Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.

9591 page 1 of 8
Healthwerks New Patient Health History
Gender: DOB: Age: Todays Date:
Name (rst) (middle) (last):
Street Address:
City: State: Zip Code:
Mailing Address (if different):
Home Phone: Work: Mobile: Email:
Emergency Contact: Telephone: Relationship:
Method of Payment (circle): Cash Group Work/Comp Auto Other
Insurance Company: Phone Number:
Policy Number: ID#: Group #:
Are you currently receiving health care? Yes No If yes, where and from whom?
Please identify the health concerns that have brought you to acupuncture below. Please list in order of importance.
Condition/Symptom Past Treatment
Ofcial Use Only
Insurance Verication Member Service Rep: Date:
Chiropractic Massage Acupuncture Naturopathic
Coverage Yes No Yes No Yes No Yes No
Effective Date
Deductible $ $ $ $
$ met this year $ $ $ $
Co-pay $ $ $ $
Referral or pre-authorization? Yes No Yes No Yes No Yes No
Maximum Benet: # of Visits:
$ Amount:
Per Year
Pre Condition
# of Visits:
$ Amount:
Per Year
Pre Condition
# of Visits:
$ Amount:
Per Year
Pre Condition
# of Visits:
$ Amount:
Per Year
Pre Condition
Insurance % X-ray %
Exam %
X-ray %
Exam %
X-ray %
Exam %
X-ray %
Exam %
Modalities covered 97010 97012 97140

Patients Name: DOB:
Successful health care and preventative medicine are only possible when the physician has a complete
understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly
as possible. Please print legibly and indicate areas that are confusing to you with a question mark. Thank you.

Have you had acupuncture before? If yes, what was your experience?




Height: Current Weight: Past Maximum Weight: When?
What was your most recent blood pressure reading? / When was this reading taken?
Do you have any reason to believe that you are pregnant? Yes No If yes, how many months:?
Do you have any chronic infectious diseases? Yes No If yes, please explain:


Are you currently suffering from any chronic illness? Yes No If yes, please explain:

If applicable, list any foods, drugs or medications you are hypersensitive or allergic to. Please include the type of reaction:

Please circle any of the following medication that you are currently taking or have taken in the last 12 months:
Laxatives Pain Relievers Antacids Thyroid Medication Appetite Suppressants Other:
Antibiotics Tranquilizers Sleeping Pills Cortisone Blood Pressure Medication
Please list any prescription medications, over-the-counter medications, vitamins and supplements that you are
currently taking:




Childhood or Adult Illnesses (please circle any that apply to you):
Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles Other:
MRSA Chicken Pox Staphylococcus Streptococcus German Measles
Immunizations (please circle any that you have had):
Polio Tetanus Pertussis Diphtheria Measles/Mumps/Rubella Hepatitis Other:
Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 2 of 8
Heathwerks New Patient Health History
Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 3 of 8
Patients Name: DOB:
Healthwerks New Patient Health History
History of injuries or illnesses (Include description and date)

Hospitalizations and surgeries (Include reason and date of hospitalization or surgery):

X-Rays/CAT Scans/MRIs/NMRs/Special Studies (Include reason, date of test and ndings):


Emotional (please circle any that you experience now and underline any that you have experienced in the past):
Mood Swings Anxiety Nervousness Mental Tension Depression

Energy and Immunity (please circle any that you experience now and underline any that you have experienced in the past):
Frequent Common Cold Slow Wound Healing Chronic Infections Fatigue Chronic Fatigue Syndrome
Eye, Ear, Nose and Throat (please circle any that you experience now and underline any that you have experienced in the past):
Impaired Vision Glaucoma Impaired Hearing Sinus Problems Teeth Grinding
Eye Pain/Strain Tearing/Dryness Ear Ringing Nose Bleeds TMJ/Jaw Problems
Glasses/Contacts Earaches Frequent Sore Throats Hay Fever
Respiratory (please circle any that you experience now and underline any that you have experienced in the past):
Pneumonia Emphysema Shortness of Breath Frequent Common Colds Other:
Pleurisy Persistent Cough Asthma Tuberculosis

Cardiovascular (please circle any that you experience now and underline any that you have experienced in the past):
Heart Disease High Blood Pressure Heart Murmur Rheumatic Fever Swelling of Ankles
Chest Pain Stroke Palpitations/Fluttering Varicose Veins Other:

Gastrointestinal (please circle any that you experience now and underline any that you have experienced 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 Diarrhea Constipation Mucous or Blood in Stool
Genito-Urinary Tract (please circle any that you experience now and underline any that you have experienced in the past):
Kidney Disease Painful Urination Frequent Urination Sexually Transmitted Infection
Impaired Urination Frequent Urination at Night Kidney Stones Frequent Urinary Tract Infections
Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 4 of 8
Patients Name: DOB:
Healthwerks New Patient Health History
Female Reproductive/Breasts (please circle any that you experience now and underline any that you have experienced in the past):
Irregular Cycles Heavy Flow Clotting Vaginal Discharge Bleeding Between Cycles
Difculty Conceiving Menopausal Symptoms Nipple Discharge Breast Lumps/Tenderness PMS
Sexual Difculties Other:
Menstrual/Birthing History:

Age of rst menses: Do you experience painful periods? Yes No Bleeding between cycles? Yes No
Are your cycles regular? Yes No How many days?(bleeding/entire cycle):
No. of pregnancies: No. of births: Any complications? Any miscarriages or abortions?
Method of birth control (if any): How long have you been using this method?
Male Reproductive (please circle any that you experience now and underline any that you have experienced in the past):
Sexual Difculties Prostate Problems Testicular Pain/Swelling Penile Discharge Other:

Musculoskeletal (please circle any that you experience now and underline any that you have experienced in the past):
Neck/Shoulder Pain Upper Back Pain Mid Back Pain Low Back Pain Joint Pain (if so, where?):
Shoulder Pain Arm Pain Leg Pain Muscle Spasms/Cramps

Neurologic (please circle any that you experience now and underline any that you have experienced in the past):
Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy

Endocrine (please circle any that you experience now and underline any that you have experienced in the past):
Hypothyroid Hyperthyroid Hypoglycemia Diabetes Mellitus Night Sweats Feeling Hot or Cold

Other (please circle any that you experience now and underline any that you have experienced in the past):
Skin Rashes Eczema/Hives Psoriasis Anemia Cancer

Family History:
Mother Father Brothers Sisters Spouse Children
Age (if living)
Health (G=good, P=poor)
Age at death (if deceased)
Cause of death
Check any conditions that apply to members of your family:
Cancer
Diabetes
Heart Disease
High Blood Pressure
Stroke
Mental Illness
Asthma/Hayfever
Kidney Disease
Other:

Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 5 of 8
Patients Name: DOB:
Healthwerks New Patient Health History
Lifestyle: Please indicate typical food intake:
Breakfast: Lunch: Dinner: Snacks:
How much exercise do you get? Doing what?
Do you have any difculty sleeping?
How many hours of sleep do you get per night?
How much water or other non-caffeinated liquids do you consume per day?
What are your interests and hobbies?
How much nicotine, alcohol or caffeine do you consume?
What is your occupation?
How many hours/week do you work?
Do you enjoy work? Yes No Why/Why not?

Do you have a spiritual practice or religion?


Have you experienced any major traumas (Physical, Emotional, Mental or Spiritual)? Yes No Please explain:



Is there anything else I should know?



Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 6 of 8
Patients Name: DOB:
Healthwerks Privacy Policy
Notice of Privacy Practices
This notice describes how your medical information may be used and
disclosed and how you may gain access to this information. This ofce
is dedicated to providing service with respect and dignity. Protecting
your privacy and health care information is fundamental during the
course of our relationship.
We are required to tell you how we will be keeping your protected
health information condential. We are asking every patient to sign an
acknowledgment form that they received this notice. This notice will
remain in effect until it is replaced or amended by changes in the law.
We gather personal information and health information in several
ways:
Information we receive from you.
Information we receive from other health care providers.
Information we receive from third party payers.
Your Health Information May Be Used for the Following Purposes
1. You should be aware that during the course of our relationship with
you we will likely use and disclose health information about you for
treatment, payment, and health care operations.
2. We may use your health information to provide, coordinate and
manage health care treatment or service. We may disclose health
information about you to health professionals who are involved in
taking care of you.
3. We may use information to receive payment from you, an insurance
company, or a third party for services we provide.
4. We may use information for certain activities related to business
functions of this ofce.
5. We may use and disclose health information to contact you as a
reminder that you have an appointment or we may need to reschedule
your appointment.
6. Unless you object, we may disclose your information directly as it
relates to such persons involvement in your health care or payment
for such health care.
7. We may use and disclose health information to inform you about
recommended possible treatment aftercare options that will benet
you.
8. We may disclose or use minimally necessary health information for
other special situations such as public health activities, for averting
a serious threat to health or safety, or for workers compensation
purposes.
9. We will disclose minimally necessary health information about you
when required to do so by federal, state, or local laws.
Right to Request Condential Communications
You may specically authorize us to protect health information for
any purpose or to disclose our health information by submitting the
authorization in writing. Such disclosure will be made to any personal
representative with whom you choose to share your protected health
information.
Marketing
This ofce will not use your health information for marketing
communications without your written authorization. This ofce may
send you birthday cards, and newsletters, post cards, letters or calls.
Patient Rights
Upon written request you have the right to access, review or receive
copies of your health care records.
Upon written request you have the right to receive a list of items this
ofce has disclosed about your health care information.
You have the right to request that this ofce place additional
restrictions on disclosure of your Protected Health Information.
You have the right to request that we amend your Protected Health
Information. The request must be in writing.
You have the right to receive all notices in writing.
If you have questions, complaints, or want more information, please
contact this ofce. Complaints about your privacy rights or how your
privacy is handled at this ofce can be directed to the ofce manager
by phone or in writing.
If you are not satisfed with how this offce handles your complaint
you may submit a formal complaint to U.S. Department of Health and
Human Services.
DHHS (Offce of Civil Rights) 200 Independent Avenue, S.W. Room
509F HHH Building, Washington, D.C. 20201
Signature of Patient / Date
Printed Name
Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 7 of 8
Patients Name: DOB:
Healthwerks Consent Form
Informed Consent Form
For Acupuncture & Oriental Medicine
The scope of practice for an acupuncturist in the state of Washington includes but is
not limited to the following list of techniques:
Use of acupuncture needles to stimulate acupuncture points and meridians
Use of electrical, mechanical, or magnetic devices to stimulate acupuncture points
and meridians
Moxibustion
Acupressure
Cupping
Dermal friction technique (gua sha)
Infra-red
Sonopuncture
Laserpuncture
Dietary advice based on traditional Chinese medical theory
Point injection therapy (aquapuncture)
I recognize the potential risks and benefts of these procedures as described below:
Potential risks: Side effects may include, but are not limited to the following: pain
following treatment in insertion area, minor bruising, infection, needle shock, broken
needle, temporary discoloration of the skin, aggravation of symptoms existing prior to
the treatment, pneumothorax.
Patients with bleeding disorders, pacemakers, seizure disorders, or women
who are currently pregnant, please notify the practitioner.
Potential benets: Drugless relief of presenting symptoms, improved general health,
elimination of the presenting problem, reduction of pain and associated symptoms.
With this knowledge, I voluntarily consent to the above procedures, realizing that
no guarantees have been given to me by Andrew Schlabach regarding cure or
improvement of my condition. I hereby release Andrew Schlabach MAcOM LAc
from any and all liability, which may occur in connection with the above mentioned
procedures, except for failure to perform the procedures with appropriate medical care.
I understand that I am free to withdraw this consent and to discontinue participation in
these procedures at any time.
Signature of Patient / Date
Printed Name


Andrew Schlabach LAc received his Masters
Degree in Acupuncture from Oregon College of
Oriental Medicine in Portland, OR. He has passed
the National Board Examination for Acupuncture
administered by the National Committee for the
Certication of Acupuncture and Oriental Medicine
(NCCAOM) and is designated a Diplomat of
Acupuncture by the NCCAOM. He is a Licensed
Acupuncturist in the State of Washington, holding
Acupuncture License number AC60043511. He is
a Licensed Acupuncturist in the State of Oregon,
holding Acupuncture License number AC01236.
Andrew Schlabach LAc, 3712 NE 40th Avenue, Vancouver WA 98661 360.695.9591 page 8 of 8
Patients Name: DOB:
Healthwerks Financial Agreement
Welcome to Healthwerks Acupuncture Wellness Clinic. We want your
experience here to be as pleasant as possible. Please ask the staff
or your practitioner if you have any questions. To acquaint you with
our payment arrangements please review the following and sign in
acknowledgement.
1. No insurance: Unless other arrangements are made with the
billing manager, payment is expected at the time services are
rendered. We accept personal checks, cash, debit, Visa, or MasterCard.
2. Group Health Insurance: We will bill your insurance claims for
you. However, we ask that you remember the following: insurance
is an agreement between yourself and the insurance company. Any
balance beyond what the insurance covers is your responsibility. We
will contact your insurance company to verify eligibility and coverage,
but we are not responsible for any misinformation that the insurance
company may give us. Most insurance plans require you make a
co-payment, co-insurance and/or deductible. It is your responsibility
to pay these amounts at the time service is rendered unless a specic
agreement is made with the billing manager. We are willing to carry
the portion owed by your insurance company for 60 days. If your
insurance company does not pay their expected amount within 60
days then the charges in full will be collected from the patient. Any
unpaid balances beyond 60 days is subject to a 5% service charge per
month.
3. Work Comp: Work related injuries are managed in conjunction
with your employer. Employers carry insurance for this type of injury
and they must authorize care and give us the billing information. Most
employers will authorize care however, they have medical control
for the rst thirty days, meaning they can choose who treats you,
unless you have a designated doctor form on le with the employer
previous to your injury. You will not be responsible for your charges
unless you elect to treat with us against your employers wishes. If you
require an attorney to represent you in a contested work related injury
case we can recommend several to choose from.
4. Personal Injury: We will bill your auto insurance med pay. If you
have group insurance we will also bill that for you unless your med
pay coverage covers the entire amount of your medical claim. We
do not accept group insurance benets as full payment when there
is a third party. If you retain a Personal Injury attorney (approved
by this offce), we will accept a lien. An approved attorney will fall
under the following guidelines: you must formally retain the attorney,
attorney must respond to monthly status calls, you and the attorney
agree to sign a lien insuring we will be paid from the proceeds of the
settlement. If you need a referral to an attorney, please ask and we
will provide a list of attorneys that specialize in personal injury cases.
Ultimately, you are responsible for the total amount of the bill, the
terms are explained in the lien agreement that you and your attorney
are required to sign. We reserve the right to cancel the lien agreement
at any time. In any case, once you are released from care we will wait
only six months for payment. We reserve the right to charge a 5%
service charge per month on the unpaid balance until settlement.
5. Medicare: I understand that my Medicare insurance policy covers
80% for spinal manipulation only. It does NOT cover examinations,
radiographs (x-rays), or modalities. Therefore, I agree to be personally
responsible for all non-covered services. I understand that this offce
must perform an initial evaluation in order to render manipulation
under the Medicare agreement. I also understand that I am
responsible for a yearly deductible and a co-insurance amount for
covered services at the time those services are rendered.
6. Missed Appointments/Cancellations: We require 24 hours
notice for missed or cancelled acupuncture appointments. There is
a $25.00 cancellation charge for missed or cancelled appointments
with less than 24 hours notice. You will be billed directly for any
cancellation charges.
ACKNOWLEDGMENT AND UNDERSTANDING: I understand and
agree that health and accident insurance policies are an arrangement
between an insurance carrier and myself. Furthermore I understand
that this ofce will prepare any necessary reports and forms to
assist me in making collection from the insurance company and
that any amount authorized to be paid directly to this ofce will be
credited to my account upon receipt. I permit this offce to endorse
co-issued remittances for the conveyances of credit to my account.
However, I clearly understand and agree that all services rendered
me are charged directly to me and that I am personally responsible
for payment. I also understand that if I suspend or terminate care
and treatment, any fees for professional services rendered me will
be immediately due and payable. In the event that my account is
forwarded to a collection agency, a charge of 35% of the ENTIRE
balance will be applied for proper processing and settlement of the
account. The collection agency also charges daily interest.
There is a $35 non-suffcient funds fee for returned checks in addition
to what the bank charges for this offce for a non-suffcient funds
returned check. We reserve the right to charge a 5% service charge
per month on any unpaid balances beyond 60 days.
Please notify us in advance if there are any circumstances that
prevent you from meeting these nancial arrangements.
Signature of Patient / Date
Printed Name