Health History and Consent Forms

Page 1 of 8 Legacy Wellness
Acupuncture & Oriental Medicine
INITIAL HEALTH ASSESSMENT
Name: ______________________________________________ Date of birth: ________________________
Address: _______________________________________________ City: _____________________________
State: ___________________ Zip: __________________ Phone: ___________________________________
Email: _________________________________________________ Occupation: ______________________
Notify in case of emergency: ______________________________________ Phone: _____________________
Welcome to Legacy Wellness. Your answers to the following questions will help to determine our goals as
partners in a journey toward optimal health. Please fill in the requested information and check the boxes that
apply to your health, listing dates when necessary.
HEALTH GOALS
Please list your top five health goals. In other words, what are your primary concerns or aspects of your health
that you would like to change? Your health goals can be physical or emotional, general or specific. Please list in
order of importance, number one being most important.
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
5. ___________________________________________________________________________________
MEDICAL HISTORY
Please list any/all Western medical diagnoses you have been given for your current state of health.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please list all surgeries and significant traumas.
_________________________________________________________________________________________
_________________________________________________________________________________________
NUTRITION & LIFESTYLE

Please describe your typical diet.
Breakfast: ________________________________________________________________________________
3249 Hennepin Avenue, Suite 227 Minneapolis, MN 55408 Ph: 612.991.0098 Web: www.legacy-wellness.com
Mid-morning snack: ________________________________________________________________________

Lunch: ___________________________________________________________________________________
Afternoon snack: ___________________________________________________________________________
Dinner: __________________________________________________________________________________
Evening snack: ____________________________________________________________________________
Please indicate if you participate in the following activities. If yes, what type, and how frequently?
Exercise Yes / No ______________________________________________________________________
Alcohol use Yes / No ______________________________________________________________________
Caffeine use Yes / No ______________________________________________________________________
What are your 3 favorite activities/hobbies?

 ___________________________________________________________________________________
 ___________________________________________________________________________________
 ___________________________________________________________________________________
Vitamins & Supplements Dose How does this supplement benefit your health?
For what health condition was this medicine

Medications and over-the- Dose prescribed?
counter medicines
*If you are taking more supplements or medications than the tables above allows you to list, please include a separate sheet with a full
list of your supplements and medications with this health history form.
FAMILY MEDICAL HISTORY Please indicate family member.
 Diabetes  Heart Disease  Cancer

 Stroke  Allergies  High blood pressure
 Seizures  Drug and/or Alcohol  Mental illness
 Asthma addiction  Other: ____________
DIGESTIVE HEALTH
 Diarrhea  Weight loss  Abdominal bloating

 Constipation  Food cravings after meals
 Alternating  Belching  Hemorrhoids
diarrhea/constipation  Bloody/black stools  Strong appetite
 Vomiting  Food allergies  Weak appetite
 Flatulence  Abdominal pain after  Rumbling/noisy
 Bad breath meals abdomen
 Nausea  Rectal pain/itch  Other: ____________
 Weight gain  Fatigue after meals
NEUROPHSYCHOLOGICAL
 Anxiety  Mood swings  Tendency toward

 Depression  Vivid dreaming worry/over-thinking
 Dull/unclear thinking  Chronic fatigue  Tendency toward fear
 Easily stressed  Poor memory  Tendency toward joy
 Insomnia  Tendency toward anger  Other: ____________
 Irritability  Tendency toward sorrow
Do you have regular meditation or spiritual practices? Yes / No

Do you have a happy home life? Yes / No A healthy work environment? Yes / No
Do you make time to relax regularly? Yes / No
MUSCULOSKELETAL
 Generalized muscle  Muscle tremors  Upper back pain

pain/aching  Stiff neck  Mid back pain
 Muscle weakness  Stiff joint  Tingling
 Osteoporosis  Swollen feet  Numbness
 Arthritis  Knee pain  Other: __________
 Chronic low back pain  Weak knees
 Muscle spasms  Joint pain
Please mark areas where you experience pain or discomfort:
WOMENS HEALTH
Age of first menses Cycle length Period length Age of menopause
 Heavy period flow  Excessive vaginal  Vaginal sores

 Light period flow discharge  Endometriosis
 Yeast infections  Irregular periods  Pain with ovulation
 Ovarian cysts  Clots  Abdominal cramping
 Uterine fibroids  Breast lumps  Infertility
 Breast tenderness  Decreased sexual drive
Please describe your pre-menstrual symptoms:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Do you practice birth control? Yes / No Type: _________________________________________
Do you currently use or have you used an oral contraceptive birth control in the past? Yes / No
If yes, for how long? ____________________
Number of pregnancies: ______ Live births: ______ Miscarriages: ______ Cesarian sections: ______
Premature births: _______
MENS HEALTH
 Premature ejaculation  Impotence/weak  Prostate problems

