Address ____________________________________________City____________________________State_______Zip_________________

Home Phone___________________________Work Phone_____________________Cell________________________________________

Email___________________________________Date of Birth_____/____/_________Age_________Place of Birth__________________

Relationship Status ❍ Married ❍ Single ❍ Divorced ❍ Separated ❍ Partner ❍ Widowed

Height_________Weight____________

Name of Partner/Spouse____________________________Years w/ Partner/Married_______________________________________

Emergency Contact Name_____________________________________________Telephone Number_________________________

Children (Names & Ages)__________________________________________________________________________________________

Education____________________________________________Pets__________________________________________________________

Occupation(s)________________________________________Employer_____________________________________________________

Name of Physician__________________________________________Physician Telephone___________________________________

Date of Last physician appointment________________________________________________________________________________

How did you hear about us? __________________________________________________________________________

May we have your permission to add you to our mailing list? ❍ Yes ❍ No

List any other type of therapies or treatments that are a part of your overall approach to wellness ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________

Have you ever been treated with acupuncture and/or Chinese herbal medicine? ❍ Yes ❍ No

Comments ________________________________________________________________________________________________________

1)

2)

3)

4)

5)

____________________________________________________________________________________________________________________

Surgeries/Hospitalizations____________________________________________________________________________________________

Trauma (Physical/Emotional/Any)________________________________________________________________________

____________________________________________________________________________________________________________________ Recent Tests (w/in the last 2 years) Including; Physical, Cholesterol, Other blood, Food Allergies/Sensitivities, Prostate,

HIV/STD, Lyme, Other(s) _____________________________________________________________________________________________

____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

1

Patient Intake FormName_________________________________________________

Date__________________________________________________

301 W 29th Street | Baltimore, MD 21211

Food Log (Example of typical day of eating)

Crave Sugar ❍ Yes ❍ No ❍ Niether Crave Salt ❍ Yes ❍ No ❍ Niether Thirst for water ❍ Yes ❍ No ❍ Niether

Alcohol # of drinks/day_______/wk________ Tobacco Frequency__________________________________________

Marijuana Frequency_____________________ Other drugs Type___________________Frequency_______________

Coffee # of cups/day_______/wk__________ Soft Drinks ❍ Yes ❍ No # of drinks/day_________/wk __________

❍ Yes ❍ No Diet Beverages ❍ Yes ❍ No How often?___________________If yes, which kind? ________________________

Exercise Type(s) ______________________Frequency______#/wk______ Water # of cups or ounces/day_______/wk________

List all medications and supplements (Alert your practitioner immediately if anything changes)

Medication/Supplement Specify reason taking Medication/Supplement Specify reason taking

1)________________________ _______________________ 4)________________________ _______________________

2)________________________ _______________________ 5)________________________ _______________________

3)________________________ _______________________ 6)________________________ _______________________

Have you taken antibiotics or steroids within the last year? ❍ Yes ❍ No

If so, frequency?_______________________ For what condition? __________________________________________________________

Please check any previously diagnosed conditions or health history (include the year)

Other(s)___________________________________________________________________________________________________________

FAMILY MEDICAL HISTORY

Breakfast Snack Lunch Snack Dinner Snack

__Asthma__AIDS/HIV__Alcoholism__Arteriosclerosis__Bronchitis__Cancer Type________Chicken Pox__Epilepsy__Emphysema

__Diabetes__Gout__Goiter__Thyroid Disorder__Heart Disease__High Blood Pressure__Hepatitis__Herpes__Pancreatitis

__Meningitis__Syphilis__Gonorrhea__Paralysis__Stroke__Migrains__Vein Condition__Multiple Sclerosis__Parkinsons

__Fibromyalgia__Measles__Mumps__Mononucleosis__Pacemaker__Pneumonia__Polio__Tuberculosis__Rheumatic Fever

__Glaucoma__Lupus__Ulcerative Colitis__Chrohns Disease__Kidney Stones__Gall Stones__Lyme

2

Age

Alive

Deceased

Health History

Time Time Time Time Time Time

Father Mother Sibling Sibing Child Child

Kidney/Bladder Function____Wake to Urinate____Tinnitus____Early graying of hair____Need excessive sleep____Easily defeated or disgruntled____Dark circles under eyes____Phobias____Hair Loss____Hearing Loss or trouble hearing____Urgency or frequent urination

