Happy Charting

Information

Name *

Email *

Birthdate *

Phone Number *

Birthdate

Phone Number

Address

Emergency Contact/Phone:

Occupation:

Have you had acupuncture or facial acupuncture treatments before?

How did you hear about us?

Because this is a holistic approach to healthcare, it is important for the practitioner to have a complete understanding of the patient; physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. If there is confusion on any area of the form, indicate with a question mark, and we can discuss during consultation.Thank you.

Primary Reason for seeking acupuncture, and when did it first occur, and how often do you experience these symptoms?

Secondary Reasons for seeking acupuncture:

To what extend does this problem affect your daily activities? (work, sleep, eating, energy etc)

When or under what circumstances does it seem to get better? worse?

Have you undergone any other treatments for this condition?

Major Medical History (list relevant past illnesses, injuries, surgeries, with dates)

Significant Family Medical History (List briefly and whom)

Allergies or Sensitivities: (List foods, drugs/medications, metals or skin care products you are allergic to and include reaction:

LIFESTYLE QUESTIONS:

Please answer the following questions about lifestyle:

Do you follow a regular exercise program? if so, please describe:

Relaxation or stress management practices:

Sleep Habits/Hours of sleep per night? do you feel rested when waking up?

Please describe your average daily diet: Do you typically eat at least three meals per day? examples of Breakfast, lunch dinner, snacks, drinks?

Do you follow a particular diet or nutritional program? (IE: macrobiotic, paleo, Keto, vegetarian or vegan, Meat and potatoes, low carb, intermittent fasting etc)

Do you generally cook your own meals?

Please Check any of the following habits that apply.

Cigarette Smoking

Alcoholic beverages

Coffee, tea, cola (caffeine)

Recreational substances

MEDICATIONS/SUPPLEMENTS (prescribed and over-the-counter), herbs, vitamins and supplements you are currently taking or taken within last two months:

How would you describe your sex drive?

Low

Average

High

Up and Down

General Energy Level

SKIN AND HAIR

Rashes

Itching

Hives

Eczema

Acne

Ulcerations

Recent Moles

Hairloss

Dandruff

Changes in hair or skin

Any other skin problems

Ear Ringing? If so, describe: pitch - low or high? volume - low or high?

Production of phlegm? if so, how much and what color?

Any other lung problems?

Any other heart of blood vessel problems?

Do you have daily bowel movements? if not, how often?

Formed or loose/soft stools

Any other problems with stomach or intestines?

Particular odor to urine?

Do you wake at night to urinate? if so, how often?

What color is your urine? (clear, light yellow, dark yellow, brown etc)

Amount? (Scanty or profuse)

WOMEN'S HEALTH:

If applicable, Please answer the follow questions regarding women's health

Date of Last Menses:

Age of first menses:

Typical duration of bleeding:

Is your cycle regular? Average cycle length? (from day one of a period until next period):

If irregular cycles, please explain:

Other women's health or menstrual symptoms:

Are you on birth control? type? How long?

Total number of pregnancies:

Total number of births

Premature births?

Miscarriages?

Are you pregnant now? if so how many weeks?

If pregnant, approx due date?

If pregnant, are you under the care of an OBGYN or Midwife

If pregnant, Any complications or concerns?

If pregnant, Any symptoms causing discomfort?

Any other joint or bone problems?

Have you ever been treated for Mental health or emotional problems?

Any other neurological or psychological problems?

MISC: Anything else that you would like me to know that is not listed in this form?

Colorado Disclosure Form:
Amelia Vargas earned her Master of Sciences in Acupuncture and Oriental Medicine degree from South West Acupuncture College in Boulder Colorado. This four year program consisted of 3000 educational hours including 1095 hours of clinical practice. She is certified as a Diplomate in Acupuncture and Oriental Medicine by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). This includes certification in Clean Needle Technique and Chinese Herbology. Amelia’s training also includes adjunctive therapies such as moxibustion, tui na, acupressure, cupping, auriculotherapy, facial renewal acupuncture, microneedling and dietary and lifestyle recommendations. She is a licensed Acupuncturist in the state of Colorado and is a member of the Acupuncture Association of Colorado. Additionally, Amelia is a Colorado licensed Esthetician and a practitioner of Acutonics and craniosacral therapy, and is certified in Facial Rejuvenation Acupuncture, Constitutional Facial Renewal Acupuncture, Microneedling, Facial Soundscapes Harmonic Renewal, and Oriental Medicine Pediatrics and Obstetrics. None of these licenses or certificates have ever been revoked or suspended.
This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized.
Suggested Fee Schedule
Initial Consultation and Treatment 60-75 min - $125 + cost of herbs 
Follow-up Treatment 45-60 min - $95 + cost of herbs
Pediatric Chinese Medicine 30 min - $60
Facial Rejuvenation Acupuncture 60 min- $140
Enhanced Facial Rejuvenation Acupuncture (includes facial products and LED light therapy) 60-75min - $180
Ultimate Facial Rejuvenation Acupuncture (includes facial products, Stem Cells and LED or Microcurrent) 75min - $210
Patient’s Rights
-The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known.
-The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time.
-In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies.
-The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202.Telephone (303) 894-2440.

