pediatric new patient form

8/3/2019 Pediatric New Patient Form

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New Patient (Pediatric) the Los Angeles Mobile Acupuncture group Page 1

PATIENT INFORMATION and BENEFITS ASSIGNMENT & RELEASE

PATIENT INFORMATION

First Name:________________ Middle Initial_____

Last Name:________________________________

Address:__________________________________

City:______________________________________

State:_________________ Zip:________________

E-mail:_________________@_________________

Twitter:@__________________________________

Facebook.com/_____________________________

Google+__________________________________

Sex: M F Age:_______________

Birth Date:________________________________Married Widowed Single Minor

Separated Divorced Partner for___years

Occupation:_______________________________

Employer/School:__________________________

Address:__________________________

__________________________

State:__________ Zip:_______________

Phone: ( ) _________ -_________

# of hours per week:_________________

Spouse:__________________________________

Date of Birth:__________ SSN:_____-_____-_____

Employer:_________________________________

Whom may we thank for referring you?_________

_________________________________________

PHONE NUMBERS

Home: (_______)__________-________________

Cell: (_______)__________-________________

Work: (_______)__________-________________Best time and place to reach you:______________

_________________________________________

EMERGENCY CONTACT

Name:____________________________________

Relationship:__________________________

Cell #: (_____) ______ - ________________

INSURANCE

Who is responsible for this account?_______________

____________________________________________Relationship to Patient:__________________________

Date of Birth:__________ SSN:_____-_____-_______

Insurance Co:_________________________________

Group #:_____________________________________

Phone #:(_______)_________ - _________________

Is patient covered by any additional insurance?

Y N

Subscribers Name:____________________________

Date of Birth:__________ SSN:_____-_____-_______

Relationship to patient:__________________________Secondary Insurance Co:________________________

Group #:_____________________________________

Phone #:(______)________ - ____________________

Assignment and Release

I certify that I, and/or my dependant(s), have insurance

coverage with:________________________________

and assign directly to the Los Angeles MobileAcupuncture group, assigned provider or agents all

insurance benefits, if any, otherwise payable to me for

services rendered. I understand that I am financially

responsible for all charges whether or not paid by my

insurance submissions.

Los Angeles Mobile Acupuncture and its providers may

use my health care information and may disclose such

information to the above named insurance

company(ies) and their agents for the purpose of

obtaining payment for services and determininginsurance benefits or the benefits payable for related

services. This consent will end upon written notice or 7

years after last visit.

Patient Signature (Or Patient Representative) Date

PO Box 352116, Los Angeles, CA 90035-1515 P: (866) 629-8089 F: (866) 629-8089 www.lamobileacu.com version 1-18-2012
http://www.lamobileacu.com/http://www.lamobileacu.com/http://www.lamobileacu.com/http://www.lamobileacu.com/


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Intake & Medical History the Los Angeles Mobile Acupuncture group Page 2

Home: (_____) ______ - ________________

Work: (_____) ______ - _________________

(Indicate relationship if signing for patient)



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Patient Printed Name:________________________________________________________________________

FINANCIAL AGREEMENT HEALTH INSURANCE

We would like to take a moment to welcome you to our office and assure you that you

will receive the very best of care available for your condition. In order to familiarize youwith the financial policy of this office we would like to explain how your medical bills willbe handled.

Explanation of Insurance Coverage:Many insurance policies do cover acupuncture care but this office makes norepresentation that yours does. Insurance policies may vary greatly in terms ofdeductible and percentage of coverage for acupuncture care. Because of the variancefrom one insurance policy to another, we require that you, the patient, be personallyresponsible for the payment of your deductibles, as well as any unpaid balances in thisoffice. We will do our best to verify your insurance coverage, and will bill your insurance

in a timely manner.

Payment ArrangementsWe require that you pay $20 towards todays charges and $20 on each visit. Your fullportion of the bill is expected to be when payment is received from your insurancecarrier. Any unpaid balances will be considered past due 30 days following insurancereimbursement Past due balances may have an interest charge of 1.5 % applied permonth.

