Please print this form and complete it before your first appointment.

East-West Wellness Center

Please Print this form and bring it with you

Patient Information

Patient Information                                              Today’s date: ______________

Name: ________________________________ Birth date: __________Age: ________

Street Address: _________________________________________________City:__________________________ State:_____

Home phone: __________________________ Cell Phone: ______________________

E-mail Address: _________________________________ Occupation: ____________________________

Emergency contact: Name: _________________________________Phone: _________________Relationship: ______________

How did you hear about our center: ________________________________________ Referred by ________________________

May we send a thank you card? Yes No Primary treating physician: ____________________ Phone: ____________________

Other specialist: _____________________________ Phone: ____________________

Other specialist: ______________________________Phone: ____________________

Have you ever been treated with acupuncture?     Yes     No

If yes, condition treated? ________________________________________________

Health History

Reason for visit: Please list your 5 major health concerns in order of importance:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. ____________________________________________________________________

4. ____________________________________________________________________

5. ____________________________________________________________________

Major hospitalizations, surgeries, illnesses, injuries: Year Surgery, illness, injury Outcome

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _______________________

Please circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 10

Identify the major causes of stress (e.g., changes in job, work, residence or finances, legal problems): __________________________________________________________________________________________

Height: __________________ Weight: _________________

Do you consider yourself:  Under-weight     Over-weight      Just right

Have you experienced unexpected weight gain or weight loss of greater than 10 pounds in the last three months?   Yes    No

If yes, how much? _______________

Do you smoke?  Yes  No    If yes, how much per day? _________ Per week? ________

Do you drink alcohol?  Yes  No  Type: ____________ Quantity: _________________ 

 Medications & Supplements

Please list any known allergies: ________________________________________________________________ 

Please list all current medications that you are taking:

Start date            Name of medication                                            Amount                                         Frequency: 

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Please list all current vitamins, supplements and herbs that you are taking  ________________________________________________________________________________________________ ________________________________________________________________________________________________

The following questions are for female patients only

Are you pregnant? ________ Any chance you could be pregnant? _____________

Describe your menstrual cycles      REGULAR        IRREGULAR       EARLY       LATE __________________________________________________________________________________________________

Is your menstrual flow    NORMAL     LIGHT     HEAVY     WITH CLOTTS ?

Do you experience PMS? Please describe ________________________________________________________________

Number of Pregnancies: _______________Number of childbirths ______________________________________________

Have you had fertility therapy in the past? _________ Present _________________________________________________

What type of fertility therapy? ___________________________________________________________________________

Type of birth control used in the past ____________________ Present __________________________________________

Do you have problem with conceiving ________________ infertility _____________________________________________

Do you have signs and symptoms of menopause?  __________________________________________________________

Please describe any other GYN/ obstetric issues you may have ________________________________________________

Informed Consent

I ____________________________ (name) hereby request and consent to the performance of acupuncture treatments, other Oriental medicine and/or Functional/Energetic Medicine procedures by the licensed practitioner listed below. I understand that the treatment may include, but not limited to: acupuncture, acupressure, moxibustion, cupping, heat lamp, Chinese or Western herbal medicine, homeopathy, nutritional testing or kinesiology. I have had an opportunity to discuss with the practitioner named below the nature and purpose of these treatment modalities and other procedures. I understand that results are not guaranteed.

Acupuncture: I have had an opportunity to discuss with a practitioner the nature and purpose of said treatment and/or other procedures. I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that may last a few days. Initial here______.

Neuro-Emotional Technique (NET): Emotions have a psychological aspect, however this technology is not psychology or psychiatry. Psychological aspects of emotional health will be referred out to an appropriate health care professional. Additionally, this technology does not deal with the spiritual realm. It does not make claims as to what events may have historically happened in the past. It does not tell people what their psychological plan of action may, must, or should be for the future. Initial here_____.

Nambudripad Allergy Elimination technique (NAET): I understand that once I have been cleared for a sensitivity to an allergen, it is my responsibility to recheck the clearing within one week. I understand that I may still have a reaction to that allergen if it is not cleared and additional treatment sessions may be necessary to clear the allergen completely. Initial here_____.

Nutritional Response Testing (NRT): I understand that this technique will test for the nutritional supplements which my body may be craving to reach maximum health benefits from nutrition. I understand that the supplements selected are not a replacement for my regular medications, and that I will not make any changes regarding the prescribed medications without discussing it with my medical doctor. Initial here_____.

To present, there may not be formal scientific studies completed for my particular condition now or those conditions that are treated in the future with these technologies. I understand that my return to health is a process of brining my body into harmony with the bodies own ability to heal. Initial here______.

I understand the contents of this consent form and I have had an opportunity to ask questions about this consent.

By signing below I agree to the above named procedures.

Patient’s printed name ______________________________

Patient’s signature__________________________________

Date __________

Parent or Guardian's name_____________________________

Signature _________________________________________

Date _____________

Practitioner: Veronica Bolhovitinova, L.Ac.