PATIENT INFORMATION FORM

Name: ____________________________________________________ Date: ______________ Address: _______________________________ City: ________________________ Zip: _________ Home Phone: ____________________ Cell Phone: ____________________ Work Phone: ____________________ Email: ________________________________ Which is the best method to contact you? Home Phone □ Cell Phone □ Work Phone □ Email □ SS#: ______-____-______ Age: ______ DOB: ____________ Drivers License #: _______________ Male □ Female □ Married □ Single □ Divorced □ Widowed □ Name of Spouse: __________________________ Occupation/Profession: ____________________________ Employer: ______________________ Emergency Contact: _________________________ Relation: _____________________ Emergency Contact Phone: ___________________________ Who may we thank for referring you? ______________________________________________ May we send you our email newsletter? (Your information will be kept confidential) Yes □ No □

PRIMARY INSURANCE Name of Insurance Co: _______________________ ID#: ____________________ Group#: ___________________ Name of Insured: ___________________________ Relationship to Patient: Self □ Spouse □ Parent □ Secondary Insurance: ______________________ Name of Insured: _______________________

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NAME_______________________________ DATE_________________________ I. Goals: What would you most like to achieve through your work with Traditional Chinese Medicine? 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ 4. _________________________________________________________________________________________________ 5. _________________________________________________________________________________________________ II. Major Symptoms: Please list in order of importance what symptoms are of concern to you. (most concerning to least, along with the duration of the symptom) 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ 4. _________________________________________________________________________________________________ Use the following illustration to indicate painful or distressed areas:

Are you experiencing pain/discomfort in any area of your body? Y / N If yes, using the models to the left, please indicate the location of the discomfort by using the symbol that best describes the feeling:

X X X Sharp/stabbing P P P Pins & Needles D D D Dull/Aching N N N Numbness

For Women: 1. Are you pregnant now? [ ]Yes [ ]No [ ]Unsure 2. Indicate number of occurrences: Live Births _______ Pregnancies_______ Miscarriages _______ Abortions _______ 3. Age: First period _____ Menopause (if applicable) _____ 4. Date: Last Pap Smear _____ /_____ Last Mammogram _____ / ______ 5. Any History of an Abnormal Pap Smear? [ ] Yes [ ] No If so, what / when? __________________________

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6. Is your menses cycle regular? [ ] Yes [ ] No a) Average number of days of flow ______ b) The flow is: [ ] Normal [ ] Heavy [ ] Light c) The color is: [ ] Normal [ ] Dark [ ] Purple [ ] Light Brown [ ] Brown 7. Do you have the following menstruation related signs/symptoms? [ ] Difficulty with Orgasm [ ] Cramps [ ] PMS [ ] Heavy Vaginal discharge

between periods [ ] Pain with Intercourse [ ] Nausea [ ] Bleeding between Periods

[ ] Blood Clots [ ] Breast Distention

[ ] Vaginal Discharge

For Men: 1. Do you have any bothersome urinary symptoms? [ ] Yes [ ] No Describe:__________________________________________________________________________________________ 2. Check all that apply: [ ] Erectile dysfunction

[ ] Difficulty with orgasm [ ] Pain or swelling of the testicles

[ ] Frequent need to urinate at night

[ ] Impotence/erectile dysfunction

[ ] Premature ejaculation [ ] Feeling of coldness or numbness in genitalia

[ ] Pain/Subtly of testicles

3. Do you get up at night to urinate? [ ] Yes [ ] No How often? ______________________________________________ 4. To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)? ____________________________________________________________________________________________________ 5. Have you sought Medical intervention for these problems? If so, when? __________________________________________ ____________________________________________________________________________________________________ 6. What treatments have you tried for these problems and how successful have they been? ____________________________________________________________________________________________________ III. Medical History Please check all that apply Date Diagnosed Date Diagnosed Diabetes ___ / ___ / ___ High Cholesterol ___ / ___ / ___ High Blood Pressure ___ / ___ / ___ High Blood Pressure ___ / ___ / ___ Thyroid Disease ___ / ___ / ___ Seizures ___ / ___ / ___ Cancer ___ / ___ / ___ Hepatitis ___ / ___ / ___ HIV ___ / ___ / ___ Others ___ / ___ / ___ IV. Surgical History ____________________________________________________________________________ Date _______________ ____________________________________________________________________________ Date _______________ ____________________________________________________________________________ Date _______________ Do you have any type of cosmetic implants? Yes ____ No ____Do you have a pacemaker? Yes ____ No ____

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V. Family History Please check all that apply and state how you are related to the family member with that condition.

