Informed Consent for Acupuncture Treatment and Care

I hereby rcquest and consent to the performance of acupuncture treafinents and other Oriental Medicine procedures,

including various modes of physio-therapy on me (or on the patiem named below, for whom I am legally

responsible) by the below named licensed acupuncturist and/or other licerrsed acupuncturist for now or in the future

treat me while employed by, working or associated with or servicing as a back-up for the kearing acupuncturist

named below, including those working at this office/clinic or any other office or clinic.

I understand the methods of treatment may include, but are not limited to, acupuncture, acupressure, moxibustion,

cupping electrical stimulation, Tui-Na (Chinese massage), Chinese or Western herbs and nutritional counseling

I have had the opportunity discuss with the Acupuncturist named below and/or other office or clinic personnel the

nahre and purpose ofacupuncture treatrnents and other procedures.

Acupuncture had the effect to normalizs physiological functions, to modifu the perceprtion of pain, and to treat

certain diseases or dysfunctions of the body- I have been informed that acupuncture is a safe method of tneatment,

but occasionally there may be some bruisbg or tinglitrg near tbe needling sites trat last a few days. There have been

very rare instances of fainting, infections and scarring- There have been extemely rare inshnces of spontaneous

miscarriage and pneumothorax- There may be somc bruising after cupping.

The herbs and nutritional supplements (which are &orn plant, animal and mineral sources) that have been

recommended are traditionally considered safe in the practice of Chinese Medicine. I understand that some herbs

may be inappropriate drring pregnancy. If I experience any gastro-intestinal upset, or allergic reaction to the herbs I

will inform the acupunchrrist.

I do not expect the acupuncturist to be able to anticipate and explain,all risks and complications, and I wish to rely

on the acupuncturist to exercis! judgment during the course of the procedure which the acupuncturist feels at the

time, based upon the facts then known, is in my best intercst.

I understand the clinical and administrative staffmay review my medical records and lab reports, but all my records

will be kept confidential and will not be rcleased witltout my written consent'

I have read, or have had read to me, the above consent. I have also had the opportuniry to ask qusstions about its

content, and by sigring below I agre! to the above-named procedures- I intend this consent form to cover the entire

course of treatment for my present condition and any funIre condition(s) for which I s!!k trcatment.

To be completed by patient: To be completed by the patient's representafive, if

necessary, e.g. ifthe patient is a minor or isphysically or legally in capacitated:

Print patient's name Print patient's name

frint n'onrc oiputi""t's r"pt"s"n

Patients-fislature Date Signature of patient's repres!nhtive

R"lutio;rhip of r"p."*ntuti* io duri*t

Pure Life Acupuncture & Wellness Center

Erika Barrantes, LAc.23421 Hawthorne Blvd. Torrance CA 90505Phone (310) 373-7363 Fax[310) 373-7365

www.purelifeacupuncture.com

Pure Lffe Acupuncture & Wellness Center

Con fidentia I ity Ag reernent

To Our Valued Patients;

We at Pure Ufe Acupuncture have always made vour priua6/ one of our top priorities. Wewoufd like to inbrm you of the measures our'office has iaken to insure'ybur rights ofpatient prilacy. (ln accdrdance with HIPPA)

We comrnunicate with our patients throuqh mail, e-mail, and by phone. Below is a list ofwa)s in which our of{ace corresponds wfth-you. Please indicate ariy'iternsthat you do NOTwish to receive.

Mailer ln o({rcn

1, -Birthday greetingsZ. -Healthcare rnaintenance rerninders3. -Holiday cards4. -lhankyou car.ds (or your referrals5. -Health tttewsleuer

'

I prefur all mailed corespondence to be sent to my -Home -O(fice. (Please Check One)

Phone C-alls6. Health care maintenance reminders7. - Appointment reminden .B. Miised appointment rescheduling

In the !vent lhat we a!9 unable to speak with you diregtly, please indicate the vqys in which itis acceptable for our o(ficeto leave a courteqf message for you.

----On your home answering machine or with htnily-Office voicernail or with receptionist

O.K. to leave deta;led message wlth information

-_-Please leave message with a call back nurnber only

We will do our best to alnays honor your reguests when communicating with you.

Yours In Health.

