Patient Medical History Gentle Heart Acupuncture

Joanna Resnick L.Ac. 899 N Logan St, Suite 310

Denver, CO 80203 303-505-9060

Name ____________________________________ Date______________

Address_______________________________________________________________________

City / State / Zip ________________________________________________________________

Home phone _____________________ Work Phone __________________________________

Cell Phone _____________________ Email _________________________________________

Occupation ______________________Birth Date ____________________________________

Emergency contact ____________________________________________________ (Name & phone)

Referred by _____________________________________________________

___ Single ___ Married ___ Divorced ___ Significant Other ___ Widowed Children ____

Have you ever had acupuncture? _______ If yes, when? __________________

For what condition? ________________________________________________

Are you currently under the care of a physician? If so, who, and for what condition(s)?______________________________________________________ ________________________________________________________________

Main reason(s) for seeking acupuncture_________________________________ How long have you experienced symptoms? __________

Your condition is improved by __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your condition is aggravated by __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all current medications, prescribed or over the counter ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all current vitamins, herbs and other supplements __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please circle any areas you have pain

Family History (Pease Put M for Maternal and P for Paternal) Cancer_________________ Asthma___________________

Diabetes________________ Allergies__________________

Heart Disease____________ Substance Abuse___________

High Blood Pressure_______ Migraines__________________

Mental Illness_____________ Osteoporosis_______________

Depression_______________ Digestive Disorders__________

Stroke____________________ Chronic Back Pain___________

Alzheimer’s Disease_________ Arthritis___________________

Significant illnesses (please check all that apply) Cancer___ Diabetes___ Hepatitis___ Heart Disease___ Stroke___ Seizures___ HIV / AIDS___ Pneumonia___ Tuberculosis___ Multiple sclerosis___ Thyroid___ Asthma___ Stomach Ulcers___

Obesity___ Depression___ Shingles___ Chronic Fatigue___ Rheumatic Fever___ High Blood Pressure ___ STD’s___ Other ___________

Please list any surgeries you’ve had including dates ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list any Allergies ____________________________________________________________________________________________________________________________________________________________________________

Please list any major emotional or physical traumas you’ve experienced __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Lifestyle (please check all that apply, and note frequency of use) ___ Tobacco ___ Alcohol ___ Recreational drugs ___ Caffeinated beverages

Do you exercise? _______ Please list types of activity and frequency: ____________________________________________________________________________________________________________________________________________________________________________

Dietary preferences Vegetarian___ Raw foods diet___ Low fat diet___ High protein/low carb___ Dairy /milk /cheese___ Eggs___ Chicken___ Fish / seafood___ Red meat___ Artificial sweeteners___ Fast food/ burgers/fries___ Spicy / hot___ Sweet___Sour___Salty ___ Cold drinks___ Hot drinks___ Ice chewing ___ Extreme thirst ___ Thirst with no desire to drink___

General symptoms Fatigue___ Sweat without exertion___ Night sweats___ Fever / chills___ Dizziness / vertigo___ Bleed / bruise easily___ Low immunity___ Other ___

Digestion Extreme appetite___ No appetite___ Cravings___ Dieting___ Tired after eating___ Bloating___ Gas___ Acid regurgitation___ Heartburn/Ulcers___ GERD___ Nausea___ Vomiting___ Bulimia___ Anorexia___ Irritability or low energy between meals___ Other ________How many meals per day? _______ How many snacks per day?___________

Intestinal Diarrhea___ Constipation___ Hemorrhoids___ Anal itching / burning___ Laxative use___ Bloody stool___ Mucous in stool___ Anal fissures___ Rectal prolapse__ Intestinal pain/cramping ___ Incomplete evacuation___ IBS___ Colitis___ Crohn’s Disease___ Gout___ Celiac Disease___ Gallstones___ Other________

Sleep Falls asleep easily___ Lie in bed with eyes open___ Wake as specific times___ Wake repeatedly___ Wake frequently to urinate___ Vivid or Lucid Dreams___ Wake up not feeling rested___ Nightmares or Frightening dreams___ Need drugs or supplements to fall asleep___

Head, Eyes, Ears, Nose and Throat Dry eyes___ Spots / flowery vision___ Blurred vision___ Poor vision___ Eye strain___ Night blindness___ Cataracts___ Macular degeneration___ Bleeding gums___ TMJ___ Sores on tongue or mouth___ Dry mouth___ Excess saliva___ Sinus problems___ Post-nasal drip___ Sore throat___ Headaches___ Swollen glands___ Difficulty swallowing___ Earaches___ Tinnitus / ringing___ Deafness___ Nosebleed___ Other__________________

Cardiovascular / respiratory Heart palpitations___ Chest pain___ Difficulty breathing___ High cholesterolVaricose veins___ Blood clots___ Swollen ankles___ Heart valve abnormality______ Shortness of breath___ Cold hands / feet___

