1 6685 Doubletree Ave, Columbus, OH 43229 ® 614.825.6255 ® aiam.edu Revised 4.26.17

American Institute of Alternative Medicine Clinic Policies

AIAM offers professional and student services for both Acupuncture and Massage. The AIAM clinic provides students and interns a place to integrate their classroom studies. Your feedback is an important part of ensuring our student’s success in their field of study. Our mission is helping you achieve your wellness goals.

1. Clinic treatment may be inadvisable for certain medical conditions and medications so it is imperative to completely identify your current medical conditions and medications on the intake form. A referral from your primary care provider may be required prior to treatment.

2. An informed consent form must be signed by the parent or guardian before anyone under the age of 18 can be treated. Children under 16 or those under guardianship must be accompanied for the duration of their session by the parent, guardian or caretaker. Minors under the age of 16 or those under guardianship are not allowed in the clinic or lobby unless they are patients.

3. If you arrive late for your appointment it is at the clinic’s discretion to determine the remaining length of your session or if the appointment must be rescheduled. The full rate of service may apply.

4. Clients deemed to be under the influence of drugs or alcohol will be asked to leave the clinic. The client is responsible for full payment of the appointment.

5. AIAM reserves the right to refuse service to clients that fail to complete the intake form, do not exhibit courteous and considerate behavior to other clients, staff, faculty and students.

6. Sexual misconduct from clinic clients is strictly forbidden. Sexual advances, physical conduct of a sexual nature or any request for sexual favors will result in the immediate termination of the session. The client is responsible for full payment of the appointment and will be prohibited from receiving any future treatment at the clinic.

7. STUDENT MASSAGE CLINIC ONLY: In the best interest of students’ education, we do not honor requests for a specific student therapist for any reason including requests for a specific gender. If you prefer to choose the gender of your therapist, please schedule with one of our Licensed Massage Therapists.

2 6685 Doubletree Ave, Columbus, OH 43229 ® 614.825.6255 ® aiam.edu Revised 4.26.17

Contact Preferences?

Phone __________________________ May we leave a voicemail? _________________________

Email: __________________________________________________________________________

By providing your email you agree to receive email appointment reminders from AIAM.

You may opt out of Promotions/Newsletters by checking here:

Opt out of Promotions/Newsletters

Cancellation Policy:

o You may cancel your appointment without charge any time before the close of the business on the day preceding your appointment.

o Same day cancellations will be charged 50% of the scheduled service price.

o Please arrive at least fifteen minutes before your scheduled appointment time in order to guarantee a full session. Tardiness in excess of 20 minutes is considered a “No Call/No Show” and will be charged the full price of the session.

o If AIAM must cancel your appointment for any reason, we follow the same policy.

o Emergency situations will be addressed on a case by case basis.

By signing below I acknowledge the above policies and that I have been given the opportunity to review AIAM’s Notice of Privacy Practices (HIPAA) and have been offered a copy of the notice.

___________________________________ __________________________ Patient/Parent/Guardian Signature Date

3 6685 Doubletree Ave, Columbus, OH 43229 ® 614.825.6255 ® aiam.edu Revised 4.26.17

Acupuncture & Traditional Chinese Medicine Clinic New Patient Information Form

Name First Last Date

/ /

Date of birth Age Email (required)

Street address Apartment/Unit City/State/Zip code

Telephone (home) (cell) Best number to contact: Home/ cell/ other

How did you hear about our clinic? Internet Referred by a friend/relative, other patient/client______

At an event ________ Other __________

Have you been treated using acupuncture, herbs, or Traditional Chinese Medicine before? Yes No

IIn case of emergency, please contact:

________________________________ ____________________ __________________________

Name Relationship Contact number

1. Main concern you would like help with:

2. How long ago did this problem begin?

3. Have you been given a diagnosis for this concern? Yes/No If so, what?

4. What treatments have you tried?

5. Are you currently receiving treatment for this issue? Yes/No If so, please describe:

6. What, if anything, improves your condition?

7. What, if anything, makes your condition worse?

8. Do you have, or have you ever had any infectious diseases? Yes/No (Hepatitis, Herpes, HIV/AIDS, Other)

Past Medical History

Major illnesses/medical conditions(hospitalizations, flu, bronchitis, etc) : Surgeries (when, for what reason): Significant trauma (accidents, falls):

Medication & Supplements (prescription and over-the-counter drugs, vitamins, herbs, etc. taken within the last 3 months)

Medication/Supplement Dosage Reason for use/condition treated

Allergies. Please list any seasonal, dietary, skin or other allergies you have/may have:

Family Medical History (General Health)

Mother’s side: Father’s side: Sibling’s: If any are deceased, please list cause:

Personal Health & Wellness History

Birth History (premature, prolonged labor, forceps, delivery, etc.):

Childhood general health:

Location of upbringing (Geographically prone to certain diseases, habits, etc.):

Current quality of home life: work life: work/life balance:

Current quality of emotional/mental health:

Current relationship quality:

Current predominant emotion:

Occupation:

Stress level: Any unusual/recent stressors?

