Egan Acupuncture, LLC - First Visit Form

Egan Acupuncture, LLC - Chinese Medicine in Manitowoc

Egan Acupuncture, LLC

PO Box 412, Manitowoc, WI 54221

920-242-9947

Patient's first visit form package

NAME _______________________________________ DATE _______________

ADDRESS_________________________________________________________

CITY___________________________ STATE___________ZIP______________

HOME PHONE___________________________CELLPHONE_______________________

EMAIL____________________________________________________________

DATE OF BIRTH _________________ HEIGHT _____________WEIGHT__________

OCCUPATION ________________________________________________________________

REFERRED BY______________________________________________________________

PRIMARY CARE PHYSICIAN_____________________Date of last physical_______________

Emergency Contact: Name and phone #

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MAY WE COMMUNICATE WITH YOUR PHYSICIAN REGARDING YOUR TREATMENT? YES NO

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WHAT ARE THE MAIN CONDITIONS YOU WOULD LIKE TO BE HELPED WITH?

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WHEN DID IT/THEY BEGIN? PLEASE BE SPECIFIC.

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TO WHAT EXTENT DOES THIS INTERFERE WITH YOUR DAILY LIFE (SLEEP, WORK, PLAY, ETC)?

HAVE YOU BEEN GIVEN A MEDICAL DIAGNOSIS? IF SO, PLEASE EXPLAIN.

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WHAT KINDS OF TREATMENT HAVE YOU TRIED?

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ARE YOU PRESENTLY BEING TREATED WITH OTHER HEALTH CARE MODALITIES? IF SO, WHICH?

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FAMILY HISTORY

PLEASE NOTE ALL MAJOR ILLNESSES IN YOUR FAMILY, SUCH AS DIABETES, HEART DISEASE, BLOOD PRESSURE, NEUROLOGICAL DISORDERS, PSYCHOLOGICAL DISORDERS, BLOOD DISORDERS, ORTHOPEDIC DISORDERS,ETC.

GRANDPARENTS: ___________________________________________________________________

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PARENTS:___________________________________________________________________________

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SIBLINGS: __________________________________________________________________________

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YOUR HEALTH HISTORY

PLEASE DESCRIBE ANY SURGERIES, INJURIES, ACCIDENTS, OR ILLNESS DATE/AGE

BIRTH (ANY COMPLICATIONS?)

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CHILDHOOD ________________________________________________________________________

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ADOLESCENCE ______________________________________________________________________

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ADULTHOOD _______________________________________________________________________

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DO YOU HAVE ANY SCARS? PLEASE NOTE THE LOCATION OF ALL OPERATION OR INJURY SCARS

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PLEASE CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * TO INDICATE CURRENT PROBLEMS:

SKIN:

~ECZEMA

~ACNE

~SKIN RASH

~DERMATITIS

~FURUNCLES

~FUNGAL INFECTION

~WARTS

~PSORIASIS

~DANDRUFF

~DRY SCALP

~HERPES SIMPLEX/ZOSTERS

~BRITTLE NAILS

~CHANGES IN NAILS

~BRUISES EASILY

~HIVES

~ITCHING (PRURITES)

~UNUSUAL SWEATING

~NEVER SWEATING

HEART AND VASCULAR:

~FAST PULSE (OVER 100 BEATS/MIN)

~SLOW PULSE (LESS THAN 60 BEATS/MIN)

~IRREGULAR PULSE

~PALPITATIONS

~FEELING OF PRESSURE IN THE CHEST

~CHEST PAIN

~DIZZINESS

~MIGRAINE

~HEADACHE WITH NAUSEA

~COLD HANDS

~COLD FEET

~REYNAUD’S DISEASE

~ANGINA PECTORIS

~FLUSHED FACE

~HIGH BLOOD PRESSURE

~LOW BLOOD PRESSURE

~EDEMA (GENERALIZED SWELLING)

