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Initial patient intake form

Persimmon Health Center of Eastern Medicine Thank you for coming here for treatment. The questions below have been chosen carefully to help make a complete holistic evaluation. Please take the time to answer as completely as possible. Preferred way of contacting you or leaving messages: Current medical treatment and western medical diagnosis: Current Medications and dosages, including prescribed and over the counter: Current vitamins, herbs, and other supplements: Significant illnesses (please check all that apply):
Persimmon Health Center of Eastern Medicine Please check if any of the following are true:
□ I have a pacemaker
□ I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Please list any surgeries you’ve had, including dates: Please list any significant physical or emotional trauma (car accidents, sports injuries, death of family Please list any allergies or food sensitivities: Family Medical History (please specify family member):
Lifestyle (please check all that apply and note frequency of use):
□ Recreational Drugs □ Caffeinated beverages Please list types of exercise/physical activity and frequency: Please list your dietary preferences and frequency of meals and snacks: Persimmon Health Center of Eastern Medicine Please check all that apply:
Respiratory
Gastrointestinal
Concussion
Hair loss
Heart and Thorax
Urogenital
Circulation
Persimmon Health Center of Eastern Medicine Neuropsychological
Musculoskeletal
Anxiety
Social Anxiety
Other
Tics/Tremors
Other

Please rate how you feel about the following areas of your life (1=bad; 10=great):

Persimmon Health Center of Eastern Medicine Women only
Age of first period:
Please list any symptoms related to your period (pains, cravings, emotions, etc): Men only
Date of last prostate check-up:
Persimmon Health Center of Eastern Medicine Notice of Privacy Practices for HIPAA Regulations
This note describes general office practices regarding confidentiality of your medical information.
Office Practices:
All information regarding patients, their treatments, diagnosis, and appointments is kept strictly confidential within the confines of the practitioner. Patient charts and financial data will be seen only by the practitioner. There is no electronic transfer of your medical data from this office. For treatment purposes, information will be provided to another practitioner only after your written consent Discussion of treatment is confined to the consultation room or treatment room, not in the presence of other
Communication:
I routinely communicate with patients over the phone to schedule and confirm appointments. While the name “Persimmon Health Center of Eastern Medicine-Yonie Young” is given in the messages, no reference If you have a preferred number that I can reach you, please provide that phone number below. By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how medical information may be used and disclosed in this office and have been informed on how I can gain access to and control this medical information. Signature of Patient or Personal Representative Print name of Patient or Personal Representative Persimmon Health Center of Eastern Medicine Financial Agreement
Assignment of Benefits for Insurance
I authorize payment of benefits be made directly to Persimmon Health Center of Eastern Medicine and I understand I am responsible for charges not covered by this assignment. I also authorize the release of any information requested to process this claim.
Cancellation Policy
Please be respectful of the time set aside for your treatment. If you need to change or cancel an appointment,
be sure to make up the missed appointment within a week so that the effects from the treatment will not be All scheduled appointment require a 24 hour cancellation notice or the patient will be charged for a full office
Returned Check Policy
All returned checks will be subject to an additional charge of $25.

By signing this agreement, I am acknowledging that I have read the above financial policies
and will be responsible for all charges stated above.
Signature of Patient or Personal Representative Print name of Patient or Personal Representative Persimmon Health Center of Eastern Medicine Patient Advisory to Consult a Physician and Informed Consent
Patient Advisory to Consult a Physician:
While Eastern medicine has a great deal to offer as a health care system, it cannot replace the resources available through traditional Western Medical practices. Consequently, we recommend that you consult a physician regarding condition (s) for which you are seeking acupuncture and Eastern medicine.
Informed Consent to Acupuncture Treatment:

I understand that methods of treatment may include but are not limited to: acupuncture, acupressure, therapeutic massage, bioelectrical stimulation, moxibustion, cupping therapy, and reiki. Acupuncture is a safe method of treatment with a history of over 2, 500 years. However, acupuncture may have side effects such as dizziness, fainting, bruising, numbness or tingling near the needling sites that may last a few days on rare occasions. Slight bruising is a possible side effect of acupuncture and cupping therapy. Mild burns and/or scarring are a possible risk of moxibustion. Highly unusual risks of acupuncture may include infections, spontaneous miscarriage, minor nerve damage, and organ puncture. We comply with strict protocols for needle usage and associated healing modalities. I understand while this document describes the possible risks of treatments,
Informed Consent to Herbal Medicine:
Eastern Medicine uses and recommends herbs and nutritional supplements from plant, animal, and mineral sources which are traditionally considered safe in oriental medicinal practices. However, taking large doses may be toxic. Herbs may have an unpleasant smell or taste. Possible side effects from taking herbs are nausea, stomachache, vomiting, diarrhea, rashes, hives, and tingling of the tongue. Some herbs may be inappropriate during pregnancy. I will notify my treating acupuncturist if I am pregnant or suspect that I am pregnant before each treatment begins. I understand that the recommended herbs need to be prepared and consumed according to the instructions provided orally and in writing by the attending acupuncturist. I will immediately notify my acupuncturist of any unanticipated or unpleasant effects associated with the consumption of the herbal recommendations.
I understand that it is my responsibility to inform my treating acupuncturist if I become pregnant or suspect that I
am pregnant before each treatment begins.

I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of

treatment. I wish to rely of the acupuncturist to exercise judgment in my best interest during the course of
treatments which are determined based upon the facts clearly presented to the treating acupuncturist prior to
treatment. All of my records will be kept confidential and will not be released to any party without my written
consent.

By voluntarily signing below, I show that I have read, or have had read to me, the entire contents of this Patient

Advisory to Consult a Physician and Informed Consent Form. I understand the risks and benefits of acupuncture
and other associated procedures. I have had an opportunity to ask questions. I intend this consent form to cover
the entire course of treatment for my present conditions and for any future conditions for which I seek treatment at
Persimmon Health Center of Eastern Medicine.
Signature of Patient or Personal Representative Print name of Patient or Personal Representative

Source: http://persimmonhealth.com/IntakeForm.pdf

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