218-670-0599 [email protected] 601 Bunker Hill Dr...Indicate any supplements or herbs or herbal teas you are currently taking: !multivitamin !vit B complex !vit C !vit D !vit E !fish

218-670-0599 [email protected]

601 Bunker Hill Dr Aitkin, MN 56431

Today’s Date _____ /______ /_______

Patient Information Name ___________________________________________ Email _________________________________________ Primary Phone (____) ____ - _______ [ ] cell [ ] landline 2nd Phone (____) ____ - _______ [ ]cell [ ]landline Address _____________________________________________ City ________________ State _______ Zip _________ Occupation ___________________ If emergency notify __________________________ Phone (____) ____ - _______ Primary Care Physician/Clinic Location _________________________________ /______________________________ Marital Status ________________________ Date of Birth _____ / _____ / ___________ Gender __________________ Medical Insurance Primary Insurance ______________________ Policy or ID# ________________________ Group# _______________ Provider Phone Number (back of card) __________________________________ Secondary Insurance ____________________ Policy or ID# ________________________ Group# _______________ Provider Phone Number (back of card) __________________________________ For Auto Accidents/Personal Injury Only Insurance Company ____________________________________________ Date of Injury ____/_____ /____________ Company’s Address ____________________________________________ Claim No. _________________________ Name of Insured _____________________________________ Relationship to Insured ________________________ Contact/Adjustors Name _______________________________________ Adjustor’s Phone (____) ____ - _______ For Work Injuries Only Employer _________________________________________________ Date of Injury _____/_____ /___________ Contact at Employer ________________________________________ Contact Phone (____) ____ - _______ Attorney _________________________ Attorney’s Ph (____) ____ - _______ Claim No. ______________________

Informed Consent to Treatment

I hereby authorize Jean Twomey, L.Ac. to diagnose and treat according to the professional standards of Chinese medicine and her professional judgment. This authorization extends to other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as a back-up for the acupuncturist named above, whether signatories to this form or not. I understand that in Minnesota, acupuncturists must be licensed to practice Traditional Chinese Medicine by the Minnesota Board of Medical Practice (MBMP) and be nationally certified by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). I understand that my treatment may include a variety of Traditional Chinese medicine modalities, such as acupuncture, tui na (Chinese massage therapy), moxibustion, herbal therapies, cupping, electrical stimulation, magnet therapy, dermal friction (guasha), acupressure, dietary and nutritional counseling, breathing techniques, and exercises based on Chinese medicine principles. This authority shall extend to remedying any unforeseen conditions or reactions to treatment procedures. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including but not limited to: local bruising, numbness or tingling near the needling sites that may last a few days, minor bleeding, dizziness, fainting, brief generalized fatigue or nausea, temporary pain or discomfort, skin irritation, and the possible aggravation of symptoms existing prior to the treatment. Bruising is a common side effect of cupping. Unusual and rare risks of acupuncture include spontaneous miscarriage, nerve damage, broken needles, organ puncture, and infection. I have been informed that acupuncture needles are sterile, single-use, and disposable. If moxibustion, heat lamp or fire-cupping is provided, there is a risk of burn or scarring from its use. I understand that I am free to stop acupuncture treatment or associated therapies at any time, or refuse any therapy completely. Substances from the Oriental Materia Medica and/or western nutritional supplements may be recommended to me to treat my condition(s). I am aware that certain adverse side effects may result from taking these substances including but not limited to: nausea, gas, vomiting, headache, changes in bowel movement, abdominal pain, rashes, hives, tingling of the tongue, and the possible aggravation of symptoms existing prior to supplemental treatment. If I choose a nutritional consultation, I consent to use muscle testing to develop a natural, complementary health improvement program for me, which may include dietary guidelines or nutritional supplements in order to assist me in improving my health, and not for the treatment, or “cure” of any disease. I understand that muscle testing has not been scientifically validated, and is not considered diagnostic or prescriptive for any condition. I understand I am not required to take any of these substances but should follow directions for administration and dosage if I do decide to take them. Should I experience any problems that may be associated with these substances, I will suspend their use and contact the prescribing provider as soon as possible. I understand that acupuncturists do not make Western medical (biomedical) diagnoses and that it is my responsibility to seek such diagnosis elsewhere if I have not already done so. I will notify the Licensed Acupuncturist who is caring for me if I am pregnant or become pregnant, or if I have, or develop any serious medical condition at any time. I understand that no promises or guarantees can be made regarding the outcome of any treatment received, and that reasonable efforts will be made to give me information so that I may make an educated decision regarding the duration and appropriateness of continuing care at Aitkin Acupuncture, LLC. By voluntarily signing below, I show that I have read or have had read to me, the above consent to treatment, understand the risks and benefits of treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

To be completed by patient (or by patient’s representative if To be completed by the Licensed Acupuncturist the patient is a minor or is physically or legally incapacitated). providing information and obtaining consent.