Dry cough___ Wheezing___ Chest tightness___ Difficult inhalation___ Difficult exhalation___ Productive cough(color of phlegm?)___Other ___________

Skin / hair Dry skin___ Rashes / hives___ Eczema___ Psoriasis___ Pimples / acne___ Fungal infections___ Brittle nails___ Ridged nails___ Hair loss___ Dandruff___ Other ____________

Musculoskeletal Spinal pain___ Joint pain___ Tendonitis___ Swelling___ Arthritis___ Limited range of motion___ Disc degeneration___ Osteoporosis___ Numbness___ Carpal tunnel___ Other ____________

Neuropsychological Anxiety___ Irritability___ Insomnia___ Depression___ Easily stressed___ Poor memory___ Seasonal mood disorder___ Tics___ Tremors___ Death of someone close___ Job stress___ Recent divorce___ Currently in therapy___Financial setback___ Other ____________

Emotional stress scale 1 2 3 4 5 6 7 8 9 10 no stress___ moderate___ extremely stressed___ Rate your stress level regarding Work _____Health _____Love _____Money _____Family ______The future ______

Genito-urinary Frequent urination___ Loss of urine when laughing or sneezing___ Incomplete urination / retention___ Dribbling___ Burning urination___Blood in urine___ Wake frequently to urinate___ Kidney stones___Bedwetting___ Bladder Prolapse___ Decreased libido / sexual desire___ Other ____________

Men only Enlarged prostate___ Prostate cancer___ Testicular cancer___ Testicular pain or swelling___ Erectile dysfunction___ Impotency___ STD’s____________

Women only Age menses began _______ Age menses ended (if applicable)______________ Date of last ob/gyn exam ___________ Hysterectomy? ___ partial ___ full

Hormone replacement therapy___ Live births___ Miscarriage___ Abortions___ Infertility___ Birth control pills___ Breast cancer___ Ovarian cysts___ Fibroids___ Endometriosis___ Candida / yeast___ Vaginal discharge___ Vaginal odor___ Vaginal sores___ Herpes___ Human Papilloma Virus positive__Uterine prolapse___ STD history (chlamydia, PID, etc)___ Fibrocystic breast___

Period lasts ______ days Usual number of days in cycle __________ Headaches ___ before menstrual cycle ___ during cycle ___ after cycle___ Pain at ovulation___ Cramps / low back pain___ Acne associated with period___ Constipation associated with period___ Diarrhea associated with period___ Depression or irritability with period___ Bleeding outside of normal menstrual cycle___ No period / skipped cycles___ Irregular cycle___

Menstrual flow Clotting___ Brownish___ Watery, thin and bright red___ Normal red___ Flooding and trickling___ Stop and start flow___

HIPAA Notice of Privacy Practices Gentle Heart Acupuncture

Joanna Resnick L.Ac. 899 N Logan St, Suite 310, Denver, CO 80203

303-505-9060

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

'This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) and for other purposed that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information- is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

i. Uses and Disclosure of Protected Health Information

Users and Disclosure of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third part. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you_ For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: WE may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, qualify assessment business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicated your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration Requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosure to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

Print Name: _______________ ___________________

Signature__________________________________Date________________

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the

physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights Following is a statement of your rights that respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may

not inspect or copy the following records, psychotherapy notes, information complied in reasonable anticipation of, or use

in, a civil, criminal, or administrative action or proceeding and protected health information that is subject to law that

prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to

use or disclose any part of your protected health information for the purpose of treatment, payment or healthcare

operations. You may also request that any part of your protected health information not be disclosed to family members or

friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices_

Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to

permit use and disclosure of your protected health information, your protected health information will not be restricted. You

then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an

alternative location. You have the right to obtain a paper copy of his notice from us, upon request, even if you have

agreed to accept this notice alternatively Le. electronically.

You have the rieht to have your physician amend your protected health information. If we deny your request

for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your

statement and will provide you with a copy of any such rebuttal.

You have the right to have receive an accounting of certain disclosures we have made, if any, of your

protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any charges. You then have the right

to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been

violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not

retaliate against you for filing a complaint.

This notice was published and becomes effective on or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and

privacy practices with respect to protected health information. If you have objections to this from, please ask to speak

with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Patient Consent Form Gentle Heart Acupuncture

Joanna Resnick L.Ac. 899 N Logan St, Suite 310

Denver, CO 80203 303-505-9060

Acupuncture is NOT a substitute for conventional medical diagnosis and treatment.

