Traditional Chinese Medicine is based on the principle of balancing an individual's body, mind, emotions, and spirit. The following confidential questionnaire is a detailed and invaluable source of information about you. It provides the practitioner with a complete sense of you as a unique individual as opposed to a collection of symptioms.
24 Hour Notice is required for cancellation to avoid a $25 service fee. Payment is due at time of service. Patient Information
Date of Birth
Emergency Contact Information
Physicians Phone #
Present Health Concers
Please list you most important health concerns in order of their significance
Approx. Date of Onset
Approx. Date of Onset
Approx. Date of Onset
Please list all medications that you are currently taking (or have used in the past two months), with dosages:
Please list any vitamins, minerals, herbs, or homeopathic remedies that you are presently taking
Please list allergies that you have to any drugs
Please list allergies that you have to any foods
Other (i.e. pollen, paint, etc.)
Please list past injuries, broken bones, surgeries and hospitalizations, with approximate dates
Tobacco - packs/day
Alcohol - drinks/wk
Coffee/Tea/Cola - cups/day
Recreational drugs - times/wk
High Stress Level - Reason
If Yes, describe
Sitting - % of time
Standing - % of time
Light labor - % of time
Heavy labor - % of time
If Yes, describe & tell how often
If Yes, how many?
Other hair or skin concerns:
Head, Eyes, Ears, Nose, and Throat
Headaches (location, triggers, severity)?
Excessive phlegm - color?
Other head & neck concers
Other heart or blood vessel concerns
Production of phlegm - color?
Other lung related concerns
History of chronic laxative use?
Other concerns with your general digestion
If you wake to urinate, how often?
Other concerns with genitals or urinary system
Joint with limited range of motion
Other muscle, joint or bone concerns
Have you ever been treated for emotional problems?
Have you ever considered or attempted suicide?
Other neurological or psychological concerns
Age of first menses
If no longer menstruating, approximate date ceased
First day of last menses
Length between menses (days)
Duration of period (days)
Vaginal discharge - color?
Changes in body or psyche prior to menstruation (PMS")
Date of last PAP
If you use birth control, what type & for how long?
Have you ever used hormonal methods for contraception or period regulation? (i.e. the pit, Depo-Provera, etc.)
Other gynecological concerns
Number of pregnancies
Number of Births
Number of Miscarriages
Number of Abortions
Were your births relatively normal? Explain
Other related concerns
Please let us know of any other concerns you would like to address
Please select for each condition that applies to one of your family members.
Our Clinic Protects Your Health Information and Privacy
This notice describes our office's policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at our facility. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our facility, whether made by facility personnel, or your personal doctor.
We may use and/or disclose medical information about you:
To doctors, nurses, technicians, medical students, or other acupuncturist who are involved at taking care of you at our facility
So that the treatment and services you receive at our facility may be billed to, and payment may be collected from you, an insurance company or third party
Types of information that we gather and use:
In administering your health care, we gather and maintain information that may include non-public personal information.
About your financial transaction with as (billing transactions)
From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.
From health care providers, insurance companies, workers comp, and your employer, and other third part administrators (ex. Requests for medical records, claim payment information)
In certain states, you may be able to access and correct personal information we have collected about you (information that can identify you-ex. your name, address, social security number, etc)
We at Ebb and Flow acupuncture respect your right to privacy. If you have questions about our privacy guidelines, please call us during regular business hours at 802-9027.
By signing below, I confirm that I consent and understand the HIPPA policy.