Confidential Case History

Patient Information & Reason for Visit

Page 1

Name *

Today's Date *

Address *

City *

State *

Zip *

Home Phone

Work or cell phone *

E mail *

Date of Birth *

Occupation

Referred by

Have you had acupuncture before?

Yes No

Have you had massage therapy before?

Yes No

In case of emergency contact (leave blank if none)

Phone

Reason for Visit

Present symptoms / Major concerns *

How long have you had this condition?

What was the initial cause?

What seems to make it better?

What seems to make it worse?

Has there been a medical diagnosis?

Yes No

When?

Name of the doctor who gave the diagnosis

Are you currently receiving treatment for this condition?

Yes No

If yes, please describe your treatment:

Medical History & Lifestyle

Page 2

Please list previous conditions for which you were treated

List any conditions for which you are currently being treated

Please list any medications you are taking

Please list any medical implants (pacemaker, joint replacements, etc.)

List previous surgeries

Describe any significant traumas (car accidents, falls, etc.)

List any allergies

(Note: we may use lubricants that contain peanut, soy or other nut, seed or vegetable oils, essential oils of plants such as lavender, pine, etc. or metal needles and pellets that contain silver, gold, other metals or silicon coating.)

Do you have, or have you ever had, any infectious disease?

Yes No

(Note: These include HIV/Aids, Hepatitis B or C, TB etc.)

General Symptoms

Page 3

Please check any symptoms you experience or have experienced:

Fatigue/tiredness Lack of strength Easy bruising Poor appetite Crave sweets Bloating after meals Loose stools Shortness of breath Spontaneous sweating Weakness of voice Weak cough Phlegm Heart palpitations Tightness in chest Poor memory Weak or sore low back or knees Incontinence Nervous tension Irritability Depression Symptoms worse with menstruation Blurred vision Night blindness Numbness of extremities Dry or pale skin Dry, brittle or pale nails Spider or varicose veins Fixed lumps in breast or abdomen Age spots Symptoms worse at night Purple lips or nails Menstrual clots Night sweats Heat in the chest, palms of hands or soles of feet Dry mouth or throat Red or flushed cheeks Darker yellow urine Aversion to cold Cold hands, feet or nose Clear, abundant urine Waking at night to urinate Decreased sexual desire Increased or rapid hunger Mouth or tongue sores Bleeding gums Insomnia Dizziness Constipation

If there is phlegm, what color is it?

Yellow, brown or green White

Distention, fullness, pressure or oppression in any areas. Where?

Where do you have pain (if any)?

What is the quality of the pain?

Dull Pressure/distention Fixed/stabbing/sharp Moves around from one area to another Heavy Burning

List any other symptoms or health concerns

Consent to Treatment & Notice of Privacy Practices

Pages 4 & 5

Consent to Treatment: By signing below, I voluntarily consent to be treated with acupuncture and/or massage by Michael Vahila, National Board Certified Acupuncturist and Licensed Massage Therapist. I understand that acupuncturists practicing in the state of Ohio are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this office.

Massage therapy: I understand that Massage therapy involves the manipulation of the body through manual techniques. I am aware that certain side effects may result. These include, but are not limited to: bruising, and the possible aggravation of symptoms.

Acupuncture: I understand that acupuncture is performed by the insertion of needles through the skin at certain points on the body to treat dysfunction or disease, to modify or prevent pain perception, and to normalize the body's physiological functions. I understand that acupuncture is a generally safe method of treatment but it may have some side effects. These include, but are not limited to: bruising, numbness or tingling near needling sites, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that there are no guarantees concerning its use and that I am free to stop acupuncture treatment at any time.

Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with acupuncture. I am aware that certain side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may choose not to have this treatment.

Notice of Privacy Practices: Your personal health information (PHI) will be used to provide you with treatment and for payment information. It will be disclosed to others only if you have given a written consent, if there is a threat to you or others, or it is required by law. You have a right to inspect your PHI. You may request an amendment to your PHI if there is an error or if it is incomplete. I acknowledge that I have received a copy of the Informed Consent and Notice of Privacy Practices.

I affirm that all information provided on this intake form is correct and assume any and all responsibility for incorrect or withheld information. I have read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask questions about the benefits and risks of treatment. I give my permission and consent to treatment. This permission is to cover the entire course of treatment for my present condition and any future conditions for which I seek treatment.

Patient Digital Signature *

I agree to the Consent to Treatment and Notice of Privacy Practices stated above. *

Total Health and Wellness Center

Patient Information & Reason for Visit

Reason for Visit

Medical History & Lifestyle

Lifestyle

General Symptoms

Consent to Treatment & Notice of Privacy Practices

Case History Submitted