Authorization to Release Information
-Indicate any and ALL symptoms. (write 1,2,3,4,.. by priority, 1 being the most important).
NOTE: If you are coming in for infertiity please make sure that all symptoms in addition to infertity are indicated.
Please list any other symptoms and concerns:
*Is your health conditions related to work or auto accident? Yes No
Date of Loss:
I, , am receiving Acupuncture and related treatments from an Awaken Wellness Practitioner, I hereby authorize the Awaken Wellness.LLC. center to verify information required for processing payment, and to collect payment directly from my insurance. I also authorize the clinic to obtain any medical information on me as needed. I understand that if my insurance fails to cover my treatments, or pays me directly, I am responsible for making payments to Awaken Wellness, LLC. I agree to provide my credit card number today to be kept in a secured file with Awaken Wellness in the case that my insurance fails to cover my treatments. I understand that Awaken Wellness will contact me before charging my account, but if my insurance doesn’t pay for the services provided my credit card will be charged for the unpaid portion(s) of the service(s) rendered.
By signing below, I certify that all information I have provided is accurate to the best of my knowledge and that I agree to pay any and all portions of treatment(s) that are not covered by my insurance.
Medical Insurance Evaluation
Medical insurance requires this form to be completed once a month
||Date of Birth:
Pain Rating Scale: Use the number scale that is listed below to describe the INTENSITY of your pain.
||1 2 3
||4 5 6
||7 8 9
Using the number system above, describe your:
Using the images above and letters below, please indicate which areas are of concern (for example pain and tenderness in the right area of the head would be notated by 1-O):
Pain and Tenderness = O
Numbness and Tingling = Z
Swelling and Stiffness = X
Instructions: These questions ask your views about how your pain now affects how you function in everyday activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.
1. Does your pain interfere with your normal work inside and outside the home?
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
3. Does your pain interfere with your traveling?
4. Does your pain affect your ability to sit or stand?
5. Does your pain affect your ability to lift overhead, grasp objects, or reach for things?
6. Does your pain affect your ability to lift objects off the floor, bend, stoop, or squat?
7. Does your pain affect your ability to walk or run?
8. Has your income declined since your pain began?
9. Do you have to take pain medication every day to control your pain?
10. Does your pain force you to see doctors much more often than before your pain began?
11. Does your pain interfere with your ability to see the people who are important to you as much as you would like?
12. Does your pain interfere with recreational activities and hobbies that are important to you?
13. Do you need the help of your family and friends to complete everyday tasks (including both work outside the home and housework) because of your pain?
14. Do you now feel more depressed, tense, or anxious than before your pain began?
15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
With Permission from: Anagnostis C et al: The Pain Disability Questionnaire: A New Psychometrically Sound Measure for Chronic Musculoskeletal Disorders. Spine 2004; 29(20:2290-2302.