Intake form Dr. Paul F. Ryan DACM L.Ac. (EWIW)

Clinical Intake form

Dr. Paul F. Ryan, DACM, L.Ac.

East-West Integrated Wellness

302 5th Avenue, 8th Fl. #817 New York, NY, 10001

Personal Identification Information:
Date

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip
Home Number

Area CodePhone Number
Work Number

Area CodePhone Number
ext
Mobile Number*

Area CodePhone Number
Email*
example@example.com
Birth Date*

MonthDayYear
Date
Age*
Place of Birth
Gender*

FemaleMaleNon-binaryOther
Height*
Weight*
Occupation
Relationship Status*

MarriedSingleCommitted partnership
Insurance Provider Information

Our practice accepts only out-of-network insurance plans. If you have out-of-network benefits and are not sure if you have coverage for acupuncture our biller is happy to verify for you. To initiate verification, please fill out our separate insurance verification form. You'll find the link in our appointment confirmation email and on our website. Thank you.
Company
Name as it appears on policy.
Policy #
Member ID
Name & number of person to contact in case of an emergency?
How did you find out about this practice?
POLICIES FOR CANCELLATIONS AND LATE APPOINTMENTS
Twenty-four hour notice for cancellations will be required. No penalty fees will be applied for appointment cancelled 24 hours in advance of your appointment. Cancellation within 24 hours will result in a $88.00 cancellation fee for the first appointment and a full $168 session fee for follow-up ones. Missed appointments will be billed at full rate of scheduled appointment type.

If an emergency prevents you from keeping your appointment special arrangements can be made. If you know that you will be late, please call. We will make every effort to reschedule you for a later time.
Patient's (or Patient Representative's) Signature*
I have obtained a copy of this office’s HIPAA/Privacy policies (download from EWIW FORMS or have requested a copy to be emailed to me).
Patient's (or Patient Representative's) Signature*
INFORMED CONSENT TO TREATMENT
I,   First Name   Last Name     , do give consent to acupuncture treatments and other procedures associated with Traditional Chinese Medicine by Dr. Paul F. Ryan, DACM, L.Ac., and/or any guest Licensed Acupuncturist, tutorial students, or clinic assistants working under his supervision.

I understand that methods of treatment may include, but are not limited to acupuncture, moxibustion, cupping, scraping (gua sha), electric stimulation, massage, stretching, exercises, herbal medicine, and/or nutritional/dietary counseling. Instruction and guidance in non-religious mindfulness meditation is offered when deemed appropriate.

Initials*
I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including, but not limited to bruising, numbness, or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping and scraping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes major risks of treatment, other unanticipated side effects may occur. I do not expect the Licensed Acupuncturist to be able to anticipate a possible complications from treatment, but I do wish to rely on the Licensed Acupuncturist to exercise judgment during the course of the procedure which the Licensed Acupuncturist feels at the time, based upon the facts then known, is in my best interests.

    Initials*
Chinese and Western herbs (which are from plant, animal, and mineral sources) are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. New York State recognize the use of herbs, or oriental/herbal medicine, as part of the profession of acupuncture. The effects of herbal medicine are generally mild and comfortable. However, sometimes the desired effects are difficult to distinguish from adverse effects. Some desired effects that can be confused with side effects are profuse sweating, nausea and vomiting, an increase in pain or tingling in the body and skin disease eruptions (e.g., rashes, hives). The possibility of experiencing these desired effect will be explained and predicted whenever possible. Examples of clear side effects are tingling of the tongue, and spontaneous miscarriage.

I understand that recommended herbs may need to be prepared and the tea consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant taste or smell. I will immediately notify Paul or a member of the clinic staff of any unpleasant effects associated with the consumption of the herbal teas or products.

    Initials*

I will notify my practitioner if I am or become pregnant.

COVID-19 CARE
There is publicly available information in peer reviewed journals via PubMed on the use of Chinese herbal medicine for COVID-19 prevention, treatment and convalescence (email appt@ewiw.org for links to and PDF versions of the articles, one link below). One such article indicates that Chinese herbal medicine became standard practice in China and it was used in 85% all cases. The authors evaluate the results of usage as decreasing severity of symptoms, hospitalization rates, use of ventilators and improved recovery. The FDA and CDC do not recognize or recommend Chinese herbal medicine as a treatment for COVID-19 at any stage of the disease process.
PubMed Article

I am aware that neither the CDC or FDA recognize or recommend Chinese herbal medicine as a treatment for COVID-19 at any stage of the disease or its recovery. I take full responsibility for all treatment outcomes should I choose to use Chinese herbal medicine in my treatment of this disease.

Initials*

It is agreed with regard to medical care and services, the attending Licensed Acupuncturist will provide services to the patient and to the best of his skill and knowledge, medical care appropriate to the situation. The patient will cooperate fully with the Licensed Acupuncturist by following his instructions and adhering to such treatment plan or course of action as may be set forth and agreed. It is the patient’s right to accept or reject any diagnostic procedure, or any part of it, before or during the diagnosis or treatment.