______________________________________ ____________________________________ ________________________________________ Print Name of Patient Print Name of Representative (if applicable) Print Name of Licensed Acupuncturist X____________________________________ ___________________________________ X_______________________________________ Signature of Patient (or Representative) Date Signed Signature of Licensed Acupuncturist

Page 3 of 7updated 06/20/2019

Please take the time to fill out this questionnaire carefully. The information you provide will assist me in formulating a complete health profile for you. If you need more room, please use the other side of these sheets. General Health History List any Western Medical disease or syndrome diagnosis you have been given (examples: diabetes, high blood pressure, bronchitis, heart disease, fibromyalgia, bursitis, sciatica, etc): ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ List any Western Medical disease or syndrome diagnosis your parents or siblings have been given: Father ____________________________________________________________________________________________ Mother ___________________________________________________________________________________________ Siblings __________________________________________________________________________________________ Describe any hospitalizations or surgeries you have had: ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ ____________________________________________________________________________ Year: ________________ Check the box next to any of the following medications you are currently taking: ! aspirin ! acetaminophen/Tylenol ! ibuprofen ! prescription pain meds ! muscle relaxants ! thyroid medication ! oral contraceptives ! hormone replacements ! allergy tablets / inhalers

! antacids, H2 blockers, or PPI’s ! diet pills ! laxatives ! insulin, diabetic pills ! blood pressure pills ! diuretics ! blood thinning medication ! statin or cholesterol lowering ! history of antibiotics > 5x

! antibiotic/antifungal ! anti-anxiety ! antidepressant ! sleeping pills ! recreational drugs ! other_______________ ! other_______________ ! other_______________

Indicate any supplements or herbs or herbal teas you are currently taking: ! multivitamin ! vit B complex ! vit C ! vit D ! vit E

! fish or flax seed oil ! primrose or other oil ! fiber supplements ! calcium ___________mg ! magnesium __________mg

! CoQ10 ! probiotics ! digestive enzymes ! other __________________ ! other __________________

List any allergies or sensitivities you may have to medications, chemicals, pollens, or foods: ____________________________________________________________________________________________________________________________________________________________________________________________________

Have you experienced acupuncture before? ! yes ! no

Do you have a pacemaker? ! yes ! no

Do you have a bleeding disorder? ! yes ! no

Do you have lymph nodes removed? ! yes ! no

Your Top 1-3 Items to be Treated: Severity Rating What Makes Better What Makes Worse Chief Complaint Problem and associated symptoms: Date of onset: Possible cause: Western medicine diagnosis: Other treatments received:

Scale of 0 - 10 Best: / 10 Worst: / 10 Interferes with ! Work ! Daily living ! Sleep ! Other

! Rest ! Movement ! Heat ! Cold ! Medicines ________ ___________________ ! Other: eating, crying,

fresh air, remedies, teas, therapies, etc

! _________________ ! _________________ ! _________________

! Stress ! Fatigue ! Rest ! Movement ! Heat ! Cold ! Time of day ! Weather ___________ ! Foods _____________ ! ___________________ ! ___________________ ! ___________________

2nd Complaint (optional) Problem and associated symptoms: Date of onset: Possible cause: Western medicine diagnosis: Other treatments received:

Scale of 0 - 10 Best: / 10 Worst: / 10 Interferes with ! Work ! Daily living ! Sleep ! Other

! Rest ! Movement ! Heat ! Cold ! Medicines ________ ___________________ ! Other: eating, crying,

fresh air, remedies, teas, therapies, etc

! _________________ ! _________________ ! _________________

! Stress ! Fatigue ! Rest ! Movement ! Heat ! Cold ! Time of day ! Weather ___________ ! Foods _____________ ! ___________________ ! ___________________ ! ___________________

3rd Complaint (optional) Problem and associated symptoms: Date of onset: Possible cause: Western medicine diagnosis: Other treatments received:

Scale of 0 - 10 Best: / 10 Worst: / 10 Interferes with ! Work ! Daily living ! Sleep ! Other

! Rest ! Movement ! Heat ! Cold ! Medicines ________ ___________________ ! Other: eating, crying,

fresh air, remedies, teas, therapies, etc

! _________________ ! _________________ ! _________________

! Stress ! Fatigue ! Rest ! Movement ! Heat ! Cold ! Time of day ! Weather ___________ ! Foods _____________ ! ___________________ ! ___________________ ! ___________________

On the diagram, please indicate the areas where you feel symptoms associated with your complaints:

