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                                 Fan Acupuncture Clinic
                    Acupuncture & Chinese Herbal Medicine
     90 Madison Street, Suite 402, Denver, CO 80206 Phone: (720)244-3035

Patient Name ______________    Age _____    Male / Female ____

Date of Birth ______/______/______  Height _________    Weight ______  Marital Status _____

Occupation __________Referred By __________    E-mail________________________

Phone (H) (_______) _________ - ________          Phone (Cell) (______) _______-________

Address__________________________________________________________________________

City _________________   State________   Zip _________  Driver’s License No.___________

Emergency Information (Please indicate who to notify in case of emergency)

Name ________________________ Relationship ____________________________

Phone (H) (____) _____-_____Phone (W) (___ ) ______-______Phone (C) (____) _____-_____

Chief Complaint(s) Please indicate how long you’ve had the condition(s).





What kinds of treatments have you received?


List any Hospitalizations & Surgeries (include Date and Place)



List medications being taken (include dosage)



Family History (please include the relationship)
[] Migraines ___________    [] Stroke __________     [] Heart Disease __________
[] High Blood Pressure________     []Allergies_________     [] Mental Illness ______
[] Asthma ___________     [] Gall Stones_________         [] Arthritis ___________
[] Cancer____________     [] Diabetes___________     [] Thyroid Disease________
[] Glaucoma_________      [] Epilepsy___________

Are you allergic to any of the following? If yes, please specify)
[] Medicine     [] Food     [] Herbs     [] Others

Do you have or are you any of the following?
[] Pacemaker     [] Electric Implants     [] Metal Implants     [] Severe Bleeding Disorders
[] Pregnant      [] HIV Positive     [] Hepatitis A/B/C

Life style:
[] Exercise     [] Sedentary    [] Eat three meals every day   [] Eat at regular time every day
[] Tea          [] Coffee          []Softt drink         [] Alcohol
[] Cigarettes    [] Drug 

                                                       Confidential Patient Health History

    Name: ______________________________________ Date: ___/___/________

Please check if you have had (in the past three months):
General
[]Anemia                    [] Poor Appetite                   [] Tremors
[] Fatigue                    [] Localized Weakness                  [] Poor Balance
[] Fever                    [] Bleed or Bruise Easily                  [] Cravings
[] Weight Loss             [] Peculiar Tastes or Smells               [] Weight Gain
[] Sweats                [] Strong Thirst (hot or cold drinks)        [] Alcoholism
[] Chills                         [] Energy Drop                     [] Tetanus Shot
[] Drug Addiction        [] Poor Sleep Habits             [] Frequent cold/flu

Skin and Hair
[] Rashes                 [] Open sore            [] Recent moles                         [] Itching
[] Acne               []Loss of Hair                [] Dandruff               [] Corns
[] Hives              [] Change in hair/skin texturebsp;    [] Warts             [] Nail Problems
[] Ulcerations               [] Psoriasis         [] Dry skinPsoriasis             [] Eczema

Head, Eyes, Ears, Nose and Throat
[] Dizziness/Vertigo                [] Concussions             []Migraines   Psoriasis      [] Poor Vision
[] Eye Strain                  [] Eye Pain                    [] Cataracts                   [] Night Blindness
[] Color Blindness                  [] Ringing in ears         [] Blurry Vision       [] Earaches
[] Sinus Problems             [] Poor Hearing         [] Spots in front of eyes    [] Grinding Teeth
[] Nose Bleeds                 [] Recurrent Sore Throats           [] Nasal Congestion
[] Hoarseness       Psoriasis   [] Facial Pain                  [] Headaches

Cardiovascular
[] High Blood Pressure        [] Myocarditis        [] Coronary Heart Disease      [] Low Blood Pressure
[] Pneumatic Heart Disease       [] Difficulty in Breathing  [] Palpitations       [] Chest Pain
[] Hardening of Arteries         [] Irregular Heartbeat      [] Varicose Veins          [] Phlebitis
[] Mitral Stenosis          [] Swelling of Hands/Feet     [] Blood Clots
[] Mitral Prolapse                           [] Fainting                       [] Cold hands/feet

Respiratory
[] Cough                    [] Coughing Blood          [] Pain w/ deep breath            [] Bronchitis
[] Pneumonia            []Production of phlegm                 [] Difficulty breathing lying down              [] Asthma                                      [] Pleurisy                       [] Emphysema

Gastrointestinal
[] Nausea              [] Constipation                 [] Diarrhea             [] Vomiting
[] Gas             [] Belching                       [] Bad Breath          [] Blood in Stools
[] Black Stools            [] Abdominal Pain or Cramps             [] Rectal Pain
[] Hemorrhoids         ; [] Indigestion            [] Chronic Laxative Use       [] Acid Reflux
[] Ulcer              [] Colitis

Genitourinary
[] Bed Wetting            [] Blood in Urine              [] Frequent Urination       
[] Kidney Infections / Stones           [] Painful Urination               [] Bladder Infections           
[] Genital Herpes       [] Venereal Disease            & [] Cystitis             [] Incontinence

