Acupuncture Center of Minneapolis: Essential Acupuncture ...€¦ · Acupuncture Center of...

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Acupuncture Center of Minneapolis: Essential Acupuncture, Herbs, and Nutrition Matt Bierschbach, L.Ac and Laconia Koerner, L.Ac Name:_________________________________________ Date of Birth: __________________ Address: _______________________________________ City:_________________________ State: _____ Zip: _______________ Referred by:__________________________________ Cell: _______________________________ E-mail: __________________________________ Welcome to the Acupuncture Center of Minneapolis! Section 1: Healing Goals Please list your top five primary concerns for which you’d like support. They can be physical or emotional, general or specific. Please list in order of importance, along with approximately when it started, and what makes it better or worse (eg. neck pain since 5/2017, worse with cold, better with rest). 1. __________________________________________________________________ 2. __________________________________________________________________ 3. __________________________________________________________________ 4. __________________________________________________________________ 5. __________________________________________________________________ Section 2: Health History 1. Have you had any surgeries, injuries, or hospitalizations? If yes, when and why? __________________________________ ____________________________________ __________________________________ ____________________________________ __________________________________ ____________________________________ 2. Please list any medications, approximately when you started on the medicine, and what the medication is treating. You can also list supplements you have been taking in the past few months. __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________

Transcript of Acupuncture Center of Minneapolis: Essential Acupuncture ...€¦ · Acupuncture Center of...

Page 1: Acupuncture Center of Minneapolis: Essential Acupuncture ...€¦ · Acupuncture Center of Minneapolis Welcome to the Acupuncture Center of Minneapolis. This paper informs you of

Acupuncture Center of Minneapolis: Essential Acupuncture, Herbs, and Nutrition Matt Bierschbach, L.Ac and Laconia Koerner, L.Ac

Name:_________________________________________ Date of Birth: __________________

Address: _______________________________________ City:_________________________

State: _____ Zip: _______________ Referred by:__________________________________

Cell: _______________________________ E-mail: __________________________________

Welcome to the Acupuncture Center of Minneapolis!

Section 1: Healing Goals Please list your top five primary concerns for which you’d like support. They can be physical or emotional, general or specific. Please list in order of importance, along with approximately when it started, and what makes it better or worse (eg. neck pain since 5/2017, worse with cold, better with rest).

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________

4. __________________________________________________________________

5. __________________________________________________________________

Section 2: Health History 1. Have you had any surgeries, injuries, or hospitalizations? If yes, when and why?

__________________________________ ____________________________________

__________________________________ ____________________________________

__________________________________ ____________________________________

2. Please list any medications, approximately when you started on the medicine, and what the medication is treating. You can also list supplements you have been taking in the past few months.

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

__________________________________ __________________________________

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Section 3: Nutrition and Lifestyle1. Please indicate if you participate in the following activities, and how frequent:

exercise _____ times per week smoking_____ cigarettes per day

drinking soda ____ cans per week chewing gum ____ times per day

drinking coffee ____ cups per day alcohol ____ servings per week

2. Please describe a typical day of eating:

Breakfast: _____________________________________________________________

Lunch: ________________________________________________________________

Snacks: ________________________________________________________________

Dinner: ________________________________________________________________

Snacks / Desserts: ________________________________________________________

3. What are your 3 favorite activities in life? ___________________________________

________________________________________________________________________

4. Who or what are your top 3 priorities? ______________________________________

________________________________________________________________________

Page 3: Acupuncture Center of Minneapolis: Essential Acupuncture ...€¦ · Acupuncture Center of Minneapolis Welcome to the Acupuncture Center of Minneapolis. This paper informs you of

Page 4: Acupuncture Center of Minneapolis: Essential Acupuncture ...€¦ · Acupuncture Center of Minneapolis Welcome to the Acupuncture Center of Minneapolis. This paper informs you of

Acupuncture Center of Minneapolis Welcome to the Acupuncture Center of Minneapolis. This paper informs you of the practitioners’ credentials, the scope of practice for Traditional Chinese Medicine (TCM), and the potential side effects of treatment.

Matt Bierschbach and Laconia Koerner are graduates of the American College of Traditional Chinese Medicine and Northwestern Health Sciences University respectively, where they each received a Masters in Traditional Chinese Medicine after four years of study. Along with the formal education, they apprenticed with teachers outside of school and continue to deepen their education with advanced studies. They are nationally certified in acupuncture and herbology, and licensed to practice in Minnesota by the Minnesota Board of Medical Practice.

The treatment techniques for TCM include: acupuncture, herbs, tui na, cupping, gua sha, nutritional counseling, electrical stimulation, qi gong, and exercise therapy.

TCM therapies are very safe. Infrequent minor side effects may include temporary slight pain and minor bruising or bleeding, and a very small chance of infection. Relaxation and a general sense of wellness and balance are the most common side effects.

Our needles are single-use, sterile, and disposable. All of your medical and personal information is kept confidential in accordance with HIPPA regulations. Let us know if you need to see the full HIPPA documentation.

24 Hour Notice Policy Please provide notice at least 24 hours before your scheduled appointment if you need to make any changes. After this period, you are responsible for the full cost of the session. *Please initial to acknowledge the cancelation policy_______

Statement of Consent I have read and understand the practitioners’ credentials, the scope of practice, and potential side effects, and I consent to having acupuncture treatment.

Signature:____________________________________ Date:________________

Printed Name: ________________________________