Acupuncturehealthcompany.com

Welcome to Acupuncture Health Company!

I am Stacy Hewitt, Licensed Acupuncturist, Licensed Massage Therapist and owner of Acupuncture
Health Company. I'm very happy that you have chosen me to be your complementary health care provider. I’m excited about the new partnership we are about to embark on together to bring you to In this packet you will find several forms. Please print, read and fill them out prior to your first appointment. By bringing these COMPLETED forms to your first appointment we wil be able to spend more time together for treatment. Included you wil find: a Welcome Letter, an Acupuncture Fact Sheet, a New Patient Intake and an Office Policy Form. Most people know how effective acupuncture is for treating pain, but the treatment of pain is only the “tip of the iceberg” for the endless list of health concerns for which acupuncture is effective. I’ve included a one page list of some of the health issues acupuncture can assist with. Some of the health issues on the list may surprise you. If anything resonates with your current health condition, please make sure to bring them up, or if you see something on the list that might benefit someone you know, please pass on the list or talk to them about the possibilities of treatment through acupuncture. At Acupuncture Health Company we strive to provide the highest quality of health care and spread optimal Here are few suggestions to prepare for your treatment: • Eat a light meal or snack a few hours prior to your visit. Acupuncture is not performed on • Avoid alcohol on the day of your treatment. • Wear loose, comfortable clothing. Many of the acupuncture points that are commonly used are located between the wrists and elbows and the ankles and knees. You wil be more comfortable if your clothing can be easily rol ed up to your elbows and knees. • Please bring a list of current medications you are taking and/or any lab reports that are relevant • Please bring your date book or calendar. Depending on the chronicity and severity of your health issues you may need 2-5 treatments. My appointments get booked quickly. Please be prepared to schedule your appointments at the end of our session, so we can maintain continuity and a successful progression towards your health goal. • I accept cash and check as payment. I do not accept credit cards.
Thanks again for taking the time to fill out your paperwork prior to treatment. I look forward to meeting with you and formulating a individualize plan to optimize your health and wel ness! Acupuncture can help with the fol owing:
Cardiac Palpitations (Irregular Heartbeat) Indigestion, Gas, Bloating, Constipation Women’s Health, Fertility & Pregnancy
Anemia
Labor issues: pre-term labor, delayed labor PUPPs & other pregnancy-related skin conditions Nausea, vomiting, and hyperemesis gravidarum Thyroid Dysfunction
Children’s Health
Allergies
These are some of the conditions that acupuncture can help. Please review or pass along to a friend. If you do not see your health concern above, please call for a free consultation. Acupuncture Health Company
919-960-1054
Acupuncture Health Company – New Patient Questionnaire
PATIENT DATA
Date: ___________

Name: ______________________________________________________________________
Address: ____________________________________________________________________
City/State/Zip: _______________________________________________________________
Phone: (H) ___________________ (W) ___________________ (C) _____________________
Email: ______________________________________________________________________
Occupation:_________________________ Name of Employer:________________________
Date of Birth: __________________ Age: _______ Sex: Male
Circle one:
Referred by: _________________________________________________________________
Please list your current primary care physical and any other specialist or therapist you may be
seeing:
Name
Contact Number

Please list any Current Western Medical Diagnosis:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Which of the fol owing have you experienced before? Circle al that apply.

Acupuncture Health Company – New Patient Questionnaire
PRIMARY CONCERN(S)
1.
2.
3.
MEDICAL HISTORY
A. Medication(s): List all prescribed (allopathic) drugs, non-prescribed medications, vitamins, herbs, etc… you are taking and stating what you are using them for. Have you ever been on any muscle/tendon compromising antibiotics such as Cipro, Levaquin, Avelox, Floxin or Noroxin? No_____ Yes_____If yes, when?_____________ Are you on any type of blood thinners (for example: Coumadin (warfarin), Dicumarol (dicumarol), Miradon (anisinidione), Pradaxa (dabigatran)? No______ Yes______ B. Do you use or do any of the following on a regular basis? Circle all that apply. C. List any hospitalizations, accidents, and past il nesses. Include dates and your age at the time. 1. 2. 3. D. List any serious diseases in your FAMILY HISTORY, such as cancer, diabetes, hypertension,
E. Do you currently have, or have you ever had:
Acupuncture Health Company – New Patient Questionnaire ____ fainting easily _____bruising easily ____ slow blood clotting ____ brittle/easily torn skin ____ heart problems _____ breathing difficulties ____ hepatitis (note type: _____ ) ______HIV/AIDS ____ high blood pressure (most recent blood pressure reading: ( _____ / ______ ) ____ col apsed lung ____ diabetes ____ fear of needles
F. Are you Allergic to any substance or have seasonal allergies? Yes____ No____ If yes, please
list:
1.
2.
3.
Do you have any allergies to gold? Yes____ No____

