New Patient Form – Golden Monkey Healing

Patient Information

Contact Information

Name

Age Birthdate

Address City State Zip

Home Phone Work Phone Mobile Phone Email

Occupation Company Name

Primary Physician Physician Phone Number

How did you hear about us?

Emergency Contact Emergency Contact Relationship Home Phone Work Phone Mobile Phone

Current Concerns

In order of importance, please list your primary reason for coming in for treatment and indicate if you have seen any other specialists for these conditions (Yes or No/Name of Specialist):

Primary Reason for Visiting Us Today

Secondary Reason for Visiting Us Today

Third Reason for Visiting Us Today

How is your sleep?

How is your digestion?

List Medications / Food supplements you are taking:

List serious illnesses, accidents or surgeries:

Muscle / Joint / Bones

Tremors or cramps Swollen joints

Pain weakness, numbness in:

Arms or hips Back or legs Feet Neck Hands Shoulders

Other

Skin Boils Bruise Easily Dry Skin Itching / Rash / Exzema / Psoriasis / Acne Sensitive skin Sore won't heal Sweats

Genito / Urinary Blood / pus in urine Frequent urination Inability to control urine Kidney infection / stones Lowered libido

Cardiovascular Chest Pain High or Low blood pressure Hardening of arteries Pain over heart Poor circulation Previous heart attack Rapid / irregular heart beat Swelling of ankles

For Men Only Erection difficulties Penis Discharge Prostrate trouble

Policies

By submitting this form, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by Matt Schwartz. I understand that acupuncturists practicing in the state of California are primary care providers and that regular primary care by a licensed physician in addition is an important choice that is strongly recommended.

Acupuncture/Moxibustion: I understand that acupuncture is performed by the insertion of needles through the skin or by the application of heat to the skin (or both) at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time.

Direct Moxibustion: I understand that if I receive direct moxibustion as part of therapy, there is a risk of burning or scarring from its use. I understand that I may refuse this therapy.

Chinese Herbs: I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body's physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call the Chinese Medical Clinic as soon as possible.

Acupressure/Tui-Na Massage: I understand that I may also be given acupressure/tui-na massage as part of my treatment to modify or prevent pain perception and to normalize the body's physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable.

Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment.

24 hour cancellation policy-
In order to maintain the integrity of Golden Monkey Healing we must request that all cancellations be made with a minimum of 24- hour notice. Failure to provide 24- hour notice or a failure to show will result in your account being charged for the visitation at our standard fee.

-Thank you for your understanding

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