Assignment of BenefitsAttached is an Assignment of Benefits form which we would like you to sign. This form

directs your insurance company to send payments directly to this office. If yourinsurance carrier sends payment to you for services incurred in this office, you agree tosend or bring those payments to this office upon receipt. If you pay for your visits in fullthe assignment need not be signed and the payments will be sent directly to you fromthe insurance.

Release of InformationIf your insurance company requires medical reports or records to document yourtreatment or progress, your signature below authorizes this office to release the medicalinformation necessary to process your claim.

Voluntary Termination of CareIf you suspend or terminate your care at any time, your portion of all charges forprofessional services is immediately due and payable to this office. All services renderedby this office are charged directly to you, and you, ultimately will be personallyresponsible for payment regardless of your insurance coverage.



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We hope this answers any questions you might have concerning the financial policy ofthis office. Once again we welcome your to our office, and will be glad to answer anyfurther questions that you might have.

I have read and agree to the above.

Patient Signature (Or Patient Representative) Date(Indicate relationship if signing for patient)



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Acknowledgement of Notice of Privacy Practices

I have been presented with a copy of the Notice of Privacy Practices for the offices of the Los

Angeles Mobile Acupuncture group, detailing how my information may be used and disclosed aspermitted under federal and state law.


Acupuncture Informed Consent to Treat

I hereby request and consent to the performance of acupuncture treatments nd other procedures within the scope of the practice of

acupuncture on me (or on the patient name below for whom I am legally responsible) by the acupuncturist below or any acupuncturistat the Los Angele Mobile Acupuncture group who now or in the future treat me while employed by, working or associated with or

serving as back-up for the acupuncturist listed below, including those working at the clinic, office, or group listed below or any other

office or clinic, whether signatories to this form or not.

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 the herbs may need to be prepared

and the teas consumed according to the instructions provided orally and in writing. The herbs may be an unpleasant smell o taste. Iwill immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of

the herbs.

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 the use of heat lamps. Bruising is a common side effect ofcupping. 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 disposable 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 ay occur. The herbs and

nutritional supplements (which are from plant, anima and mineral sources) that have been recommended are traditionally considered

safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand tat some herbs may be inappropriate

during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes,

hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

I do not expect the clinic staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely

on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the factsthen known is in my best interest. I understand that results are not guaranteed.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the

risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to

cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.




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Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services renderedunder this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submissionto arbitration as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicia

review of arbitration proceedings. Both parties to this contract by entering into it, are giving up their constitutional right to have any such disputedecided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as towhether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that i

agreement bind all parties as to all claims arising out of or relating to treatment or services provided by the health care provider including any heirs orpast, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind anychildren of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patienand the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while

employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care providersclinic or office or any other office where signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the

small claims court against the health care provider, and/or the health care providers associates, association, corporation, partnership, employeesagents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief

or punitive damages.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select anarbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the partieswithin thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration Each party to the arbitration shal

pay such partys pro rata share of expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by

the neutral arbitrator, not including counsel fees, witness fees or other expenses incurred by a party for such partys own benefit.

Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The partieconsent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action,

and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as abenefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for

future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that theCommercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this ArbitrationAgreement.

Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceedingA claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the

applicable legal statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein withreasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if no

revoked will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before this date it is signed (for example, emergencytreatment) patient should initial here. _____________. Effective as the date of first professional services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not beaffected by the invalidly of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature

below, I acknowledge that I have received a copy.

Notice: By signing this contract you are agreeing to have any issue of medical malpractice decided by neutral arbitration and you are giving

up your right to a jury or court trial. See Article 1 of this contract.


Office Signature Date



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GENERAL PAIN INDEX QUESTIONNAIRE

We would like to know how much your childs pain presentlyprevents them from doing what they would

normally do. Regarding each category, please indicate the overallimpact their present pain has on their life, not

just when the pain is at its worst.

Please circle the numberwhich best describes how your childs typical level of pain affects these fivecategories of activities.

