Bey Acupuncture Patient Health History
Dear Valued Client,

This notice describes our office’s policy for how medical information about you may be used and disclosed, how you can get access to this information, and how your privacy is being protected.

In order to maintain the level of service that you expect from our office, we may need to share limited personal medical and financial information with your insurance company, Workers' Compensation (and your employer as well in this instance), or with other medical practitioners that you authorize.

Safeguards in place at our office include:
• Limited access to facilities where information is stored.
• Policies and procedures for handling information.
• Requirements for third parties to contractually comply with privacy laws.
• All medical files and records (including email, regular mail, telephone, and faxes sent) are kept on permanent file.

Types of information that we gather and use:

In administering your health care, we gather and maintain information that may include non-public personal information:

• About your financial transactions with us (billing transactions).
• From your medical history, treatment notes, all test results, and any letters, faxes, emails or telephone conversations to or from other health care practitioners.
• From health care providers, insurance companies, workers' compensation, and your employer and other third part administrators (e.g. requests for medical records, claim payment information).

In certain states, you may be able to access and correct personal information we have collected about you, (information that can identify you- e.g. your name, address, Social Security number, etc.).

We value your relationship, and respect your right to privacy. If you have questions about our privacy guidelines, please feel free to call us at
512-536-0801.

Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally, and emotionally. Please complete this consent to treatment questionnaire as thoroughly as possible.

Truly,

Simel E. J. Bey, DAOM (c), L.Ac., MSAOM, AAHAS

A. Patient Information
Date *
Your answer
Name *
First, Middle, Last
Your answer
1. When and where did you last receive health care? *
Your answer
2. For what reason? *
Your answer
3. Has your case been referred to an attorney?
4. Height, Weight *
Your answer
5. Past Maximum
Your answer
6. Blood Pressure
(please indicate when this reading was taken)
Your answer
7. Childhood Illness
(please check any you have had)
8. Immunizations *
(please check any you have had)
Required
9. Please identify and Hospitalizations and Surgeries *
When, Reason
Your answer
10. Please identify any X-Rays/CAT Scans, MRI's NMR's, Special Studies *
When, Reason
Your answer
11a. Please identify the health concerns that have brought you to Bey Acupuncture Clinic: *
Describe conditions in order of importance
Your answer
11b. How does this affect you? *
Your answer
11c. Have you had any prior treatment for this condition? *
Your answer
12. Please list any medications (prescribed and over-the-counter) vitamins and supplements you are currently taking: *
Your answer
13. Do you have any reason to believe you may be pregnant? *
Required
14a. Do you have any infectious diseases? *
Required
14b. If yes, please identify
Your answer
15. Emotional
Please check any that you have had now or in the past
Now
In the Past
Mood Swings
Nervousness
Mental Tension
16. Energy and Immunity
Please check any that you have had now or in the past
Now
In the Past
Fatigue
Slow Wound Healing
Chronic Infections
Chronic Fatigue Syndrome
17. Head, Eye, Ear, Nose, and Throat
Please check any that you experience now or in the past
Now
In the Past
Impaired Vision
Impaired Hearing
Nose Bleeds
Eye Pain/Strain
Ear Ringing
Frequent Sore Throats
Glaucoma
Earaches
Teeth Grinding
Glasses/Contacts
Headaches
TMJ/Jaw Problems
Tearing/Dryness
Sinus Problems
Hay Fever
18. Respiratory
Please check any that you experience now or in the past
Now
In the Past
Pneumonia
Frequent Common Colds
Difficulty Breathing
Emphysema
Peristent Cough
Pleurisy
Asthma
Tuberculosis
Shortness of Breath
Glasses/Contacts
Headaches
TMJ/Jaw Problems
19. Cardiovascular
Please check any that you experience now or in the past
Now
In the Past
Heart Disease
Chest Pain
Swelling of Ankles
High Blood Pressure
Palpitations/Fluttering
Stroke
Heart Murmurs
Rheumatic Fever
Varicose Vains
20. Gastrointestinal
Please check any that you experience now or in the past
Now
In the Past
Ulcers
Changes in Appetite
Nausea/Vomiting
Epigastric Pain
Passing Gas
Heartburn
Belching
Gall Bladder Disease
Liver Disease
Hepatitis B or C
Hemorrhoids
Abdominal Pain
21. Genito-Urinary Tract
Please check any that you experience now or in the past
Now
In the Past
Kidney Disease
Kidney Stones
Painful Urination
Impaired Urination
Frequent UTI
Blood in Urine
Frequent Urination
Frequent Urination in the Night
Heavy Flow
22. Female Reproductive/Breasts
Please check any that you experience now or in the past
Now
In the Past
Irregular Cycles
Vaginal Discharge
Menopausal Symptoms
Breast Lumps/Tenderness
Premenstrual Problems
Difficulty Conceiving
Nipple Discharge
Clotting
Painful Periods
Heavy Flow
Bleeding Between Cycles
23. Menstrual/Birthing History
Please check any that you experience now or in the past
Now
In the Past
Age of First Menses
# of days, Menses
Length of Cycle
Birth Control Type
# of Pregnancies
# of Miscarriages
# of Abortions
# of Live Births
24. Male Reproductive
Please check any that you experience now or in the past
Now
In the Past
Sexual Difficulties
Prostrate Problems
Testicular Pain/Swelling
Penile Discharge
25. Musculoskeletal
Please check any that you experience now or in the past
Now
In the Past
Neck/Shoulder Pain
Muscle Spasms/Cramps
Arm Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Leg Pain
Joint Pain
If yes for Joint Pain, Where?
26. Neurologic
Please check any that you experience now or in the past
Now
In the Past
Vertigo/Dizziness
Paralysis
Numbness/Tingling
Loss of Balance
Seizures/Epilepsy
27. Endocrine
Please check any that you experience now or in the past
Now
In the Past
Hypothyroid
Hypoglycemic
Hyperthyroid
Diabetes Mellitus
Night Sweats
Felling Hot or Cold
28. Other
Please check any that you experience now or in the past
Now
In the Past
Anemia
Cancer
Rashes
Eczema/Hives
Cold Hands/Feet
Lifestyle
29. Do you eat at least 3 meals per day?
(if not no, how many?)
30. Exercise Routine *
Please describe exercise routine
Your answer
31. Spiritual Practice
Please describe spiritual practice
Your answer
32a. How Many hours per night do you sleep? *
Your answer
32b. Do you wake rested? *
Your answer
33. Level of Education Completed *
Required
34a. Occupation *
Your answer
34b. Employer *
Please list employer and how many hours a week you work
Your answer
34c. Do you enjoy work? *
Please explain why or why not you enjoy work
Your answer
35. Do you use any of these substances? *
Required
36a. Have you had any major Traumas? *
Required
36b. Please explain *
Your answer
37. How many glasses of non-caffeinated, non-carbonated beverages do you drink per day? *
Your answer
38a. Please describe your Television Habits
Your answer
38b. Please describe your Reading Habits
Your answer
38c. Please describe your Interests and Hobbies
Your answer
B. Family History
8a. Health
Good
Poor
Column 3
Column 4
Father
Mother
Brothers
Sisters
8b. Health *
Good
Spouse
Spouse
Children
9a. Family History
check all that are applicable
Father
Mother
Brothers
Sisters
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever/Hives
Kidney Disease
9b. Family History
check all that are applicable
Spouse
Children
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hay Fever/Hives
Kidney Disease
How did you hear about us? *
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