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Select the symptoms that are most concerning to you, then rate them as either mild, moderate, or severe in intensity and/or frequency. Leave anything that does not apply to you blank.
Liver:
Heart:
Kidney:
Lung:
Spleen:
List all of the medications, supplements, vitamins, and herbs that you have taken recently.
Include the reason taken, dose, and if it has been discontinued.
Describe your average daily diet
List any of the following that apply to you: Endometriosis Polycystic ovaries Diminishes ovarian reserve Fibroids Polyps Blocked/damaged fallopian tubes Sexually Transmitted Disease Unexplained Infertility Other
List the date and result for any of the following lab tests that you have received:
List any assisted reproductive procedures starting with the most recent (ex: Egg Retrieval, FET, medicated IUI, or un-medicated IUI). If applicable, please include the number of embryos frozen, genetically tested, and transferred under outcomes.
Menstrual History
List any pregnancies including the date of conception, how long it took to conceive, and if there were losses or complications.
Medical HistoryPlease list any conditions that you have or have had below including but not limited to the following: Undescended testicles, Injury to testicles, Hernia Repair, Varicocele, Vasectomy, Bladder or prostate issues, Urinary tract infection, Sexually transmitted disease, Problems achieving erection, Problems with sex drive, Abnormal sexual development, Fever within the last 3 months, Family history of fertility problems, Hormonal problems (ex: diabetes, thyroid), Late puberty, History of mumps, Neurological problems.
Semen analysis results
do hereby request and give permission to receive treatment from Sage Acupuncture LLC, and any affiliated Licensed Acupuncturist. Traditional Chinese Medical treatments include various modalities including but not limited to acupuncture, cupping, gua sha, herbal, and dietary supplements. I understand that I have the right to inquire about and refuse any part of the treatment.
I understand and am informed that, as in allopathic medicine, in the practice of Traditional Chinese Medicine there are some risks of treatment. I understand that although these risks are unlikely to occur, they are possible. These risks include but are not limited to: bleeding, bruising, nerve damage, punctured organs, aggravation of symptoms, the appearance of new symptoms, fainting, and fatigue. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise such judgment to be in my best interest based on the known facts at the time. Although I am aware that acupuncture and the other procedures used in Traditional Chinese Medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied.
Appointment Reminders and Follow Up Communication
We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, text (including SMS), email, or letter.
Privacy PracticesI have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.
PaymentPayment is due at the time of service. We accept cash, checks, and most major credit cards.Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment canceled for any reason with less than 24 business hours notice you will be charged a fee.A $30 fee will be charged for returned checks.We reserve the right to change our fee scale without notice.
Media ReleaseAny photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.
I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacies & Procedures information. By signing below I agree to a course of treatment in Traditional Chinese Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.
I have completed this form to the best of my knowledge. I have read and understand the informed consent, privacy, and procedures information. By entering my initials below I agree to a course of treatment in Oriental Medicine and intend this consent form to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.
