Fertility Worksheet - Women - Affinity Acupuncture and Rolfing™

- Step 1 of 5

Name *

First

Last

Pronouns

You are

Date of Birth *

Age *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone (Home)

Phone (Cell) *

Email *

Do you want to get our quarterly newsletter? *

May we correspond with you via text for scheduling? *

All care related correspondence must be done via phone call or email.

In Case of Emergency

Contact:

Relationship and Phone:

Family Physician:

Phone:

How did you hear about us?

Insurance Information:

If Affinity Acupuncture and Rolfing will be billing your insurance, please fill out the following:

Insurance Name and Phone Number:

Name of Guarantor (Primary Plan Holder):

Guarantor’s Date of Birth:

ID Number:

Group Number:

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am financially responsible for any balance not paid by my insurance company or Medicare. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.

Reason for Today’s Visit

What is the reason for your visit today? *

How, when and where did this condition begin?

What types of treatments have you tried, if any?

How does this condition impair your daily activities?

What makes it better or worse?

Please list your main health problems that you would like to be free of in order of importance:

Your Height (in inches) *

Your Weight (in lbs) *

Your Medical History:

Surgeries, Major Illnesses, Hospitalizations, Falls and Major Accidents (incl. Dates):

Any falls/injuries to sacrum/head/tailbone (describe):

Any birth trauma that you know of:

Family History:

Health and major emotional states as a child:

List any major health issues in your family (going back to grandparents)

Family History of Substance:

Abuse
Suicide
Other Trauma

History of Abuse:

Physical
Emotional
Sexual
Other

Please list any medications/vitamins/supplements you are currently taking:

List out each medication, Reason of use, When & For how long

Herb/Medication allergies and reaction (if any):

Do you have, or have you ever had any of the following illnesses?

AIDS
Allergies
Arthritis
Asthma
Cancer
Chronic Fatigue
Diabetes
Gall Stones
Heart Disease
Hepatitis
High Blood Pressure
Herpes
HIV+
Kidney Stones
Mental Illness
Mononucleosis
Osteoporosis
Parasites
Rheumatic Fever
Seizures
Stroke
Thyroid Problems
Ulcers
Venereal Disease

Other Illness (Other than above)

Lifestyle

How good do you feel your nutrition is?

Typical

Breakfast:

Lunch:

Dinner:

Snacks:

Worst food in your diet?

What foods do you crave?

Water intake per day?

Caffeine(what form & how much)

Do you use

Tobacco?

How much Tobacco?

Alcohol?

How much Alcohol?

Work: Do you enjoy your work?

Hours per week working:

Exercise: Do you Exercise?

Number of times/ week:

Type of exercise:

Sleep

Do you have trouble falling asleep?

Time to bed:

Time to rise:

How many hours of sleep do you get per night?

Are you rested in the morning?

Do you wake in the night?

How is your home environment?

Describe any stressors occurring at this time:

What are hobbies/activities that provide you with a sense of pleasure and accomplishment?

What is your opinion of yourself?

What is the most negative emotion you experience?

When and Where?

Urination

Please check any of the following symptoms you are currently experiencing:

Burning
Urgent
Retention
Scanty
Profuse
Dribbling
Greater than 1x a night

Bowel Movements

Frequency:

Feels complete?

Painful?

Consistency (check):

Well-formed
Hard
Loose
Alternates
Undigested food
Blood
Mucus
Sink
Float

Head

Please check any of the following symptoms you are currently experiencing:

Ear pain
Dry mouth
Migraines
Ringing in ears
Clogged/popping ears
Frequent headaches

Body Fluids

Do you perspire abnormally during the day?

At night?

Are you always thirsty?

At what age did you get your first period?

What was that like?

Date of last menstrual cycle?

Are you currently using contraception?

How long have you used contraception throughout your life?

Dates/Type:

Are you pregnant now?

How many pregnancies have you had?

No. of deliveries:

Delivery Dates:

No. of Terminations:

Termination Dates

Termination Complications?

No. of Miscarriages:

Miscarriage Dates

Miscarriage Complications?

Maternal Family History of (please check):

Infertility
Fibroids
Endometriosis
Menstrual Problems
PMS
Menopause

Cancer (type)

Medications your mother took when she was pregnant with you (if any)

Number of days from the start of one period to the start of the next:

Are your menstrual cycles spaced regularly?

