x
We are experiencing some issues with intake forms. We are working on getting this fixed as soon as possible. Thank you.
Lakewood Community Acupuncture
Information
Name
*
Email
*
Birthdate
*
Phone Number
*
Welcome to Lakewood Community Acupuncture, a 501(C)3 non-profit holistic healthcare clinic focusing on affordable acupuncture & natural healing arts in Lakewood, Colorado. Community Acupuncture is a national and international model for low cost, accessible and inclusive acupuncture. Our unique nonprofit design for community acupuncture allows our clinic to offer quality acupuncture services at approximately 1/2 the cost of full price privately offered acupuncture. This makes acupuncture services available to most income levels and reduces the financial stress for those who need regular acupuncture treatments. The community acupuncture experience allows patients to relax while receiving an acupuncture treatment in a healthy, healing environment with others. In addition to our low cost acupuncture, as part of our commitment to affordable and accessible healthcare, all of our herbal medicine and nutritional supplement products are sold at 25% reduced resale cost or more. The Initial Nutrition for Heart and Body Appointment is a free gift from us as a tool for optimal health and well-being. Our practitioners, Jamie & Crystal are passionate about offering affordable and effective acupuncture and holistic healthcare. Through the practitioner’s extensive training in Acupuncture and Chinese herbal medicine, massage/bodywork, nutritional therapies and other holistic modalities, Lakewood Community Acupuncture is able to offer the best of natural healthcare in an affordable and comfortable model. We do not require or ask for any proof of income to receive our low cost services, and offer the same service to any person regardless of sex, race, color, income, national origin, age, ability or disability, marital status, gender, familial situation, religion, size and shape, sexual orientation, veterans status, political beliefs or any differences of any kind. From all of us at Lakewood Community Acupuncture, welcome to our community. We look forward to helping you on your way back to vitality and health.
Full Address (Address, Unit, City, State, & Zip)
Gender
Height & Weight
Occupation
Have you had acupuncture before?
Yes
No
How did you hear about us?
Emergency Contact (name & phone)
Main Problem/Problems (what brings you in to see us today?)
*
Treatments you have tried
What makes this problem worse? (example: standing for long periods, sitting, work, etc.)
What makes this problem better? (example: working out, meditation, lying down, etc.)
Allergies (food allergies, environmental allergies, etc.)
Medications taken within the last 2 months (this includes vitamins, herbs and supplements)
Self & Family Illness (please indicate if you or a blood relative have had the following)
hemophilia or bleeding disorder (self)
Cancer (self)
Cancer (family)
Hepatitis (self)
Hepatitis (Family)
Heart Disease (self)
Heart Disease (family)
Diabetes (self)
Diabetes (family)
Infectious Disease (self)
Sexually Transmitted Infection (self)
Do you smoke?
Yes: Cigarrettes
Yes: Marijuana
No
Caffeine Intake (what kind & how much caffeine do you drink, if any?)
Alcohol Intake (what kind & how much alcohol do you drink, if any?)
Daily Dietary Intake (please describe, in as much detail, an ordinary day of food intake for yourself)
Please describe any special diet (example: vegetarian, paleo, gluten free, etc.)
General Symptoms Survey
Poor appetite
Poor sleep
Fatigue
Fevers
Chills
Night sweats
Sweat easily
Tremors
Cravings
Change in appetite
Poor balance
Easily Bruise
Desire hot food
Desire cold food
Recent weight gain
Recent weight loss
Musculoskeletal
Back pain
Hip pain
Neck pain
Shoulder pain
Wrist/hand pain
Joint disorder
Muscle cramping
Paralysis
Numbness/tingling
Spinal curvature
Other
Skin & Hair
Rashes
Eczema
Hives
Psoriasis
Hair loss
Ulcerations
Other
Head, Eyes, Ears, Nose and Throat
Blurry vision
Eye strain/pain
Cataracts
Concussions
Migraines
TMJ
Ringing in ears/tinnitus
Other
Cardiovascular
High blood pressure
Low blood pressure
Irregular heart beat
Rapid heart beat
High cholestorol
Chest pain
Other
Digestive
Nausea
Vomiting
Diarrhea
Constipation
Gas and bloating
Acid reflux/GERD
Abdominal pain
Hemorrhoids
Parasites
Other
Neuro-psychological
Stress
Anxiety
Depression
Anger
Post traumatic stress disorder (PTSD)
Bipolar
Other
Genital-urinary
Painful urination
Frequent urination
Urgent urination
Blood in urine
Can't hold urine/dribbling
Frequent UTI
Genital pain
Genital rashes
Kidney stone
Sexually transmitted infection (STI)
Other
Reproductive Disorders & Symptoms (if not applicable, skip to next section)
Fibroids
Ovarian cysts
Endometriosis
Irregular periods
Painful periods
Vaginal discharge
Yeast infection
Breast tenderness
Fertility problems
Hot flashes
Peri-menopause/menopause
Other
Reproductive: List number of pregnancies, births, miscarriages, premature births, abortions and/or C- sections (if not applicable skip to next section)
Reproductive: Do you practice birth control? If so, what kind? (if not applicable skip to next section)
Reproductive: Quality of Period Example: color, clotting, heavy or light volume, etc. (if not applicable skip to next section)
Reproductive: Length of Period Time between start of one cycle and start of the next (example: 28 days) & length of bleeding. Example: 2 days heavy, 3 days spotting. (if not applicable skip to next section)
Reproductive Disorders & Symptoms (if not applicable skip to next section)
Prostate problems
Erectile dysfunction (ED)
Testical pain
Testical swelling
Fertility problems
