new patient information - flying needle medicine · 2017. 5. 16. · this information is used for...

Mary Sudduth MAOM, Dipl. OM., L.Ac., RDMS., FLYING NEEDLE, PLLC, 8831 Long Point Road, suite #302-B, Houston, TX., 77055

832-557-8535, Email: [email protected] Website: www.flyingneedlemedicine.com

New Patient Information

Name ____________________________________________ Today’s Date ___________________ Street Address _________________________________________________ Apt. ______________ City _______________________________________ State ______________ Zip _______________ Preferred Phone _________________________ Email ___________________________________ Birth Date (include year) _____________________ Age ____________ Gender _____________ Occupation _______________________________ Employer ______________________________ Referred by _______________________________________________________________________

Emergency Contact: Name __________________________ Phone _________________________

Fees: It is our policy that you pay the entire session fee or co-pay at the time of each session. We will provide a minimum of one month’s notice of any changes to our fees.

Insurance Company ___________________________________________

Insurance Company Phone Number (Provider Line) _____________________________

ID # ____________________________

Please bring a photocopy of your insurance card (front and back) or bring your card to your

first appointment so we can make a copy at the clinic.

Cancellation Policy:

If you need to change or cancel your appointment please do so with a minimum of 24 hours notice. Failure to do so will result in being charged the equivalent of the cash rate of the missed appointment to your account.

□ I understand the cancellation policy.

Signature:______________________________ Date: _____/_____/_____

mailto:[email protected]

http://www.flyingneedlemedicine.com



Health History

Have you had acupuncture before? __________ If so, for what reason? ___________________ Main issue(s) you are seeking treatment for: __________________________________________ _________________________________________________________________________________ Diagnosis from a medical professional (if applicable): __________________________________

Please mark any areas of pain or discomfort:





Please check any symptoms that you have experienced in the past or currently experience:

General

past current past current

sweating easily during the day □ □ fatigue □ □night sweating □ □ fevers □ □bleed or bruise easily □ □ chills □ □change in appetite □ □ weight loss/gain □ □dizziness/vertigo □ □ poor sleep □ □

Skin & Hair


rashes/hives □ □ psoriasis □ □eczema □ □ loss of hair □ □acne □ □

Head, Ears, Eyes, Nose & Throat


earaches/pressure in the ears □ □ headaches/migraines □ □ringing in the ears □ □ sinus pressure □ □ hearing loss □ □ nose bleeds □ □eye floaters □ □ dizziness/vertigo □ □itchy eyes □ □ teeth/jaw clenching □ □blurry vision □ □





Cardiovascular/Circulatory


chest pain □ □ swelling/edema □ □fainting □ □ high blood pressure □ □ lightheadedness □ □ low blood pressure □ □cold hands & feet □ □

Respiratory


pain on inhaling □ □ sneezing □ □chest tightness □ □ seasonal/other allergies □ □ cough □ □ phlegm production □ □asthma □ □

Genito-Urinary


difficulty urinating □ □ urgent/frequent urination□ □blood in urine □ □ sores on genitals □ □ pain upon urination □ □ genital pain □ □





Neurological/Psychological


anxiety □ □ poor memory □ □depression □ □ quick temper □ □


loss of balance/coordination □ □ easily susceptible to stress □ □areas of numbness/paralysis □ □

Digestive


heartburn □ □ gas □ □belching □ □ diarrhea □ □bloating □ □ constipation □ □nausea □ □ abdominal pain/cramps □ □vomiting □ □ mucus in stool □ □chronic bad breath □ □ blood in stool □ □sores on lips/tongue □ □ hemorrhoids □ □





For Women Only:

past current past currentirregular periods □ □ breast pain □ □painful periods □ □ vaginal discharge □ □bleeding between periods □ □ vaginal sores □ □period clots □ □ hot flashes □ □menstrual cramping □ □ night sweating □ □

age of first menses ____________ duration of typical period ___________________

duration of typical cycle ______________ date of last PAP _____________________

# of pregnancies ____________________ # of live births (+ years) ______________

# of miscarriages ____________________ # of abortions _______________________

Have you been through menopause? Age? ___________________________________________

Have you ever taken birth control pills? When and for how long? _______________________

Other premenstrual & menstrual symptoms (bloating, breast tenderness, irritability, mood

swings, fatigue, loose stools, acne, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________





For Men Only:

past current past currenterectile dysfunction/impotence □ □ ejaculatory pain □ □varicocele □ □ BPH □ □

Lifestyle

Current medications/herbs/supplements:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Do you follow any certain diet or way of eating? (vegetarian, gluten-free, paleo, etc.)

