1-215-322-7733

East-West Wellness Center
202 Holland Rd, suit 220, Holland PA 18966
Phone: (215) 322-7733
Fax: (267) 401-5920

Patient Information

 

Today’s date: ___________________
Name: ____________________________________ Birth Date: _______________
Home address: _____________________________ City: ____________________
State:_______ Zip Code: _______________ Email: ________________________
Home Phone: _____________________ Cell Phone: ________________________
Work Phone: _____________________ Occupation: ________________________
Emergency Contact: ________________________ Phone: ____________________
Insurance Co: ___________________ Policy number: _______________________
Name of insured: ___________________ Relationship with pt: ________________
Primary Care Doctor: ____________________ Phone: _______________________
Other specialist: ________________________ Specialty: _____________________
Other therapist: ________________________ Specialty: _____________________

For Personal Injury Patient’s Only:
Auto or Worker’s Comp insurance name: __________________________________
Name of Attorney: _________________________ Phone : ____________________
Claim number ____________________________ Date of Injury: ______________

Marital Status: ____________________
How did you hear about EWWC: _________________________________________
Referred by: _____________________ May we send a thank you card? Yes No
Have you ever been treated with Acupuncture, NAET, NET? Yes No
If yes, conditions treated: ________________________________________________

 

Health History
Name: _______________________________
Reason for visit: please list your five major health concerns in order of importance:
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
5. _________________________________________________________________
Major hospitalisations, surgeries, illnesses, injuries:
Year Health Issue Outcome
___________ _________________________________ _________________
___________ _________________________________ _________________
___________ _________________________________ _________________
___________ _________________________________ _________________
___________ _________________________________ _________________
Food or environmental allergies or sensitivities: ______________________________
________________________________________________________________________________________________________________________________________
Level of stress currently: 1 2 3 4 5 6 7 8 9 10
How would you rate yourself in terms of overall stress: easily stressed out worried anxious irritable depressed easy going overly responsible
Major causes of stress: _________________________________________________
Hight: _________ Weight: __________
Do you consider yourself: Underweight Overweight Just Right
Have you experienced weight gain or weight loss of greater than 10 pounds in the last 6 months? Yes No If yes, how much? __________________
Do you smoke? Yes No If yes how many cigarettes per day? ________
Do you drink alcohol? Yes No How many drinks per week? _____________
Preferred alcoholic beverage _____________________________________________
Any controlled substances or elicit drugs? Yes No Drug name: ______________

Medications and Supplements

Name: ____________________________________

Drug allergies: ________________________________________________________
Medications you are taking:
Start Date Medication Amount Frequency
____________ _______________________ ____________ ___________
____________ _______________________ ____________ ___________
____________ _______________________ ____________ ___________
____________ _______________________ ____________ ___________
____________ _______________________ ____________ ___________
____________ _______________________ ____________ ___________

Vitamin Supplements and herbs you are taking

 

For female patients only: Are you pregnant? _______ May you be pregnant? _______
Number of pregnancies ______________ Number of childbirths __________
Do you have signs and symptoms of menopause? ____________________________
Other GYN issues? ____________________________________________________

East-West Wellness Center
202 Holland rd, suit 220, Holland PA 18966
(215) 322-7733, fax (267) 401-5920
Informed Consent
I hereby request and content to the performance of acupuncture treatments, other oriental Medical treatments and/or Functional/ Energetic Medicine procedures by the licensed acupuncturist Veronica Bolhovitinova, L.Ac. I understand that the treatment may include, but not limited to: acupuncture, acupressure, moxibustion, cupping, tuna therapy, heat therapy, Chinese herbal therapy, nutritional supplements, homeopathy, emotional stress reduction therapy, allergy elimination, nutritional testing and applied kinesiology. I have had an opportunity to discuss with the practitioner listed below the nature and purpose of these treatment modalities. I understand that the results are not guaranteed.

Acupuncture: I have been informed that acupuncture is a safe and all natural method of treatment, however there may be occasional bruising or discomfort at the needling site that may last a few days. Additional therapies of cupping, Tui Na, Gua Sha, Heat therapy, and vibrocussor therapies may be incorporated to enhance the positive effects of acupuncture. Initials ________.

Neuro-Emotional Technique (NET): I understand that NET is a safe and effective stress reduction technique which is based on Chinese medical knowledge and Applied Kinesiology and is not a replacement for any other psychological therapies or treatment. It does not inform patients about their plan of actions for the future, nor does is deal with actual events in their past. This technique deals with emotional reality for each individual patient and helps to reduce stress by accepting the present moment and what is. Initials ______.

Nambudripad Alergy Elimination Technique (NAET): NAET is a natural allergy elimination technique based on Chinese medicine and Applied Kinesiology. It is designed to completely eliminate nutritional and environmental allergies and sensitivities. I understand that I must avoid the item treated for 25 hours after the treatment and recheck the clearing within one week. I understand that I may still have a reaction to that allergen if it is not completely cleared and additional treatment sessions may be necessary. Initials: _______.

Nutritional Response Testing (NRT): I understand that this technique will test for the nutritional supplements which my body may be needing in order to reach maximum health benefits from nutrition. I understand that the supplements selected are not a replacement for my regular medications. Initials: ________.

I understand the contents of this consent form, and I have had an opportunity to ask questions about these therapies. By signing below, I agree to the above named procedures.

__________________________________ _________________________ ______________
Patient’s Name Patient’s Signature Date
__________________________________ _________________________ ______________
Parent’s name Parent’s signature Date

Child’s name: _______________________________________________ Age: _________________

Credit Card Authorisation

 

We require a current credit card number on file to secure your appointments and for any mailed supplement or special orders. For out-of-state Medical Insurance claims, payments may be issued directly to patients, and the credit card on file secures these reimbursements to be paid to East-West Wellness Center. We will never charge your credit card without giving you a prior notice.

 

I, ________________________________ authorise Veronica Bolhovitinova, L.Ac. to charge my credit card as listed below:

Name on credit card ____________________________________________________

Credit Card number: ___________________________________________________

Expiration Date: _____________________ CVV Code _______________________

 

Billing Address:
Street Address: _______________________________________________________

City: ____________________________ State: ________ Zip: _________________

Phone: _____________________

 

AUTHORISATION:

 

_______________________________________ ______________________
Cardholder’s name Date

 

This authorisation can be revoked upon your written notice to our office.