Pure Life Acupuncture & Wellness Center

Date Witness

Pure Life Acupuncture & Wellness Center

Erika Barrantes, LAc.23421Har,nthorne Blvd. Torr:ance CA 9OS0SPhone (310) 373-7363 Fax [310) 373-7365

www.purelifeacupunctu ne.com

Patient 5ignature Date

COM PREH ENSIVE HEALTH EVALUATIONW9 are asking you to answer the íollowing guestÍons as accurately as possibíe. Your answers will províd7 us with impoftantinformation to help us in diagnosing, treating and providing you with quatity âotistic health care. (Treating the whole'personrequires attention to ail symptoms and conditions).

Name Date

What is your present major complaint

1. ls your condition caused by: n Work injury n Auto accident n lllness

tr Fall I Other (specify)

Date oÍ above injury/accidenVillness or when your first noticed it:

Duration and Írequency oÍ your pain?

2.

3.

4.

5.

6.

7.

Does any position relieve your pain? (explain)

What makes your condition worse?

ls it D Better n Worse in the I Morning? f

Does it interfere with your: n Work? fÌ Standing

! Bendíng ! Stooping tr Lifting n Pulling tr

Evening?

D Walking tr Sitting

Pushing D Reaching nGripping

8.

9.

10.

11.

12.

13.

14.

15.

I Climbing D Kneeling I Balance tr Other

When bending Íorward is the pain in your ! Neck n Mid back E Low back

When bending backwards is the pain in your ! Neck ! Mid back ! Low back

When bending sideways (right) is the pain in your D Neck I Mid back n Low back

When bending sideways (left) is the pain in your D Neck D Mid back X Low back

When twisting sideways (right) is the pain in your D Neck ! Mid back D Low back

When twisting sideways (left) is the pain in your n Neck D Mid back ! Low back

List any other movements or positions which cause you pain

Have you had

lÍ yes, when?

previous treatment Íor this condition? n Yes nNo

Who treated you?

16. List and give dates oÍ previous accidents or illnesses

17. List and give dates oÍ major illnesses, operations or hospitalizations

Do you Íeel your present condition is

X Temporary n Permanent I Don't know

PLEASE MARK YOUR AREAS OF PAIN

#106&NI"IISSION PRIÍ\nNG (5591 227-7eO . (8@) 69&2t(E

18.

Patient Name:

PATIENT SYMPTOM SURVEY

Date:

PIEASE CHECK YOUR PASÍ & PRESEVT SYI}'PTO'I'S SO WE CAN BEÍIER EUALUATE YOIJR PROBLEM

GENERALPAST NOW

n ! ÍatigueI ! sleep problemsn D swollen glandsX ! hot or cold intoleranceE n frequent headachesI n weight losstr ! weight gainMever or chil lsn ! allergies

NERVOUS SYSTEMtr ! dizzinessn ! blurred visionI D ÍaintingI ! paralysisn n tremorsn ! numbness/tinglingI ! convulsionstr n imbalanceI n memory lossn ! muscle weakness

URINARYX n painÍul urination! ! Írequent urination! n hard to urinate! tr incontinenceI n bed wettingn ! discolored urineI [ Írequent infectionsn ! prostate problemsI ! unusual discharge

HEADD n headache

I entire head! back oÍ headn Íoreheadn templestr migraine

! D head Íeels heavyD n loss oÍ memoryn n l ight-headednessn ! Íaintingn ! light bothers eyesI n loss oÍ smellMoss oÍ tasteX ! loss oÍ balance! ! dizzinesstr tr loss oÍ hearingI n pain in earsn I ringing in earstr fl buzzing in ears

NECKD I pain in neck! n neck pain wiih movementn ü pinched nerve in neckn ! neck feels out of placen n stiff neckD ! muscle spasms in neckn D grinding sounds in neckn ! grating sounds in neckn n popping sounds in neckn ! arthritis in neck

EMOTIONALPAST NOW

n ! anxiety or worry! I frequent cryingn I angern n tensionn ! mood swingsn I Íearn ! restlessnesstr I conÍusion! I depressionf n suicidal

REPRODUCTIVE SYSTEMI ! painÍul intercoursen ! prostate problemsn ! sexual problemsn n loss oÍ sex driven ! genital infections

Birth Control Method _

WOMEN ONLYn n crampsNIPMS! n irregular periods

Are you Pregnant? n YestrNodate last period _# oÍ pregnancies _# of miscarriages _# oÍ abortionsdate last PAP

I f difficult laborI I breast problems

LOW BACKI n low back pain

Low Back pain is worsewhen:

