Egan Acupuncture, LLC
PO Box 412, 818 S 8th Street 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_____________________ last physical________________________
Emergency Contact: Name and phone #
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WHAT ARE THE MAIN CONDITIONS YOU WOULD LIKE TO BE HELPED WITH?
WHEN DID IT/THEY BEGIN?
TO WHAT EXTENT DOES THIS INTERFERE WITH YOUR DAILY LIFE (SLEEP, WORK, etc)?
HAVE YOU BEEN GIVEN A MEDICAL DIAGNOSIS? IF SO, PLEASE EXPLAIN.
WHAT KINDS OF TREATMENT HAVE YOU TRIED?
ARE YOU PRESENTLY BEING TREATED WITH OTHER HEALTH CARE MODALITIES?
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.
YOUR HEALTH HISTORY
PLEASE DESCRIBE ANY SURGERIES, INJURIES, ACCIDENTS, OR ILLNESS :
CHILDHOOD
ADOLESCENCE
ADULTHOOD
ANY OTHER ILLNESSES OR PROBLEMS, CURRENT OR PAST, NOT LISTED ABOVE:?
MEDICATIONS, HERBS, VITAMINS OR SUPPLEMENTS CURRENTLY TAKING?
ALLERGIES TO ANY MEDICATIONS, HERBS, VITAMINS?
HOW WOULD YOU DESCRIBE YOUR APPETITE (WEAK, STRONG, EXCESSIVE, ETC)?
CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * FOR 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:
PLEASE LIST ANY FOODS OR TASTES YOU HAVE CRAVINGS FOR:
PLEASE LIST ANY FOODS OR TASTES YOU HAVE ANY AVERSION TO:
PLEASE LIST ANY FOODS YOU ARE SENSITIVE OR ALLERGIC TO:
PLEASE DESCRIBE YOUR PROGRAM OF PHYSICAL FITNESS:
FEMALES ONLY : DATE OF LAST MENSTRUAL PERIOD:
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?
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:
MALES ONLY PLEASE CIRCLE ANY PROBLEMS YOU HAVE HAD, ADD A * TO INDICATE CURRENT:
~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:
TYPE OF CONTRACEPTION USED?
HAVE YOU EVER HAD A PROSTATE EXAMINATION? IF SO, WHEN?
ALL PATIENTS: STRESS, EMOTIONS, AND TRAUMAS DESCRIBE THE LEVELS OF STRESS IN YOUR LIFE. HOW DOES STRESS IMPACT YOU, AND HOW DO YOU DEAL WITH STRESS?
WHAT TYPE OF ACUTE ILLNESSES DO YOU GET AND HOW OFTEN HAVE YOU EXPERIENCED THEM DURING THE LAST TWO YEARS?
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
SERVICES AND FEES (cash or check only)
INITIAL VISIT $80.00
INSERTION OF SECOND SET OF NEEDLES (COMPLEX CONDITIONS) $45
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 $80.00
INSERTION OF SECOND SET OF NEEDLES (COMPLEX CONDITIONS) $45
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, or space treatments progressively further apart to maintain level of relief achieved. 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, etc. Any appointments missed or cancelled with less than 24 hours notice may 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 may be asked to pay for that visit.
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PATIENT SIGNATURE/ DATE
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PRACTITIONER SIGNATURE/ Date
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.
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PATIENT SIGNATURE/ DATE
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PRACTITIONER SIGNATURE/ Date
