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Katherine Kim Acupuncture Arts

212 Post Road West Westport CT 06880 * www.KatherineKimCT.com Today’s Date ____/_____/____ Time of Appt:________AM/PM Referred by ___________________________________

Full Name (Please print)___________________________________________________________ Birthdate ___________

Insurance company: ____________________ ID# _____________________________ Group # ___________________

Mailing Address_______________________________________________ City, Sate, Zip __________________________

Tel: !Home !Work: __________________________________ !Cell ! Text __________________________________

E-mail _______________________________________________ Age ______ Height _____ Weight ______ Gender_____

Employer ________________________________Occupation_____________________________

Emergency Contact: ___________________________________Tel#____________________ Relationship ____________

Medical diagnosis or main reasons for office visit today: ___________________________________________________

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Better with: !heat !cold !rest !movement !massage !worse in a.m. !p.m. Other: _________________________

Last Western medical check-up: __________ Traveled out of the U.S. w/in past year: !No !Yes: ___________________

Current meds Please list any over-the counter or prescription meds, herbs, vitamins you are taking and reason(s).

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List all years of hospitalizations or institutionalization (ie 1998 knee surgery, 2014 c-section, rehab 2000, etc.)

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Tried acupuncture before? !No If Yes, please check: !Individual !community # Sessions received: ____________

What other treatments have you tried:__________________________________________________________________

Please list Doctors, Wellness Practitioners & Therapists:

1) ______________________________________________________________________Town: _____________________

2) ______________________________________________________________________Town: _____________________

3) ______________________________________________________________________Town: _____________________

Medical History - Please check the following:

Pregnant? !Don’t know !Yes !No #Pregnancies_____ #Deliveries _____Trying to conceive? !Yes !No

Bruise/bleed easily? !Yes !No On blood thinning meds? !Yes !No !Arthritis !AIDS/HIV !Alcoholism !

Allergies: ____________________________ !Asthma !Cancer !Diabetes !Emphysema !Falls !Hepatitis A/B/C

!Heart Disease !Herpes !Lyme disease !Multiple Sclerosis !Pacemaker !Recreational Drug Use !Seizures

!Smoking !Tendonitis !Thyroid disease !Tuberculosis !Venereal disease ! Car accidents !Sports injury

!Work-related injury !Trauma/abuse/physical injuries ! Scars ! Tattoos ! Piercings ! Implanted medical device !

Cosmetic Surgery !12-Step Program !Sponsor ! Year of recent arrest: ________ !Incarceration: _______

What type of support appeals to you? !Emotional !Physical !Mind-Body !Family !Social !Spiritual !Other

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EYES: !painful !burning !red eyes !poor vision !seeing spots/floaters !night blindness !blurry !cataracts Other:______________________________________________________________________________________________ EARS: !ear pain !ear infections !hearing loss !trauma !ringing in ears (low droning or high pitch) Other:______________________________________________________________________________________________ NOSE: !nose bleeds !chronic runny nose !chronic stuffy nose !post-nasal drip !sinus problems Other:______________________________________________________________________________________________ MOUTH/TONGUE/THROAT: !sore throat !bleeding gums !sores on lips/tongue !gum problems !dental abscess !facial pain !TMJ !jaw pain !_______________________________________________________________ RESPIRATORY: !asthma/wheezing !inhaler !bronchitis !pneumonia !tuberculosis !shortness of breath !difficulty breathing lying down !excessive phlegm !frequent colds !_______________________________________ HEADACHES: Location ________________________________ How often? __________________________ When usually occur?____________How long HA last? ____________ Since when _____________ Does anyone in your family suffer from headaches? __________________________________________________________________________ Have you sought medical attention for the headaches before? Yes No When: ___________________________________ What makes the headache better? ________________________________________________________________________ Other:______________________________________________________________________________________________ CARDIOVASCULAR: Have you been diagnosed with any heart trouble? ______________________________________ !chest pressure or pain !shortness of breath !cold hands and feet !cold sweats !poor circulation !palpitations/arrhythmia !high blood pressure !low blood pressure !flushed face !stroke !slurred speech !fainting !dizziness/vertigo !varicose veins !blood clots !______________________________________________ Other:______________________________________________________________________________________________ SKIN HAIR NAILS: !dry skin !rashes !itching !acne !eczema !hives !ulcerations !fungal infections !psoriasis !dry hair !dandruff !hair loss !brittle nails ! _______________________________________________ Other:______________________________________________________________________________________________ SLEEP Usual bedtime _______ Wake up__________ Energy/experience waking up: ____________________________ Any issues: !falling asleep ! staying asleep !waking too early !vivid dreaming !nightmares !racing mind !Sleep apnea !Restless leg syndrome !Uncomfortable mattress/pillow !Pain upon waking !___________________ !Have a television or computer near your bed !Sleep with your cell phone/tablet/laptop !Feel safe/secure at home/bed Do you take: !sleeping pills or other meds to sleep !alcohol !recreational drugs !2 hrs+ online a day !eat late PM Other:______________________________________________________________________________________________ GI ISSUES: ! poor appetite !always hungry !diarrhea/loose stool !constipation !unfinished or painful BM !abdominal pain !distention/bloating !ulcer !nausea !vomiting !vomiting with blood !acid reflux !foul breath !sour taste !belching !gas !irritable bowel !blood in stool !hemorrhoids !itching BM (__________x/day) Other:______________________________________________________________________________________________

