Thrive Acupuncture and Wellness / / HEALTH HISTORY Date · Discover, Flexible Spending Accounts...

HEALTH HISTORY Name: Sex: Age:

Address: City: State: Zip Code:

Phone #: Work Cell Other

Emergency Contact: Name & Phone

Email:

Date of Birth:

Usual Blood Pressure:

Weight One Year Ago: Height: Weight:

Relationship Status:

Employer: Occupation:

Health Care Providers:

For Women: Are you or may you be currently pregnant?

How did you hear of our clinic?

Have you been treated by Acupuncture or Oriental Medicine Before?

MAIN COMPLAINTS Please write up to 3 health complaints / concerns in

order of importance to you. Circle the items that make it better or worse and mark on the scale from 1-10 the severity of the

condition (1=no symptoms, 10=worst ever)

1

2

3

1 10

1 10

1 10

When did this start? __________________ago Heat makes it: better no change worse Cold makes it: better no change worse Damp weather: better no change worse Exercise / Activity: better no change worse

When did this start? ___________________ago Heat makes it: better no change worse Cold makes it: better no change worse Damp weather: better no change worse Exercise / Activity: better no change worse

When did this start? ___________________ago Heat makes it: better no change worse Cold makes it: better no change worse Damp weather: better no change worse Exercise / Activity: better no change worse

INJURIES & SURGERIES Please note what happened to what body area and when it occurred (incl. dental)

_______________________________________________________________________________ _______________________________________________________________________________ _____________________________________________________________________________

Date: ___ / ___ / _____

HEALTH HISTORY Check the r if you have / had the condition and note the year it started.

Check the m if there is a family history of the condition.

Cancer type(s)? ____________________________ Diabetes Hepatitis High Blood Pressure Heart Disease Stroke Seizure Disorder Thyroid Disease Asthma Pacemaker

Osteoporosis Herpes AIDS / HIV Other STD Rheumatic Fever Alcoholism Allergies type(s)? _________________________ Mental Illness Kidney Disease Anemia

YOU Year FAMILY r ______ m

r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m

YOU Year FAMILY r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m r ______ m

r ______ m r ______ m r ______ m

HABITS Amount / Week If Quit, Year?

Coffee / Tea ______________ _______ Soda ____________________ _______ Tobacco _________________ _______ Alcohol __________________ _______ Drugs ___________________ _______

EXERCISE Do you exercise regularly? � Yes � No

If so, what and how often: _____________________________ _____________________________ _____________________________

m No m Yes: when ____/____/____

r Single r Married r Separated

r Divorced r Widowed r Living w/partner r Other: ___________

MEDICATIONS Please note what medications, herbs or supplements that you take regularly

_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

DIET Low Carb, Vegetarian/Vegan, Portion Control, Low Fat, Organic, Standard American Current or past eating disorder?

Employer:

Thrive Acupuncture and Wellness

Thrive Acupuncture and Wellness

Please mark an X on the scales and check any boxes of symptoms you have had in the past month

Thirst for cold / hot drinks

HEALTH HISTORY for MEN

TEMPERATURE How warm / cold you feel (not in degrees); relative to other people do you wear more or less layers, etc.

MOISTURE Your overall body moisture (hair, skin, mouth, bowels, etc.)

DIGESTION

ENERGY

SLEEP EMOTIONS What emotion(s) can you be prone to?

EYES, EARS, NOSE, THROAT

URINARY REPRODUCTIVE

COLD HOT

DRY OILY

! Cold hands or feet ! Chills ! Cold “in the bones” ! Areas of numbness

! Night sweats ! Unusual sweats

When_______ am / pm Where on body ___________

! Dry skin ! Dry hair ! Dry eyes ! Dry brittle nails

DIARRHEA CONSTIPATION

LOW HIGH

BM: How often? _____x / every _____days Stools keep shape? ! Y ! N ! Alternating diarrhea & constipation (IBS) ! Indigestion

# Hours per night ______ ! Difficulty falling asleep ! Wake ___x/ night @_____am / pm ! Wake to urinate How often? ________ ! Disturbing dreams ! Restless sleep ! Not rested upon waking

! Gas ! Bloating ! Belching ! Poor appetite

! Sudden energy drop Time of day: ______ am / pm ! Energy drop after eating ! Fatigue

! Dependence on caffeine / stimulants ! Wired / ungrounded feeling ! Body / Limbs feel heavy ! Body / Limbs feel weak