1. FAMILY / AT-HOME RESPONSIBILITIES: (SUCH AS YARD WORK, CHORES AROUND THE

HOUSE OR DOING HOMEWORK FOR SCHOOL)

0 1 2 3 4 5 6 7 8 9 10COMPLETELY ABLE TO FUNCTION UNABLE TO FUNCTION

2. RECREATION: (INCLUDING HOBBIES, SPORTS OR OTHER LEISURE ACTIVITIES)


3. SOCIAL ACTIVITIES: (INCLUDING PARTIES, THEATER, CONCERTS, DINING OUT AND

ATTENDING OTHER SOCIAL FUNCTIONS)


4. SELF CARE: (SUCH AS TAKING A SHOWER, DRIVING OR GETTING DRESSED)


5. LIFE SUPPORT ACTIVITIES: (SUCH AS EATING AND SLEEPING)


SCORE _ [60] BENCHMARK = 5



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AFTER FILLING OUT: Please, e-Mail [email protected], Fax to(866)629-8089 orHold for us.

PEDIATRIC INTAKE and MEDICAL HISTORY

Patient Name: _________________________________ Gender: M F Today's Date: _________________Date of Birth: __________________ Mother: _____________________ Father: ____________________________How did you hear of Los Angeles Mobile Acupuncture? ________________________________________________________

GENERAL

Is the child yours by: ___ Birth ___ Adoption ___ Stepchild ___ Other:__________________________________Present Health Concerns: Why are you bringing your child in to see the doctor? For each item, try to include thefollowing information: a description of symptoms, when did it start, and to the best of your memory what other thingswere going on in your life around the time it started. If necessary, use additional sheets of paper.1.___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PRENATAL HISTORY

Age of Mother at birth: ______ Number of Previous Pregnancies:_______Indicate any medical problems during this child's pregnancy ___ none ___ Specify:_________________________

________________________________________________________________________________________________Medications during pregnancy: _____________________________________________________________________Y / N Alcohol or Tobacco Use during pregnancy or LactationMother's Allergies: _______________________________________________________________________________

BIRTH HISTORY

Duration of Pregnancy: _________ weeksDelivery by: ___ vaginal birth ___ Caesarian: if so, why was C-Section performed?_________________________Was Labor: ___ spontaneous ___ induced Hours of labor ___ Birth position: ___ Head first ___ Feet firstBirth Weight_______ Birth length___________ Any difficulties with birth?________________________________Any medical problems during first year?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Continued on next)

mailto:[email protected]:[email protected]://www.lamobileacu.com/http://www.lamobileacu.com/http://www.lamobileacu.com/mailto:[email protected]://www.lamobileacu.com/


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NEWBORN HISTORY NUTRITION AND FEEDING

Y / N Baby cried or breathed spontaneously Y / N Was Child Breast Fed?within 1 or 2 minutes? If yes, how long? _____

Y / N Was baby jaundiced? How old when solid food Introduced? ______________

Y / N Did baby spend time in hospital following birth?If yes, how long? _____________________

VACCINATION HISTORY List the dates of all vaccinations.

MMR:____________________________ Polio ___________________________ Hepatitis A______________________DPT:____________________________ Hib_____________________________ Hepatitis B ______________________Tetanus booster __________________ Varicella________________________ Other___________________________

DEVELOPMENTAL HISTORY Give the age at which your child accomplished the following skills:

Roll from stomach to back _____ Drink from a cup _____Laugh out loud _____ Pull themselves up, stand w/support _____

Reach out for objects _____ Stand w/o support _____Sit without support _____ Walk well _____Feed him/herself _____ Toilet trained in daytime _____Say Mama, Dada appropriately _____ Combine two words appropriately _____

ALLERGIES Indicate any allergies you suspect or are aware of:

Allergen Reaction Allergen Reaction ___ Milk/dairy ________________________ ___ Medications (list) ___ Wheat ________________________ __________________ ________________________ ___ Soy ________________________ __________________ ________________________ ___ Orange juice ________________________ __________________ ________________________ ___ Peanuts ________________________ __________________ ________________________ ___ Pollen ________________________ __________________ ________________________

___ Animals/Hair ________________________ ___ Other Items ___ Dust ________________________ __________________ ________________________ ___ Bee stings ________________________ __________________ ________________________ ___ insect bites ________________________ __________________ ________________________



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Intake & Medical History the Los Angeles Mobile Acupuncture group Page

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FAMILY MEDICAL HISTORY

Father

Mother

Brothers

Sisters OtherRelatives

1 2 3 1 2 3

Age (ifliving)