 Decreased sexual desire erection  Genital itch
 Sores on penis/testicles  Other: ____________
DERMATOLOGY
 Rashes/hives  Psoriasis  Change in hair/skin

 Eczema  Itching quality
 Cysts  Acne  Other: ____________
 Dandruff  Hair loss
 Ulcerations/sores  Dry skin
CARDIOVASCULAR
 High blood pressure  Low blood pressure  Swollen hands/feet

 Irregular heart beat  Palpitations  Phlebitis
 Hot hands/feet  Cold hands/feet  Shortness of breath
 Varicose/spider veins  Chest pain/angina  Heart failure
 Artereosclerosis  Dizziness  Other: ____________
RESPIRATORY
 Cough  Pneumonia  Other: ____________

 Bronchitis  Asthma
 Allergies  Difficulty breathing
Do you smoke cigarettes? Yes / No
Do you have a history of smoking cigarettes? Yes / No
HEAD / EYES / EARS / NOSE / THROAT
 Eye strain  Nosebleeds  Tinnitis (ringing in ears)

 Blurry vision  Post nasal drip  Dry mouth
 Dry eyes  Recurrent sore throats  Tension headaches
 “Floaters” in vision  TMJ syndrome  Migraine headaches
 Sinus congestion  Poor hearing  Other: ____________
GENERAL
 Aversion to drafts  Low energy  Sweating without

 Aversion to cold  Food cravings exertion
temperatures  Vegetarian/Vegan diet  Night sweats
 Aversion to warm  Special diet  Prefer hot beverages
temperatures  Reduced sexual energy  Prefer cold beverage
 Weight gain  Bruising easily  Other: _____________
 Weight loss
_________________________________________________________________________________________
Have you ever been diagnosed with AIDS/HIV? Yes / No
Have you ever been diagnosed with Hepatitis (A, B, other)? Yes / No
Do you wear a pacemaker? Yes / No
Do you have a bleeding disorder? Yes / No
Do you or have you ever had Botox injections? Yes / No
Women: Are you or might you be pregnant? Yes / No

Do you have breast implants? Yes / No
How would you like Legacy Wellness to contact you? Phone / Email / Mail
Client/Patient signature: _________________________________________ Date: ____________________
Thank you for taking the time to complete this health assessment form. If there is further information you would
like me to be aware of, please describe here:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
INFORMED CONSENT FORM
I understand that the treatment I receive at Legacy Wellness is performed by Monica Helland, Ma.OM., L.Ac., a
graduate of the Minnesota College of Acupuncture and Oriental Medicine. I have been informed that Monica
Helland is certified by the National Certification Commission of Acupuncture and Oriental Medicine
(NCCAOM) and licensed to practice in the state of Minnesota by the Minnesota Board of Medical Practice.
I understand that Oriental medicine practitioners do not make Western medical (biomedical) diagnoses and that
it is my responsibility to seek such diagnosis elsewhere if I have not already done so.
I have been informed that acupuncture needles are single-use, sterile, and disposable.
I hereby authorize Monica Helland, Ma.OM., L.Ac. to diagnose and treat according to the professional
standards of Oriental medicine. This authority shall extend to remedying any unforeseen conditions or reactions
to treatment procedures. I understand that my treatment at Legacy Wellness may include a variety of Oriental
medicine modalities, such as acupuncture, acupressure, moxibustion, herbal therapies, cupping, electrical
stimulation, magnet therapy, dermal friction (guasha), dietary counseling, breathing techniques, and exercises
based on Oriental medicine principles.
I understand that there are possible unforeseen risks attendant to the performance of the procedures of Oriental
medicine. I have been informed that possible side effects of Oriental medicine treatment are rare and may
include, but are not limited to, transient bruising, bleeding, skin irritation, mild pain in the treated area, muscle
weakness and soreness, brief generalized fatigue or nausea, dizziness, slight drop in blood pressure, fainting,
temporary worsening of some symptoms, and risk of infection. Moxibustion can cause burns or temporary skin
discoloration. Herbal remedies may have side effects including, but not limited to, gastrointestinal disturbance.
I understand that no promises or guarantees can be made regarding the outcome of treatment and that
reasonable efforts will be made to give me information so that I may make an educated decision regarding the
duration and appropriateness of continuing care at Legacy Wellness. All of my questions prior to receiving
treatment have been answered to my satisfaction.
I understand and agree that I am ultimately responsible for the balance on my account. I understand that all fees
are payable at the time that service is received.
I understand that missed appointments and cancellations not made at least 24 hours prior to an appointment will
be charged to the patient.
Client/Patient signature __________________________________________ Date: _______________________
CONSENT/AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
LEGACY WELLNESS PRIVACY PLEDGE: Legacy Wellness is committed to full compliance with federal and state laws and
regulations ensuring the privacy and confidentiality of patients’ and clients’ personal health information; Monica Helland, Ma.OM.,
L.Ac. will make every effort to respect your privacy and keep confidential the health information entrusted to Legacy Wellness.
Ways in which Legacy Wellness may use or disclose your health care information include, but are not limited to:
• Another health care provider or facility for the purpose of diagnosis, assessment, or treatment of your health condition.
• Another party, such as an insurance carrier, HMO, or employer for the purpose of receiving payment for services rendered to
you.
• The use of that information within the Legacy Wellness practice for quality control or other operational purposes.
• Business associates that Legacy Wellness contract with to perform service for your benefit.
• Research, when established protocols to ensure the privacy of your health information are used.
• The use of that information to contact you by telephone, mail, or email with appointment reminders, lab or imaging results,
information about the Legacy Wellness clinic facilities, treatment alternatives, or other health-related information that may be
of interest to you.
Along with this consent form, you have been given a copy of the Legacy Wellness privacy policy that describes the privacy policies in
detail. You have the right to review that notice before you sign this consent form. Legacy Wellness reserves the right to change the
privacy practices as described in that notice. The current notice, including the effective date, will be posted in the clinic facility and
will be given to you prior to or at your first treatment.
Your Right to Limit Uses or Disclosures: You have the right to request that Legacy Wellness does not disclose your health information
to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health
information, please let Monica Helland, Ma.OM., L.Ac. know in writing. Legacy Wellness, however, is not required to agree to your
restrictions.
Your Right to Revoke Your Authorization: You may revoke any of your authorizations at any time; however, your revocation must be
in writing. Legacy Wellness will not be able to honor you revocation request if the health information had already been released before
the request to revoke your authorization was received. If you were required to give your authorization as a condition of obtaining
insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
YOU HAVE A RIGHT TO REFUSE CONSENT FOR DISLCOSURE OF YOUR PERSONAL HEALTH INFORMATION.
WITHOUT YOUR CONSENT, HOWEVER, THE LEGACY WELLNESS SYSTEM WILL NOT BE ABLE TO SUBMIT CLAIMS
TO INSURANCE CARRIERS OR OTHER THIRD PARTY PAYERS AND MAY NOT ACCEPT YOU AS A PATIENT/CLIENT.
Initial here
[ ] I acknowledge receipt of the Legacy Wellness Notice of Privacy Practice
By signing below, I give consent to the Monica Helland, Ma.OM., L.Ac., the Legacy Wellness practitioner, to disclose my
personal health information as noted above.
______________________________________________ _______________________________________
Printed Name Authorized Provider Representative
______________________________________________ _______________________________________
Signature Date
______________________________________________
Date

