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Microsoft word - healthy.body.acupuncture.consulation.form.2.doc

This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. If you have questions, please ask. Thank you. Name ______________________________________________ Date _____________ Social Security # ___________________ Home Address _____________________________________________________________________________________________ City _______________________________________________ State _______________________ Zip ____________________ Home Phone ___________________ E-mail _______________________________________ Work Phone _________________ Occupation ____________________________ Person Responsible for your account _____________________________________ Emergency Contact ________________________________________________________ Phone ___________________________ Who should we thank for referring you to this office? ______________________________________________________________ Sex: Male Female Trans ___MTF ___FTM Height _______ Weight ______ Birth date ____________ Age _____ Marital Status: Married Single Divorced Widowed Partnered Number of children _________ Have you received acupuncture therapy before? Yes No When? _______________________________ With whom? _______________________________________________________ Insurance Company __________________________________________________ Phone _______________________________ Address of Insurance Company ______________________________________________________________________________ Who is the primary insured? ________________________________________ Birth Date _______________________________ Identification # ____________________________ Policy # _______________________ Group # _______________________ Date Policy Begins ___________________ Total Yearly Deductible Individual $ ______________ Family $ ____________ Deductible Met to Date (Approx.) $ ____________________________________________________________________________ Insurance Company __________________________________________________ Phone _______________________________ Address of Insurance Company ______________________________________________________________________________ Who is the secondary insured? __________________________________________ Birth Date ___________________________ Identification # ____________________________ Policy # _______________________ Group # _______________________ Date Policy Begins ___________________ Total Yearly Deductible Individual $ ______________ Family $ ____________ Deductible Met to Date (Approx.) $ ____________________________________________________________________________ Name _____________________________________________________________ Phone _______________________________ Address of Primary Physician ________________________________________________________________________________ Assign and Release: I hereby authorize payment of medical benefits to Healthy Body Acupuncture for the services rendered to me during this and subsequent visits. I also authorize the release of any __________________________________________ information necessary to process medical claims Please indicate any significant illnesses you or a blood relative (grandparent, parent or sibling) have had: Illness Sexually Transmitted Diseases: Gonorrhea Syphilis HIV HPV Chlamydia Herpes Date _______ List any medications and supplements you are currently taking: (Continue on back if necessary.) Medicine Dosage Reason How long Prescribed by Date of last checkup _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Check the box if any of the following statements is true? I am taking lithium (Eskalith, Lithobid, Lithonate, Lithotabs) Please indicate the use and frequency of the following: Are you pregnant? Yes No # of pregnancies _________________ # of live births ______ # of Abortions ______ # of Miscarriages ____________ Date of last: Gynecologic exam _______________ Pap Smear _______________ Mammogram ______________ Bone Density Scan _________________________ Results _____________________________________________________________ ____________________________________________________________________ Average number of pads you use per day: 1st day _____ 2nd day _____ 3rd day _____ 4th day _____ + days _________ Have you ever been diagnosed with: Fibroids Fibrocystic breasts Endometriosis Ovarian Cysts PID Other _____ Location of Pain: Lower abdomen Lower back Thighs Other_________________________________________ Nature of Pain (please indicate before, during or after menses) Dull ____________________ Bloating _______________ Bearing down sensation ____________________________ Date of last prostate check up __________ PSA results _________________ Manual prostate exam results ________________ Lab results ________________________________________________________________________________________________ Frequency of Urination: daytime ________ nighttime ________ Color of urine: clear murky odor: ______________ Symptoms related to prostate Other ___________________________________ The following is a list of symptoms that you may or may not ever experience. Please indicate as follows: no mark () = never experience check mark ( ) = sometimes experience plus sign (+) = frequently experience __ lack of appetite __ digestive problems, indigestion __ headaches ———————————————— ———————————————— ———————————————— What are the main problems for which you are What other forms of treatment have you sought? ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any other health problems you now have. ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any allergies, food sensitivities or food craving that you have. ______________________________________ ______________________________________ ______________________________________ ______________________________________ List any accidents, surgeries or hospitalizations (include date) ______________________________________ ______________________________________ ______________________________________ ______________________________________ Lab Results (please include copies) ______________________________________ ______________________________________ ______________________________________ How do you FEEL about the following areas of your life? Please check the appropriate boxes and indicate any problems you may be experiencing. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________

Source: http://acupunctureservicesnyc.com/clients/7447/documents/Healthy.Body.Acupuncture.Consulation.Form.pdf

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The SAR Newsletter is published by Society for Acupuncture Research (http://www.acupunctureresearch.org/) Welcome to SAR's Summer 2011 newsletter. This issue provides you with selected information on recent and upcoming meetings and events, acupuncture in the news, highlights of new relevant research, and more. SAR Newsletter Committee SAR's newsletter will keep you up-to-date a

Microsoft word - b+a aktuell 23.01.rtf

“ Parkvillen am Kickerlingsberg“ Ehrensteinstraße 3 - 5 / Lumumbastraße 25 Ausstattungsbeschreibung 1. ANSCHLÜSSE: Die Versorgung mit Fernwärme, Wasser, elektrischen Strom, Telefon und Breitbandkabel erfolgt zentral über das öffentliche Netz und für jedes Haus separat. 2. ABWASSER: Die Schmutzwässer werden ebenso wie die Oberflächen- und Dachwässer mittels Sc

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