~HEART DISEASE

~COLD SWEATS

~FAINTING

~BLEEDING TENDENCY

~CHANGES IN SKIN TEMPERATURE AND COLOR

~SWELLING AT ANKLES OR LEGS

~SKIN ULCERATIONS

GASTROINTESTINAL:

~ABDOMINAL DISTENTION

~ABDOMINAL MASS

~ABDOMINAL PAIN

~VOMITING

~CONSTIPATION

~DIARRHEA

~RECTAL BLEEDING

~NO APPETITE

~INDIGESTION

~HEARTBURN/ACID REFLUX/GERD

~INTESTINAL GAS

~GALL STONES

~STOMACH DISORDER

~BELCHING

~ULCER

~GASTRITIS

~LACK OF STOMACH ACID

~HEMORRHOIDS

~ILEOCECAL VALVE SPASMS

~PERITONITIS

~PANCREATITIS

~IRRITABLE BOWEL

~POLYPS

~GI TUMORS

~HEPATITIS A, B, OR C

~LIVER DISEASE

NEUROLOGICAL:

~CHANGES IN CONSCIOUSNESS

~CONFUSION

~DIFFICULTY CONCENTRATING

~DYSPHASIA (DIFFICULTY SPEAKING)

~GAIT DISTURBANCE

~NUMBNESS OR TINGLING

~LOSS OF CONSCIOUSNESS

~PARALYSIS

~POST SHINGLES PAIN

~PROBLEMS COORDINATING MOVEMENTS

~SEVERE FORGETFULNESS

~TREMOR

~VISUAL DISTURBANCES

~WEAKNESS

UROGENITAL:

~KIDNEY DISEASE

~KIDNEY STONES

~URINARY TRACT INFECTION (UTI)

~GLOMERULONEPHRITIS

~DIFFICULTY WITH FLOW

~RED URINE

~INCONTINENCE

ORAL DISEASE:

~BLEEDING GUMS

~PERIONDONTITIS

~DENTAL ABSCESS

~MUMPS

~STOMATITIS (INFLAMATION OF THE MOUTH)

~TMJ

~TOOTHACHE WITHOUT CAVITY

RESPIRATORY:

~ASTHMA

~BRONCHITIS

~EMPHYSEMA

~COUGH

~WHEEZE

~PNEUMONIA

~TUBERCULOSIS

~HAY FEVER

~CHEST PAIN OR TIGHTNESS

~BLUISH DISCOLORATION OF SKIN

~VOICE CHANGES

~SPUTUM PRODUCTION

~SHORTNESS OF BREATH

AUTOIMMUNE, INFECTION AND

INFLAMMATORY CONDITIONS:

~AIDS

~HIV

~HASHIMOTOS DISEASE(THYROID)

~RHEUMATISM

~SYSTEMIC LUPUS ERYTHEMATOSUS

~COLITIS

~CROHNS DISEASE

~ALOPECIA(BALDNESS)

~ALLERGY

~FOOD ALLERGY ________________

~VULVITIS

~ATOPIC DERMATITIS

~NEURALGIA/NEURITIS

~NEURODERMATITIS

~CELLULITIS

~SINUS ALLERGY

~LOW IMMUNITY

~RHEUMATIC DISEASE

~RHEUMATIC FEVER

~RHEUMATOID ARTHRITIS

~SKIN DISEASE

~MALARIA

~GENITAL HERPES

~MONONUCLEOSIS

~CHICKEN POX/SHINGLES

~MEASLES/MUMPS

EAR, EYES, NOSE AND THROAT:

~LOSS OF HEARING

~TINNITUS (RINGING IN THE EARS)

~ITCHY EAR

~EAR PAIN

~FREQUENT EAR INFECTION

~EAR DISCHARGE

~PROBLEMS WITH BALANCE (VERTIGO)