____Lack of bladder control____Stress incontinence

____Crave Caffeine or Stimulants____Thin hair____Warm/hot at night____Night sweats

Heart Function____Bedwetting____Palpitations or Fluttering at rest____Easily startled____Irregular Heart beat____Pacemaker____Palpitations____Anxiety____Panic attacks____Spontaneous sweating If so, where________________________

Liver/Gall Bladder Function____Tend toward numbness in extremities____Nearsighted____Floaters ____Blurry vision____Muscle cramps or tight muscles____Brittle nails____Vertigo____Cold Feet____Dream disturbed sleep____Feel better after exercise____Rib-side or breast distention/pain____Dry, itchy or irritated Eyes____Watery Eyes____Cataracts____Anger easily____Frustration or irritability____Dizziness/light-headed when standing____Frequent dreams____Lump in throat/trouble swallowing____Headache on top or side of head____Neck and Shoulder tension____Seizures

Blood Physiology____Palpitations or Heart Fluttering ____Absent Minded

mind is scattered or suddenly blank____Poor memory recall____Insomnia

____Dry Skin____Trouble falling asleep____Light sleeper____Dry hair, nails or skin____Emotional Sensitivity____Ever Fainted____Muscle spasms ____Numbness/Tingling____Anemia

Overall Energy/Immune Funtion____Fatigue during the day____General weakness____Easily catch colds or other illness ____Prolonged recovery from illness ____Aversion to talking____Get cold easily____Feel worse after exercise____Frequent sore throats____Poor healing Skin

Overall Temperature____Cold hands/feet____Sweaty hands/feet____Feel generally more hot____Feel generally more cold

____Flushed feeling any time of day____Feel heat in hands, feet and/or chest____Thirsty, drink in gulps____Lack of perspiration ____Alternating chills & fever____Scanty yellow urination____Nose bleeds____Dry cough____Skin Rashes

Stomach/Spleen Function____Vericose Veins____Low appetite____Abrubt weight gain/loss____Abdominal bloating after eating____Gurgling noises in stomach____Fatigue after eating____Prolapsed organs____Hernias____Hemorrhoids____Easily bruise____Worry, Over-thinking

____Feeling Overwhelmed____Lack of strength in four extremities____Excessive Saliva____Abdominal gas____Snoring____Large appetite/insatiable____Mouth (canker) sores____Bad breath or bad taste in mouth____Bleeding, swollen or painful gums____Burning sensation after eating ____Ulcer____Belching____Hiccoughs____Nausea If so, when____________

____Bulimia/Anorexia____Headache over forehead____Aversion to strong

____Vomiting

Large/Small Intestine Function____Bowel movement #/day____ or #/wk______ Formed? Yes/No____Loose stools____Diarrhea ____Constipation____Dry stool____Incomplete feeling____Blood in stool____Mucous in stool____Undigested food in stool____Alternating diarrhea/constipation

Sexual/Endocrine Function____Normal Libido____High Libido____Low Libido

Lung Function

____Sadness, melancholy, grief ____Sinus congestion____Seasonal allergies (If so, when_____)____Nasal discharge (Color_____________)

Fluid Physiology____Itchy Skin____Cough when laying down____Thirsty with no desire to drink____Mental sluggishness or fogginess____Swollen hands, feet, joints____Chest congestion____Thirst for Water Very/Normal/Not at all____Dry mucous membranes____Productive cough (Color__________)____Dry mouth, nose, throat

Other____Swollen Glands____Grinding teeth____TMJ____Depression____Unable to adapt to stress____Wake up feeling tired or unrested____Shortness of breath____Asthma____Abdominal cramping____Stomach ache/pain____Restlessness____Chest pain or discomfort____Overall Achy feeling____Migraines If so, how often___________Tremors____Paralysis

MEN ONLY____ Prostate complications Describe_________________________ __________________________

____ Lack of Semen____ Premature ejaculation____ Impotence____ Swollen testicles

____ Testicular pain____ Feeling of coldness in genitals____ Pain/itching____ Nocturnal Emissions 3

Please check any that apply by writing “P” for past or “C” for current next to the word

Consent to Services: By signing below, I do hereby voluntarily consent to be treated with acupuncture, moxibustion, aromatherapy oils, and/or herbs and medicinal substances by my practioner, licensed acupuncturist. I have read and understand the potential risks of these services described below. I have the right to consent to or refuse any proposed treatment or course of treatment. I understand that I am free to discontinue treatment services at any time.

