Health History Questionnaire
Please help us provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. This information is considered confidential. If we sincerely believe your condition will not respond satisfactorily, we will not accept your case. If you have any questions, please ask. If you have anything you wish to bring to our attention, which is not asked on this form, please note it in the Additional Comments section. Thank You.
Main problem you would like help with:
When did the problem begin?
To what extent does the problem interfere with your daily activity (work, exercise, sleep, sex, etc.)?
Have you been given a diagnosis for the problem? If so, what?
What kind of treatments have you tried?
What medications and/or supplements are you currently taking?
Have you had any courses of antibiotics in the past six months? Many 1 or 2 None
Allergies (drugs, chemicals, food, etc.):
Do you have a regular exercise program? Please describe:
Are you or have you been on a restricted diet? What kind and why?
Women: Are you nursing or pregnant?
What was the date of the start of your last menstrual cycle?
Additional Comments/Previous Health Conditions:
Informed Consent for Acupuncture, Chiropractic, Massge & Bodywork
I, the undersigned, hereby request and consent to the performance of procedures including, but not limited to, acupuncture, moxibustion, chiropractic, Holistic Medicine, cupping, plum blossom, gua sha, electro acupuncture, Tuina, yoga, Thai Yoga Therapy, reflexology, craniosacral therapy, massage, Reiki, Ayurveda, Energy healing, and Chinese herbal supplements, on me or the patient for whom I am legally responsible, by my practitioner. I recognize the potential risk and benefit of this procedure as described below:
Discomfort, pain, infection, weakness, fainting, nausea, temporary discoloration at site of procedure, and occasional aggravation of symptoms existing prior to the treatment.
Drugless relief of presenting symptoms and improved balance of the body’s energies, which may lead to prevention or elimination of the presenting problems and strengthen the constitution.
I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my presenting condition and for any future conditions for which I seek treatment.
I hereby release Pekoe Acupuncture and Wellness Center, PLLC, both employees and contracted practitioners, from any and all liability that may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. I understand that I am free to withdraw my consent and discontinue participation.
I fully understand that Pekoe Acupuncture and Wellness Center, PLLC is a professional medical establishment. Pekoe has a no-tolerance sexual harassment policy: Inappropriate and unwanted suggestions, requests, touching (of the practitioner and of yourself) will result in your therapist promptly ending the session and notifying the police.
- Our Acupuncturists are participating providers with certain insurance carriers. Please fill out the insurance eligibility request form if you will be using your insurance to pay for acupuncture services.
- You can use your FSA or HSA to pay for ALL services at Pekoe. The Foreign Services Benefit Plan also pays a percentage of most services.
- As a courtesy, we will provide you with a detailed super bill for you to submit to your insurance company as an out of network provider or for other insurance companies. You can submit this form to your insurance company for reimbursement. We cannot bill other health insurances from this office or therapists who are not participating providers. Please be sure to indicate for us to provide you with a super bill.
- Personal injury cases will be verified with the auto insurance company. If the patient does not have PIP (Personal Injury Protection), the patient must pay at each visit.
- Failure to give 24-hour notice for cancellation of any appointment will result in a $50 cancellation fee or 50% of the service cost, whichever is higher.
- Payment is due at time of service, unless otherwise arranged prior to treatment.
Payment Agreement (PLEASE SELECT ONE):
I agree to keep my account balance current by paying at each visit. I understand that I will automatically recieve an email reciept for services.
I agree to keep my account balance current by paying at each visit, though I do require a detailed super bill to submit to insurance for reimbursement.
(FOR ACUPUNCTURE ONLY) Please bill my insurance company for acupuncture services.
- I understand that I will be responsible for copayments or coinsurance payments, supplements and herbs, and for payment on services that are not covered by my plan.
- I have completed an insurance eligibility form and understand my insurance benefits.
I fully understand that insurance policies are arrangements between my insurance company and myself. I am ultimately responsible for any expenses not paid by my insurance company.
I understand and agree to the informed consent and financial policy as explained above.