blockchiropracticcenter.com - Acupuncture Form

Acupuncture Patient Intake Form
Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential. Please print clearly in ink.

IDENTIFICATION
Name
Sex

MF
Date

MonthDayYear
Date
Telephone (Home)
Please enter a valid phone number.
Telephone (Work)
Please enter a valid phone number.
Cell

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

MonthDayYear
Date
Age
Email
example@example.com
Marital Status

SingleMarriedPartneredWidowedSeparated/Divorced
Height
Weight
Occupation
Education (degrees/credentials)
How did you learn about us?
Anyone referred to us?

YesNo
If referred, who:
ADDITIONAL CONTACTS

Emergency information required
Emergency contact name
Relation
Emergency contact telephone (Home)
Please enter a valid phone number.
Cell

Area CodePhone Number
Name of physician
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of counselor/psychologist”
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of gynecologist”
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
No contact will be made without your permission.
Special problems or symptoms
INSURANCE INFORMATION
Who is responsible for this account?
Relationship to Patient:
Insurance Co
Insurance lD#
Is patient covered by additional insurance?

YesNo
Subscriber's Name:
Subscriber's Birth Date:
SS#
FAMILY HISTORY

Please complete for each family member, as best as you can, indicating any illnesses that they have ever had. Check in the appropriate box or boxes.

	Self	Mother	Father	Sibling	Spouse/Partner	Children
Adopted
Good health
Cancer or tumors
Diabetes
Thyroid disorders
Kidney disorders
Kidney disorders
High blood pressure/heat disease/stroke
Blood or bleeding disorders/anemia
Seizures
Allergies (specify type)
Alcohol or other drug us
Depression or mental illness
Hepatitis/other liver disorder
Musculoskeletal disorder
HIV/AIDS
Deceased (age : Self N/A)

PERSONAL LIFESTYLE HABITS

For each item, please indicate the amount and how often.
Cigarettes (packs per day)
Alcohol (drinks per week)
Drug use (specify type & amount per day)
Coffee (cups per day)
Tea (cups per day)
SodaRegular
Diet cans per day
Exercise

YesNo
How often?
What kind of exercise?
MEDICAL

If you have ever been hospitalized or in the emergency room for a serious medical illness or operation, please list all of them below: (do not include normal pregnancies).

	Year	OPERATION/ ILLNESS	HOSPITAL/TREATMENT LOCATION
1
2
3

MEDICAL

Please list all medications, vitamins and/or food supplements you are currently taking

Please list all medications

	Medications	Dosage	For what condition?
1
2
3

Please list all vitamins

	Vitamins	Dosage	For what condition?
1
2
3

Please list all supplements

	Supplements	Dosage	For what condition?
1
2
3

CURRENT AND PAST CONDITIONS/SYMPTOMS/TRAUMAS

If you are currently experiencing any of the following, please check it with a "C". If you have experienced any of the following in the past, please check it with a "P". Mark both if you have experienced the condition both in the past and currently.

General

	P	C
Insomnia
Dreams/ nightmares
Fatigue
Poor memory
Strongly like cold drinks
Strongly like hot drinks
Recent weight loss/gain
Cold hands & feet
Chills
Fever
Bad breathe

Other:

Head & Neck

	P	C
Headaches
Migraines
Stiff neck
Dizziness
Fainting
Swollen glands
Ears Ringing
Hearing loss
Hearing aids
Infections
Earache
Vertigo

Eyes

	P	C
Glasses/contact lenses
Blurred vision
Poor night vision
Spots or floaters
inflammation
Double vision
Glaucoma
Cataracts
"Lazy" eye

Other:

Nose, Throat & Mouth

	P	C
Sinus infection
Hay fever/ allergies
Frequent sore throat
Difficulty swallowing
Mouth & tongue ulcers
Frequent colds
Nosebleed
Dry nose
Nasal congestion
Loss of voice
Thirst
Excessive phlegm
TMJ
Facial pain
Gum problems
Dry mouth

Dental Problems?