~FAR SIGHTED

~NEAR SIGHTED

~EYE INFECTION

~LOSS OF VISION

~EYE REDNESS

~TEARING OR EYE DRYNESS

~EYE PAIN

~EYE DISCHARGE

~SINUS PAIN/PRESSURE/HEADACHE

~YELLOW MUCUS

~CONSTANT SINUS CONGESTION

~STUFFY NOSE

~NOSE BLEEDS

~POST-NASAL-DRIP

~OLFACTION (SENSE OF SMELL) IMPAIRED

~ITCHY THROAT

~DRY THROAT

~TONSILITIS

~STREPTOCOCCI THROAT INFECTIONS

~EASILY CATCH COLD

CONNECTIVE TISSUE OR LIGAMENT

DISEASE:

~MYOFACIAL PAIN SYMPTOMS

~FIBROMYALGIA

~TENDONITIS

~LIGAMENT PERICARDITIS

~CONSTANT SLIGHT FEVER

~PLANTER FASCIITIS

~SCARLET FEVER

~SWOLLEN GLANDS

~STREPTOCOCCI THROAT INFECTION

MUSCULOSKELETAL:

~WEAK LEGS

~RESTLESS LEGS

~OSTEOPOROSIS

~MUSCLE PAIN

~STIFFNESS

~SWELLING

~SPASMS OR CRAMPS

~LIMITED RANGE OF MOTION

~JOINT CLICKING

HORMONAL IMBALANCE:

~LOW THYROID

~OVERACTIVE THYROID

~DIABETES

~HYPOGLYCEMIA

~BLOOD SUGAR

PSYCHOLOGICAL:

~FEELINGS OF GRIEF

~FEELINGS OF SADNESS

~FEELINGS OF FEAR/ANXIETY/ NERVOUSNESS

~DIFFICULTY MANAGING ANGER

~FEELING MANIC

~FEELING WORRIED OR OVERLY PENSIVE

~FEELINGS OF PANIC

~FEELING OVERWHELMED

~EXTREME MOOD SWINGS

~EXTREME LACK OF EMOTION

GENERAL:

~INSOMNIA

~NIGHTMARES

~VIVID DREAMS

~PERSPIRE EASILY

~SWEATY PALMS/SOLES

~PSYCHOSOMATIC WEAKNESS

~EXHAUSTION

~DIFFICULTY CONCENTRATING

~LOW ENERGY

~CAR/SEA/AIR SICKNESS

~NO APPETITE IN THE A.M.

~MOODY IN THE A.M.

~TEETH GRINDING

PLEASE LIST ANY OTHER ILLNESSES OR PROBLEMS, CURRENT OR PAST, NOT LISTED ABOVE:

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PLEASE LIST ANY MEDICATIONS, HERBS, VITAMINS OR SUPPLEMENTS YOU ARE CURRENTLY TAKING.

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PLEASE LIST ANY MEDICATIONS, HERBS, VITAMINS, ETC. TO WHICH YOU ARE ALLERGIC.

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HOW WOULD YOU DESCRIBE YOUR APPETITE (WEAK, STRONG, EXCESSIVE, ETC)?

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PLEASE CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * TO INDICATE CURRENT PROBLEMS:

~ANOREXIA ~BULIMIA ~OBESITY

~OVERWEIGHT ~BELCHING ~FLATULENCE

~HEARTBURN ~ABDOMINAL BLOATING ~ABDOMINAL PAIN

~PAIN AFTER EATIING ~PAIN BEFORE EATING ~TIRED AFTER EATING

~UNDERWEIGHT ~ULCER ~COLITIS NAUSEA

~RAPID WEIGHT CHANGE ~HYPOGLYCEMIA ~IRRITABLE BEFORE EATING

~STOMACH TENSION ~DIFFICULTY SWALLOWING

~CONSTIPATION ~DIARRHEA

~HEMORRHOIDS ~RECTAL BLEEDING

~DISTRESS FROM FATS (NAUSEA, DIZZINESS, HEADACHES, ETC.)