! Nausea / Vomiting ! Bad breath ! Heartburn ! Excessive hunger

! Dry Stools ! Difficult to pass ! Tired after BM ! Foul smelling stools

! Edema / Swelling ______________ ! Rashes ______________________ ! Itching _______________________ ! Dandruff

! Oily skin ! Oily hair ! Pimples ! Weight gain / loss

! Dry mouth ! Dry lips ! Dry throat ! Dry nose / Nosebleeds

! Anger ! Irritability ! Anxiety ! Worry ! Obsessive thinking ! Sadness

! Grief ! Depression ! Joy ! Fear ! Timid / shy ! Indecision

! Poor vision ! Night blindness ! Red eyes ! Itchy eyes ! Spots in front of eyes ! Sinus congestion ! Phlegm (color _______)

! Poor hearing ! Ringing in ears ! Excess earwax ! Sore throat ! Dental problems ! Mouth sores ! Cough

! Hot hands, feet, chest ! Hot flashes ! Hot in afternoon ! Hot at night

! Thirst, no desire to drink ! Absence of thirst ! Excessive thirst

! Shortness of breath ! Heart Palpitations ! Blood pressure High / Low ! Bleed / Bruise easy

Where on your body?

! Hard to concentrate ! Poor memory ! Dizziness / lightheaded ! Headaches _____x / week

! Urgency to urinate ! Frequent urination ! Pain on urination ! Burning sensation ! Cloudy urine ! Blood in urine

Fluid in = fluid out? ! Y ! N ! Decrease in flow ! Dribbling ! Difficulty starting / stopping ! Incontinence ! Kidney stones

Are you sexually active? ! Y ! N ! Change of sexual drive: ! " ! Erectile dysfunction ! Premature ejaculation !

ChristinaNess-Hawks,LAc,DiplOM,MSTCM3412MendocinoAve,SantaRosa,CA95403

707.527.0868|www.thrive-acupuncture.com

Financial Agreement Payment is due at the time of your appointment, unless alternate financial arrangements have been made. Accepted methods of payment are cash, check, Visa, Mastercard, Discover, Flexible Spending Accounts (FSA), or Health Savings Accounts (HSA). Cancellation Policy We have a goal to give you the time and service you need so we do not overbook patient appointments. We require 24 hours notice if you can’t make your appointment, otherwise you are responsible for a $40 missed appointment fee. If you are more than 10 minutes late for a scheduled appointment, we may not be able to see you and will treat it as a missed appointment. Please get in touch with us as soon as you know you may be delayed. Insurance If you choose to use Insurance to pay for any portion of the services we offer, as a courtesy, our office will bill your insurance directly for you at the full insurance fee rate. It is your responsibility to provide us with the proper insurance identification information and any updates if your coverage changes during your treatment in this office. We will call to verify benefits, but it is your responsibility to know your benefits and we urge you to carefully review your insurance coverage prior to your office visit. If you wish to use one of the following forms of insurance, please provide us with the following information before your first appointment so we can verify your benefits for you:

! Health Insurance: name, date of birth, insurance carrier, ID number, and the phone number for providers on the back of your insurance card.

! Personal Injury or Auto Insurance: name, date of birth, date of injury, name of insurance carrier, case number, and the name and direct phone number of the adjuster.

! Worker’s Compensation Insurance: a signed copy of the authorization for treatment; fax to (707) 703-1473 or scan and email to [email protected].

If we are billing your insurance directly, and if for any reason your insurance company sends payments directly to you for services performed in this office, you agree to inform the office of any payments received and pay forward these amounts to the office immediately upon receipt. If the office has been informed that you received payment for services performed in this office, and you have not notified the office or paid forward the amounts paid by your insurance to the office within 30 days of the payment’s issue date, lack of communication on your part will result in the claims being turned over to collections. _______ Please initial here.



