Treatment Information
Pre-Treatment Considerations: Please eat an adequate amount of food before your treatment. You should not receive acupuncture with an empty or overly full stomach.
Post-Treatment Care: If you receive treatments for pain, avoid aggravation of the painful area between treatments. It is recommended to “baby” that area and avoid strenuous or aggravating activity as much as possible in order to receive maximum benefits. Following your treatment, your body makes adjustments for up to 36 hours. There is a 10% chance that you may experience an aggravation of the condition that you are being treated for. There is no cause for concern, as this is a healing response to the effective and unique treatment employed. The pain/discomfort and usually subsides within 36 to 48 hours. Typically, the pain will then subside to a lower level than before the treatment.
Treatment Progression and Recovery: Acupuncture treatments stimulate your body’s own healing capacity. Therefore, the progress of your healing will follow a natural course. As this occurs, you are likely to experience a reoccurrence of the pain/condition in between your treatments to some degree. The degree of pain, if not aggravated, progressively decreases over a series of treatments. Finally, the pain will decrease to the level where the condition has recovered. The individual time for recovery will be different from patient to patient.
Informed Consent
I hereby request and consent to the performance of acupuncture treatments and other modalities within the scope of practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Eileen Yue-Ling Han LAc. Or other licensed acupuncturists who now or in the future treat me while serving as hers substitute.
I understand that methods of treatment may include acupuncture with sterile and disposable needles, Tui-Na massage, cupping, Chinese herbal medicine and nutritional counseling. I understand that acupuncture is a safe method of treatment, but side effects may include bruising or tingling near the needling sites, dizziness or fainting. Extremely rare risks include nerve damage, organ puncture and spontaneous miscarriage.
The herbs prescribed are considered safe in the practice of Oriental medicine. I understand that the herbs prescribed and given by the acupuncturist must be taken according to the practitioner’s instruction only. I agree to inform the acupuncturist about any other herbs, medications or supplements that I am taking currently or during future courses of treatments. The herbs prescribed may have a strong medicinal taste. Occasional side effects may include digestive upset or allergic reactions. If any discomfort is noticed while taking the prescribed herbs, I understand to discontinue use and notify the office immediately. I understand that some herbs may be inappropriate during pregnancy. I agree to inform the acupuncturist if I am or become pregnant.
I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist considers at the time, based upon the facts then known, is in my best interest.
I understand the clinical and administrative staff may review my medical records and lab reports, but all my records will be kept confidential and will not be released without my written consent.
I have read, or have had read to me, the above “treatment information” and “informed consent.” I have also had an opportunity to ask questions about the content, and by signing below I agree to the above-named procedures. I intend this consent from to cover the entire course of treatment for my present condition and for any future condition(s) for which I Seek treatment.
Patient Signature: _______________________________________ Date:_________________________
(or patient representative)
Eileen Yue-Ling Han L.Ac.
Financial Policy
Thank you for choosing our acupuncture office as you health care provider. The following is a statement of our Financial Policy, which we require that you read, and sign prior to treatment. We are happy to provide you with a copy for your records.
FULL PAYMENT IS EXPECTED AT THE TIME OF SERVICE UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN WRITING PRIOR TO TREATMENT. We accept cash, checks and major credit cards. All returned checks will incur a $25.00 (twenty-five) dollar fee, which will automatically be charged to your account.
INSURANCE
As a courtesy, we will accept an assignment of insurance benefits. This means that we will be responsible for billing your insurance and providing any additional information that may be requested. The patient portion (co-pay) of the bill is due at the time of service. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you, your employer and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be deemed “non-covered” services (not considered reasonable and necessary under the insurance program). It is your responsibility to familiarize yourself the terms and conditions of your policy (such as how many treatments per year, what will be the reimbursement, and the co-pay) as we cannot be responsible for knowing the terms of each patients’ coverage. We will assist you in every way possible to obtain the maximum benefit from your plan. If you have questions about your coverage, please contact your employers’ Human Resource Department.
UCR (Usual and Customary Rates)
Our practice is committed to providing the best treatment possible for our patients. We charge what is usual and customary for our area. You are responsible for payment in full, regardless of any insurance company’s determination of usual and customary rates.
Minor Patients
Minor children must be accompanied by a parent or guardian for all treatment. The parent or guardian is responsible for payment.
Missed Appointments
Unless cancelled at least 24 (twenty-four) hours in advance, our policy is to charge a $50.00 (fifty) dollar fee for a missed appointment. Please help us serve you better by keeping scheduled appointments.
Please let us know if you have any questions or concerns.
I have read the above Financial Policy. I understand and agree to the terms stated above.
_______________________________________ ________________________
Signature of Patient or Responsible party Date
Eileen Yue-Ling Han LA.c.
Practice of Chinese Medicine
4550 Kearny Villa Road #107 San Diego, CA 92123
Tel: 619-249-7660
The following is a confidential questionnaire to determine the best possible treatment plan for you. Please take your time in completing the information. Thank you!