PLEASE LIST ANY OTHER DIGESTIVE CONDITION, CURRENT OR PAST, NOT LISTED ABOVE:

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PLEASE LIST ANY FOODS OR TASTES YOU HAVE CRAVINGS FOR:

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PLEASE LIST ANY FOODS OR TASTES YOU HAVE ANY AVERSION TO:

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PLEASE LIST ANY FOODS YOU ARE SENSITIVE OR ALLERGIC TO:

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PLEASE DESCRIBE YOUR PROGRAM OF PHYSICAL FITNESS:

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FEMALES ONLY (MALES, PLEASE SKIP THIS SECTION AND CONTINUE WITH THE NEXT)

DATE OF LAST MENSTRUAL PERIOD:

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HOW MANY DAYS DOES YOUR PERIOD LAST? ___________________________________________

HOW MANY DAYS IN YOUR MONTHLY CYCLE? __________________________________________

AGE YOU FIRST BEGAN TO MENSTRUATE? ___________ AGE AT MENOPAUSE? ____________

DO YOU CURRENTLY TAKE BIRTH CONTROL PILLS? ___________ FOR HOW LONG? _________

HAVE YOU EVER TAKEN BIRTH CONTROL PILLS, WHEN AND HOW LONG?_______________________

TYPE OF CONTRACEPTION NOW USED? _______________________________________________

PLEASE CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * TO INDICATE CURRENT PROBLEMS:

~HEAVY BLEEDING ~CRAMPING BEFORE PERIOD ~PMS

~CRAMPING W/ PERIOD ~CLOTS W/ PERIOD ~OVARIAN CYST

~BLEEDING B/W PERIOD ~GENITAL HERPES ~PID

~GENITAL BURNING ~URINARY TRACT INFECTION ~BREAST LUMPS

~YEAST INFECTION ~VAGINAL DISCHARGE/ITCH ~PAIN DURING

~INFERTILITY ~BLEEDING AFTER INTERCOURSE INTERCOURSE

PLEASE LIST ANY GYNECOLOGICAL CONDITIONS, CURRENT OR PAST, NOT LISTED ABOVE:

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MALES ONLY (FEMALES PLEASE SKIP THIS SECTION AND CONTINUE WITH THE NEXT SECTION)

PLEASE CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * TO INDICATE CURRENT PROBLEMS:

~URINE STREAM WEAK OR SLOW ~GENITAL BURNING

~FREQUENT URINATION W/ SMALL AMOUNT ~URINARY TRACT INFECTION

~DRIBBLING AFTER URINATION ~YEAST INFECTION

~BURNING URINATION ~GENITAL ITCHING

~WAKING AT NIGHT TO URINATE ~INFERTILITY

~PROSTATE DISORDER ~GENITAL HERPES

~DISCHARGE FROM PENIS ~PAIN DURING INTERCOURSE

~NOCTURNAL EMISSION ~PREMATURE EJACULATION

~LOSS OF SEXUAL ACTIVITY ~HERNIA

~SWELLING OR LUMP ON TESTICLES ~PAINFUL TESTICLES OR PENIS

PLEASE LIST ANY OTHER CONDITIONS, CURRENT OR PAST, NOT LISTED ABOVE:

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TYPE OF CONTRACEPTION USED? ____________________________________________________

HAVE YOU EVER HAD A PROSTATE EXAMINATION? IF SO, WHEN?

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STRESS, EMOTIONS, AND TRAUMAS (TO BE COMPLETED BY EVERYONE)

DESCRIBE THE LEVELS OF STRESS IN YOUR LIFE. HOW DOES STRESS IMPACT YOU, AND HOW DO YOU DEAL WITH STRESS?

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WHAT TYPE OF ACUTE ILLNESS DO YOU GET AND HOW OFTEN HAVE YOU EXPERIENCED THEM DURING THE LAST TWO YEARS?