YesNo
Last dental visit

Skin

	P	C
Hives
Rashes
Eczema/ psoriasis
Night sweating
Excess sweating
Dry skin
Easily bruised
Changes in moles, lumps
Itching

Other:

Gastrointestinal

	P	C
Nausea
Indigestion
Stomach pain
Diarrhea
Constipation
Poor appetite
Excessive hunger
Vomiting
Gas
Hiccups
Acid regurgitation
Bloating
Laxative use
Bloody stool

Other:

Respiratory

	P	C
Difficulty breathing
Difficulty breathing when reclining
Wheezing
Asthma
Chronic cough
Wet cough
Dry cough
Coughing up phlegm
Coughing up blood
Shortness of breath
Tight chest
Pneumonia

Other:

Cardiovascular

	P	C
High blood pressure
Low blood pressure
Chest pain or tightness
Palpitation
Rapid heart beat
Irregular heart beat
Poor circulation
Swollen ankles
Phlebitis
Anemia
History of heart disease
Heart murmur
Night sweats
Tendency to be cold
Tendency to be warm

Other:

Mental/Emotional

	P	C
Depression
Mood swings
Irritability
Difficulty relaxing
Loneliness
Sensitive
Shyness
Frequent crying
Worries frequently
Compulsive behaviors
Difficulty focusing
Hopeless outlook
Suicidal thoughts
Lose temper
Frustration

Other:

Urinary

	P	C
Pain on urination
Frequent urination
Urgent urination
Blood in urine
Incontinence
Incomplete urination
Bedwetting
Wake to urinate
History of UTI
Kidney (specify)

Other:

Male Genital

	P	C
Impotence
Premature ejaculation
Nocturnal emission
Pain/itching of genitalia
Lumps in testicles
Increased libido
Decreased libido
Breast checked

Other:

Infection (check self and/orPartner)

	Self	Partner
HIV risks
TB
Hepatitis risk
History of sexually transmitted disease

History of sexually transmitted disease(Specify)
Trauma(Specify)
Other important information

Musculoskeletal

	P	C
Joint pain/swelling
Sore muscles
Weak muscles
Difficulty walking
Limited range of motion
Pain

Pain(describe)

Neurological

	P	C
Seizures
Tremors
Numbness or tingling
Pain
Paralysis
Poor coordination

Pain (describe)
Other:

Gynecology (Women)

	P	C
Currently pregnant
Menopause
Irregular periods
Menstrual cramps
Excessive blood flow
Menstrual blood clots
Breast tenderness
Abnormal Pap smear
Vaginal infections
Vaginal pain/itching
Uterine fibroids
Endometriosis
Breast lumps, cysts
Increased libido
Decreased libido

# of Pregnancies
# of Live births
# of Miscarriages
# of Abortions
Other

YesNo
Please describe
Client Signature

Clear
Print Name
Date

MonthDayYear
Date

Block Chiropractic and Rehabilitation Center, LLC

Burtonsville, MD 20866

301-476-7575

301-476-7730 fax

www.blockchiropracticcenter.com
I Name , hereby authorize the release of any and all medical records pertaining to my current state of health to be released to by Dr. Debra Block of Block Chiropractic and Rehabilitation Center LLC. Please send all diagnostic results, lab work, and history information that you have on record for me to .
Patient Name
Patient Signature

Clear
Date

MonthDayYear
Date
Date of birth

MonthDayYear
Date
Social security #
Doctors Signature

Clear
Date

MonthDayYear
Date
I Name , hereby allow Dr. Debra Block of Block Chiropractic to share my healthcare information with the following individuals.

	Contact Name	Relationship to patient	Phone number
1
2

Patient Signature

Clear
Date

MonthDayYear
Date

AUTHORIZATION AND ASSIGNMENT
Section A: Authorization and Assignment

Medical Information Release Authorization

I hereby authorize release of all records pertaining to my medical history, treatment or payment information which is required in the processing of applications for payment of benefits, to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block.

Insurance Information Release Authorization

I hereby authorize Block Chiropractic & Rehabilitation Center and Dr. Debra Block to release to my referring doctor, any other doctor(s) I am a patient of, and insurance company any information concerning my physical condition or treatment.