Irregular discharge
Other
Terms And Conditions
MANDATORY DISCLOSURE, CONSENT TO TREAT, HIPAA POLICY & ACKNOWLEDGEMENT Mandatory Disclosure & Consent to Treat Cancellation policy: 24 hour or more notice is requested for change of appointment or cancellation, unless there is an emergency. A $30 fee will be charged for missed appointments or late cancellations made within the 24 hour timeframe. This fee will be donated to our Pay It Forward Program, to help out those who can’t afford acupuncture. Fee waived for emergencies or dangerous weather conditions. Practitioner Education, Certification, and Experience Jamie Holland, Dipl O.M., L.Ac., ACN Master of Science in Acupuncture & Oriental Medicine from AOMA Graduate School of Integrative Medicine in 2013 Nationally board certified as a Diplomate in Oriental Medicine by the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM #151347) Licensed Acupuncturist of Colorado (#ACU.1937) Applied Clinical Nutritionist (TX Chiropractic College) Asian Bodywork Therapist (American Organization of Bodywork Therapies of Asia) Crystal Jancovic, Dipl O.M., L.Ac, LMT Master of Science in Acupuncture & Oriental Medicine from Five Branches University in Santa Cruz, California in 2012 Associates Degree in Massage Therapy Licensed Acupuncturist of Colorado (#ACU.0002104) Nationally board certified as a Diplomate in Oriental Medicine by the National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM # 152318) Licensed Massage Therapist in Colorado (#MT.0019735) Active Member of CAMRC (Colorado Acupuncture Medical Reserve Corps) Wei Fang, Diplomat O.M., L.Ac Master of Science in Traditional Chinese Medicine from the Colorado School of Traditional Chinese Medicine, Denver CO Licensed Acupuncturist of Colorado (DORA License #ACU.0001298) Nationally board certified as a Diplomate in Oriental Medicine by the National Certification Commission for Acupuncture & Oriental Medicine No license, certificate or registration has ever been revoked or suspended. What we offer & service costs (due at time of service) Lakewood Community Acupuncture is a 501(c)3 nonprofit organization Service cost + $20 for initial appointment Acupuncture: $40 Acupuncture + eStim: $55 Acupuncture + Cupping: $55 Acupuncture + Tuina Bodywork: $60 Cupping (no acupuncture): $40 Acupuncture + motor point eStim: $60 Acupuncture + Low Level Laser Therapy: $60 Low Level Laser Therapy- Cold Laser Therapy (no acupuncture): $40 Nutrition for the Heart & Body: $80 (supplements not included in price) Purification & Healthy Weight Program: $200. Free consult. Herbal Medicine & Nutritional Supplements: Cost varies. (As a commitment to affordable healthcare, we sell all our herbal medicines and supplements at a 25% reduced cost!) Insurance: We do not bill insurance. Upon request, we will provide you with a receipt for your insurance company. I hereby request and consent to the performance of the following on myself (or the patient named, for whom I am legally responsible) by the practitioners of Lakewood Community Acupuncture: acupuncture and other Eastern medical procedures including diagnostic techniques such as questioning, pulse evaluation, tongue evaluation, palpitation, observation, range of motion, muscle and orthopedic testing; modes of manual therapy such as Asian bodywork therapy (including: rocking, kneading, pushing, pulling, stretching, rhythmic striking, pressing, rolling, vibrating, grasping, etc…), cupping, moxibustion heat therapy, bleeding therapy, laser therapy, injection therapy, magnetic stimulation, the application of topical ointments, liniments and lotions; the prescription of herbal and homeopathic medicines as well as dietary supplements; dietary recommendations; exercise advice and healthy lifestyle recommendations. I give permission to the Licensed Acupuncturists and staff at Lakewood Community Acupuncture to record the sound of my heart and to create a graph of that sound on the Heart Sound Recorder (a general wellness cardiac stress monitor). I have been informed and understand that the Heart Sound Recorder is not an electrocardiograph, which is used in hospitals or by physicians, that it is not used for diagnosing heart conditions and that it is not in any way a substitute for such a device. I further understand that the Heart Sound Recorder has not been reviewed or cleared by the US Food and Drug Administration. I understand that if I have or believe I have a heart condition, that I should see a physician qualified to evaluate and treat that condition. Any suggested nutritional or dietary advice is not intended as treatment or therapy for any disease or symptom of disease. Nutritional counseling, supplement recommendations, and exercise considerations provided to me are to support the normal physiological processes of the body. I understand that any techniques, treatments, or lifestyle changes suggested after the use of this device should be undertaken only with the guidance of a licensed physician, therapist, or healthcare practitioner. The findings from this device can be used to support, but should not be used in place of sound medical therapies and recommendations. I am also giving permission to share my graph with other practitioners for educational purposes only, so long as my name and other personal information are removed. I understand I have opportunities to discuss with my practitioner, or with other personnel, the nature and purpose of acupuncture and Eastern medical procedures, the methods of therapy, the techniques used, and the duration of therapy. Although I am aware that acupuncture and other procedures used in Eastern medicine have helped millions of people, I