Favorite season of year: Least favorite: Hobbies & recreational habits: Do you have a regular exercise/movement program? Yes/No If yes, please describe:

Have you traveled abroad in the past year? Yes/ No If yes, where? Please describe smoking, alcohol, recreational drug, caffeine, sugar, water intake (How much, how often, any noticeable effects):

Neurological, emotional, mental (please check if you’ve experienced in the past 3 months) Anxiety Dizziness Areas of numbness Depression Concussion Tremors Mania Seizure Stroke/paralysis Easily stressed Fainting Emotional changes Easily angered Loss of balance Nervous habits Lack of mental focus Disorientation Grief Poor memory Lack of coordination Other: ___________ Are you, or have you ever been under care for emotional/mental concerns? Yes/No If

yes, please describe: Have you considered suicide? Have you ever attempted suicide?

General (please check if you’ve experienced in the past 3 months) Fever Day time sweating Weight loss Chills Night sweats Weight gain Fatigue Absence of sweating Areas of weakness Energy drops

(time of day?) _______ Dream disturbed sleep Difficulty falling asleep

Sleeping more than usual Difficulty staying asleep Other: _____________

Cardiovascular (please check if you’ve experienced in the past 3 months)

High blood pressure Palpitations Cold hands/feet Low blood pressure Swelling of hands Blood clots Anemia Swelling of feet Other: _____________ Irregular heartbeat Phlebitis Chest pain/tightness Cold sweats

Respiratory (please check if you’ve experienced in the past 3 months) Cough Bronchitis Sleep apnea Asthma Easily winded with exertion or when lying down Difficulty breathing Coughing blood Shortness of breath Production of phlegm Pain with deep breaths Color of phlegm _______ Other, describe:_______

Musculoskeletal (please check if you’ve experienced in the past 3 months)

Injuries, falls Muscle sprain, strain Joint inflammation

Muscle weakness Arthritis Other, describe:_______

Muscle atrophy Joint instability Other, describe:_______

Muscle cramps Bone spurs

Muscle spasms Easily bruised

Reproductive (male/female)

Age at first menses Irregular periods Emotional changes w/period

# Days between menses Painful periods Number of pregnancies

# of days period lasts Breast tenderness/lumps Number of live births

Recent menstrual changes Spotting Number of miscarriages

Clots Very heavy or light flow Date of last period _______

Birth control method________

For how long____________ Vaginal discharge_________

Low libido Fertility concerns Date of last pap smear

Impotence Other: ___________

Digestive, Gastrointestinal (please check if you’ve experienced in the past 3 months)

Change in appetite Irregular eating Indigestion

Poor appetite Loose stools Ulcers

Excessive appetite Constipation Hemorrhoids

Food cravings Vomiting/nausea Blood in stool

Bloating, distention Belching Digestive disorders

Eating disorders Bad breath Other, describe:_______

Urinary(please check if you’ve experienced in the past 3 months)

Pain/burning on urination Blood in urine Waking at night to urinate

Urgent urination Kidney stones How often?____________times

Frequent urination Difficulty holding urine Urinary tract infection Changes in urine

flow/volume Hesitation or pain on

urination Other: _______________

Please circle on the diagram any areas of pain or injury.

1. Is the pain constant? _________________________

2. Is the pain sharp, dull, achy, burning, stabbing, radiating? ____________________________

3. Which areas experience numbness or tingling? ___________________________________

___________________________________________________________________________________________ Signature Date ___________________________________________________________________________________ Signature of parent or guardian Date Guardian is required to accompany patient throughout duration of treatment

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For patient review, regarding diagnostic exam: Please sign one of the 2 options below

Option 1

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

X ______________________________________________________________ Patient signature Date Option 2

I have NOT received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturist recommend that you receive a diagnostic exam by a physician or chiropractor regarding the condition for which you are seeking treatment.

X ______________________________________________________________ Patient signature Date