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NUTRITION & DAILY DIET Vegan/Vegetarian? How long?_____Food cravings? ______________________________ Food allergies/sensitivities?_____________________________________________________________________________ Breakfast ___________________________________________________________________________________________ Lunch _____________________________________________________________________________________________ Dinner _____________________________________________________________________________________________ Snacks _____________________________________________________________________________________________ Beverage prefer: !Hot !Cold !Soda _______ !Tea _______ !Water_______ !Alcohol _______ !Coffee _______ Dry mouth? Y N Thirsty, but no desire to drink? Y N Drinking habits: ______________________________________ !emotional eating !binge !purge !laxatives !other activity or cravings: ___________________________________ History of eating disorder: Y N Dates: ________________________________________________________________ Other:______________________________________________________________________________________________ EXERCISE: Y N How often? ______ Motivation level: + _____ ENERGY: +_______ When highest? _____ lowest? ______ Right now +______ EMOTIONS: Do you experience ! depression !anxiety !panic attacks !irritability/anger !cry easily !overly sensitive !poor memory !difficult concentration/focus !over-thinking, worrying!withdrawal/mania !obsessions/habits/compulsions: _______________________________________________________________________ Other:______________________________________________________________________________________________ Describe your emotions today: __________________________________________________________________________ Major event or situation in the past few years? _____________________________________________________________ ___________________________________________________________________________________________________

MEN: !prostatitis !impotence !premature ejaculation !seminal emission !reduced libido !genital pain ! sores !vasectomy !prostate cancer Other:____________________________________________________________________ WOMEN: Age at first menses _______ days cycles _____ flow duration _____ Color/quality of blood________________ !no period !abnormal period !irregular menstruation !pain before !pain during !heavy cycle !light cycle !clots !spotting between periods ! anemia !vaginal itching !vaginal burning !pain during sex !vaginal dryness !PMS !yeast infection !cysts !PCOS !vaginal discharge: frequency___________ color ____________ amount __________ !urinary infection !hemorrhoids !reduced libido !genital sores/lesions !STD: _______________________________ !breast lumps !breast surgery !breast infection !dense breasts !breast pain !breast discharge ! breast cancer !menopausal symptoms ! Age at menopause: ___________ !hot flashes !night sweats !_______________________ Birth control type ____________________________ Use: ___________________________________________________ Number of pregnancies ______ deliveries _____ abortions_____ miscarriages _____ Pregnancy complications ______________________________________________________________________________ ! Interested in trying to conceive? ! Planning to have a baby within the next _______ year(s). Other:______________________________________________________________________________________________ !fertility support info: ______________________________________________________________________________ Practitioners:________________________________________________________________________________________

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* Please color in current aches and pains. (Office use: Hwlng * Pain scale)

! FamHx ! Birth Hx !

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Katherine Kim Acupuncture Arts

212 Post Road West Westport CT 06880

OFFICE POLICIES & FINANCIAL AGREEMENT/ASSIGNMENT OF BENEFITS Our office provides exceptional therapeutic services and promotes open communication between practitioners and clients. These policies help us to create comfortable clinical experiences. Pls feel free to ask any questions. All office-related policies including weather updates are available 24/7 on www.KatherineKimCT.com I, (PRINT FULL NAME) ________________________________________________, am receiving or about to receive health care services at Realia World LLC DBA Katherine Kim Acupuncture Arts. FEES We accept cash, credit cards, and personal checks with valid ID. Please note there is a $25.00 charge for checks returned due to insufficient funds. Initial___________ INSURANCE COVERAGE We are happy to verify coverage and submit your claim form for reimbursement, provided you sign this financial agreement below. Please note: Sometimes insurance companies give us the wrong info and it takes our office one to two months to clarify details of your coverage. We ask all Patient’s to also confirm accurate insurance coverage within the first month or two of treatment. Patients remain responsible for any co-pays, non-covered fees associated with office visits, and balances, which are to be paid in full.

Initial___________ RELEASE OF INFORMATION Your insurance company may require medical reports to document your treatment and progress. Your initials below authorize the release of medical information necessary to process your claim. In addition I authorize insurance payment of medical benefits to Realia World LLC DBA Katherine Kim Acupuncture Arts.

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PHOTOGRAPHY/VIDEOGRAPHY Periodically, we take photographs or quick videos of patients who are deeply relaxed during treatments. These images may be used for educational and clinical purposes. Upon request, your images may be sent to you.

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CANCELLATIONS NOTICE As a courtesy to our office and other patients who may be waiting for any available appointment times, we ask that you please notify our office at least 48 hours in advance if you need to cancel or reschedule your appointment. We charge a FULL RATE FEE for any missed appointment or cancellation. We charge a $100 missed appointment fee giving less than 24 hours notice for any non-emergency situations.

Initial____________ LATENESS & MISSED APPOINTMENTS We ask clients who will be late to text us asap. Patients who arrive more than 15-20 mins may forfeit their appointment time. Although we do everything possible to help our clients reschedule, we do reserve the right to charge a “Missed Appointment” fee (full rate) if necessary.

Initial_____________ ARRIVALS We invite you to arrive 5 mins before your appointment time to relax, change clothes if necessary, etc. We request minimal makeup and perfume/cologne whenever possible. We look forward to partnering with you in health! Thank you. By initialing above and signing below, I agree to comply with the office policies stated above which I have read and understood. I also authorize the use of this signature on all insurance submissions. Signed_________________________________________________________________ Date_______________

Thank you for your time and information. Please bring this form to your acupuncture appointment.