Patient Form "*" indicates required fields Patient InformationName* First Last Email* Date of Birth* MM slash DD slash YYYY Phone: Mobile*Phone: HomePhone: WorkCan we call you at work?* Yes No Sex:* Male Female Marital Status:* Single Married Divorced Widowed Seperated Minor Race:* Caucasian African American Asian Native American Latin American Other Ethnicity* Hispanic Latino Non-Hispanic / Non-Latino Occupation:Employer:Patient Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about our practice?*Emergency contact Name* First Last Relationship to the Patient:Relation Phone numberAccident InformationIs this visit due to an accident?* Yes No What type?* Auto Work Other Has it been reported?* Yes No To whom?* Auto Work Other Insurance InformationPolicy Holder Name* First Last Date of Birth: Policy Holder* MM slash DD slash YYYY Relationship to the Patient:Relation Phone numberDo you have health insurance? Yes No Name of Carrier:Do you have secondary insurance? Yes No Name of Carrier:PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)Assignment and Release (insured patients)I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.SIGNATURE (X)Date MM slash DD slash YYYY Patient NameDate of Birth MM slash DD slash YYYY Social Security NumberMember ID NumberGroup NumberCustomer Service/Provider Number located on back of cardHealth HistoryWho is your primary care physician? (doctor and/or practice)Please check to indicate if you are currently experiencing any of the following conditions: Neck Pain/Stiffness Pins/Needles in Arms Light Bothers Eyes Sudden Weight Loss Nausea Back Pain/Stiffness Pins/Needles in Legs Depression Loss of Taste Cold Feet Arm/Hand Pain Fatigue Nervousness Loss of Memory Chest Pain Leg/Knee Pain Sleeping Difficulties Tension Jaw Problems Fever Headaches Loss of Smell Cold Sweats Constipation Fainting Dizziness Allergies Stomach Problems Shortness of Breath Asthma Blurred Vision Night Pain Bowel/Bladder Changes Please check to indicate if you have ever had any of the following: Aids/HIV Cancer Hepatitis Osteoporosis Stroke Alcoholism Cataracts Hernia Pacemaker Suicide Attempt Allergy Shots Chemical Dependency Herniated Disc Parkinson’s Disease Thyroid Problems Anemia Chicken Pox Herpes Pinched Nerve Tonsillitis Anorexia Diabetes High Cholesterol Pneumonia Tuberculosis Appendicitis Emphysema Kidney Disease Polio Tumors/Growths Arthritis Epilepsy Liver Disease Prostate Problems Typhoid Fever Asthma Fractures Measles Prosthesis Ulcers Bleeding Disorders Glaucoma Migraines Psychiatric Care Vaginal Infections Breast Lump Goiter Miscarriage Rheumatoid Arthritis Venereal Disease Bronchitis Gonorrhea Mononucleosis Rheumatic Fever Whooping Cough Bulimia Gout Multiple Sclerosis Scarlet Fever Heart Disease Mumps Other Please specifyAre you currently under drug and/or medical care? Yes No If yes, explainPlease list any medications you are currently taking (Be sure to include dosage and frequency)Please list any surgeries and/or hospitalizations you have had (type & date):Please list any allergies:Please list any supplements you are currently taking (vitamins/herbs/minerals):Is there a family history of any of the following conditions? (Indicate family member including parents, grandparents & siblings) Heart Disease Diabetes Cancer Arthritis Other Do you exercise: Never Daily Weekly Walks Runs Swims Do your work activities mostly involve: Sitting Standing Light Labor Heavy Labor What is your daily/weekly intake of the following:CaffeineAlcoholCigarettesI certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health.SIGNATURE (X)Date MM slash DD slash YYYY Informed Consent to CareNatural Life Acupuncture and Kinesiology A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare case, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. This office does not perform breast, pelvic, prostate, rectal, or full skin evaluations. These examinations should be performed by your family physician, GYN, and dermatologist to exclude cancers, abnormal skin lesions that should undergo biopsy/removal or other treatments.. We also do not prescribe or refill ANY controlled substances. All prescriptions should be refilled by your original prescriber and any new prescriptions should be issued by your primary care provider. The patient assumes all responsibility/liability if the patient does not report on health forms any past medical history, illnesses, medicines, or allergies. I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. Acupuncture care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with acupuncture care. The types of complications that have been reported secondary to acupuncture care include bruising, bleeding, tingling, strong sensation at location of needle insertion. One of the rarest complications associated with acupuncture care is lung or organ puncture. I wish to rely on the doctors judgement based on the facts known at this time. Prior to receiving acupuncture care in this office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your whole body health. These procedures will assist us in determining if acupuncture care is needed, or if any further examinations or studies needed. In addition, they will help us determine if there is any reason to modify your care to provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan. This notice is effective as of the date it is signed and will expire seven years after the date on which you last received servies from us. Patient SignACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESPatient NameDate MM slash DD slash YYYY I acknowledge that I have reviewed the Notice of Privacy Practices of Natural Life Acupuncture and Kinesiology. (Please initial one of the following options and sign below.) I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office. Please initial below: I acknowledge that it is the policy of this office to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing. I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the staff about my concerns. Signature of Patient/GuardianDate MM slash DD slash YYYY Witness (Office Staff)Date MM slash DD slash YYYY CONSULTATION HISTORY:”What symptoms are you suffering with?How long have you had it?What does it feel like?Is there an earlier accident/ injury/ repetitive motion that is related to these problems? (i.e. Fall, auto injury, work injury, sports injury, repetitive motion on the job).Since the time you began suffering with this problem, what have you tried? .(i.e. Ice, Heat, Rest, Over the Counter Meds, Prescriptions, P.T., Chiro. other)What activities do you have trouble doing because of these symptoms?Looking forward a few years from now, what are those things you wish to be doing more of? (i.e. travel, relationship, work, physical…)On a scale of 1-10, ten being the highest, rate your commitment to getting rid of the problem.Is there anything preventing you from getting this problem taken care of?Notes:CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