D working! lifting! stooping! standing! sitting! bending'! coughing

D I low back Íeels out oÍ place! I muscle sDasmstr I arthritis

MID BACKX I mid back painI n pain between shoulder

bladesI ! sharp stabbing

pain/midbacktr ! muscle spasms

CHESTtr n chest painú n shortness oÍ breathtr ! pain around ribs

EENTPAST NOW

I I earachetr D ear dischargetr tr ringing in earsMearing loss! tr nosebleedsX I hoarsenessn D problems swallowingD tr sore throatn n jaw tight or soren tr dental problemsü ü glasses/contacts

MUSCULOSKELETALI D joint swellingfÌ ! muscle crampsD I neck painn ! shoulder painn n tennis elbown n arm painD n hand sensationsn n loss oÍ gripn n midback oainn ! rib painn tr low back problernstr n hip painD n Íoot problemstr I leg crampsI D knee painI n ankle weaknessI tr tingling Íoot

SHOULDERSn tr pain in shoulder jointI I pain across shoulderstr tr bursitis (R-L)I I arthritis (R-L)I I Can't raise arm:

D above shoulder levelX over head

I I tension in shouldersI D pinched nerve in shouldertr D muscle spasms in

shoulders

HEART/LUNGPAST NOW

n tr chest paint-Ligh blood pressure! I low blood pressuretr n persistent cough! n hard to breathe! I coughing bloodn ! coughing phlegm! I irregulaÍ heartbeatn n varicose veinstr I ankle swell ing

GASTROINTESTINALtr n change in appetiteI n thirst! n nauseaI n vomiting! D diarrhea! n constipationnlgasn D hemorrhoidsn D gal lb ladderf f belchingI D heartburn! n abdominal painI n bloody/black stoolsD ! indigestionn ! l iver trouble

SKIND n easy bruisingfLryskinn |] itchingD ! boils! n rashesn n excessive sweat! n hairchanges

HIPS, LEGS & FEET! n pain in buttocks (R-L)n n pain in hip joint (R-L)ú I pain down leg (R-L)n tr pain down both legsI I leg crampsn D pins & needles in legsn I numbness oÍ leg (R-L)n n numbness oÍ feet (R-L)n tr numbness of toesn ! Íeet feel coldI ! cramps in feet (R-L)n fl swollen ankles (R-L)I I swollen feet (R-L)n tr painÍuljoints in toestr ! pain in Íoot (R-L)n tr pain in knee (R-L)

GENERALtr n nervousnessn ! irritableú n depressedD ! ÍatigueI n generally Íeel rundownn ! loss oÍ sleeptr ü loss oÍ weight

D I pinched nerve in low back! I sl ipped disk ARMS & HANDS

I X paìn in upper armtr I pain in Íorearmtr I pain in handsD ! pain in fingerstr n pinched nerve in armn n pinched nerve in fingersX I pins & needles in armsI I pins & needles in Íingersn I Íingers go to sleepn X hands coldn I swollen joints in Íingerstr I arthritis in Íingersf [J loss oÍ grip strength

1. Date of your last physical examination

2. Are you CURRENTLY receiving care from a ! Chiropractor ! Acupuncturist tr Medical X Dentist ! Physical Therapist

I Massage Therapist n Nutritionist n Other

3. Who are you seeing and why?

4. What results did you get?

5. What medications have you taken within the last 2 months (lnclude over-the-counter drugs, vitamins, herbs, etc.)

1. Has your father or mother ever had:! Alcoholism D Diabetes

FAMILY HISTORY

I High blood pressure n TuberculosisI Ulcersn Other

! Allergies tr Drug problem I Kidney disease! Arthritis I Epilepsy D MentaldisorderI Asthma I Glaucoma I ScoliosisI Cancer tr Heart Trouble ! Stroke

N UTRITIONAL EVALUATION

1. List some oÍ your Íavorite Íoods

2. Do you: I Skip breakfast ! Eat a snack I Eat a hearty breakÍast

3. How many meals a day do you eat? When is your biggest meal?

4. Do you eat when you are worried or rushed? I Yes ! No How otten?

5. Do you plan your meals according to the "Four basic Íood groups"? D Yes I No

6. DO YOU: Eat raw fruits or vegetables at least twice a day? ! Yes tr NoEat green or yellow vegetables at least twice a day? fl Yes I NoEat frequently between meals? ! Yes n NoChew your Íood thoroughly before swallowing it? n Yes n NoDrink juice, milk or other drinks instead oÍ water when thirsty? ! Yes n NoAlways add salt at the table? n Yes tr NoEat meat or dairy products 2 or more times a day? I Yes n NoEat the same Íoods almost every day? I Yes n NoEaÌ when you are not hungry? n Yes tr NoEat untilyou Íeel full? n Yes ü NoOccasionally go on a "crash" diet? n Yes n NoAlways buy the cheapest Íoods? D Yes D No

7. Check below the types of Íoods you normally eat each day:

ú Non Íoods: beverages etc.! Desserts, candies, pastries, etc.