Techniques commonly employed in the application of acupuncture: Acupuncture needling – treatment will consist of the insertion of sterile disposable needles at specific sites on the body. Stimulation of said needles may be by manipulation, electrical stimulation or the application of warming substances (Moxa) on the needle itself. Injection therapy- treatment consists of injecting B12 or homeopathic remedies with the use of a disposable sterile syringe. Auxiliary / Associated therapies – massage, gua sha, cupping, assisted stretching, topical application of liniments Herbal or homeopathic Remedies-

There is no guarantee that acupuncture, injection therapy or associated therapies will help any condition. Certain medications and social habits may decrease the beneficial effects of acupuncture. These include the use and abuse of alcohol, tobacco, steroids, painkillers, narcotics, stimulants, antidepressants, psycho pharmaceuticals and illegal drugs.

You need to be aware that: Drowsiness may occur after treatment in a small number of patients, and if affected, you are advised not to drive. Minor bleeding or bruising may occur in about 3% of treatments. Fainting can occur in certain patients, particularly at the first treatment. Pain during treatment occurs in about 1% of treatments. Existing symptoms can get worse after treatment (less than 3% of patients). You should tell your acupuncturist about this. Injection therapy may cause bruising and swelling at site of injection. Cupping may cause bruising and soreness. Herbal Remedies may cause but not limited to certain adverse side effects such as aggravation of current symptoms, change in bowel movements and allergic reaction. Take all remedies as recommended and discontinue use immediately if adverse reactions occur.

I, (print name) ______________________________________, certify that I have read and understood the statements above. I also certify that I have informed my acupuncturist of all known physical, mental and medical conditions and medications, and I will keep them updated on any changes.

Patient Signature: _____________________________ Date: _______________

Print Child’s Name: _______________________________________

Print Legal Guardian’s Name:_______________________________

Legal Guardian’s Signature:_______________________Date:_______________ Practitioner Signature: ________________________ Date: _________________

(Colorado Mandatory Disclosure Statement)

Gentle Heart Acupuncture Joanna Resnick L.Ac. 899 N Logan St suite 310Denver, CO 80203303-505-9060

Education and Experience Joanna Resnick earned her Bachelors Degree in Social Psychology in 2003 from Florida Atlantic University in Boca Raton, Florida. She then furthered her education by earning a Bachelors degree in Health Science and a Masters degree in Oriental Medicine and Acupuncture attending Acupuncture and Massage College in Miami, Florida. Acupuncture and Massage College's four year program consists of 2815 hours of education including 940 hours of hands on clinical experience. She is certified in clean needle technique and is a certified Diplomat in Acupuncture by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). After Graduation Joanna started her practice in 2007 and practiced in South Florida until she moved to Denver in 2013.

Joanna is trained in tui na, cupping, moxibustion, acupressure, dietary and lifestyle recommendations, qi gong and injection therapy.

She is a licensed acupuncturist in Colorado. This license has never been suspended or revoked.

This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized.

Patient’s Rights The patient is entitled to receive information about the methods of therapy, the techniques used,

and the duration of therapy, if known. The patient may seek a second opinion from another health care professional or may terminate therapy at

any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director

of the Division of Registrations in the Department of Regulatory Agencies.

The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office, 1560 Broadway Suite # 1350, Denver, Colorado 80202. Phone number 303-894-7800

Fee Schedule

First Consultation and Treatment $85 + cost of herbs Follow-up Treatment $65 + cost of herbs Herbal Consultation $45 + cost of herbs

I have read and understand this document.

_____________________________ ________________ Patient’s or Guardian’s Signature Date

*This fee schedule is for self pay patients who pay all fees at the time services are rendered and no insuranceis billed.

OFFICE FINANCIAL POLICY AND AUTHORIZATION TO BILL INSURANCE

There are two billing options available for you. Please select the one you prefer us to use for your visits. If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.

_____ Private Pay

Private Pay patients are patients that do not bill insurance. This discounted cash rate is only applied to the published rate if you pay at the time of service.

______ Insurance Billing (Medical or Auto Insurance)

Your insurance will be billed the reasonable and customary rates for each procedure performed in our office. I understand that I must pay all co-payments and/or co-insurances not covered by my insurance company at the time of check in for today’s visit, and every visit hereafter Gentle Heart Acupuncture, Inc. will submit my claim for me to my insurance company. Although Gentle Heart Acupuncture verifies my insurance; I understand that this verification is not a guarantee of payment. I understand that any and all charges incurred at this office including co-payment, co-insurance, percentage due and/or deductibles or any other fees or services not covered by my insurance company are my responsibility. I further understand that any unpaid balance over 90 days may be sent to collections for recovery unless prior arrangements have been made.

I authorize my insurance benefits to be paid directly to Gentle Heart Acupuncture. I understand if my insurance company pays me directly, I am responsible for signing check over to Gentle Heart Acupuncture or sending a personal payment immediately of receipt. I also authorize the doctor to release any information and medical records required by my insurance company. I understand that I may revoke this consent by written request, at any time. No other records shall be released without my signed consent.

________________________________________ _____________________________ Signature of Responsible Party Date

________________________________________ _____________________________ Signature of Person Authorized to Consent Date