In some situations, it will not be possible for the office to bill your insurance directly. In such cases, payment in full will be due at each office visit; however, we can provide you with a Superbill that you can submit to your insurance company for reimbursement. Any reimbursements that you may be entitled to are determined by the rules of your particular insurance plan, and are a contract between you and your insurance provider. Your insurance company will reimburse you directly for your Superbill submission. A Superbill is not a guarantee for reimbursement, and we reserve the right to not be involved in any claim disputes. Time Of Service Discount If our office will not be billing your insurance directly for any portion of the services we offer and you will be paying in full on the same day as your appointment, we will give a time of service discount. I, _______________________________, have read and agree with the above statements. ____ I authorize Thrive Acupuncture and Wellness to bill my insurance and for the insurance benefits to be assigned to Thrive Acupuncture and Wellness for health care services provided to me in this office. I understand that Thrive Acupuncture and Wellness will bill my insurance carrier for services rendered upon verification of coverage by my insurance company. I understand that verification of benefits and benefits quoted by my insurance company is not a guarantee of payment and my financial responsibility is subject to change. I understand that a full fee schedule for services is available upon request. If for any reason my insurance company sends payment directly to me for services billed directly by this office, I agree to pay forward these amounts to the office immediately upon receipt. If my insurance company fails to render payment for services, I hereby personally guarantee payment for medical care and services. I understand that I am responsible for paying for any non-covered services, my co-payments, co-insurance, or deductibles at the time of service. I also understand that I am responsible for any balance due after payment by my insurance company. ____ I do not have insurance or choose not to have my insurance billed for me; I will receive a time of service discount and will pay with cash, check, or credit card for my treatments at the time of service. ______________________ __________________________________________ Patient Name Signature of Patient Date

ChristinaNessHawks,LAc,DiplOM,MSTCM3412MendocinoAve,SantaRosa,CA95403


Health Information Privacy Practices

Thrive Acupuncture and Wellness is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. This notice describes how your medical information may be used and disclosed and how you get access to the information. Please review carefully. In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information in the following cases:

! Payment: In order to secure payment we may disclose health care information to your Insurance company or with Worker’s Compensation and, in this instance, your employer as well. If payment is not made as arranged, our office may utilize an outside collection agency, credit reporting agency, or other means of collecting outstanding debt. The designated collection agency or authority may review your file containing protected health care information.

! Treatment: Your health care information may be disclosed to other healthcare professionals within the practice or to your other healthcare providers to ensure continuity of care.

! Emergencies: In the event of an emergency, we may need to notify a family member or other person responsible for your care that you have been in an emergency situation.

! Public Health: For example, as required by law, we may disclose your health information to public health authorities for the purpose of preventing or controlling disease, reporting child or elder abuse or neglect, reporting domestic violence, or reporting disease or infectious exposure.

! Judicial and Administrative Proceedings or Law Enforcement: For example in the case of complying with a court order or subpoena.

! Other Communication: For example, we may call your home to remind you of an appointment. No protected health information will be provided on this call except for the date and time of your scheduled appointment. This office may send birthday cards, newsletters, and appointment reminders by email, phone, post card, or letter.

Safeguards in place at our office include:

! Limited access to facilities where information is stored. ! Policies and procedures for handling information. ! Requirements for third parties to contractually comply with privacy laws.

In administering your health care, we gather and maintain information that may include:

! Non-public personal information. ! Information about your financial transactions with us (billing transactions). ! Medical history, treatment notes, medical test results, and any letters, faxes, emails or telephone

conversations to or from this office, to or from other health care practitioners, from health care providers, insurance companies, Workman’s Comp and your employer, and other third party administrators (e.g. requests for medical records, claim payment information).

Upon written request, you have the right to access, review, or receive copies of your healthcare records. We value our relationship, and respect your right to privacy. If you have questions about our privacy practices, please call us during regular business hours at 707-527-0868. By signing this document, I acknowledge that I have received a copy of Thrive Acupuncture and Wellness’s Privacy Practices. ______________________ __________________________________________________ Patient Name Signature of Patient Date



New Patient Commitment Form

Thank you for choosing our office to meet your healthcare needs. We request that you read and hold onto this form as it will clearly lay out what you can expect as a new patient and the steps you will need to take to gain maximum benefit from your treatment. Health has a lot to do with personal responsibility. Our clinic can certainly offer you very deep and powerful support in overcoming chronic health conditions or pain. But it will ultimately be up to you to be accountable for your own health by being compliant with the recommended treatment plan and the lifestyle recommendations we offer, such as dietary changes, exercises, or stress reduction techniques. I practice a style of acupuncture that is renowned for quick results, meaning that most patients leave the office feeling significantly better, many times after their first treatment and in most cases within the first 3 treatments. At this point it may feel like acupuncture works like magic and all you have to do is show up for a treatment and your health problems will disappear. This is not the best way to use Chinese medicine. Acupuncture is a therapy that activates your body’s ability to heal. Patients experience the best most long lasting results with a course of treatment that will make sure we got to the root of the problem. And with chronic health issues, we have to work together as a team and implement a variety of lifestyle strategies for the acupuncture to work on the deepest level possible. Many times, people feel amazing after the first 1-3 acupuncture treatments. The effects are cumulative; typically the deeper benefits start to take hold after an initial series of 6-8 treatments depending on your situation. For some conditions it may take longer than 3 treatments to notice significant changes. For people suffering from chronic issues, while the effects of acupuncture may be noticeable after the initial treatments, you can expect it to take some more time for the results to last. Here are the steps I recommend you take to gain maximum benefit from your treatment and feel more like your best version of yourself as fast as possible. I am very excited to work with you if you are willing to hold yourself accountable to these very important actions steps:

1. Consistency in Treatment—On your first visit, we will discuss frequency and number of treatments to reach maximum progress. We ask that you make a commitment to the treatment plan by making your visits a top priority. Acupuncture works best with consistent and cumulative care.