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Page 1 of 8 Legacy Wellness

Acupuncture & Oriental Medicine

INITIAL HEALTH ASSESSMENT

Name: ______________________________________________ Date of birth: ________________________

Address: _______________________________________________ City: _____________________________

State: ___________________ Zip: __________________ Phone: ___________________________________

Email: _________________________________________________ Occupation: ______________________

Notify in case of emergency: ______________________________________ Phone: _____________________

NUTRITION & LIFESTYLE

Mid-morning snack: ________________________________________________________________________

What are your 3 favorite activities/hobbies?

For what health condition was this medicine

FAMILY MEDICAL HISTORY Please indicate family member.

 Diabetes  Heart Disease  Cancer

 Diarrhea  Weight loss  Abdominal bloating

 Anxiety  Mood swings  Tendency toward

Do you have regular meditation or spiritual practices? Yes / No

 Generalized muscle  Muscle tremors  Upper back pain

Please mark areas where you experience pain or discomfort:

Age of first menses Cycle length Period length Age of menopause

 Heavy period flow  Excessive vaginal  Vaginal sores

Please describe your pre-menstrual symptoms:

Do you practice birth control? Yes / No Type: _________________________________________

 Premature ejaculation  Impotence/weak  Prostate problems

 Rashes/hives  Psoriasis  Change in hair/skin

 High blood pressure  Low blood pressure  Swollen hands/feet

 Cough  Pneumonia  Other: ____________

Do you smoke cigarettes? Yes / No

Do you have a history of smoking cigarettes? Yes / No

HEAD / EYES / EARS / NOSE / THROAT

 Eye strain  Nosebleeds  Tinnitis (ringing in ears)

 Aversion to drafts  Low energy  Sweating without

Have you ever been diagnosed with AIDS/HIV? Yes / No

Do you wear a pacemaker? Yes / No

Do you have a bleeding disorder? Yes / No

Do you or have you ever had Botox injections? Yes / No

Women: Are you or might you be pregnant? Yes / No

Client/Patient signature: _________________________________________ Date: ____________________

INFORMED CONSENT FORM

Client/Patient signature __________________________________________ Date: _______________________

CONSENT/AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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