Cancer

Diabetes

HeartTrouble

HighBloodPressure

Stroke

Epilepsy

MentalDisorders

Asthma

Allergies

OtherConditions

Age at

deathCause ofdeath



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New Patient (Pediatric) the Los Angeles Mobile Acupuncture group Page

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CHILDHOOD ILLNESSES Please check all the following illnesses/conditions your child has had:

Constitutional Cardiovascular Infectious Diseases ___ Fevers/Chills/Excess Sweat ___ Tires easily with exertion ___ Mumps ___ Unexplained Weight loss/gain ___ Shortness of breath ___ MeaslesEyes ___Fainting ___ German Measles (Rubella)

___ Vision Problems ___ Heart murmur ___ Chicken Pox___ Eye Pain Gastrointestinal ___ Whooping Cough ___ Squinting/Cross-eyed ___ Nausea/Vomiting/Diarrhea ___ MeningitisEars/Nose Throat ___ Constipation Musculoskeletal ___ Hearing problems ___ Blood in bowel movement ___ Broken Bones (list) ____________ ___ Ear Infectons ___ Frequent Stomach Aches ___ Balance/Coordination Problems___ Tonsillitis Genito-urinary ___Muscle Pain ___ Frequent Runny Nose ___ Bedwetting ___ Joint Pain ___ Bad Breath ___ Pain with urination ___ Leg Pain ___ Sore Throats ___ discharge from penis or vagina Blood/LymphRespiratory ___ Urinary Tract Infections ___ Unexplained Lumps ___ Coughing/Wheezing ___ Frequent Urination ___ Easy Bruising/Bleeding___ Frequent Bronchitis Neurological Emotional ___ Asthma ___ Knocked unconscious ___ Speech Problems (poor ___ Pneumonia ___ Weakness pronounciation, etc ___ Tuberculosis ___ Clumsiness ___ lack of speech/interactionSkin ___ Headaches ___ Problems w/ sleep, nightmares ___ Rashes ___ Seizures ___ Depression ___ Unusual Moles ___ Numbness of hand/arms, ___ Nail biting/thumbsucking ___ Birth marks feet/legs ___ Bad temper tantrums

___ dizziness ___ Anxiety/Stress



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Intake & Medical History the Los Angeles Mobile Acupuncture group Page

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Current Metabolic Status: Please indicate your child's present state for each of the following items

Sleep. usual bedtime, hours slept, problems with fallingasleep or waking up after your fall asleep. dreams and ornightmares,

Urination. approximate number of times per day,waking up at night to urinate, bed wetting, etc.

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

Meals Times each day. Typical food for each meal. Perspiration. do you perspire excessively during the dayor at night. do you NOT perspire when it would beappropriate to do so (for example, during exercise)

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

Bowel Movements. frequency (number per day), quality ofstools (small and hard, loose, etc.)

Energy Level when waking up, throughout the day.

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

Where was your child raised during the following time periods? During each of these time frames, did he or she have any majorillnesses, recurring illnesses even if minor, or major injuries? (fill out only those portions that are appropriate for his/her age)

- birth to 2 years - 5 years to puberty

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

- 2 years to 5 years - puberty through roughly age 20

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________



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New Patient (Pediatric) the Los Angeles Mobile Acupuncture group Page

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CURRENT MEDICATIONS, VITAMINS, SUPPLEMENTS

Name of Medication Dosage/Frequency Length of Use Reason for Medication

1

2

34

5

Vitamin or Supplement Dosage/Frequency Length of Use Reason for Supplement

1

2

3

4

5

OTHER INFORMATIONPlease use this space to tell us anything else about your child's health or behavior that you feel is important and thatwe haven't asked.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thanks for filling this all out. We know its a lot to fill out. Please understand the more weknow about your child and their development, the better we can understand how to helpthem feel better.

Welcome to Los Angeles Mobile Acupuncture group and our home health care family.

Please feel free ask your provider questions or for information about acupuncture, primary health care withalternative medicine or any of our services and how we can help you, your family, friends and community. We

are here to help and educate you about your health, not to judge you for it.


pediatric new patient form

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