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Current exercise routine:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Do you use tobacco? If so, how often? __________________________________________________________________________________

__________________________________________________________________________________

Do you drink alcohol? If so, how many drinks/week? __________________________________________________________________________________

__________________________________________________________________________________





Are you currently taking any of the following medications?

(circle if yes and indicate how often)

Advil/Motrin/Ibuprofen Aleve/Naproxen Bayer/Aspirin

Celebrex/Celecoxib Prednisone/Prednisolone

Are you currently taking any other pain medications? If yes, list name and amounts per day: _________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Allergies (medications/foods/chemicals/etc.): __________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever had a seizure? If yes, indicate date of last: ____________________

Please circle any significant illnesses and indicate date:

Cancer Hepatitis Diabetes

High blood pressure Epilepsy Heart Attack

Stroke Ulcer Disease Liver Disease

Colon Polyps Other _________________





Please list any major surgeries/hospitalizations and approximate dates:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Family Medical History

□ Cancer □ Seizures □ High blood pressure □ Stroke □ Diabetes

□ Heart Attack □ Hepatitis □ Asthma □ Other __________________

Please list any other relevant information or issues you would like to discuss:

Thank you for taking the time to fill out these forms. Please let us know if you have any questions or concerns.





Informed Consent for Acupuncture Treatment and Care

I hereby request and consent to the performance of acupuncture treatments and other complementary medicine procedures including various modes of physio-therapy on me (or on the patient named below, for whom I am legally responsible) by Mary Sudduth L.Ac.

I understand that methods or treatment may include, but are not limited to: acupuncture, moxibustion, cupping, moving cupping, electrical stimulation, acu-pressure, Chinese or Western herbal medicine, supplement recommendations, and nutritional and lifestyle considerations.

Acupuncture attempts to normalize physiological functions, to modify the perception of pain, and to treat certain diseases or dysfunctions of the body. I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances reported of spontaneous miscarriage and pneumothorax. There may be some bruising after cupping.

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 Chinese Medicine. I understand that some herbs may be inappropriate during pregnancy. If I experience any gastrointestinal upset or allergic reactions to the herbs, I will inform the acupuncturist.

I do not expect the acupuncturist to be able to anticipate and explain all risks and complications. I wish to rely on the acupuncturist to exercise judgment during the course of the procedure, which the acupuncturist feels at the time, based upon the facts then known, is in my best interests.

I understand the clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my consent. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content.





I understand my patient records and patient information will be kept confidential and shared only when necessary to provide care and services, or by my authorization, or when required or permitted by law.

By signing below, I agree to the above- named 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.

Patient's Name ___________________________________

Patient's/Patient Representative's Signature ___________________________________

Today's Date _________/_________/________





Notice of Privacy Policies

This notice describes our policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected. 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, information we receive from other healthcare providers, and information we receive from third party payers.

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 our health information by submitting the authorization in writing. Such disclosures will be made to any personal representation you choose to have your protected health information.

This office may use or disclose your Protected Health Information when required by law.

Upon written request, you have the right to access, review or receive copies of your healthcare records. Upon written request, you have the right to receive a list of items this office disclosed about your healthcare information. Upon written request, You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information. Upon written request, you have the right to request that we amend your Protected Health Information. You have a right to receive all notices in writing.

If you have questions, complaints or want more information, please contact Mary Sudduth LAc at (832-557-8535).



2

You may also send a written complaint to the

Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018 Assistance in filing a complaint is available by calling the following telephone number: 1-800-201-9353 For more information please visit our website at www.tmb.state.tx.us

_____________________________________________

AVISO SOBRE LAS QUEJAS Las quejas sobre médicos, así como sobre otros profesionales acreditados e inscritos en la Junta de Examinadores Médicos del Estado de Texas, incluyendo asistentes de médicos, practicantes de acupuntura y asistentes de cirugía, se pueden presentar en la siguiente dirección para ser investigadas: Texas Medical Board Attention: Investigations 333 Guadalupe, Tower 3, Suite 610 P.O. Box 2018, MC-263 Austin, Texas 78768-2018 Si necesita ayuda para presentar una queja, llame al: 1-800-201-9353 Para obtener más información, visite nuestro sitio web en www.tmb.state.tx.us

______________________________________ ____________________Signature Date

http://www.tmb.state.tx.us

http://www.tmb.state.tx.us

new patient information - flying needle medicine · 2017. 5. 16. · this information is used for...

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