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PLEASE MARK ANY AREAS OF PAIN ON THE DIAGRAMS BELOW:

THANK YOU FOR YOUR HONESTY, AS IT WILL HELP US BETTER UNDERSTAND YOUR CURRENT STATE AND ALLOW US TO MOVE MORE ACCURATELY TOWARD YOUR IMPROVED HEALTH.

All patients are advised to consult a physician regarding the condition or conditions for which they are seeking acupuncture treatment. In addition, patients are responsible for seeking the advice and treatment of a physician should their symptoms change for the worse, or should any new condition arise.

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PATIENT SIGNATURE/ DATE

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PRACTITIONER SIGNATURE/ Date

Egan Acupuncture, LLC

SERVICES AND FEES (cash or check only)

INITIAL VISIT $75.00

A thorough history and evaluation is followed by a full treatment. The plan of treatment will be

determined at this time. Please allow one hour and 30 minutes.

FOLLOW UP VISITS $75.00

Acupuncture’s effects are cumulative. Some patients will maximize the benefits of acupuncture by having 2 treatments per week for the first several weeks. For most patients, one session per week for the first 3 -4 weeks,

is recommended. Following this, a weekly session is appropriate until the patients' issues are resolved .

Many people use acupuncture for health maintenance or to address chronic health concerns.

The schedule of these treatments varies from twice a month to four times per year, at the

change of seasons.

Any appointments missed or cancelled with less than 24 hours notice will incur the full service fee

billed to your account.

I have read the above and agree to pay the fees listed at the time of service. I understand that

if I miss an appointment or cancel with less than 24 hour notice I will pay for that visit.

Egan Acupuncture, LLC

PO Box 412, 818 S 8 Street, Manitowoc, WI 54221

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

This notice summarizes how the health data about you may be used and shared and how you

can get access to this data.

I. How we may use and share health data about you:

a) Treatment – To give you medical treatment or other types of health services.

b) Payment – To bill you or a third party for payment for services provided to you.

c) Health Care operations – For our own operations such as quality control, compliance

monitoring, audit, etc.

II. Disclosures where we do not have to give you a chance to agree or object:

a) To you

b) As required by a federal, state, or local law

c) If child abuse or neglect is suspected

d) Public health risks (for public activities to prevent and control spread of disease)

e) Lawsuits and disputes (in response to a court or administrative order)

f) Law enforcement(to help law enforcement officials respond to criminal activities)

g) Coroners, medical examiners and funeral directors

h) Organ or tissue donation facilities if you are an organ donor

i) To avert a threat to an individual or to public health safety

III. Disclosures where we have to give you a chance to agree or object:

a) Patient directories – You can decide what health data, if any, you want to be listed in

patient directories.

b) Persons involved in your care or payment for your care – We may share your health data

with your family member, a close friend, or other person that you have named as being

involved with your health care.

IV. Other uses of health data: Other uses not covered by this notice or the laws that apply to

us will be made only with your written consent.

V. You have the following rights relating to health data we keep about you:

a) Right to inspect your health record and to receive a copy upon request

b) Right to amend information in your health record you believe is inaccurate or incomplete

c) Right to know to whom we have disclosed your health information

d) Right to ask for limits on the health information data we give out about you

e) Right to receive communication from us about your health information in alternate ways

f) Right to a paper copy of the complete Notice of Privacy Practices

I acknowledge that I have received the NOTICE OF PRIVACY PRACTICES of this practice.

Signature of patient or representative/ Date

Print patient name Patient Birth/ Date

We are located in the historic Rummele's building, just south of the 8th street bridge and across the street from the Farmer's Market. Stop in for a tour!

818 S. 8th Street

Manitowoc, WI 54220

Hours:

Mon - Fri: 9AM - 5PM

Sat: 10AM - 5PM

Sun: Closed