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CONSULTATION FORM P. 1 of 3
C J HERBAL REMEDIES, INC.
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_____________________________________________________________
List your full name, age, sex, and today's date
_____________________________________________________________
List your complete address
_____________________________________________________________
List your home phone, work phone, and cell phone numbers
________________________________
List your E-mail address
________________________________
Occupation
________________________________
Referred by whom
WHAT ARE YOUR COMPLAINTS?
#1___________________________________________How long?______
#2___________________________________________How long?______
#3___________________________________________How long?______
#4___________________________________________How long?______
#5___________________________________________How long?______
#6___________________________________________How long?______
#7___________________________________________How long? _____
#8___________________________________________How long?______
#9___________________________________________How long?______
#10__________________________________________How long?______
#11__________________________________________How long?______
#12__________________________________________How long?______
#13__________________________________________How long?______
#14__________________________________________How long?______
#15__________________________________________How long?______
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CONSULTATION FORM P. 2 OF 3
C J HERBAL REMEDIES, INC.
Please check the appropriate descriptions and fill in the necessary information:
Emotions: depress ____ sad ____ panic attack ____ anger ____ anxiety ____
Energy: low ____ exhausted ____ hyperactive ____
Sleep Pattern: have difficulty falling asleep _____ wake up _______times per night
wake up too early ____ cannot go back to sleep after waking up _____
Menstrual Cycle: average days from the last cycle _________
days of menstration period _______
clots _____ menstrual pain _____
Color: pale red _____ bright red _____ dark red _____
Emotion around period: depression ____ irritability ____ anger ____
crying ____ anxiety ____ others: ______________
Emotions occur: before period ____ during period ____ after period ____
Temperature: fever ____ cold hands ____ cold feet ____ hot flash ____
Sweating: too little ____ too much ____ night sweats ____
Sensitivity and Allergy: cold ____ hot ____ dampness ____ food ___________
dust ____ hay ____ pollen ____ others _____________
Appetite and Digestion: poor appetite ____ rapid hungering ____ craving ____
nausea ____ bloating ____ gas ____
Bowel Movement: constipation ____ diarrhea ____ loose ____ watery ____
incomplete ____ hard and dry ____ strong smell ____ with mucous ____
with blood ____ Time of day when BM occurs: ________________________
Body Weight: Overweight ____ Underweight ____
How many pounds would you like to gain or lose? __________________
Liquid Intake: dry mouth ____ thirsty ____ drink a lot of water____
Not thirsty, but drink a lot of water anyway ____
Urination: frequent ____ urgent ____ burning ____ painful ____ cloudy ____
dark color ____ foul smell ____ retention ____ bloody ____
Number of times per day: _______ Number of times per night: ________
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Consultation Form p. 3 of 3
Pain:
Degree of Pain: _______ (0 - 10)
Chronic ______ , Acute ______ ; How long ____________
Dull ______ , Sharp _______ , Burning _______, Spasm ________ , Ache _________
Habits: smoking______ drink coffee______ drink alcohol ______
eat chocolate ______ eat cinnamon powder______ eat spicy food______
Exercise: light______ medium_______ vigorous_______
Medication: Antacids _______ Antibiotics______ Blood pressure_______
Blood thinning_______ Hormones_______ Insulin_______ Laxatives______
Sleeping Pills_______ Thyroid Medications________
Family History(F=father,M=mother; circle your answers):
Asthma ( F ) ( M ); Arthritis ( F ) ( M ); Allergies ( F ) ( M )
Anemia ( F ) ( M ); Cancer ( F ) ( M ); Colitis ( F ) ( M )
Diabetes ( F ) ( M ); Epilepsy ( F ) ( M ); Goiter ( F ) ( M )
Hypertention ( F ) ( M ); Heart Disease ( F ) ( M ); Migraine ( F ) ( M )
Overweight ( F ) ( M ); Stroke (Clots) ( F ) ( M );
Stroke (Bleeding) ( F ) ( M )
C J Herbal Remedies, Inc. 8/8/03 Form 1-2
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ACUPUNCTURE CONSENT FORM
C J Herbal Remedies Inc.
1776 Legacy Circle, Suite 102
Naperville, IL 60563
(630) 799-9288
ACUPUNCTURE INFORMATION AND INFORMED CONSENT
Acupuncture is performed by the insertion of PRE-STERILIZED,
DISPOSABLE acupuncture needles through the skin, and / or
the application of heat stimulation to skin, or both, at certain points
on the body. The benefits and risks of receiving acupuncture
procedures and Chinese herbal consultation have been explained
to me. Although rare, certain side effects may result from
Acupuncture, I understand that each procedure has specific risks
and benefits. I understand that the practice of Acupuncture and
Herbal consultation is not an exact science, and I acknowledge that
no guarantees have been made to me. I understand that licensed
Acupuncturists perform these procedures.
I have been informed of the risk and benefits of the procedures
and products listed below that apply to my case:
Acupuncture needles to stimulate points and meridians, including
the specific risks of needling certain points, and the use of
mechanical stimulation of acupuncture points or acupressure.
I have been informed and understand the risks and side effects
listed below:
1) Needle reaction symptoms: pale face, dizziness, palpitation
shortness of breath, cold sweat, nausea, even fainting, reactions
similar like low blood sugar condition, 2) Minor burning, 3) Broken
needles, 4) Some pain at the site of needle insertion, 5) Infection,
6) The risks from needling in the vicinity of an infection,
and 7) Potential side effects of Chinese herbs.
I understand that when I have needle reaction symptoms, and
emergency care is necessary, I authorize CJ Herbal Remedies Inc.
to call 911. I am responsible for payment of the full amount of
emergency care cost.
I understand that C J Herbal Remedies Inc. may record
information concerning my case in electronic and in other
physical form. Such information may be released by C J Herbal
Remedies Inc. for the purposes authorized on this form.
I understand that portions of my records may be disclosed to other
personnel for the purpose of management, financial audits,
and licensure and program evaluation without my express consent.
RECORDS RELEASE AUTHORIZATION
I understand that I am responsible for my bill.
I authorize payment directly to C J Herbal Remedies Inc.
I authorize the use of this form for all of my insurance submissions.
I authorize release of information to all my insurance companies.
I permit a copy of this authorization to be used in place of the original.
I authorize C J Herbal Remedies Inc. to make another copy of
my previous medical information which I have provided.
I authorize the use of my previous medical information to be the basis
of acupuncture procedures and herbal consultation.
This authorization is not intended to allow the release of records
regarding my case for services requiring a restricted release under
State of Federal Law.
Client’s Name (print) ____________________________________
Client’s Signature _________________________ Date ___________
NOTICE OF PRIVACY PRACTICES
I have received a copy of C J Herbal Remedies Inc. Notice of
Privacy Practices. I understand this information defines my rights
under 45 CFR 164.528 of the federal regulations and is intended to
comply with federal patient privacy rights.
Client’s Signature ________________________ Date: _____________
CONSENT FOR A MINOR CLIENT
I authorize C J Herbal Remedies Inc. and whomever it designates
as assistants to administer Acupuncture procedures and Chinese
herbal consultation as deemed necessary to my
_________________(relationship).
Minor Client’s Name_______________________________
Custodian Signature_____________________ Date _____________
Effective 8/18/03
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