Average number of days of flow:

Flow is:

Light
Normal
Heavy

Color is:

Pale
Normal
Dark
Bright Red
Brown

Are blood clots present?

Does your period cause you pain or cramping?

When?

Before
During
After Period

Do you get nausea or vomiting with your period?

When?

Before
During
After Period

Do you experience any of the following before your period each month?

Water retention
Breast tenderness or swelling
Mental depression
Irritability
Food cravings
Migraines

Other: Anything other than above

Do you ever bleed or spot between periods?

Do your bowel movements become loose at the beginning of your period?

Do you have any vaginal discharge between periods?

Discharge Color:

Do you have/have you ever had?

Abnormal pap smear?

When/Why?

A cervical biopsy, operation, cauterization, conization?

Venereal disease?

Chlamydial infection?

Yeast infections?

Sores on your genitals?

Uterine fibroids or polyps?

Endometriosis?

Varicose veins?

Sore heels when walking?

Incompetent Cervix?

Painful intercourse?

Numb legs/feet when standing still?

Pelvic inflammatory disease?

Difficulty experiencing orgasm?

Were you treated for it?

How

Date of last pap smear?

Have you been diagnosed with pelvic adhesions?

Have you been diagnosed with any pelvic abnormalities?

Have you experienced menopause?

When

If you are experiencing menopausal symptoms, please describe:

Is there anything else that we should know to best understand and help you?

Women’s Fertility Worksheet

This worksheet is to be filled out by women coming to Acupuncture Northwest for fertility issues

Name of Patient: *

Sex: *

Men
Women

Name of Partner:

Sex: *

Men
Women

How long have you been trying to get pregnant?

Do you have a diagnosis of infertility? *

When was that diagnosis given?

What is that diagnosis?

Male factor?

Female factor?

Why do you think you aren’t getting pregnant?

What fertility treatments have you tried, when and what happened?

Explain: what, when, where/by whom in detail.

What is your plan from here?

Thank you for taking the time to fill out this form thoroughly. It will help us serve you better

Signature: *

Date *

Welcome Letter

Dear New Patient,

Welcome to Affinity Acupuncture & Rolfing. We are honored and delighted that you have chosen us as your healthcare providers. We strive to provide a blend of proven ancient Chinese Medicine practices with cutting edge modern advancements, and are committed to your treatment being successful. We look forward to partnering with you to address your health concerns, and we will do all we can to ensure you achieve the most successful result possible for you.

The doctor-patient relationship requires both cooperation and mutual trust. We will strive to provide you with the best possible medical care, and ask that you participate in this effort to the best of your ability.

This welcome letter was prepared to acquaint you with the clinic policies of Affinity Acupuncture & Rolfing. Please review our FAQ under resources on our website if you are a new to acupuncture.

Tips for Your Acupuncture Treatments

Wear loose fitting clothes that can be easily rolled up above your elbows and knees. Also, you may need to expose your abdomen from your rib cage to the top of your hips, so please avoid one -piece suits or dresses.
Be sure you have eaten at least a light meal within a few hours prior to arriving.
Avoid alcohol on the day of your treatment.
Drink plenty of water and stay hydrated after your appointment
For best results, avoid strenuous activity immediately following a treatment. Set aside enough time so that you are not rushing to and from your visit.
As we follow through on your treatment plan, look for signs of improvement and take encouragement from them. Your belief and expectation has a strong influence on your body, and - is a key factor in healing.

Please ask questions whenever you do not understand your treatment or medical advice.

Affinity Acupuncture & Rolfing practitioners act as a team. Each provider is individually responsible for their own treatment style although we strive to communicate together regarding your care and treatment plan. As a team, we share health information.

Fragrance Free Zone: Many of our patients are sensitive to smells. Please avoid wearing any perfume, cologne, or scented lotions to your appointment.

Cell phones and Electronics: Out of consideration for others, please completely turn off your mobile devices or put them in silent mode.

Music/Sound: There is typically music played during treatment. Please speak softly to not disturb other patients resting.

Always report any problems you have with herbs, nutritional supplements or any treatment. Different people react differently to the same treatment or herbal prescription. It is possible for us to properly manage your care only if you tell us about difficulties you are having, or if formulations are not effective or causing you discomfort.