Condition Mother Father Sibling Maternal Grandparent

Paternal Grandparent

Heart disease Cancer Hypertension Stroke Asthma Allergies Migraines Depression Other mental illness Substance abuse Osteoporosis Diabetes Glaucoma VI. Medications / Supplements Medications you are currently taking (please include prescription medicine, supplement, herbal supplements and over the counter medicines you take on a regular basis, along with dosages and brands if known) ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________

Allergies (to medications, chemicals or foods): ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ ________________________________ _______________________________ ______________________________ VIII. Nutrition 1. Do you follow a special diet? [ ] Yes [ ] No If yes, how would you describe the diet? (ie Vegetarian, Vegan, Low Carb, etc.) ___________________________________________________________________________________________________ 2. What do you eat on a “typical” day? ____________________________________________________________________ a) Breakfast _________________________________________________________________________________________ b) Lunch __________________________________________________________________________________________ c) Dinner _________________________________________________________________________________________ d) Snacks __________________________________________________________________________________________ e) Foods you tend to crave: ____________________________________________________________________________ f) Foods you dislike: _________________________________________________________________________________

Do you take Coumadin/Warfarin? Yes ____ No ____

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IX. Social History 1. How much per day do you use of the following? a) Coffee, tea, soft drinks: ________________________________________________________________________________ b) Alcohol: ___________________________________________________________________________________________ c) Cigarettes, cigars, other tobacco: _________________________________________________________________________ d) Other drugs: ________________________________________________________________________________________ 2. Have you ever had a problem with alcohol or alcoholism? [ ] Yes [ ] No 3. Have you ever had a problem with dependency on other drugs? [ ] Yes [ ] No 4. If yes which and when? ____________________________________________________________________________________________________ 5. Do you have a known history of any exposure to toxic substances? [ ] Yes [ ] No 6. If so, please list which and when you first noticed symptoms? ________________________________________________________________________________________________________________________________________________________________________________________________________ 7. In the past year, how many days have been significantly affected by your health? ______________ 8. How many days did you feel generally poor? ________ 9. How many times were you in the hospital? _________ 10. Please describe your current exercise regimen: Hours per week: ______ Activities: _______________________________________ [ ] No Exercise 11. How many hours of sleep do you usually get per night during the week? _____________ 12. Do you awake feeling rested? [ ] Yes [ ] No Do you feel you sleep well at night? [ ] Yes [ ] No 13. Who would you describe as your source of primary social support? (relationship to you) X. Other Information Please list and briefly describe the most significant events in your life: 1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ 4. _________________________________________________________________________________________________ Have you been treated for emotional issues? [ ] Yes [ ] No Have you ever considered or attempted suicide? [ ] Yes [ ] No Do you have any other neurological or psychological problem? [ ] Yes [ ] No Please provide us with any other information that you think is relevant for us to know: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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HEALTH: CHECK ALL THAT APPLY GENERAL CARDIOVASCULAR FEMALE Past Current Condition Past Current Condition Past Current Condition[ ] [ ] Poor appetite [ ] [ ] High blood pressure [ ] [ ] Frequent urinary tract infections [ ] [ ] Excessive appetite [ ] [ ] Low blood pressure [ ] [ ] Frequent vaginal infections [ ] [ ] Insomnia [ ] [ ] Blood clots [ ] [ ] Pain / itching of genitalia [ ] [ ] Fatigue [ ] [ ] Palpitations [ ] [ ] Genital lesions / discharge [ ] [ ] Fevers [ ] [ ] Phlebitis [ ] [ ] Pelvic inflammatory disease [ ] [ ] Night sweats [ ] [ ] Chest pain [ ] [ ] Abnormal pap smear [ ] [ ] Sweat easily [ ] [ ] Irregular heart beat [ ] [ ] Irregular menstrual periods [ ] [ ] Chills [ ] [ ] Cold hands / feet [ ] [ ] Painful menstrual periods [ ] [ ] Localized weakness [ ] [ ] Fainting [ ] [ ] Premenstrual syndrome [ ] [ ] Poor coordination [ ] [ ] Difficult breathing [ ] [ ] Abnormal bleeding [ ] [ ] Bleed or bruise easily [ ] [ ] Swelling of hands / feet [ ] [ ] Menopausal syndrome [ ] [ ] Catch cold easily [ ] [ ] Other: _____________ [ ] [ ] Breast lumps [ ] [ ] Change in appetite [ ] [ ] Hot flashes [ ] [ ] Strong thirst RESPIRATORY [ ] [ ] Menopausal syndrome [ ] [ ] Other: _______________ Past Current Condition [ ] [ ] Other: _____________

