Informed Consent Form

I understand that doctor may use different techniques and Acupuncture implements dr:ring thetreatment, such as Body Acupuncture, Electrotherapy, Auricular Seed Pressing, Cupping,intradermal Needles, and Spot Pricking according to different cases of patients in order to havethe ideal result for the patients.

I understand that there may be needling sensation during and after Acupuncture treatment orthe local area may become flushed or bruises after cupping; or mild hematoma caused by a littlesubcutaneous bleeding. All this is normal and will disappear by itself. A very few patients mayfeel uncornfortable due to neryousness at the beginning of the Acupuncture treatment, youshould let your doctor know as soon as you have such a feeling.

I understand that the herbal medicine the doctor prescnbed should be taken according to thedoctor's prescription. The herbai medicine shouid be regarded as a drug for patients and it is notnatural supplement for everyone.

i understand that an acupunctunst is not licensed to practice medicine or camot practicemedicine in the State of Georgia (unless the practitioner has a license to practice medicine fromthe state of Georgia); that the acupunctunst is not making a medical diagnosis of the person'sdisease or medical condition; that if the person wants to obtain a medical diagnosis, the personshould see a licensed physician and seek medical advice fiom a licensed physician.

My signarure indicates that I have read and understand this consent form and that I am willingto have the Acupuncture treatment, and I will cooperate with my doctor during the treatment inorder to have the ideal results.

Signature: Patient or relative

Name: Phone:

Acupuncture & Herb Center suite 5 t22l south Houston Lake Road Ll/arner Robins, GA 3t0gg

ACUPUNCTT]RE & HERB CENTERSuite5 l22l Sguth Houston Lake Road Warner Robins, CA 310S8

218-5296

Nelv Patient Form

Name:(First) (Middle) (Last) (Maiden)

Residence Address:(Street Name) (Aparhnent Number) or (Post Office Box)

(City) (Stare) (.Zip) (Counry)

G:_-_-_DateofBirth[iffi6r $/vDr{)

CityI

Age_ Sex -- Home Phone:

Business Phone: Business Address

State Zrp Code

Piease check the follorving befbre you see the doctor:

1. Famrly History: Heart Disease ( ), Drabetes ( ), and Hypertension ( )2. MedicalHistory: Allerges: Skin ( ), Food ( ), Medicine ( ), and Pollen ( ).3. Hrstory of Infectrous Diseases: AIDS Yes ( ) No ( ), T.B. Yes ( ) No ( ).Hepatitis Yes ( ), No ( ).

Medical Diagnosis by licensed health care practitioner:t. 2.

3. 4.

Smokrng?Yes( )No( )Alcohol ? Yes( )No( )

Signarure:

Aspuctw & Hrb Cotcr Suitc 5 l22l Soutb Houroo Rord Wmcr Robior, C^ 3l0gg phOne: 2lg_5296

HEALTH HISTORY INVENTORY HI{I-4Name or I.D. : Date:

Please check an" X " mark in the boxes(E ) beiow forthose irems that apply to you.

l. Healthllistory:Haveyousvgrbeendiagnosedbyalicensedhealthcarepractitionerforanyofthefollorving?J Tension Headaches -l Coronary Disorder or Heart Altack J Srroket Migraine or Cluster Headaches D Asthma, Bronchitis, or Emphvsema i1 Tuberculosis or pneumonia3 TMJ Disorder or Jaw Pain -'l Liver Disease or Hepatitis I Brain Seizures or Epilepsy3 Low Back Pain or Sciatica t Urinary or Bladder Disorder J Concussion or Head Trauma3 Rheumatoid Arthritis D Kidney Disorder or Stones J Cancer or TumorsD Osteoarthritis I Gall Bladder Disorder or Stones -I AIDS or HIV Disease-I Fibromyalgia f In'itable Bowel Syndrome or Colitis 3 tvlultiple Sclerosis or PalsyD Tremors or Tics I Hypertension / High Blood Pressure il Polio or Mononucleosis5 Tendonitis or Bursitis t Hemon-hoids or Hernia f Allergres or Hayfever3 Carpai Tunnel Syndrome il Diabetes N'lellitus J Chronic Fatigue Syndrome3 Bone Fracture or Joint Sprain ? Thyroid Disorder J Anorexia or Bulimia3 Radiculopathy A Dysmenorrhea or Irregular Menses ll Attention Deficit Disorder3 Neuralgia f Peri-lvlenstn:ai Syndrome (Plv'is) J Panic Artacks or Phobias3 PeripheralNeuropathy ii lv{enopause Problems or Hot Flashes 3 Depression or Bipolar Disorder-l Shingles (Herpes Zoster) J Prostate or Genital Disorder f Alcohol Abuse ProblemsC Dermatitis, Eczema. or Flives J Deafness or Tinnirus fl Substance Abuse problems

2. Accidents: Have you ever been left injured or impaired by any of the lollorving rypes of accidents?D Automobiie Accident f Work-Related Accident a Surgical Complicationf Athietic Injury f Accident in Daily Living f ivledication Side Effect3. Current Conditions: In the past 3 months, have you experienced any of the follorving symptoms?J Frequent Headaches J Chest Pain or Chest Tighmess ll! Heaci Congestion i Runny Nose3 Chronic Back Pain or Sore Back f Abdominal Pain or Discomfort 3 D.y Mouth or Dry ThroatC Stiff or Sore Neck and Shoulders I Abdominal Distension or Bloating il Sore Ttroats3 Pain in Elbows, Wrists, or Hands 3 Large Weight Gain or Weight Loss 3 Frequent CoughsD Pain in Hips, Krees, or Feet J Overeating or Binge Eating J Fever or Malaise3 Stitr, Aching, or Swollen Joints 3 Undereating or Poor Appetite f Chilis or Aversion to Cold3 Cold Hands or Cold Feet i Craving for Sweets J Nausea or Vomiting3 Frequent Daytime Srveating 3 High Level of Sexual Activiry il Diarrhea or Loose Stools3 Night Sweats J Lorv Sex Drive 3 Constipation or Dry Stools3 Skin Irritation or Skin Rash C Ovenvorked or Overstressed iI Blurred Vision or Dry EyesD Diziness, Fainting, or Vertigo C Poor Memory or Mental Confusion C Lethargy, Tiredness, or Fatigue3 Palpitations i Rapid Heart Beats t Bored or Uninterested in Things 3 insomnia or Difficulty SleepingD Shortness of Breath D Thoughts of Killing Your Self 3 Disfurbing Dreamst Feeling Restless or Agitated C Worried About Finances or Job 3 Feeling Anxious or Afraid4. Substances or Medications: In the past 3 months, did you take any of the following items on a daillr basis?I 5 or more Cigarettes J Severai Aspirin or Tylenol Type Pills J Sleeping Pills*il 4 or more Cups of Coffee J Prescribed Pain Reliever Medication J Anti-Anxiery MedicationD 3 or more Glasses of Alcohol 3 Blood Prcssure Medication 3 Anti-Depressant Medication

O Copytght 2000 Free permrssion to use thrs lorm granted by wrrhng to Dr. Turry- Oleson, atPMB 2657,30ll Sunset Blvd., Los Angeles, CA 90046, call (321) 656-2084, or dou'nload lrom w,ebsite wt;,t,auriculotherap.t com

Health Distress lndexDate

Form HDI-4O-CName or l.D.

Symptoms or Experiences During the WeekPlace a "y'" rnark in the column that applys to

Degree or Frequency of Experience

Difficulty falling asleep at nightDifficulty remaining asleep at nightFelt sleep duration was inadequate or insufficientFelt tired, drowsy, or fatigued during the dayFelt full of enerqy and vitality during theFelt good. happy, elatedTook time to engage in fun or enjoyable acSocialized with people you like to be withFelt confident or optimisuc about thingsAble to work productively and acc

Shoulder tension or stiff neckAches or stiffness in hands, feet, arms, or legsChest pain or tightness or tenderness in breastsAbdominal pain or discomfort

18. I Constipation, diarrhea, or flatulence (gas)Coughing or difficulty breathingFelt ill, feverish, sick, or malaiseSore throat, runny nose, or swollen lymph glandsFelt dizzy, weak, or faintUndereating or low appetiteCold or numb feelings in hands or feet

or rapid heart beats or heart paSweating not due to exercise or external heatTrembling, jittery, or shaking

28. I Felt tense, agitated, frustrated, or restlessNervous, anxious, or scaredWorried about finances or work,/schoolFear of losing control or being overuvhelmedDifficulty concerftrating or making decisionsExcessive overeaUng or binge eatingFelt inadequate, wofthless, or low self-esteemFelt down, depressed, or discouraged aboutFelt lonely, isolated, or withdrawnFeft sad, tearful, or cried easilyFelt little interest or satisfaction in doing thingsFelt irritable, annoyed, or resentfulHave self-critical, neqative thouqhts unable to