Acupuncture/Moxibustion Treatment: I understand that acupuncture serves individuals with a wide range of complaints including both acute and chronic health care issues. I understand that I may be treated with the insertion of thin sterilized needles through the skin and/or with the application of heat to the skin (moxibustion), Aromatherapy or the application of Oils to the skin, cupping & Gua Sha techniques and/or Zero Balancing techniques. I understand that my acupuncturist is not a licensed dietitian, however may provide dietary guidance based upon Chinese Medical principles of nutrition.

Risks/Possible Side Effects: While adverse side effects are rare, I understand that they may include but are not limited to: local bruising, minor bleeding, fainting, temporary pain and discomfort, infection, and temporary aggravation of symptoms existing prior to treatment. If direct moxibustion is used as part of therapy, there is a risk of burning or scarring from its use.

No Guarantees: I know that each person is unique and has ultimate responsibility for his or her own wellness and healthcare. I acknowledge that I have not received any guarantees or promises as to the results or success that will be obtained from the services provided.

I understand that my

Moxibustion and Essential Oils for Clinical use. Her graduate level degrees include a Master’s in Acupuncture from Maryland University of Integrative Health, formerly the Tai Sophia Institute,

She has also obtained her license to practice from the Maryland State Board of Acupuncture. I have the right to ask for copies of

Infectious Disease Prevention: I understand that infectious diseases are carried through the air, through physical contact,

universally prescribed precautions and procedures (such as clean needle technique and hand washing) to prevent the spread of

the use of clean needle technique (CNT).

Client Responsibilities: I understand that it is my responsibility as a client to inform my practitioner of all aspects of my health and as treatment services progress, inform my practitioner of changes that occur. I will inform my practitioner if I am pregnant and/or suspect pregnancy at any time, and if I am being treated for cancer or epilepsy. If I experience any pain, discomfort or possible adverse side effects, it is my responsibility to immediately notify my practitioner.

Medical Treatment: I recognize that my practitioner is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. I understand that if I am currently under a physician’s care, I should continue as long as my physician deems necessary. It is my responsibility to consult with my physician before altering any medications or medical treatments. I understand that my practitioner may request a physical exam if it has been over a year since my last exam. I am free to consult a medical doctor or any other licensed practitioner at any time. I understand that if there is an emergency, or a worsening of my health condition, or if a new ailment or condition arises, that I should consult a licensed physician.

I acknowledge that I received a copy of Lola Manekin’s Notice of Privacy Practices which describe the practitioner’s policy of respecting

information will not occur without written consent. If you would like to request a restriction or release, please request a Restriction/Release Disclosure Request Form to specify.

Fees & Cancellation Policy: I have been informed of the fees for service, and I understand that payment is due when the services are provided. If I do not cancel an appointment at least 24 hours (medical emergencies excluded) in advance, then I am responsible for paying the full treatment fee.

I have carefully read and understand all of the above information. I understand that I may ask my practitioner any questions or further explanations necessary before signing this consent form. By signing below, I give my permission and consent to treatment.

Client Signature: _____________________________________________ Date: _____________________________________________

Patient Name (print):_________________________________________ Signature of Guardian:_____________________________ (If under the age 18)