Please check al that currently apply to your health situation.
MUSCULOSKELETAL
Neck pain
NEUROPHYSIOLOGICAL/EMOTIONAL
Seizures
GENERAL
Night sweats
Acupuncture Health Company – New Patient Questionnaire Immune issues, like high ANA Dental amalgam fillings time:
CARDIOVASCULAR
High blood pressure
RESPIRATORY
Asthma

GASTROINTESTINAL
HEAD, EYES, EARS & THROAT
Headaches
FEMALES
Cycle length: ______ days
Days of bleeding: ______ days Endometriosis Menstrual blood color: _____ Number of pregnancies: ____ Sexually transmitted illness Acupuncture Health Company – New Patient Questionnaire Date of last PAP: __________ Age at menopause: ______ Tested for chlamydia: Yes No # of IUI or IVF cycles: ______ FSH level ____ AMH level ___ Fibroids Adhesions Cysts Males
Prostrate problems
Sperm analysis normal Yes No Immune issues like antisperm List any additional information you would like us to know: ____________________________ ____________________________________________________________________________ ____________________________________________________________________________ Acupuncture Health Company
General Policies
1. We make every effort to keep the cost of care down. To assist this effort, you are expected to pay in
full for acupuncture and/or herbs upon completion of each visit. We accept cash or checks. We do not
accept credit cards. If payment is not rendered at time of service there will be an additional $30.00
service charge.
2. Returned checks are subject to a $30.00 service charge.
3. Al patients are seen on an appointment basis. Please call well in advance so we can reserve a time
for you. Please be aware that AT LEAST 24 HOURS NOTICE OF CANCELLATION IS REQUIRED TO AVOID A
MISSED/LATE/CANCELLED APPOINTMENT CHARGE . If you are unable to give us 24 hours advance
notice you wil be charged the full amount of your appointment. This amount must be paid prior to or
at your next scheduled appointment.
It is the patient’s responsibility to remember an appointment. Reminder calls or e-mails are made only
as a courtesy. Anyone who either forgets or does not show up for their appointment will be considered
a “no-show.” “No-shows” wil be charged the full amount of their appointment. This amount must be
paid prior to or at your next scheduled appointment.
We strive to provide the highest level of service. Failure to cancel appointments with sufficient notice denies an opportunity for other patients on our waiting list to be seen at the time reserved for you. 4. Please arrive on time to get the full value out of your treatment. If you find that you cannot be on time, please notify our office as soon as possible. If you are late for your appointment, the practitioner may not be able to see you at that time or may not be able to give you the full amount of time originally 5. To insure we can easily contact you, please advise us of any change in your address or phone 6. We do not accept health insurance or file health insurance claims. However, we will do our best to provide you with the documentation required for you to submit claims to your insurance provider. 8. We will automatically sign you up for our e-mail newsletter. You may opt out of this at any time by e- 7. We request that you eat a snack or a small meal two hours prior to receiving your treatment. 8. Please do not be alarmed if some minor bruising results from treatment. This happens occasional y and is normal but if you have any questions or concerns, we encourage you to cal our office. By voluntarily signing below, I acknowledge that I have read each of the above statements in detail, understand each line item fully and will be compliant. Patient Ful Name: _______________________________________________ Patient Signature: ________________________________________________ Date: ________ Acupuncture Health Company
919-960-1054

Source: http://www.acupuncturehealthcompany.com/new-patient.pdf