Herbal Formulas/Supplement Price Policy. We may recommend a product to achieve the best outcome for your health and medical needs. We have stock so that you may begin your treatment promptly. We practice fair pricing and will refund the difference, if you find a better priced, retail store product. This does not include online products, but we monitor amazon prices and ours are better.

Payment and Insurance and Cancellation Policy

Payments: Payment is due at time of service. We take cash, check, Venmo and medical credit cards. For Rolfing, we only accept cash or zelle unless otherwise arranged.

Cancellation/Late Policy: If you cancel with less than 24 hours notice, or if you miss a booked appointment, you will be charged $95, the full cost of treatment. If you are more than 15 minutes late to an appointment, we may need to reschedule your appointment.

Non-Refundable Payment Policy: All services and herbs purchased are non-refundable. No refunds will be provided for the full or partial price for any used products or services

Refund Policy on Pre-Paid Packages: Refunds are accepted for “discount prepayment packages” within the first 30 days only. When refunded you will be charged at full rate for each treatment you have used and be refunded the remainder.

Insurance: We participate in many insurance networks and as a courtesy will verify your benefits. Please understand that ultimately, you are responsible for payment should there be any discrepancies with your insurance company at a later date.

Parking: There is NO ON-PREMISE parking. There is plenty of street parking, free and metered taking quarters and credit cards.

Thank you once again for selecting Affinity Acupuncture & Rolfing for your care. Should you have any specific questions that have not been answered, please do not hesitate to ask.

Sincerely,
Dr. Connie L. Christie, DAOM, L.Ac. and the entire Affinity Acupuncture Team

Signature: *

Date: *

Informed Consent to Treat

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Dr. Connie L. Christie, DAOM, L.Ac. and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for Dr. Connie L. Christie, DAOM, L.Ac., including those working at Affinity Acupuncture and Rolfing 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, Tiu-Na (Chinese massage), muscle testing, 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 or in writing. The herbs may have an unpleasant smell or taste. I will 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 site that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Unusual (rare) 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, disposal needles and maintains a clean and safe environment. Burns and/or scarring are a rare potential risk of moxibustion and cupping. I understand that this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral source) that have been recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in larger doses which will not be prescribed. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify Dr. Christie or a clinical staff member who is caring for me if I am pregnant or become pregnant.

I do not expect Dr. Christie or the clinical staff to be able to anticipate all possible risks and complications of treatment, and I wish to rely on Dr. Christie and/or the clinical staff to exercise judgment during the course of treatment which she/them thinks at the time, based upon the facts 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. I have stated all medical conditions that I am aware of and will update my practitioner of changes in my health status.

Affinity Acupuncture and Rolfing Providers: Dr. Connie L. Christie, DAOM, LAc & Associates

Patient Name *

Parent or Guardian (if under the age of 18)

Signature: *

Date: *

HIPPA Receipt of “Notice of Privacy Practices”

Click here to view the privacy policy: Privacy Policy

I have reviewed a copy of the clinic’s Notice of Privacy Practices *

Signature of Patient (Parent, if patient is minor) *

Date: *

OK to share information with

24- Hour Cancellation Policy

We understand that you may need to cancel or change your appointment. In order to maintain quality patient-centered care, we require a 24-hour cancellation notice when you are unable to keep your scheduled appointment; otherwise you will be charged $95, full price of a standard treatment For rolfing, the first time fee is $200 (full price). Please note, insurance and third party coverage do not pay this fee.

I have read and understand the above policy.

Signature: *

Date: *

COVID-19 Policy

Our Covid-19 policy follows the CDC and Los Angeles County guidelines and will be updated as required to reflect the current guidelines.

Are you vaccinated? *

Have you received a booster? *

Vaccine type

Dates of Vaccination

No clients will be treated in the clinic with any viral symptoms such as a fever, cough, or shortness of breath.

I have read and understand the above policy.

Signature: *

Date: *

Fertility Worksheet – Women

In Case of Emergency

Insurance Information:

Reason for Today’s Visit

Your Medical History:

Family History:

Lifestyle

Do you use

Sleep

Urination

Bowel Movements

Head

Body Fluids

Do you have/have you ever had?

Women’s Fertility Worksheet

Welcome Letter

Informed Consent to Treat

HIPPA Receipt of “Notice of Privacy Practices”

24- Hour Cancellation Policy

COVID-19 Policy

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Contact

Address

Hours

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