Lance Lee - Acupuncture Medical Associates
Acupuncture & You
About Lance Lee
New Patient Forms
What To Expect
What Is Acupuncture
Children's Jade Defense Formula
What Does Acupuncture Treat?
Period Cramps And PMS
Eczema
Lymphedema
Kidney Stones
Anxiety
Nausea
Allergies and Sinusitis
Stress in Children
TMJ Pain
Acupuncture & PTSD
Contact Us
CLINIC FORMS
Click the link below to download and print our medical forms. Please fill out and sign prior to coming in.
Medical Forms
File Size:
354 kb
File Type:
docx
Download File
IF COMPLETING FORMS ONLINE:
PATIENT SIGNATURES MUST BE SIGNED AT APPOINTMENT
Lance Lee - Acupuncture Medical Associates - Medical Forms
GENERAL INFORMATION
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Indicates required field
Name
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Address
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Email
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Date of Birth
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Work Phone Number
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Home Phone Number
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Cell Phone Number
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Social Security Number
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Emergency Contact
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Are You:
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Married
Single
Partner
Divorced
Widowed
Have You Had Acupuncture or Oriental Medicine Before?
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Occupation
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Referred By
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Family Physician
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Physician Contact Number
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Are You Under Doctor's Care?
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If Under Doctors: Who & For What?
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Are There Any Therapies You Are Involved In?
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If Yes Who and For What?
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FOCUS
Primary Reason For Seeking Care At Our Office?
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When Did It Begin?
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What Makes It Better?
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What Was The Initial Cause?
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What Makes It Worse?
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What Have You Done With This?
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Select The Activities Your Problem Interferes With
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Work
Sleep
Walking
Sitting
Standing
Emotional
Relationships
Social Life
Sexuality
Recreation
Bending
Stretching
Other
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Are You Interested In?
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Pain Relief
Performance Care
Maintenance Care
Preventative Care
Tai Chi
Stress Relief
Oriental Nutrition
Herbal Therapy
Other
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What Are Your Health Goals?
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List Any Significant Trauma. When Did It Occur? (Auto Accident, Falls, Emotional, Sexual, Etc.)
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List Any Past Or Future Surgeries
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List Exercise/Sports Activities You Have Been Or Are Currently Involved In.
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SYMPTOMS
Please Mark Any That Apply
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Abdominal pain
Seizures
Abuse survivor
Acid regurgitation
Shortness of breath
Asthma
Nocturnal emission
Spot in the eyes
Numbness
Enlarged thyroid
Sore throat
Breast lump / pain
Teeth or gum problem
Poor circulation
Poor memory
Limited range of motion
Premature ejaculation
Confusion
Wake to urinate
Weight loss or gain
Hemorrhoids
Please Mark Any That Apply
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Dark stool
Decrease libido
Depression
Acne
Dry mouth / throat
Skin fungus
Blood in stools
Irritable
Blurry vision
Excessive phlegm
Chest pains
Ulcerations
Gas / belching
Upper back pain
Constipation
Cough
Mucus in stools
Nasal congestion
Neck or shoulder pain
Muscle cramps / pain
Sinus
Please Mark Any That Apply
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Coughing blood
Heart palpitations
Hiccups
Hypertension
Dizziness
Increased libido
Bad breath
Ear aches
Blood in urine
Odorous stools
Eye pain / strain
Joint pain
Excessive saliva
Chills
Cold hands / feet
Urgent urination
Frequent urination
Low back pain
Grinding teeth
Wheezing
Night sweats
Please Mark Any That Apply
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Nosebleeds
Diarrhea
Indigestion
Intestinal pain / cramps
Laxative use
Poor Sleep
Vomitting
Rash
Sudden energy drop
Pain upon irritation
Itchy eyes
Poor appetite
Kidney stones
Fatigue
Fever
Concussion
Hair loss
Psoriasis
Mouth sores
Redness of eyes
Therapy
Migraine
Headaches
FEMALE CONCERNS
Date of Last Menstruation
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Is Your Cycle Painful?
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Do You Use Birth Control
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Is Your Cycle Regular?
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Have You Ever Been Pregnant?
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If You Use Birth Control, How Long?
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Choose Any That Apply
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PMS
Clotting
Vaginal sores
Vaginal pain
Discharge
MEDICAL HISTORY
Do You Have Allergies?
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If You Have Allergies, What?
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Do You Take Medication? If So What? How Often?
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Do You Take Supplements? What? How Often?
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Select Any Illness(es) That You Have Or Have Had
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Aids / HIV
Scarlet Fever
Migraines
Heart Disease
Diabetes
Sexually Transmitted Discease
Ateriosclerosis
Thyroid Disorder
Measles / Mumps
Cancer
Alcoholism
Allergies
Mononucleosis
Hepatitis
Emphysema
Arrhythmia
Fibromyalgia
Goiter
Chicken Pox
Chronic Fatigue
Polio
Genital Herpes
Oral Herpes
Endometriosis
Rheumatic Fever
Meniere's
Anemia
MS
Appendicitis
Epilepsy
Birth Trauma
Gout
Paralysis
Pleurisy
Asthma
Stroke
Tuberculosis
Ulcers
Genital Worts
Do You Sleep Well?
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Do You Dream?
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Do You Have High Points During The Day?
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When?
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Do You Have Low Points During The Day?
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When?
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What Are Your Indulgences?
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What Are You Hobbies?
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PAIN
Tells On Your Body Where You Pain Or Problem Is?
