New Paitient Forms

Clinic Forms

Fill In Your Information Below Prior To Your First Visit.

Patient Intake Forms

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

Home Phone

Cell Phone

Social Security Number

Occupation

Date of Birth

Emergency Contact

Are you:

Single

Married

Partner

Divorced

Widowed

Referred By:

Family Physician

Physician Contact Number

Have You Had Acupuncture or Oriental Medicine Before?

Are You Under Doctor's Care?

If Under Doctors Care: Who & For What?

Are There Any Therapies You Are Involved In?

If Yes, Who and For What?

Primary Reason For Seeking Care At Our Office?

When Did It Begin?

What Was The Initial Cause?

When Did It Begin?

What Makes It Better?

What Makes It Worse?

What Have You Done With This?

Select The Activities Your Problem Interferes With

Others

Are You Interested In?

Pain Relief

Performance Care

Maintenance Care

Preventative Care

Tai Chi

Stress Relief

Oriental Nutrition

Herbal Therapy

Others

What Are Your Health Goals?

List Any Past Or Future Surgeries

List Any Significant Trauma. When Did It Occur? (Auto Accident, Falls, Emotional, Sexual, Etc.)

List Exercise/Sports Activities You Have Been Or Are Currently Involved In.

Please Mark Any That Apply

Date of Last Menstruation

Is Your Cycle Regular?

Is Your Cycle Painful?

Have You Ever Been Pregnant?

Do You Use Birth Control

Choose Any That Apply

PMS

Clotting

Vaginal sores

Vaginal pain

Discharge

Do You Have Allergies?

If You Have Allergies, What?

Do You Take Medication? If So What? How Often?

Do You Take Supplements? What? How Often?

Select Any Illness(es) That You Have Or Have Had

Do You Sleep Well?

Do You Dream?

Do You Have High Points During The Day?

When?

Do You Have Low Points During The Day?

When?

What Are Your Indulgences?

What Are Your Hobbies?

Tell Us On Your Body Where You Pain Or Problem Is?

Pain Intensity Level

No Pain

Moderate Pain

Sever Pain

Terrible Pain

Sleeping

No Problem

Mildly Disturbed

Greatly Disturbed

Cannot Sleep

Work - Can Do

Usual Work

25% of Work

50% of Work

No Work

Frequency of Pain

25 % of Time

50% of Time

75% of Time

100% of Time

Travel

No Problem

Moderate Pain

Severe Pain

Terrible Pain

Recreation - Can Do

No Problem

Moderate Pain

Severe Pain

Terrible Pain

Recreation - Can Do

All Activities

Some Activities

No Activities

Walking

Walk Any Distance

Pain After 1/2 Mile

Cannot Walk

Check Any That Apply

Sitting

No Pain Sitting

Some Pain Sitting

Cannot Sit

If you have dizziness, is it mild or severe?

How long does the dizziness last?

Is the onset sudden or gradual?

Describe other symptoms that come with dizziness?

Do you have difficulty falling asleep?

Do you have difficulty staying asleep?

How many hours of sleep do you get?

Do you feel rested upon waking?

Is your sleep disturbed by dreams/nightmares?

Are there any neuro/psychological issues to discuss?

Please provide details of any family members who have had any of the following conditions.

Diabetes

Seizures

Heart Disease

Stroke

Asthma

High Blood Pressure

Cancer

Allergies

High Cholesterol

Other

Patient Signature

Please sign and date at your next appointment.

Date

Clinic Signature

Date

I have read, understand and have been provided with a copy of Notice of Privacy Practices that provides a more complete description of information and disclosures practice of Acupuncture Medical. I understand that i have the following rights and privileges. The right to review the notice prior to signing this consent The right to object to the use of my health information for directory purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations DISCLAIMER: The Acupuncture Medical Notice of Privacy Practice is subject to change. If we change our notice, you may obtain a copy of the revised notice by requesting a hard copy from the Privacy Practice officer Leesa M. Lee. Privacy Officer Contact Information 2800 N. Grimes Hobbs, NM 88240 (575) 392-2712 By signing this form, I acknowledge receipt of the Notice of Privacy Practices of Acupuncture Medical Associates, LLC.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

Patient Signature

Date

Signature of Acupuncture Medical Representative

INABILITY TO OBTAIN ACKNOWLEDGEMENT: To be completed only if no signature is obtained. If it is not possible to obtain the individual's acknowledgement was not obtained: Patient unable to sign Patient unable to sign (inactive patient) Family/significant other not available Patient declines to sign Other

Date

Patient's Name

ACUPUNCTURE MEDICAL ASSOCIATES, LLC HEALTH CARE AUTHORIZATION FORM

Patient's Social Security Number

Date of Birth

Print Name of Signature

THE PATIENT IDENTIFIED ABOVE AUTHORIZES ACUPUNCTURE MEDICAL TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING: SPECIFIC AUTHORIZATION I give permission to Acupuncture Medical to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, information about treatment alternatives or other health related information. If Acupuncture Medical contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail. (OPEN ROOM AUTHORIZATION - OPTIONAL) I give Acupuncture Medical permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear at any time in private, the doctor will provide a room for these conversations. By signing this form you are giving Acupuncture Medical permission to use the disclose your protected health information in accordance with the directives listed. RIGHT TO REVOKE AUTHORIZATION You have the right to revoke the AUTHORIZATION, in writing at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Acupuncture Medical. The written notice must contain the following information. Name Social Security Number Date of Birth A clear statement of your intent to revoke this AUTHORIZATION The date of your request Your signature The revocation is not effective until it is received by the Privacy Official. The AUTHORIZATION is requested by Acupuncture Medical for its own use/disclosure of PHI. (Minimum necessary standards apply.) You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, Acupuncture Medical will not refuse to provide treatment. You have the right to inspect or copy the PHI to be used/disclosed. ******A COPY OF THIS SIGNED AUTHORIZATION WILL BE PROVIDED TO YOU UPON REQUEST***** Please sign your next appointment.

Signature of Patient

Signature of Personal Representative

Description of Representative's Authority for Patient

New Paitient Forms

Clinic Forms

Fill In Your Information Below Prior To Your First Visit.

Patient Intake Forms

LANCE LEE - ACUPUNCTURE MEDICAL ASSOCIATES

Hobbs, NM Location:

Phone:

Hours: