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(206) 244-7973

Acupuncture Burien
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Your Health History

On your first visit we will spend a fair amount of time reviewing your health history. The intake form gives us a good start so please answer all of the questions.

In Chinese Medicine we take a very broad, encompassing view of your state of health. This includes things like the foods you eat, your sleep and exercise routines, your body's natural rhythms, whether you are generally hot or cold, and many more items.

This comprehensive history will help me develop a treatment plan that is tailored specifically to you and your wellness goals.

Forms

Intake Forms Image

Intake FormsTo help save time during your first appointment, please download our intake forms package. You can print and complete these forms when you have a few minutes and them bring them in with you. Please be sure to sign and date where appropriate.

There are four sections in this package:

Health History Questionnaire. The first two pages of the document asks about your health history, the conditions you are experiencing and the foods you eat. It leaves room at the end for anything else you would like to share with me. Please be brief, we'll discuss the contents in depth when we first meet.

Financial Policies Disclosure. This page explains how billing works with insurance and co-payments and also on a non-insurance basis. Please read, sign and date this page.

Disclosure and Consent for Acupuncture Treatment. This page is written to comply with state laws governing disclosure of risks, benefits, and limits of acupuncture treatment. Though it lists various possible adverse events, please be assured that acupuncture has an extremely good safety record and that serious side effects are exceedingly uncommon. Please read, sign and date this page (or- feel free to ask me any questions you would like before signing.)

Notice of Privacy Practices. This is required by the Health Insurance Portability and Accountability Act of1996 (HIPAA). Please read, sign and date this page.

Insurance Benefits WorksheetThis insurance benefit worksheet is provided for your convenience. You do not need to bring this with you to your appointment. It may be used to verify your acupuncture benefits with your insurance carrier. The worksheet walks through a number of questions which cover most common policy guidelines, as well as some exclusions and limitations which are easily overlooked. If you wish, I will check your benefits for you. If so, please call my office and give them the required information; I will get back to you within two business days. Please be advised that no pre-verification is a guarantee of payment.