CONSENT FORM

301 W 29th St | Baltimore, MD 21211

Patient’s Name:____________________________________________________ SS# (optional):________________________ First Name MI Last Name Date of Birth:________________________ __Male __ Female __Single __Married __Widowed __ Divorced __ SeparatedStreet Address :____________________________________________________________________________________________City/State/Zip Code:_______________________________________________________________________________________Home Phone:_____________________________________Cell Phone:_______________________________________ Fax:________________________________E-mail Address:_______________________________________________________ Can this be used for communicating with you? Yes__ No__Spouse’s Name:_______________________________________________ SS #:______________________________________Spouse’s Employer:______________________________________ Spouse’s Work Phone #:___________________________Patient’s Employer:____________________________________________________ Work Phone w/Area Code:____________________________________________Responsible Party:______________________________ Relationship: __Self __Spouse __Parent __Other:__________If patient is a Minor, are parents __Married __Divorced Custodial Parent:__________________________________Custodial Parent’s Home Phone :________________________ Work Phone:_____________________________________In case of emergency, contact (not living with you):_________________________________________________________Phone Number:_________________________________ Relationship to Patient:_________________________________Is this work-related? __Yes __No If yes, date of injury?_______________Claim #:_______________________________Is this auto accident related? __Yes __No If yes, date of injury? ___________Claim #:__________________________Insurance Company to be billed____________________________________________________________________________Adjuster’s Name & Phone

#______________________________________________________________________________________________Attorney’s Name & Phone

#______________________________________________________________________________________________Referring Physician’s Name & Phone

Number:_______________________________________________________________________________

PLEASE PRESENT INSURANCE CARD(S) & PHOTO ID FOR COPYING AND COMPLETE THE REQUESTED INFORMATIONInsurance Company # 1:________________________________________ Phone #:__________________________________Primary Insured’s Name:________________________________________ Date of Birth:______________________________Policy #:____________________ Group #:__________________________ Relationship:______________________________Address:___________________________________________________________________________________________________

Insurance Company # 2:________________________________________ Phone #:_________________________________Primary Insured’s Name:_________________________________________ Date of Birth:_____________________________Policy #:____________________ Group #:_________________________ Relationship:______________________________Address:___________________________________________________________________________________________________

◊ I hereby authorize the payment of medical benefits to LM at BlueGreen, LLC for services rendered. I understand that I am financially responsible for any services not covered by my insurance carrier. I permit a copy of this authorization to be used in place of the original.

◊ I further agree to pay all collections costs, attorney fees, and other collections costs that may be incurred to enforce the collection of any amounts outstanding.

◊ I hereby authorize LM at BlueGreen, LLC to release any medical information necessary to complete and process my insurance claims.

X _________________________________________________________________________________________________________ Patient’s OR Insured’s Signature (If patient is a Minor, must have Responsible Party Signature) Date

I authorize LM at BlueGreen, LLC to treat me and use my personal health information for healthcare operations.X __________________________________________________________________________________________________________ Patient’s Signature (OR Parent if patient is a Minor) Date

Billing Policy & Acknowledgement of HIPAA Privacy Policy

The following sets forth the general billing policy of LM at BlueGreen, LLC. Please review this information and sign where indicated.

I understand that it is my responsibility to provide the office of Leonora Manekin, M.Ac., L.Ac. accurate billing information at the time of check in and to notify the provider of any changes in this information.

I understand that it is my responsibility to know my co-pay and to pay it at the time that services are being rendered. I understand that this is a contractual agreement that I have with my health plan and that the provider also has a contractual agreement with my health plan to collect co-pays at the time of service, and they are required to report to the carrier any enrollees failing to pay the co-pay.

I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $25 NSF fee. I further understand that to rectify my account, I will be required to pay with either cash, a money order, cashier’s check, or credit card.

I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/ deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with two (2) statements for any balance due after insurance payment. I further understand that if I have not made payment prior to the second statement being mailed, that the second statement will be marked as “Final Notice” and may be sent to an outside collection service if I do not fulfill my financial obligations. I also understand that I will be responsible for any collection, interest or legal expenses associated with the collection efforts.

I understand that the provider will obtain the necessary prior authorizations prior to rendering treatment. I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier.

I have received a copy of the Notice of Privacy Practices as required by HIPAA from LM at BlueGreen, LLC and understand my rights with regard to my personal health information disclosure.

My signature below confirms that I have read and understand these billing policies, privacy practices and my financial obligation as pertains to the health care provider, LM at BlueGreen, LLC. .