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Pain Intensity Level
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No Pain
Moderate Pain
Sever Pain
Terrible Pain
Sleeping
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No Problem
Mildly Disturbed
Greatly Disturbed
Cannot Sleep
Work - Can Do
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Usual Work
25% of Work
50% of Work
No Work
Frequency of Pain
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25 % of Time
50% of Time
75% of Time
100% of Time
Travel
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No Problem
Moderate Pain
Severe Pain
Terrible Pain
Recreation - Can Do
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All Activities
Some Activities
No Activities
Walking
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Walk Any Distance
Pain After 1/2 Mile
Cannot Walk
Sitting
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No Pain Sitting
Some Pain Sitting
Cannot Sit
NEUROLOGICAL - PSYCHOLOGICAL
Check Any That Apply
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Seizures
Areas of Numbness
Excess Sleepiness
Loss of Balance
Poor Memory
Insomnia
Concussion
Anxiety
Poor Concentration
Sharp Zapping Pain
Depression
If you have dizziness, is it mild or severe?
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How long does the dizziness last?
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Is the onset sudden or gradual?
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Describe other symptoms that come with dizziness?
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Do you have difficulty falling asleep?
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How many hours of sleep do you get?
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Is your sleep disturbed by dreams/nightmares?
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Do you have difficulty staying asleep?
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Do you feel rested upon waking?
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Are there any neuro/psychological issues to discuss?
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FAMILY HEALTH HISTORY
Please provide details of any family members who have had any of the following conditions.
Diabetes
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Heart Disease
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Asthma
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Cancer
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High Cholesterol
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Seizures
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Stroke
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High Blood Pressure
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Allergies
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Other
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Comment: Please feel free to identify other concerns
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Please sign and date at your next appointment.
Patient Signature
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Clinic Signature
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Date
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Date
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INSURANCE
Name on Insurance Card
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Relationship to Insured
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Name of Insurance
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If the insurance company decides not to pay, the charges are the responsibility of the patient.
Please sign and date at your next appointment.
Patient Signature
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Date
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I agree to pay if the insurance does not pay.
To be completed by an Acupuncture Medical Associates Representative.
Benefits Check By
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Date
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Policy Holder
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Policy Number
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Group Number
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Deductible
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Co Pay or Co Insurance
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Deductible Met?
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Effective Date
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Other Notes
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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
I have read, understand and have been provided with a copy of Notice of Privacy Practices that provides a more complete description of information and disclosures practice of Acupuncture Medical. I understand that i have the following rights and privileges.
The right to review the notice prior to signing this consent
The right to object to the use of my health information for directory purposes, and
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
DISCLAIMER: The Acupuncture Medical Notice of Privacy Practice is subject to change. If we change our notice, you may obtain a copy of the revised notice by requesting a hard copy from the Privacy Practice officer Leesa M. Lee.
Privacy Officer Contact Information
2800 N. Grimes
Hobbs, NM 88240
(575) 392-2712
By signing this form, I acknowledge receipt of the Notice of Privacy Practices of Acupuncture Medical Associates, LLC.
Patient Signature
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Date
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INABILITY TO OBTAIN ACKNOWLEDGEMENT:
To be completed only if no signature is obtained. If it is not possible to obtain the individual's acknowledgement was not obtained:
Patient unable to sign
Patient unable to sign (inactive patient)
Family/significant other not available
Patient declines to sign
Other
Signature of Acupuncture Medical Representative
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Date
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ACUPUNCTURE MEDICAL ASSOCIATES, LLC
HEALTH CARE AUTHORIZATION FORM
Patient's Name
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Patient's Social Security Number
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Date of Birth
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THE PATIENT IDENTIFIED ABOVE AUTHORIZES ACUPUNCTURE MEDICAL TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:
SPECIFIC AUTHORIZATION
I give permission to Acupuncture Medical to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, information about treatment alternatives or other health related information.
If Acupuncture Medical contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.
(OPEN ROOM AUTHORIZATION - OPTIONAL) I give Acupuncture Medical permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear at any time in private, the doctor will provide a room for these conversations.
By signing this form you are giving Acupuncture Medical permission to use the disclose your protected health information in accordance with the directives listed.
RIGHT TO REVOKE AUTHORIZATION
You have the right to revoke the AUTHORIZATION, in writing at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization.
You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Acupuncture Medical. The written notice must contain the following information.
Name
Social Security Number
Date of Birth
A clear statement of your intent to revoke this AUTHORIZATION
The date of your request
Your signature
The revocation is not effective until it is received by the Privacy Official.
The AUTHORIZATION is requested by Acupuncture Medical for its own use/disclosure of PHI. (Minimum necessary standards apply.)
You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, Acupuncture Medical will not refuse to provide treatment.
You have the right to inspect or copy the PHI to be used/disclosed.
******A COPY OF THIS SIGNED AUTHORIZATION WILL BE PROVIDED TO YOU UPON REQUEST*****
Please sign your next appointment.
Print Name of Signature
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Signature of Patient
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Signature of Personal Representative
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Description of Representative's Authority for Patient
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Submit Medical Forms
Acupuncture & You
About Lance Lee
New Patient Forms
What To Expect
What Is Acupuncture
Children's Jade Defense Formula
What Does Acupuncture Treat?
Period Cramps And PMS
Eczema
Lymphedema
Kidney Stones
Anxiety
Nausea
Allergies and Sinusitis
Stress in Children
TMJ Pain
Acupuncture & PTSD
Contact Us
