Confidential Patient Intake — Manhattan Sports Acupuncture
Confidential New Patient Intake

Manhattan Sports Acupuncture

Dry Needling · Trigger Point · Orthopedic Acupuncture
89 Fifth Ave, Suite 305 · New York, NY 10003
(347) 948-3533 · [email protected]

Please complete this form before your first visit so we can understand your full story — not just where it hurts. Fields marked * are required. When you finish, your PDF downloads and an email to the clinic opens — just attach it and send.

1

Patient Information

Today's date:

I

Experience with Acupuncture & Dry Needling

A little background on prior treatment.

Have you received acupuncture treatment before?
Have you received dry needling before?
II

Your Main Complaints

What brings you in?

Primary complaint — details

1.History: how long have you had it? Was the onset sudden or gradual? Any significant event that led to it?

2.Have you seen a physician or other provider for it? If yes, when, and what diagnosis did you receive?

3.Other care — what else have you tried (PT, medication, chiropractic, etc.)? Did it help?

Secondary complaint — details if applicable

1.History: how long, sudden or gradual, any significant event?

2.Seen a provider for it? When, and what diagnosis?

3.Other care tried — did it help?

III

Symptom Diagram

Shade the areas where you feel symptoms. Pick a color and draw on the figures — you can use a second color for your secondary complaint if you like.

Color:
Body chart
IV

Medications, Supplements & Herbs

List everything you currently take and what it's for.

V

Personal Medical History

Surgeries, accidents, and major illnesses across your life. Include approximate ages.

VI

Family Medical History

Major illnesses in close family (diabetes, heart disease, hypertension, cancer, neurological or psychological disorders, etc.).

VII

Symptom Review by System

For any symptom you currently or frequently experience, tap A, C, or F. Leave the rest blank.

A = Acute (under 3 months)  ·  C = Chronic (over 3 months, most days)  ·  F = Frequent (comes & goes)
For women
Are you pregnant or trying to become pregnant?
Have you ever been pregnant?
VIII

Medical Conditions

For anything that applies, tap C or P. Leave the rest blank.

C = Current condition  ·  P = Past condition, now resolved
IX

Lifestyle

A few questions about stress, habits, and diet.

Stress, energy & sleep

1.Is stress or a recent major life change contributing to your complaints or affecting your health? If yes, describe.

2.Any problems with your energy level? If yes, describe.

3.Any problems with sleep? If yes, describe.

Smoking, alcohol & other substances
Do you smoke tobacco?
Do you drink alcohol?
Diet & nutrition
Do you think your diet has any impact on your complaints?
Are you concerned about your weight or appetite?
Would you be interested in a treatment plan that also helps with lifestyle issues?
X

Notice of Privacy Practices

Please read, then sign below to acknowledge receipt.

This notice describes how health information about you may be used and disclosed, and how you can get access to this information.

Respect for patient privacy is highly valued in this practice. As required by law, we will protect the privacy of your health information that may reveal your identity.

Use and disclosure of your protected health information

We will obtain a one-time general written consent to use and disclose your health information in order to treat you, obtain payment for treatments received, and conduct clinical operations. This general written consent is obtained the first time you receive services and is a broad permission that does not have to be repeated each time.

Uses and disclosures

We use health information about you for treatment, to obtain payment, for administrative purposes, and to evaluate the quality of care you receive. Outside of these instances, we will ask for your written authorization before using or disclosing any identifiable health information about you.

Your rights

In most cases you have the right to look at or get a copy of your health information. You also have the right to receive a list of certain disclosures we made. If you believe information in your record is incorrect, you have the right to request that we correct it.

Our legal duty

We are required by law to protect the privacy of your information, provide this notice, follow the practices described here, and seek your acknowledgement of receipt.

Complaints

If you believe we have violated your privacy rights, or you disagree with a decision about access to your records, you may contact the privacy officer below, or send a written complaint to the U.S. Department of Health and Human Services.

Privacy Officer: Edd Lee, MSOM, LAc, LMT, ADS · Manhattan Sports Acupuncture
(347) 948-3533 · [email protected]
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XI

Informed Consent to Treat

Please read, then sign below to consent to treatment.

I hereby request and consent to the performance of acupuncture and other procedures within the scope of the practice of acupuncture on me (or on the person for whom I am legally responsible) by the licensed acupuncturist named below and any licensed acupuncturist who now or in the future treats me while associated with this practice.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that herbs may need to be prepared and consumed according to instructions, may have an unpleasant smell or taste, and I will notify the clinic of any unanticipated or unpleasant effects.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile, single-use needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. Herbs and nutritional supplements recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses, and some may be inappropriate during pregnancy. I will notify the clinic if I become pregnant.

While I do not expect the clinical staff to anticipate and explain every possible risk, I wish to rely on the clinical staff to exercise judgment during my care which they believe, based on the facts then known, is in my best interest. I understand that results are not guaranteed. My records will be kept confidential and will not be released without my written consent.

By signing below, I show that I have read (or had read to me) the above consent, have been told about the risks and benefits, and have had an opportunity to ask questions. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Treating practitioner: Edd Lee, MSOM, LAc, LMT, ADS · Manhattan Sports Acupuncture
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✓

Almost done — one last step.

← Back to New Patients

Manhattan Sports Acupuncture · 89 Fifth Ave, Suite 305 · New York, NY 10003
Specialized care for athletes, performers, and the discerning New Yorker — since 2009
Your information is kept strictly confidential.