Pregnancy and Gynecology
[] Number of Pregnancies           []Age at 1st Menstruation            [] Unusual Character (heavy/light)
[] Number of Abortions ___ Time between Menstruation            [] Vaginal Sores
[] Number of Births ___ Duration of Menstruation          [] Vaginal Discharge
[] Number of Miscarriages ___ First Date of Last Menstruation                          [] Breast Lumps
[] Use of Birth Control                [] Irregular Periods           [] Uterine Fibroids
[] Hot Flash/Night Sweats           [] Frequent changes in emotion                       [] Osteoporosis

Fertility Information
# of IVF procedures____________# of IUI procedures__________________________________

Has a physician diagnosed a difficulty with fertility due to:
[] Female Factor?                          [] Male Factor?                   [] Unexplained

Musculoskeletal
[] Neck Pain              [] Muscle Pain              [] Knee Pain
[] Back Pain              [] Muscle Weakness                  [] Foot/Ankle Pain
[] Hand/Wrist Pain          [] Shoulder Pain         [] Hip Pain

Please indicate on the figures below the areas of the body you experience your pain:
[] dull/achy                  [] sharp/stabbing                [] burning
[] tingling                         [] numbness          [] electrical

Neuropsychological
[] Seizures               [] Dizziness           [] Loss of Balance         [] Areas of Numbness
[] Lack of Coordination        [] Poor Memory           [] Concussion           [] Depression
[] Anxiety           [] Bad Temper             [] Easily susceptible to stress             
[] ADD               [] Difficulty Concentrating

Infection
[] Measles             [] Mumps           [] Whopping Cough         [] Rheumatic Fever 
[] Tuberculosis          [] Typhoid Fever         [] Malaria        [] Chicken Pox               
[] Scarlet Fever                         [] Small Pox 






                                                                    Fan Acupuncture Clinic
                                                          Acupuncture & Chinese Herbal Medicine
                                   90 Madison Street, Ste 402, Denver, Colorado 80206 Phone: (720)244-3035

                                                                    Car Accident Information
                                                                 (Just for car accident patient)

Patient’s Name____________________________________ Date of injury ______/______/___________

Injury Location ________________________________________ City___________________________

Patient’s Car Insurance __________________________________ Phone _________________________

Claim #__________________________Adjuster______________________ Phone_________________

Address__________________________________________ City__________ Zip __________________

Person at Fault’s Name ___________________ Person at Fault’s Auto Insurance Carrier _____________

Phone________________________________ Claim # _______________________________________

Adjuster ______________________________ Phone ________________________________________

Address ________________________________________ City ______________ Zip _______________

Patient’s Attorney ______ ________________________________ Phone ________________________

Address _____________________________________ City ________________ Zip ________________

Contact person _____________________________________________ _______ Fax ______________


AUTHORIZATION TO RELEASE INFORMATION & PAYMENT OF MEDICAL BENEFITS

I certify that I have read and understand the above information to the best of my knowledge. The above question has been accurately answered. I hereby authorize the release of any medical information necessary to process insurance claim. I also authorize the release of payment of medical benefit to Dr. Cheng / Dr. Fan for service or product rendered. I understand that my insurance carrier may pay less than actually billed for services. I agree to be responsible for payment of all service rendered on my behalf for my dependents in accordance with my plan benefit. By signing below I have accepted and consent to the treatment recommended.

Patient or responsible parties’ signature __________________________            Date ___________________ 



                                                                     Fan Acupuncture Clinic
                                                         Acupuncture & Chinese Herbal Medicine
                              90 Madison Street, Suite 402, Denver, Colorado 80206 Phone: (720)244-3035

                                                                      Insurance Information
                                          (For the patient whose insurance covers acupuncture benefits)

PRIMARY Insurance

Insurance ______________________________                  Subscriber’s Name _______________________

Date of Birth _______/________/___________                   S. S # (I.D#) ___________________________

Group #: _______________________________                 Insured Employer________________________

Phone __________________________________


SECONDARY Insurance

Insurance _______________________________                 Subscriber’s Name _______________________

Date of Birth _______/________/____________                  S. S # (I.D#) ___________________________

Group #: _______________________________                  Insured Employer________________________

Phone __________________________________


AUTHORIZATION TO RELEASE INFORMATION & PAYMENT OF MEDICAL BENEFITS

I certify that I have read and understand the above information to the best of my knowledge. The above question has been accurately answered. I hereby authorize the release of any medical information necessary to process insurance claim. I also authorize the release of payment of medical benefit to Dr. Cheng / Dr. Fan for service or product rendered. I understand that my insurance carrier may pay less than actually billed for services. I agree to be responsible for payment of all service rendered on my behalf for my dependents in accordance with my plan benefit. By signing below I have accepted and consent to the treatment recommended.

Patient or responsible parties’ signature __________________________             Date ___________________ 




                                                                Fan Acupuncture Clinic

                                          90 Madison Street, Suite 402, Denver, CO 80206
                                                                   Tel: 720-244-3035


                                                CANCELLATION & RE-SCHEDULING POLICY

We understand that there are times when you will need to cancel and/or re-schedule your appointment. We are pleased to accommodate your needs.

It is our policy, however, that all cancellations and/or re-scheduling occur at least two business days prior to the date of your appointment.

A fee of $50.00 will be charged if your cancellation/re-scheduling is not completed at least two business days prior to the date of your appointment.

Thank you for your understanding.

Please sign here indicating that you understand and accept this policy:


Signature: _______________________________________                               Date: ___________________