[ ] [ ] Asthma SKIN & HAIR [ ] [ ] Bronchitis NEUROLOGICAL Past Current Condition [ ] [ ] Frequent colds Past Current Condition[ ] [ ] Rashes [ ] [ ] Chronic obstructive [ ] [ ] Seizures [ ] [ ] Hives [ ] [ ] Pulmonary disease [ ] [ ] Tremors [ ] [ ] Itching [ ] [ ] Pneumonia [ ] [ ] Numbness/tingling of limbs [ ] [ ] Eczema [ ] [ ] Cough [ ] [ ] Concussion [ ] [ ] Pimples [ ] [ ] Coughing blood [ ] [ ] Pain [ ] [ ] Dryness [ ] [ ] Production of phlegm [ ] [ ] Paralysis [ ] [ ] Tumors, lumps [ ] [ ] Other: ______________ [ ] [ ] Other: __________________

HECK & NECK GASTRO-INTESTINAL PSYCHOLOGICAL Past Current Condition Past Current Condition Past Current Condition[ ] [ ] Dizziness [ ] [ ] Nausea [ ] [ ] Depression [ ] [ ] Fainting [ ] [ ] Vomiting [ ] [ ] Anxiety / stress [ ] [ ] Neck stiffness [ ] [ ] Diarrhea [ ] [ ] Irritability [ ] [ ] Enlarged lymph glands [ ] [ ] Belching [ ] [ ] Treated for emotional or [ ] [ ] Headaches [ ] [ ] Blood in stools/black [ ] [ ] Psychological problems [ ] [ ] Concussions [ ] [ ] Stools [ ] [ ] Other: __________________ [ ] [ ] Other: _______________ [ ] [ ] Bad breath

[ ] [ ] Rectal pain INFECTION SCREENING EARS [ ] [ ] Hemorrhoids Past Current ConditionPast Current Condition [ ] [ ] Constipation [ ] [ ] HIV [ ] [ ] Infection [ ] [ ] Pain or cramps [ ] [ ] TB [ ] [ ] Ringing [ ] [ ] Indigestion [ ] [ ] Hepatitis [ ] [ ] Decreased hearing [ ] [ ] Gall bladder disorder [ ] [ ] Gonorrhea [ ] [ ] Other: _______________ [ ] [ ] Gas [ ] [ ] Chlamydia

[ ] [ ] Other: ______________ [ ] [ ] Syphilis EYES [ ] [ ] Genital warts Past Current Condition GENITO-URINARY [ ] [ ] Herpes: oral [ ] [ ] Blurred vision Past Current Condition [ ] [ ] Herpes: genital [ ] [ ] Visual changes [ ] [ ] Kidney stones [ ] [ ] Poor night vision [ ] [ ] Pain or urination MUSCULAR-SKELETAL [ ] [ ] Spots [ ] [ ] Frequent urination Past Current Condition[ ] [ ] Cataracts [ ] [ ] Blood in urine [ ] [ ] Stiff neck / shoulders [ ] [ ] Glasses / contacts [ ] [ ] Urgency to urinate [ ] [ ] Low back pain [ ] [ ] Eye inflammation [ ] [ ] Unable to hold urine [ ] [ ] Back pain [ ] [ ] Other: _______________ [ ] [ ] Other: ______________ [ ] [ ] Muscle spasm, twitching, cramps