Check the box if you currently have, or have a long history of any of these items: Head ! Dizziness standing up ! Other dizziness ! Headaches ! Red wine headaches ! Migraines ! Facial pain ! Loss of balance/Vertigo ! Fainting ! Poor memory ! History of concussion ! Other_____________ Chest/Abdomen ! Chest pain or pressure ! Irregular heart beat ! Palpitations at rest ! Shortness of breath ! Ribside pain ! High blood pressure ! Low blood pressure ! Gall bladder removed Other______________ You generally feel: ! warmer than others ! cooler than those

around you ! about the same

Musculoskeletal ! Cold hands/feet ! Excess sweating ! Limb edema ! Tremors ! Areas of numbness ! Lack of coordination ! Muscle weakness ! Neck pain ! Shoulder pain ! Pain / stiffness between

shoulder blades ! Elbow pain ! Hand/wrist pain ! Upper Back pain ! Mid-Back pain ! Low Back pain ! Hip/buttocks pain ! Knee pain ! Foot/ankle pain ! Varicose/spider veins ! All over muscle pain ! Leg cramping ! Recent weight gain/loss ! Other______________ Skin and Hair ! Eczema/Psoriasis/Hives ! Dermatitis or rashes ! Acne ! Facial flushing

! Fungal Infection ! Weak or ridged nails ! Loss of hair ! Dandruff ! Easy bruising ! Dry, itchy feet or skin

peeling on feet ! Brown spots / bronzing ! History low Vit D labs ! Other______________ Eyes ! Visual spots/floaters ! Blurred vision ! Dark circles under eyes ! Red eyes ! Itchy eyes ! Eye pain ! Difficulty driving night ! Cataracts ! Other______________ Ears & Nose ! Earaches ! Ringing in ears ! Poor hearing ! Hay fever or allergies ! Runny nose ! Sinus problems ! Nose bleeds ! Other______________

Mouth & Throat ! Dry mouth ! Difficulty swallowing ! Feeling lump in throat ! Sores on lips/tongue ! Grinding teeth ! Teeth problems ! Gum problems ! Bad breath ! Jaw clicks/locks ! Lump in throat ! Bitter / metallic taste Other______________ Respiratory ! Freq sighing ! Freq colds/flu’s ! Freq cough ! Asthma ! Pain w/ deep inhalation ! Tight sensation in chest ! Difficult inhale/exhale ! Difficulty breathing

when lying down ! Production of phlegm

after eating ! Other______________

Digestive ! Nausea ! Bloating ! Gas shortly after eating ! Indigestion 30-60 mins

to 4 hours after eating ! Abdominal pain ! Heartburn ! Hernia ! Drowsy after eating ! Shaky if hungry ! Rapid hungering ! Loss of taste for meats ! Family member Celiac ! Family member Gluten

Sensitive ! Other______________ Diet Your appetite is: ! absent ! small ! moderate ! hearty ! voracious Do you eat or snack to ease emotions? ! often ! sometimes ! seldom ! no Regularly eat: ! Candy / sweets ! Fast food restaurants ! Fried foods ! Refined flour products ! Luncheon meats ! Margarine ! Refined sugars ! Milk/dairy products ! Ice cream Artificial sweeteners Foods avoided or special diet: _________________ _____________________ _____________________ Drink You prefer: ! hot drinks ! cold drinks ! room temp drinks Are you often thirsty? ! yes ! no

Your drinking water is: ! city ! well ! purified/filtered ! bottled ! softened or distilled Drink caffeine drinks? ! yes, avg #_____daily ! no Drink alcohol drinks? ! yes, avg #_____

daily/weekly/monthly ! no Amount of liquid intake per day: ________ oz Kinds of drinks: ____ __________________ __________________ Bowel Stool frequency: ! >2 per day ! 1-2 per day ! Every other day ! < 3x per week Stools tend to be: (Check all that apply) ! Diarrhea ! Loose ! Formed like log ! Formed but narrow ! Formed like pellets ! Difficult / Constipated ! Hard at first, soft at end ! Dark ! Light or Mustard Color ! With foul smelling gas ! With undigested food

fragments ! With blood (red/black) Urinary ! Pain on urination ! Frequent urination ! Blood in urine ! Burning urination ! Dribbling after urine ! Urgent urination ! Unable to hold urine Other______________

Sleep/Emotions Check all that apply: ! hard to fall asleep ! wake easily, hard to fall

back asleep ! wake too early in am ! not rested in a.m. ! nightmares ! excessive dreaming ! feel hot/sweat at night ! restless legs ! wake to urinate #___ ! Other _____________