________________________________ Patient’s Signature Date____________________________________________________________Legal Guardian to Patient (if patient is minor or incapable of signing)

Patient Registration

Patient’s Name:____________________________________________________ SS# (optional):________________________ First Name MI Last Name Date of Birth:________________________ __Male __ Female __Single __Married __Widowed __ Divorced __ SeparatedStreet Address :____________________________________________________________________________________________City/State/Zip Code:_______________________________________________________________________________________Home Phone:_____________________________________Cell Phone:_______________________________________ Fax:________________________________E-mail Address:_______________________________________________________ Can this be used for communicating with you? Yes__ No__Spouse’s Name:_______________________________________________ SS #:______________________________________Spouse’s Employer:______________________________________ Spouse’s Work Phone #:___________________________Patient’s Employer:____________________________________________________ Work Phone w/Area Code:____________________________________________Responsible Party:______________________________ Relationship: __Self __Spouse __Parent __Other:__________If patient is a Minor, are parents __Married __Divorced Custodial Parent:__________________________________Custodial Parent’s Home Phone :________________________ Work Phone:_____________________________________In case of emergency, contact (not living with you):_________________________________________________________Phone Number:_________________________________ Relationship to Patient:_________________________________Is this work-related? __Yes __No If yes, date of injury?_______________Claim #:_______________________________Is this auto accident related? __Yes __No If yes, date of injury? ___________Claim #:__________________________Insurance Company to be billed____________________________________________________________________________Adjuster’s Name & Phone

#______________________________________________________________________________________________Attorney’s Name & Phone

#______________________________________________________________________________________________Referring Physician’s Name & Phone

Number:_______________________________________________________________________________

PLEASE PRESENT INSURANCE CARD(S) & PHOTO ID FOR COPYING AND COMPLETE THE REQUESTED INFORMATIONInsurance Company # 1:________________________________________ Phone #:__________________________________Primary Insured’s Name:________________________________________ Date of Birth:______________________________Policy #:____________________ Group #:__________________________ Relationship:______________________________Address:___________________________________________________________________________________________________

Insurance Company # 2:________________________________________ Phone #:_________________________________Primary Insured’s Name:_________________________________________ Date of Birth:_____________________________Policy #:____________________ Group #:_________________________ Relationship:______________________________Address:___________________________________________________________________________________________________

◊ I hereby authorize the payment of medical benefits to LM at BlueGreen, LLC for services rendered. I understand that I am financially responsible for any services not covered by my insurance carrier. I permit a copy of this authorization to be used in place of the original.

◊ I further agree to pay all collections costs, attorney fees, and other collections costs that may be incurred to enforce the collection of any amounts outstanding.

◊ I hereby authorize LM at BlueGreen, LLC to release any medical information necessary to complete and process my insurance claims.

X _________________________________________________________________________________________________________ Patient’s OR Insured’s Signature (If patient is a Minor, must have Responsible Party Signature) Date

I authorize LM at BlueGreen, LLC to treat me and use my personal health information for healthcare operations.X __________________________________________________________________________________________________________ Patient’s Signature (OR Parent if patient is a Minor) Date

Billing Policy & Acknowledgement of HIPAA Privacy Policy

The following sets forth the general billing policy of LM at BlueGreen, LLC. Please review this information and sign where indicated.

I understand that it is my responsibility to provide the office of Leonora Manekin, M.Ac., L.Ac. accurate billing information at the time of check in and to notify the provider of any changes in this information.

I understand that it is my responsibility to know my co-pay and to pay it at the time that services are being rendered. I understand that this is a contractual agreement that I have with my health plan and that the provider also has a contractual agreement with my health plan to collect co-pays at the time of service, and they are required to report to the carrier any enrollees failing to pay the co-pay.

I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $25 NSF fee. I further understand that to rectify my account, I will be required to pay with either cash, a money order, cashier’s check, or credit card.

I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/ deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with two (2) statements for any balance due after insurance payment. I further understand that if I have not made payment prior to the second statement being mailed, that the second statement will be marked as “Final Notice” and may be sent to an outside collection service if I do not fulfill my financial obligations. I also understand that I will be responsible for any collection, interest or legal expenses associated with the collection efforts.

I understand that the provider will obtain the necessary prior authorizations prior to rendering treatment. I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier.

I have received a copy of the Notice of Privacy Practices as required by HIPAA from LM at BlueGreen, LLC and understand my rights with regard to my personal health information disclosure.

My signature below confirms that I have read and understand these billing policies, privacy practices and my financial obligation as pertains to the health care provider, LM at BlueGreen, LLC. .

________________________________ Patient’s Signature Date____________________________________________________________Legal Guardian to Patient (if patient is minor or incapable of signing)