Late Fees, Breach, Costs and Attornevs Fees, Venue

If a credit card payment is decline or a balance is otherwise owed and the balance is not paid within thirty (30) days of billing, interest shall begin to accrue at six percent (6%) per annum. A separate fee for a returned (bounced) check equals the amount the bank charges Block Chiropractic & Rehabilitation Center, LLC plus $25.00. In addition, a late fee shall be added to the account up to $5.00 per month, or up to ten percent (10%) per month of the payment amount which is past due, whichever is greater. If an account is turned over to an attorney for collection, the patient is responsible for payment of all attorney's fees actually incurred to collect the amount due hereunder, even if the attorney's fees exceed the amount to be collected, plus interest, late fees and the actual costs of collection, whether or not a lawsuit is filed. In the event that a lawsuit is filed, said action shall be brought in the courts of Montgomery County, Maryland.

Binding Obligation, Entire Agreement

All signatories to this Agreement warrant that they have full and complete authority to enter into this Agreement and to sign said Agreement on behalf of themselves or the entity on whose behalf they are signing or both. This Agreement shall constitute the entire Agreement between the parties hereto, and no variance or modification thereof shall be valid and enforceable except by another agreement, in writing, execute and approved in the same manner as this Agreement.
Date

MonthDayYear
Date
Patient Signature

Clear
Date

MonthDayYear
Date
Block Chiropractic & Rehabilitation Center, LLC
Section B: Authorization and Waiver

Assignment of Insurance Benefits or Legal Claim

In the case of an insurance or legal claim, I hereby assign and transfer to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block, all proceeds of any such claim and authorize the insurance company or my attorney to pay all sums due to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block from said proceeds before paying the balance of said proceeds to me. I further authorize direct payment of medical benefits from my insurance company or attorney to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block, for all services rendered. I understand that I am financially responsible for any balance not covered by my insurance or a third party claim, and hereby assume full responsibility for all charges incurred for professional services rendered by Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block. If any service is denied by my insurance company, I agree to be personally financially liable for payment for said services.

Waiver

For the purposes of assigning any insurance benefits or legal claims, I hereby waive the statute of limitations with respect to a third party cause of action.

Binding Obligation, Entire Agreement

All signatories to this Agreement warrant that they have full and complete authority to enter into this Agreement and to sign said Agreement on behalf of themselves or the entity on whose behalf they are signing or both. This Agreement shall constitute the entire Agreement between the parties hereto and no variance or modification thereof shall be valid and enforceable except by another agreement, in writing, executed and approved in the same manner as this Agreement.
Date

MonthDayYear
Date
Patient Signature

Clear
Date

MonthDayYear
Date
Block Chiropractic & Rehabilitation Center, LLC

Financial Policies
The following is the summary of our payment policies and what we expect from all our patients.

Payments:

All payment is expected at time services are rendered unless other arrangements have been made in advance. This includes but is not limited to applicable coinsurance, copayments, and deductibles for participating insurance companies. Block Chiropractic and Rehabilitation Center, LLC accepts cash, personal checks, Visa, Mastercard, and Discover. There is a $25 service charge plus the bank fee for returned checks.

Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. We realize that certain patients do experience financial hardships. In such circumstances the patient or patient's representative may request a financial consultation with the office manager to discuss other arrangements. Any action taken in response to any request is at the sole discretion of Block Chiropractic and Rehabilitation Center, LLC.

Insurance:

Block Chiropractic and Rehabilitation Center, LLC bills participating insurance companies as a courtesy to the patient. The patient is expected to pay all deductibles, copayments, and coinsurance at the time of service. We will also verify insurance benefits as a courtesy to the patient, however, it is the patient's responsibility to understand his/her policy's benefits.

We will also bill secondary insurance companies as a courtesy to the patient. Again, it is the patient's responsibility to communicate with his/her primary insurance company for any bills to be forwarded to the secondary insurance company.

HMOs:

If the patient's insurance policy is an HMO and the patient is in need of a referral prior to his/her visit, it is the patient's responsibility to obtain that referral prior to coming to the first visit at Block Chiropractic and Rehabilitation Center, LLC.

Missed appointments:

Missed appointments represent a cost to Block Chiropractic and Rehabilitation Center, LLC and to other patients who could have been seen during the time set aside for the appointment. Cancellations are required at least 24 hours prior to the appointment. Block Chiropractic and Rehabilitation Center, LLC reserves the right to charge for missed or late-canceled appointments. Block Chiropractic and Rehabilitation Center's fee for a missed appointment without adequate notice is $70. Excessive abuse of scheduled appointments may result in discharge from the practice.