2. Eat an organic whole foods diet—this is one of the most important steps you can take to heal all kinds of chronic issues. Many of our patients are asked to undergo allergy elimination protocols as well in order to achieve optimal benefit.



3. Exercise 3-4 times per week—walking, stretching, yoga, biking, etc., preferably you can find something you enjoy.

4. A few minutes a day of quiet time and introspection—meditation is ideal for this purpose but any type of quiet time will work.

5. Willingness to let go of addictions that are undermining your health. We have found that Chinese medicine can work on very profound levels if these basic steps are taken. We only ask that you do the best you can to follow these guidelines, as they will ensure that you receive the full benefit from our care. After seeing thousands of patients, we'd like to share with you an overview of the patient that does best with our approach. Our ideal patients:

• are willing to take responsibility for their health—they are not just looking for a magic bullet that will instantly cure their issues.

• are interested in working with their minds by letting go of old thought patterns or limiting beliefs—our approach to medicine very much honors the powerful role the mind and innate wisdom play in our health.

• are generally interested in living with purpose and in balance. • are compliant—they are happy to make recommended lifestyle changes and to

take their prescribed herbs. • value their health and the treatment process—they make a commitment to

showing up on time for treatment and sticking to their appointments because they know how important it is.

• see Chinese medicine as a lifestyle choice—generally we don't see patients that just have a specific pain they want to go away in 1 or 2 treatments and then they never come back.

• are curious and eager to learn and grow. If this describes you, great! We’re excited to have you at our practice and you should do very well with our approach. Be sure to start by downloading our How to Thrive ebook from our website at thrive-acupuncture.com to learn more about acupuncture, me, and our treatment methods. Please call us at (707) 527-0868 if you have any questions. I sincerely look forward to working with you! Christina Ness, LAc, Dipl OM, MSTCM



Time of Service Discount Rates If our office will not be billing your insurance directly for any portion of the services we offer and you will be paying in full on the same day as your appointment, we will give a time of service discount.

Initial Visit:

Includes a thorough Holistic Health Assessment (Health History, Goals, Chinese Medicine Diagnosis), an Acupuncture Treatment, and Report of Findings. $150.00

Follow Ups:

Per Treatment Payment $100.00 Prepayment Plans Terms and Conditions: This office offers two prepayment plans for patients paying at the time of service. In return for the patient's agreement to prepay for a specific number of visits in advance, the patient is offered free treatment(s). • $500.00: With the purchase of 5 treatments at $100/treatment, the patient receives

one treatment for free, for a total of 6 treatments. (works out to be about $83.00 per treatment)

• $900.00: With the purchase of 9 treatments at $100/treatment, the patient receives two treatments for free, for a total of 11 treatments. (works out to be about $81.00 per treatment)

If the patient decides not to continue treatment before the complete package of treatments has been utilized, they may receive a full refund for any unused treatments without any penalty. The refund will be returned to the patient as a check. Thrive Acupuncture and Wellness has up to two full weeks from the date of termination to refund the payment. The patient will be responsible for picking up the refund from the office during office hours. Payment of the prepayment plan will be taken in full on the day this contract is initially signed.

Prepayment Agreement: I agree to the above terms and conditions and allow Thrive Acupuncture and Wellness to take payment for: _____ 5 treatments at $100/treatment for a total of $500.00, followed with 1 free treatment, for a total of 6 treatments. _____ 9 treatments at $100/treatment for a total of $900.00, followed with 2 free treatments, for a total of 11 treatments. Signature of Patient: _____________________________ Date:______________ Termination of Prepayment Agreement: I wish to terminate my prepayment plan on the date of _________ and will receive my full refund for all unused treatments no later than two weeks from this date in the amount of ____________. Signature of Patient: _____________________________ Date:______________

Thrive Acupuncture and Wellness / / HEALTH HISTORY Date · Discover, Flexible Spending Accounts...

Documents

Transcript of Thrive Acupuncture and Wellness / / HEALTH HISTORY Date · Discover, Flexible Spending Accounts...