A: Personal Information:
Last Name: ____________________________ First Name: ______________________
Middle Name: __________________________ Female: _____ Male: _____
Address: ________________________________________________________________
City: _____________________ State: ____________ Zip Code: ___________________
Phone: Home ( ) __________________________________________________
Work ( ) __________________________________________________
Cell ( ) __________________________________________________
Birth Date: ______________ Birth Time: _______ Birth Location: _________________
Employer: _______________________________________________________________
Marriage Status:
( ) Married ( ) Divorced
( ) Single ( ) Widow (er)
If Married please fill out spouse’s:
Name: _________________________________ Employer: _______________________
Who referred you to our office? _____________________________________________
Have you ever been treated by an acupuncture doctor before? If yes, please give name of
the acupuncturist._________________________________________________________
B. Medical history
Height: ________________________________ Weight: __________________________
When were you last seen by a physician? ______________________________________
Reason for visit: __________________________________________________________
Name of the physician: ________________________________ Tel # _______________
Please indicate any hospitalizations you have had:
Please describe the reason (s) for visiting this office: _____________________________
________________________________________________________________________
________________________________________________________________________
Please indicate other health problems you have, if any: ___________________________
________________________________________________________________________
C. Your health information
Is there a history of cancer, tuberculosis or diabetes, etc. in your family? _____________
If yes, who: _____________________________________________________________
What Illness: ____________________________________________________________
Please list any prescribed medicine(s) that you are presently taking?
Medicine: __________________________________ Dosage: _____________________
How often do you drink tea, coffee, or alcohol? _________________________________
How often do you exercise? _________________________________________________
For woman only:
1. Are you pregnant? If yes, please indicate here ( )
2. Have you ever been pregnant? If yes,
how many births? ________________ How many miscarriage? ____________________
3. Please indicate the results of your last gynecological exam. and Pap smear:
______________________________________________________________________
Date of G. Exam. _____________________ Date of Pap smear: __________________
In the last six months, which of the following symptoms have you experienced?
Never Sometimes Often
Difficult to stop bleeding? ______ _______ ______
Excessive Appetite ______ _______ ______
Loose stools or diarrhea ______ _______ ______
Digestion problem ______ _______ ______
Vomiting ______ _______ ______
Belching or burping ______ _______ ______
Heartburn ______ _______ ______
Feeling of food retention ______ _______ ______
Cough ______ _______ ______
Shortness of breath ______ _______ ______
Decreased sense of smell ______ _______ ______
Nasal problems ______ _______ ______
Skin problems ______ _______ ______
Feeling of claustrophobia ______ _______ ______
Bronchitis ______ _______ ______
Colitis or diverticulitis ______ _______ ______
Constipation ______ _______ ______
Hemorrhoids ______ _______ ______
Recent use of antibiotics ______ _______ ______
Low back pain ______ _______ ______
Sciatica ______ _______ ______
Knee problem ______ _______ ______
Hearing impairment ______ _______ ______
Ringing in ears ______ _______ ______
Kidney stones ______ _______ ______
Decreased sex drive ______ _______ ______
Hair loss ______ _______ ______
Urinary problem ______ _______ ______
Insomnia, difficulty sleeping ______ _______ ______
Heart palpitations ______ _______ ______
Nightmares ______ _______ ______
Mentally restless ______ _______ ______
Laughing for no apparent reason ______ _______ ______
Angina pains ______ _______ ______
Eye problems ______ _______ ______
Jaundice (yellowish eyes or skin) ______ _______ ______
Hepatitis ______ _______ ______
Difficulty digesting oily foods ______ _______ ______
Gall stones ______ _______ ______
Light colored stools ______ _______ ______
Soft of brittle nails ______ _______ ______
Easily angered or agitated ______ _______ ______
Spasms or twitching of the muscles ______ _______ ______
Fatigue ______ _______ ______
Edema ______ _______ ______
Blood in stools ______ _______ ______
Black tarry stools ______ _______ ______
Easily bruised ______ _______ ______
Asthma ______ _______ ______
Tendency to catch colds easily ______ _______ ______
Intolerance to weather changes ______ _______ ______
Allergies ______ _______ ______
Hayfever ______ _______ ______
Tendency to faint easily ______ _______ ______
High blood pressure ______ _______ ______
High cholesterol ______ _______ ______
Sudden weight loss ______ _______ ______
Any related comments that you would like to share would be appreciated:
Patient’s signature: ________________________________________
Date: ___________________________________________________
Please sign the form, Thank you!
Begins….
( ) Gradually ( ) Suddenly
( ) From injury
Is ( ) Off & on ( ) Continuous
Is worse when I ( ) cough or sneeze
( ) sit down
( ) bend forward
( ) lay down
( ) wake up
( ) Walk
( ) after surgery
__________________________________________________________________
__________________________________________________________________
Good job! You did it!