. ! Products made from white Ílourn Products containing sugar! Products containing chemical additives

n Pure, natural, untreated meats! Raw milk and its unprocessed productstr Healthy, home canned Íruits and vegetablesn Healthy, home Írozen Íruits and vegetablesÜ 1000/o grain products

Type

I Processed meats: luncheon meats, bacon, etc. E Common, fresh, cooked Íruits and vegetablesI Ordinary treated, commercial meats n Organic, Íresh, cooked fruits and vegetables! Processed (pasturized) milk and its products n Sproutsn Commercially canned fruits and vegetables n Fresh, organic nutsú Commercially Írozen Íruits and vegetables ! Common, Íresh, raw Íruits and vegetables

n Organic, Íresh, raw fruits and vegetablesn Commercial nuts

8. Do you use: Alcohol? ! Yes n No Amount per weekTobacco? nYes üNo PacksperdayCoffee? fl Yes ú No Cups a day-Carbonated drinks? (Pepsi, Coca Cola, etc.) tr Yes ! No Per day

9. How many glasses of water do you drink a day? - tr Filtered ü Bottled

How many years

EN VIRONM ENTAL EVALUATION

1. Do you react to any chemicals, cosmetics, household cleaners, smoke, Íabrics, etc.? ! yes ! No lÍ yes, list2. Check any oÍ the Íollowing items you are exposed to or use:

I Aluminum cookwareI TeÍlon cookwaretr Microwave ovenI Computer termlnal

Hours per day _I Flourescent lights

Hours per day _! Secondhand cigarette smoken Periodic high noise levels! Have you been exposed to AIDS? ü Yes n Non Have you had a venereal disease? D yes ! Notr Drugs? D Recreational ! Prescription When

n Continuous background noise! Synthetic Íiberstr Heavy metals (Lead, mercury asbestos, etc.)List

I Toxic chemicals (pesticides, Dioxin, Radioactive,PCB, etc.) Lisl

! Electric blanket

List3. Do you live near:

! A Íreeway or busy streetü Major powerline or electric substationI Radio or TV transmission tower! Toxic waste site

4. Do you like your neighborhood? D Yes tr No5. Is your home:

Heated with I Electricity x Gas n wood other

n Airport! Nuclear reactortr Major industry

What kind

! Hot ! Cold n Light tr Dark f Drafty f Damp D Retaxing! Tense U New I Old n Safe ! Noisy n Recently remodelledOther

LIFESTYLE EVALUATION

1. Work Position heldHow long? Do you like your job? ü Yes D No

2. Do you have any job problems? I Yes tr No lÍ yes, what?3. Do you have financial worries? n Yes n No4. School: I Finished grade n Finished high school n Other5. What are your hobbies/interests? List6. How many hours a day do you watch rv? -

your favorite shows?7. Do you have stress in your liÍe? ! Yes tr No lf yes, what causes the stress?

8. ls your energy level n High n Low ! Up and Down9. Do you exercise? n Yes n No f lf yes, how many

D Outdoors ! Indoors ! Regularly ! Occasionallyhours a weekn Never

10. How many hours do you sleep at night? Usualbedt imeUsual time you get up Do you Íeel rested when you get up n Yes n No

11. How often do you take naps? How often do you wake up at night?1 2. How long have you been with your spouse? Companion?13. Please indicate approximate dates and briefly describe the nature oÍ any traumatic experience you have had (e.g. divorce, injury

death in'Íamily, change of residence, bankruptcy, etc.)

í4. What is the most important health change you would like to occur?

15. How do you feel about yourself? n Very good I Good tr Fair tr Not good16. What would you like to change about yourselÍ?17. How many hours do you spend alone?18. What is your religious upbringing?

Do you enjoy being alone? D Yes n NoReligious Íaith now?

19. What is your religious practice? n Prayer D Meditation OtherHow often?

Patients signature

How important is this to you?