[ ] [ ] Sore, cold or weak knees NOSE, THROAT, MOUTH MALE [ ] [ ] Joint pain Past Current Condition Past Current Condition [ ] [ ] Nose bleeds [ ] [ ] Pain / itching genitalia [ ] [ ] Sinus infections [ ] [ ] Genital lesions/ discharge [ ] [ ] Hay fever or allergies [ ] [ ] Impotence [ ] [ ] Recurring sore throats [ ] [ ] Weak urinary stream [ ] [ ] Grinding teeth [ ] [ ] Lumps in testicles [ ] [ ] Difficulty swallowing [ ] [ ] Other: ______________

Jennifer Rose Acupuncture ~ Office Policies

Welcome to the Acupuncture office of Jennifer Rose, LAc. We want you to be comfortable and to receive the best care possible. Please do not hesitate to ask any questions you might have regarding your visit, your billing, or our policies.

If you do not have health insurance coverage: Payment is due in full at the time services are rendered unless other arrangements have been made.

Insurance Coverage: Many insurance policies cover Acupuncture, but we do not claim that yours does. Policies can differ greatly in terms of deductible and percentage of coverage for Acupuncture. We can verify coverage and submit your claim form for reimbursement, provided you sign financial agreement below.

Payment: We accept cash, credit cards, and personal checks. Please note there is a $25.00 charge for checks returned due to insufficient funds.

Release of Information: Your insurance company may require medical reports to document our treatment and progress. Your signature below authorizes the release of medical information necessary to process your claim.

Cancellations: As a courtesy to our office and other patients, we ask that you please notify the office at least 24 hours in advance if you need to cancel or reschedule your appointment. If you miss or cancel an appointment without giving at least 24 hours notice, you will be charged the full cost of the scheduled appointment. The fee will be collected on the same day of the missed appointment and charged to the credit card we have on file. *Insurance cannot be billed and does not reimburse missed appointments.

I, ___________________________ authorize Jennifer Rose, LAc to charge the credit card given below, for cancellation fees, co-payments, and related charges._______-_______-_______-_______ Exp _______ Code ______ Visa □ M/C □ Amex □ Discover □

FINANCIAL AGREEMENT/ASSIGNMENT OF BENEFITSI, (print full name) ____________________________________________, am receiving or about to receive health care services in this office. I understand that I am responsible to pay all non-insurance related fees when services are rendered, including herbs. If I choose to use my insurance I understand that this is a quotation of benefits and not a guarantee of payment. I will be responsible for all “non covered” services and/or co-insurance associated with my office visit. I authorize the release of medical information necessary to process my claim. In addition, I authorize insurance payment of medical benefits to Jennifer Rose, LAc. .

By 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.

________________________________________________________________________Patient Name (print) Patient Signature Date(Or Legal Guardian - Indicate relationship if signing for patient)________________________________

Jennifer Rose Acupuncture~Notice of Privacy Policies

Our office is dedicated to providing service with respect for our patients. Protecting your privacy and healthcare information is fundamental in the course of our relationship. 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 from you. • Information we receive from healthcare providers. • 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 your 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.

Marketing - This office will not use your health information for marketing communications without your written authorization. However, this office may send birthday cards, newsletters, and appointment reminders by calls, cards, letters, or emails.

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

Patient Rights 1. Upon written request you have the right to access, review, or receive copies of your healthcare records. 2. Upon written request you have the right to receive a list of items this office disclosed about your healthcare information. 3. Upon written request you have the right to request that this office place additional restrictions on the disclosure of your Protected Health Information. 4. Upon written request you have the right to request that we amend your Protected Health Information. 5. You have the right to receive all notices in writing.

If you have questions, complaints or want more information, please contact the office directly.

Patients have the right to complain if they feel that their privacy rights were violated or if they disagree with a decision we made about access to their health information or our response to a request made to amend or restrict the use or disclosure of their health information.

Send a written complaint to the U.S. Department of Health and Human Services. Contact: DHHS (Office of Civil Rights), 200 Independence Ave S.W., Room 509F HHH Building, Washington, DC 20201.

I ________________________________ (print) have read, reviewed, understand and agree to the statement of Privacy Policy for healthcare services in this clinic.

Client Signature ______________________________________ Date____________

(Or Legal Guardian - Indicate relationship if signing for patient) _______________________________