FERTILITY PATIENTS


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HIPPA NOTICE OF PRIVACY PRACTICES

Your protected health information may be used and disclosed by Ascential Acupuncture for the purpose of providing health care ser to you, to support the healthcare operation, and as required by law.

Treatment: to provide, coordinate, or manage your health care and any related services. This includes the coordination of youcare with a third party. For example, to another healthcare professional to whom you have been referred to ensure that the prothe necessary information to diagnose or treat you.

Healthcare operations : in order to support the business activities of Ascential Acupuncture. These activities include, but are n to, quality assessment and review activities, licensing, and conducting or arranging for other business activities. For example you to remind you of your appointment or review your case to determine a continued course of treatment.

Use required by law: in the following situations without your authorization. These situations include:; Communicable DiseaseOversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Organ Do Research; National Security; Workers Compensation; Inmates; Required Uses and Disclosures. Under the law, disclosures mmade available to you and are required by the Secretary of the Department of Health and Human Services.

You have the right to inspect and copy your protected health information . Under federal law, however, you may not inspect or the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, o action or proceeding, and protected health information that is subject to law that prohibits access to protected health informa

You have the right to request a restriction of your protected health information. You may ask Ascential Acupuncture not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations You may alsorequest that any part of your protected health information not be disclosed to family or friends who may be involved in your request must state the specific restriction and to whom the restriction will apply.

You have the right to request to receive confidential communications by alternative means or at an alternative location.

You may have the right to amend your protected health information . If denied, you have the right to file a statement ofdisagreement with Ascential Acupuncture.

You have the right to receive an accounting of certain disclosures made, if any, of your protected health information.

You have the right to obtain a paper copy of this notice , upon request, even if you have agreed to accept this notice electronica

Complaints: You may complain to Ascential Acupuncture or to the Secretary of Health and Human Services if you believe your privrights have been violated.

Ascential Acupuncture is required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties andprivacy practices with respect to protected health information.

I acknowledge that I have received the HIPAA Notice of Privacy Practices.

Signature: Date:

Ascential Acupuncture LLC


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Please sign one of the two options below:

Option One:I have received a diagnostic exam by a physician or chiropractor within the last six months regarding condition for which I am seeking treatment.

__________________________________________________

Patient Signature Date

Option 2:I have NOT received a diagnostic exam by a physician or chiropractor within the last six months regarthe condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturistrecommend that you receive a diagnostic examination from a physician or chiropractor regarding thecondition for which you are seeking treatment.

I understand this recommendation.

Patient Signature Date

Date


Ascential Acupuncture makes every attempt to make acupuncture available at affordable rates:

Initial (first-time) visit $80 Follow-up visits $60 We do offer treatment packages in series of 5 ($270) and 10 ($500) visits. All payments are due at the time service.

Ascential Acupuncture understands that it is not always possible to keep scheduled appointments. Appointments cancelled or missed with less than 24 hour advance notice will be charged a $20 fee. The payment is due at the tim

next scheduled appointment. If appointments have been purchased in a package, the missed or cancelled appointbe deducted from the number of remaining appointments in that package.

Thank you for your understanding.

I have read, fully understand and agree to all the above mentioned financial policies and terms of service.

Patient Signature: Date:

For Patient Review Regarding Diagnostic Exam

Practitioner Signature

Financial Policies


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ACUPUNGTURE INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practiceacupuncture on me or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or otherlicensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for tacupuncturisl named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to thform or not.

I understand that methods of treatment may include. but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-N Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teconsumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediatelnotify 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 bruisinnumbness

ortingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk

moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risksacupuncture include spontaneous miscarriage, nerve damage apd organ puncture, including lung puncture pneumothorax). lnfectionanother possible risk, although the clinic uses sterile disposable needlds and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs annutritional supplements which are from plant, animal and mineral sources) that have been recommended are traditionally considered safethe practice of Chinese Medicine. although some may be toxic in large doses. I understand that some herbs may be inappropriate durinpregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, antingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to relythe clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts theknown, is in my best interest. I understand that results are not guaranteed.

I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidentia

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 risand benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover thentire course of treatment for my present condition and for any future condition s) for which I seek treatment.

ACUPUNCTURIST NAME:

PATIENTSIGNATURE X Or Patient Representative) lndicate relationship if signing for patient)

ALso SIGN THE ARBITRATION AGREEMENT OI.I REVERSE spe

AAC.FED


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Ascential Intake Form With Insurance

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