Terms And Conditions

Informed Consent:
I hereby consent to acupuncture treatments and related procedures associated with Chinese Medicine, by
Amelia Vargas, L.Ac. I understand that the methods of treatment may include but are not limited to acupuncture, facial acupuncture, microneedling, moxibustion, cupping, gua sha,Tui-Na, electrical stimulation, Chinese herbology, Acutonics, shoni shin, nutritional counseling and skin care and facial services.
I have been informed that acupuncture is a safe method of treatment, however it may have minor side effects, including bruising, numbness or tingling near the needling sites which may last a few days, and in rare cases, dizziness or fainting. This facility only uses sterile, disposable needles and maintains a clean and safe environment. Burns and scarring are potential risks of moxibustion. Bruising is a common side effect of cupping and gua sha treatments, and may last a few days to a week. Although rare and uncommon, there have been cases reported of nerve damage, organ puncture, including lung puncture (pneumothorax) and spontaneous miscarriages. I understand that while this document describes the major risks of treatment, other side effects and risks may occur.
If I am receiving facial renewal acupuncture, I understand that facial bruising is a possible risk. I will inform my acupuncturist if I have high blood pressure, frequent migraines, or have had resurfacing treatments such as, laser, microdermabrasion, or chemical peels within the last 3 weeks. It is not appropriate to perform facial acupuncture in the situations of pregnancy, acute colds and flus, acute herpes outbreaks or acute allergic reactions.
I understand that there are some acupuncture points and Chinese herbs that are inappropriate during pregnancy. I will notify the acupuncturist should I become pregnant or if I am trying to become pregnant.
The herbs and nutritional supplements (which are from plant, mineral, and animal sources) that are used are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in large doses. If I experience any gastrointestinal upset, headache, rashes or allergic reactions or any unpleasant side effects from the herbs I will stop taking them and immediately inform the acupuncturist.
I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of treatment. I wish to rely on the acupuncturist to exercise judgment during the course of treatment, and decide what she thinks is in my best interest, based upon the facts that are known at the time. I understand the practitioner and administrative staff may review my medical records and reports, but all of my records will be kept confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read and understand this consent to treatment and that I have read and understand the colorado mandatory disclosure form. I have been informed about the risks and benefits of acupuncture and other procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

Terms And Conditions

HIPAA Notice of Privacy Practices
This Notice describes how medical information about you may be used and disclosed and how you can access this information.
Under the Health Insurance Portability & Accountability Act of 1996 “HIPAA,” it is our legal duty to safeguard your Protected Health Information (PHI). Please note that we reserve the right to change the terms of this Notice and our privacy policies at any time as permitted by law. Any changes will apply to PHI already on file with us. Before we make any important changes to our policies, we will immediately change this Notice and post a new copy of it in our office. You may also request a copy of this Notice from us, or you can view a copy of it in our office. This Notice will remain in effect until it is replaced or amended.
During the course of our relationship with you, we will use and disclose PHI about you for treatment, payment, and healthcare operations. We gather personal information and health information from you, other healthcare providers, and third party payers. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside our practice. You may specifically authorize us to use PHI for any purpose or to disclose our health information by submitting the authorization in writing. Such disclosures will be made to any personal representative you choose to have your PHI.
DISCLOSURE
This office may use or disclose your PHI without your consent or authorization when required by law.
PATIENT RIGHTS
1. Upon written request, you have the right to review and receive copies of your PHI.
2. Upon written request, you have the right to receive a list of disclosures about your PHI. 3.You have the right to request additional restrictions on the use and disclosure of your PHI, as permitted by law.
4. Upon written request, and as permitted by law, you have the right to request that we amend your PHI.
5.You have the right to receive all notices in writing.
If you have questions about this Notice or any complaints about our privacy practices, please contact our office. Please send written complaints to the Secretary of the Department of Health & Human Services, 200 Independence Ave. S.W.,Washington, D.C. 20201. This Notice went into effect on March 1, 2008.
I acknowledge consent for use and disclosure of PHI and receipt of this Notice of Privacy Practices. I have read and understand this document.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

FACIAL REJUVENATION ACUPUNCTURE AND MICRONEEDLING

For best results a series of 10-15 Facial Rejuvenation Acupuncture treatments 2 x week, and/or 6 Microneedling treatments 1 x month is recommended, followed by monthly and seasonal maintenance treatments. Understand that results vary depending on health history, lifestyle, age and commitment to the frequency of treatments and lifestyle changes, including: diet, exercise, herbal and supplemental intake and home skin care regime.

What changes in your appearance and skin would you like to see happen?

When did your primary concern begin?

What about your skin and appearance is working for you

What is your daily skin care routine?