understand that no guarantee of cure or improvement in my condition is given or implied. I understand that I may seek a second opinion from another health care professional or may terminate therapy at any time. I understand and am informed that, as in the practice of conventional Western medicine, in the practice of Eastern medicine there are some risks to treatment. I understand that although these risks are unlikely to occur, they are possible. I understand that these risks include, but are not limited to: bleeding, bruising, pain or other strong sensation where the needle is inserted, or at location where bodywork, cupping (which will can leave marks go away between 1-4 weeks), or topical ointment/ lotion/ liniment is applied, or radiating from those locations; nerve pain, burns, aggravation of current symptoms, appearance of new symptoms and general aches. I do not expect the practitioners to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioners to exercise such judgment during the course of my treatment, as the practitioner feels at the time, based on the facts then known, to be in my best interest. I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when combined with excessive medication, alcohol consumption or illegal drug use at the time of treatment. If there is reasonable cause to believe that treatment is not appropriate for a patient who is under the influence of illegal drugs, alcohol, or appears to be overly medicated, then a treatment may not be performed at that time. In this case the patient will be informed that they may not be treated at that time and will be requested to reschedule their appointment. I understand that acupuncture and Eastern medicine treatments may not have the desired therapeutic effect when the patient has not eaten properly before the time of treatment, and may result in dizziness, sweating, light headed feeling or other experiences similar to low blood sugar symptoms. Lakewood Community Acupuncture complies with all rules and regulations promulgated by the Colorado Department of Public Health and Environment, including those related to the sterile use of needles in the practice of acupuncture and the sanitation of acupuncture offices. The Colorado Department of Regulatory Agencies, whose contact is below, regulates the practice of acupuncture. If you have any comments, questions, or complaints, contact the Acupuncturists Registrations Office: Director of Professions and Occupations Acupuncture Licensure 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894- 7800 I intend this form to cover the entire course of treatment for my condition and for any future condition(s) for which I seek treatment at Lakewood Community Acupuncture. HIPPAA POLICY & ACKNOWLEDGMENT Privacy Practices for Lakewood Community Acupuncture Notice of Privacy Policies/HIPAA Compliance The information provided below illustrates the manner in which your protected health information could be accessed and released and what you need to know about this process. This important document should be reviewed thoroughly. Managing the privacy of your protected health information is extremely important. As mandated by Federal and State legal requirements, your protected health information must be protected. As part of these regulations, we are required to ensure you are aware of privacy policies, legal duties, and your rights to your protected health information. This notice of privacy policies, outlined below, will be in effect for the duration and will be followed by our practice. This notice will be in effect until it is replaced. We reserve the right to modify our privacy policies and the terms of this notice at any time, and will make such modifications within the guidelines of the law. We reserve the right to make the modifications effective for all protected health information that we maintain, including protected health information we created or received before the changes were made. Changing the notice will precede all significant modifications. A copy of this notice will be provided upon request either digitally or printed. Protected Health Information Use and Disclosure: Information regarding your health may be used and disclosed for the purpose of treatment, payment, and other healthcare operations. Examples cited below further explain the use and disclosure process. Treatment: Use and disclosure of your protected health information may be provided to a physician or other healthcare provided providing treatment to you. However, this information will not be provided unless you have authorized it in writing. Payment: Your protected health information may be used and disclosed to obtain payment for services we provided to you. Healthcare Processes: We may use and disclose your protected healthcare information in relations with our healthcare process. These processes include an assessment, improvement activities, reviewing the competence or qualifications of healthcare professionals, provider performances and evaluating practitioner, conducting training programs, accreditation, certification, licensing, or credentialing activities. Your Authorization: At any time, you may provide in writing your authorization for use and disclosure of your protected health information for any purpose. You may choose to revoke your written permission at any time. The revocation must be in writing. If you revoke your written authorization, it will not affect any use or disclosure prior to the revocation. Your protected healthcare information may be used and disclosed to you, as described in the patient rights section of this notice. In addition, your protected health information may be used and disclosed