Average hours of sleep each night: _____ hrs Describe your general energy level: ! exhausted ! often fatigued ! moderate ! good ! excellent Do you feel your life is stressful? ! no ! yes, I feel okay with it ! yes, and it is too much Susceptible to: ! Depression ! Anxiety ! Bad temper/irritability ! Stress ! Seasonal depression ! Nervousness ! Hyperactivity Emotion you most gravitate towards: ! grief/sadness ! fear ! anger ! worry/anxiety ! overjoy/manic Lifestyle/Misc Exercise frequency: ! >5x per week ! 3-4x per week ! 1-2x per week ! my job is exercise ! none Kinds of exercise: _____________________ _____________________

Smoke cigarettes or chew tobacco? ! yes ! no ! quit ___ years ago Often exposed to: ! cleaning chemicals ! constructions materials ! pesticides, herbicides ! dust, smoke, fumes Do you have any mercury dental fillings? ! yes ! yes, but now removed ! no In order to feel better, I am also open to: ! dietary changes ! nutritional supplements ! mental/emotional work Men ! Enlarged prostate ! Prostatitis ! Pain in testicles ! Other______________ Women ! Irregular menstruation ! PMS symptoms

! Breast tenderness ! Emotionality ! Cramping ! Clots ! Painful menstru.

! Scanty or Copious flow ! Exc. vaginal discharge ! Difficulty conceiving ! Other______________ Diagnosis of: ! Endometriosis ! Polycystic Ovarian Syn. ! Uterine Fibroids ! Ovarian cysts ! Fibrocystic breast tissue _____# pregnancies _____# live births _____ age of first menses _____ date of last menses Possibly pregnant now? yes / no

Notification of Privacy Policies (effective January 30, 2019)

Aitkin Acupuncture LLC keeps all patient data and health records in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Your signature on this form is your consent to use this information as outlined. Information we gather and maintain includes your contact information, medical history, treatment notes, test results, any correspondence from other health care practitioners, insurance companies, workman’s compensation, and third party administrators (e.g. medical records requests, billing payment information). We use your information to provide you the best healthcare possible, to bill insurance, and to keep in touch with you. We safeguard your information by using a HIPAA-compliant online electronic patient health records and scheduling system, Acusimple. This system also includes a patient portal for secure communication with your acupuncture provider. A very small amount of patient data in paper form is maintained in a limited access facility. We have appropriate policies and procedures in place for handling information, and require third parties to contractually comply with privacy laws. Conditions that require us to share your information: To bill your insurance, we need to share limited medical information with your insurance company. If you are being treated under a private auto injury or worker’s compensation claim, we need to share limited medical information with your claims officer. For workman’s compensation cases, this may also include your employer. If necessary for your safety and care, Aitkin Acupuncture LLC may need to contact your primary care provider regarding treatment, or refer you to other health care practitioners. A referral is required by Minnesota law when an acupuncture practitioner sees patients with untreated and potentially serious disorders. You may revoke this consent to the use and disclosure of your PHI at any time in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. You may also request that we share a part or all of your medical records with other parties by filling out an “Authorization for Medical Records Release/Request of Information” form. We reserve the right to modify the Privacy Practices outlined above. We value our relationship and respect your right to privacy. Any complaints regarding our use of your information may be made by contacting Jean Twomey at 38400 Dove St, Aitkin MN 56431, [email protected], or 218-670-0599.

Financial and Office Policies • The cost of an initial exam and acupuncture treatment is $115, and follow-up treatment is $65 for payments received at time of service. This is discounted from the regular insurance rate as allowed by Minnesota law. The cost of any herbs, supplements, or products may be an additional cost billed to me above the standard acupuncture session fee. • I acknowledge the Aitkin Acupuncture LLC policy of appointment cancellation at least 24 hours in advance, and understand that late cancellations or no-shows are subject to a $30 fee. Canceled checks are also subject to a $30 fee. • It is acceptable for Aitkin Acupuncture LLC to call or email me regarding my appointments and/or treatments. • For the purposes of directly billing insurance, I assign Aitkin Acupuncture benefits payable and authorize them to share my information with my insurance company per the privacy policy above. I may revoke this anytime in writing. • Aitkin Acupuncture will do our best to verify my insurance benefits. I understand my responsibility to also call the insurance company to find out if I have coverage for acupuncture performed by a Licensed Acupuncturist. I understand this does not guarantee payment, and am responsible for any balance not paid or covered by insurance.

By signing below, I confirm that I have read, agreed and understand the policies listed above. ____________________________________________ ___________________________________________ Print Name of Patient Print Name of Patient Representative (if applicable) X____________________________________________________ ____________________________________________________ Signature of Patient (or Representative) Date Received and Signed