Have you had any resurfacing treatments in the last month? if so, what type? (include: microdermabrasion, laser, peels etc)

Have you had any Botox or injections? if so, how long ago?

Have you had any plastic surgery? If so, what type? and how long ago?

Please list any medications or supplements you are currently taking (including topical skin medications):

Have you taken aspirin or blood thinners in the past 7 days?

Have you been on Accutane in the last year?

Are you currently using any Retinol, Retin-A, Glycolic Acid, AHA or other exfoliating skincare ingredients?

Do you have High blood pressure? If so, Is it under control with an MD?

Do you experience frequent Migraines? How often? Last occurance?

Do you have a history of cold sores, herpes or fever blisters? If so, is it under control with medication prescribed an MD? it is important to take that medication before treatment or tell the technician to skip treatment around my lips.

Increased risk of topical allergies with microneedling:

Because microneedling increases the absorption of products significantly, it also raises the risk of allergic reaction. It is important to list any known allergies, and to understand these risks.

Please List List any allergies you have (including cbd, avocado, aloe vera, rose, lavender, metals,

Terms And Conditions

Consent For Treatment - Facial Rejuvenation Acupuncture and  Microneedling: 
I freely choose to undergo Facial Rejuvenation Acupuncture treatments and/or Microneedling with  ________________ (practitioner name), knowing that there are no guaranteed results, and I am free  to stop treatment at any time. The goal of these treatments, is improvement - not perfection. I  understand my results might not be perfect, and the number of treatments necessary may vary. There  may be more treatments necessary than I anticipated. There is no guarantee that expected or anticipated  results will be achieved. I understand that compliance with recommended Microneedling aftercare  guidelines are crucial for healing and prevention of scarring or skin textural changes. 
An acupuncture facial treatment involves the insertion of acupuncture needles into fine lines and  wrinkles on the face and neck in order to reduce the visible signs of aging. In Chinese medicine, the  meridians or pathways of Qi (energy) flow throughout the entire body from the soles of the feet up to  the face and head; consequently, a facial acupuncture treatment addresses the entire body  constitutionally, and is not merely “cosmetic.” 
An acupuncture facial involves the patient in an organic, gradual process, that is customized for each  individual. It is no way analogous to, or a substitute for, a surgical “face lift”. A treatment session may  confine itself solely to facial acupuncture, or it may be used in conjunction with other procedures. 
I understand that while acupuncture and microneedling are generally safe methods of treatment, certain  adverse effects may result from treatment. These may be, but are not limited to local bruising  (hematomas), puffiness, redness, bleeding, temporary pain or discomfort at the site of the needles during  or after the treatment, and in more rare circumstances there are the risks of fainting, infection, damage  to blood vessels or nerves. In some circumstances, local allergies to topical preparations have been reported. Systemic reactions which are more serious may occur with herbs used during an acupuncture  facial. Allergic reactions may require additional treatment. 

With microneedling there may be redness, discomfort and/or swelling, or the sensation of having a  sunburn at the area of treatment for a few to several hours after treatment. Additionally, redness may be  present for 2-3 days after treatment. There may be an increase or decrease in pigmentation and can take  4-6 months or more to resolve. Loss of pigmented lesions such as freckles may give the appearance of  loss of pigment. Small areas of scabbing may occur 2-3 days following the treatment. Infection is possible  if proper aftercare guidelines are not followed.  
I understand the methods of treatment in the scope of Chinese medicine may include but are not limited  to acupuncture, microneedling, cupping, moxibustion (applying heat to acupuncture points of the body),  electro-stimulation acupuncture, Tui-Na (Chinese massage), and herbal medicine.  
Although noticeable results may be obtained with a single MicroNeedling or Facial Acupuncture  treatment; the greatest improvement will be seen after a series of four to six consecutive monthly  Microneedling procedures, and ten to fifteen Facial Acupuncture sessions twice per week, or a  combination of the two.  
I understand the acupuncturist is not providing Western medical care, and I should look to my Western  primary care physician (MD) for those services and routine checkups. 
I understand I must inform my acupuncturist if I am Pregnant, have an acute cold or flu, an acute  herpes outbreak, an acute allergic reaction, an active inflammatory skin condition, am  using accutane or any related acne medication, high blood pressure, diabetes,  severe migraines, am HIV positive or have AIDS, cancer, or hepatitis, as these may have  additional risks or contraindications with facial acupuncture and microneedling. 
I understand all fees for services are due at the time of service, and I will be charged the full fee for  appointments that are cancelled with less than 24 hours notice. 
I have read, or have had read to me, and completely understand the risks and benefits of acupuncture  treatment, and have had an opportunity to ask questions. I intend this consent form to cover the entire  coarse of treatment for my present treatment and for any future condition(s) for which I seek  treatment.

I have read, understand and accept the Terms & Conditions. The information in this form is correct to the best of my knowledge. *

Amelia Vargas L.Ac.

Information