to a family member, friend, or other person to the extent necessary to assist you with your healthcare, but only with your written authorization. Person Involved In Care: In order to accommodate the notification of your location, your general condition, or death, your protected health information maybe used or disclosed to a family member, your personal representative, or another person responsible for your care. If you are present and wish to object to such disclosures of your protected health information, you may do so. To the extent you are incapacitated or emergency circumstances exist, we will disclose protected health information using our professional judgment disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare. We will use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of protected health information. Marketing Health-Related Services: The use of your protected health information for the purpose of marketing communications is prohibited without your written authorization. Required By Law: Your protected health information may be used or disclosed if required by law. Abuse or Neglect: As required by law, if we have reason to believe that you are the victim of possible abuse, neglect, domestic violence, or other possible crimes, your protected health information may be disclosed to the appropriate authorities. If we have reason to believe the use or disclosure of your protected health information will prevent a serious threat to your health or safety or the health or safety of others we may have to provide the necessary protected health information. National Security: Under some circumstances, the military may require disclosure of healthcare information for armed forces personnel. For the purpose of national security activities, counter intelligence and lawful intelligence, authorized federal authorities may require disclosure of protected health information. Protected healthcare information disclosure may be made to correctional facilities or law enforcement authorities with the lawful authority requiring custody of such information. Appointment Reminders: Your protected healthcare information may be used to assist you with appointment reminders in the form of voicemail messages, postcards, or letters. We may also write a thank you card to whomever referred you to our practice. We will only do this with your written authorization. There is a form in your initial paperwork authorizing this. If you change your mind at any time, you may withdraw this authorization, but you must do so in writing. Patient Rights Access: At all times, you have the right to review your protected health information, with limited exceptions. At your request, we will provide your information in a format other than photocopies. If we are able to do so, we will accommodate your request. Your request to obtain access to your information must be in writing. You may obtain a Protected Health Information Access Form by using the contact information at the end of this notice. We may need to charge you a reasonable cost-based fee for expenses including copies and staff time. You may also request access for submitting a letter using the information at the bottom of this notice. If you request copies, we will charge you $0.83 per page for the first 30 pages and $0.63 for every page after that plus $19.00 for staff time to locate and copy you protected health information. Postage will be included if you wish to have your information mailed. If you request a different format, we will charge a cost based fee for that format. An explanation of fees can be made available. Restrictions: You may request that we apply additional restrictions to any disclosure of your healthcare information. We are not required to respond to the application of these additional restrictions. If we agree to follow your request regarding additional restrictions, we will follow the agreed restrictions unless an emergency situation dictates otherwise. Alternative Communication: Your rights include the instruction to request how you are communicated to regarding your protected health information. Your request must be in writing and can spell out other ways or other locations regarding your protected health information communication. You must identify agreed upon explanations of payment arrangements under alternative communications. Amendment: You can initiate a written request to amend your protected health information. Included in the amendment must be an explanation why information should be amended. Certain conditions may exist where we may reject your request. Electronic Notice: If you receive a notice electronically, you are entitled to receive the notice in writing as well. Questions and Complaints If at any time you are unsure or concerned that your protected health information has not been protected or if you believe an error was made in the decision we made about accessing your protected health information; or in the response to a request you made to amend the use or disclosure of your protected health information; or to have us communicate to you by an alternative means or at an alternative location, you have the right to bring this issue forward. You may make a complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services at your request. Privacy of your protected health information remains extremely important; we are committed to ensuring your privacy. We are available to assist you with any questions, concerns, or complaints. The Right to Obtain a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice of privacy practices at any time by contacting our office
I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge.
*
Cancel