Patient Information Form

  • INFORMED CONSENT

  • I, the undersigned, hereby give consent for the administration of treatment by the method of acupuncture/magnet therapy. I understand that acupuncture is performed by the insertion of needles, with or without the addition of an electric current, through the skin or the application of heat to the skin, or both, at certain points on the body in an attempt to improve body function and/or relieve pain. I have been make aware that certain side effects may result. These may include, but are not limited to, some local bruising, bleeding, fainting, temporary pain or discomfort and the possible aggravation of symptoms existing prior to acupuncture treatment. I am aware that although acupuncture is a common practice, there are no guarantees about its effects. I understand that the results obtained from this treatment may be published, but that my identity will not be revealed. I understand that none of the foregoing provisions shall prevent adminstration to me of more conventional medical therapy by a licensed physician. I hereby certify that I have read the above and that I understand the provisions described therein.
  • PATIENT INFORMATION

  • HABITS AND LIFESTYLES

  • FAMILY MEDICAL HISTORY

  • MEDICAL HISTORY

  • (food, medicines, chemicals)
  • (date, description)
  • PERSONAL MEDICAL HISTORY

  • Select any symptoms that you have had in the last three months.
  • GENERAL

  • SKIN AND HAIR

  • HEAD, EYES, EARS, NOSE AND THROAT

  • MUSCULOSKELETAL

  • MEN

  • WOMEN

  • NEUROPSYCHOLOGICAL

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195 Whiting Street | Hingham, MA 02043 | 781.749.8088 | megan@acupuncturehingham.com

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