Credit Card on File policy:

At Block Chiropractic and Rehabilitation Center, LLC we require all patients to keep a credit card or debit card on file as a method of payment for the portion of services that insurance does not cover but for which the patient is liable. The credit card will also be charged for any missed appointments without 24 hours prior notice of cancellation and for any unpaid non-insurance services.

All patients' credit card information will be kept confidential and secured. The credit card will only be charged after the insurance claim has been filed and processed by the patients' health insurance company. Block Chiropractic and Rehabilitation Center, LLC will bill the patient prior to charging the card. Any bill that is left unpaid for 30 days will be charged to the credit/debit card on file; however, Block Chiropractic and Rehabilitation Center, LLC will first contact the patient to advise of the upcoming transaction.

I authorize Block Chiropractic and Rehabilitation Center, LLC to charge the portion of my bill that is my financial responsibility to my credit or debit card as per the above policy.

I, the undersigned, authorize Block Chiropractic and Rehabilitation Center, LLC to charge my credit or debit card for any balance due for services rendered that my insurance company identifies as my financial responsibility or non-insurance services that remain unpaid after 30 days. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 30 day notification to Block Chiropractic and Rehabilitation Center, LLC in writing and the account must be in good standing.
Name
Date

MonthDayYear
Date
Signature

Clear
Relationship to Patient
PLEASE GIVE CREDIT CARD TO FRONT DESK
Billing Address for credit card
Delinquent Accounts:

Block Chiropractic and Rehabilitation Center, LLC reserves the right to utilize a collection agency if, at its discretion the patient should fail to fulfill his/her obligation. Patient agrees that the responsibility for said balance plus fees charged by the collection agency for the cost of collection will be the patient's responsibility.

I have read and understand the financial policies of Block Chiropractic and Rehabilitation Center, LLC and agree to be bound by same.
Signature of insured or Authorized representative:

Clear
Date

MonthDayYear
Date

CONSENT OF ACUPUNCTURE
Consent is Voluntary
I hereby voluntarily consent to be treated by Betty Chang and/or Elizabeth Zou. The procedures involved in this treatment have been explained to me in detail. I understand I may be treated with the insertion of needles and/or with the application of heat to the skin and other methods. I have not been guaranteed any success concerning the uses and effects of acupuncture. I understand that I am free to discontinue treatment at any time.

Possible Side Effects
I understand that acupuncture may result in certain side effects, including local bruising, slight bleeding, fainting, temporary pain or discomfort, and temporary aggravation of symptoms existing prior to treatment. Conventional medical therapy may also be indicated, either in response to an emergency or as deemed necessary at the discretion of a licensed physician.

Medical Referral
I understand that if there is a worsening of my ailment or condition, or if it does not improve within the time estimated by the acupuncturist at the beginning of treatment, or if a new ailment or condition arises, then I should consult a licensed physician.

Infectious Disease/Clean Needle Procedures
I understand that infectious diseases are carried through the air, through physician contact, and through body fluids. I understand that Betty follows universally prescribed precautions to guard against the spread of infection.

In the case of infectious disease spread by physical contact, I understand that Betty washes her hands before seeing each patient to guard against contagion by contact.

In the case of blood borne infections, such as hepatitis or HIV, I understand that Betty follows strict precautions and use only sterilized prepackaged disposable needles. Needles that are used for my treatment will be used only on me and are inserted according to clean procedures based on nationally prescribed standards.

I understand that any questions I have about the safety of acupuncture and the precautions taken by Betty are welcome and will be answered as fully as possible.

Consent
I have read this form carefully. I have felt free to ask and questions regarding this process, and all my questions have been answered satisfactorily.
Name of Patient
Signature of Patient or Guardian

Clear
Date

MonthDayYear
Date
Should be Empty:

Acupuncture Patient Intake Form

ADDITIONAL CONTACTS

INSURANCE INFORMATION

FAMILY HISTORY

PERSONAL LIFESTYLE HABITS

MEDICAL

MEDICAL

CURRENT AND PAST CONDITIONS/SYMPTOMS/TRAUMAS

AUTHORIZATION AND ASSIGNMENT

Financial Policies

CONSENT OF ACUPUNCTURE