By voluntarily signing below, I show that I have read, or have had read to me, this consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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 at this clinic.
Patient's (or Patient Representative's) Signature*
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
PATIENT ADVISORY TO CONSULT A PHYSICIAN
I recommend that you consult a physician regarding any condition or conditions, including COVID-19 for which you are seeking acupuncture or Chinese herbal medicine treatment. In compliance with Article 160, Section 82.11 (b) of NYS Education law, please read and sign the following statement:
We, the undersigned, do affirm that Patient Full Name* has been advised by Paul F. Ryan, LAc. to consult a physician regarding the condition or conditions for which such patient seeks Chinese herbal medicine and/or acupuncture treatment.
Patient's (or Patient Representative's) Signature*
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
COMMUNICATIONS PRIVACY POLICY
At EWIW we take your privacy seriously and our e-mail server is HIPPA compliant. However, there are inherent confidentiality risks in communicating by e-mail and texts. While safeguards are in place to ensure your privacy, you should not use e-mail communication for sensitive health related information if you are concerned about any breaches of privacy that might inadvertently occur. We do use Signal App on our office cellphone 917-979-3949 should you want to communicate through a protected channel. We can do all electronic communication via Signal or use it only for explicitly sensitive information, such as forms, lab results and financial info. We also offer secure uploading of documents through our HIPPA compliant JotForm account. Our e-calendar notifications use Calendly and Google Calendar. We keep our calendars private, but should you wish not to receive calendar invites for extra privacy protection, please inform us at your when making your appointment.

Tele-health consultations we offer a choice of Signal and Google Meet platforms. All are end-to-end encrypted, thus secure and HIPPA compliant. Please let us know your preference.

initials*
FINANCIAL HARDSHIP POLICY
Please note that EWIW can offer financial hardship discounts in cases when the patient is in a genuine financial need. Any discounts will be applied upon provision of financial hardship documentation and/or current full-time student ID, and when applicable permission from contracted insurance provider.

Intials*
TEACHING CLINIC ASSOCIATES
Dr. Paul Ryan hosts visiting acupuncturists, trains clinical associates and
has assistants in his practice. While Paul is the primary clinician, assistants do provide support when appropriate including reviewing and organizing paperwork, making appointments, preparing patients for treatment, and removing and applying needles, cupping and moxibustion. Patients have the right to request that associates remain outside the treatment room during consultation and/or treatment. Initialing here only indicates that you are aware of this part of the practice and that you will communicate your preference to Paul directly.

Initials*
I hereby confirm that I have read and understood above Communications, Financial Hardship and Teaching Clinic disclaimers
Patient's (or Patient Representative's) Signature*
Date*

MonthDayYear
Date
Date*

MonthDayYear
Date
Agreement to Arbitration
By initialling below, I acknowledge that I will be asked to sign an agreement to arbitrate any disputes of medical malpractice in my first session and that signing it will be required prior to any treatment provided.
Your Name: {name}
Patient’s or Patient Representative’s Initials*
Date

MonthDayYear
Date
Credit Card Authorization
By initialling below, I acknowledge that at my first session I will be asked to sign a payment authorization form authorizing East-West Integrated Wellness to keep my credit card details on file as insurance for late cancelation charges and any other charges associated with received treatments and authorized by me.
Patient name: {name}
Patient's (or Patient Representative's) Initials*
Date*

MonthDayYear
Date
HEALTH HISTORY EVALUATION

Chinese medicine is a holistic system. To provide you with a comprehensive evaluation and individualized treatment, we ask that you please take the time to complete this form carefully. All answers will be held strictly confidential in accordance with our Privacy Policy. Thank you!
Main Problem(s) You Would Like to Address
Main complaint*
If your problem is pain, on a scale of 1 to 10, what is the worst level of your pain?
How long?*
Onset, duration
How often?*
constant, frequently, daily, sometimes, at night....
What caused this?*
accident, lifestyle factors, drug interactions, complication of other disease, unknown etc...
Have you received a diagnosis from a physician? If so, what is it?*
What types of treatment/therapy have you tried? (check all that apply)*

IceHeatRestOver the counter medicationPrescription medicationMassageChiropractorSurgeryOther
Do/Did past therapies...*

Fix the problemProvide temporary reliefCause side effectsDo nothingOther
What makes the problem worse?*
Secondary complaint
If your problem is pain, on a scale of 1 to 10, what is the worst level of your pain?
How long?
Onset, duration
How often?
constant, frequently, daily, sometimes, at night....
What caused this?
accident, lifestyle factors, drug interactions, complication of other disease, unknown etc...
Have you received a diagnosis from a physician? If so, what is it?
What types of treatment/therapy have you tried? (check all that apply)

IceHeatRestOver the counter medicationPrescription medicationMassageChiropractorSurgeryOther
Do/Did past therapies...

Fix the problemProvide temporary reliefCause side effectsDo nothingOther
What makes the problem worse?
Other Complaints:
anything else you might want Dr. Ryan to consider
Health Goals

For acupuncture/Chinese medicine treatment and overall
What is your desired outcome for acupuncture/Chinese medicine treatment?
Immediate treatment goal
What are your general health goals?
Long term goals and how acupuncture/Chinese medicine can help.
Where are you in your health goals? Check one.

I’m in a good place, no changes neededBeginning to think about changeKnow I need to make some changesDeveloping a plan of actionIn the process of taking actionRefining my plan of action
Medical Information
Name of primary physician and contact info:
Name of relevant specialists and their contact info:
PCP or specialist.
Date of Last Exam:

MonthDayYear
Date
Current Medical Diagnoses:
Current Medical Treatment:
Current Medical Warnings or Prohibitions:
Medications
Are you taking blood thinners?

YesNoNot Sure
Are you taking blood pressure medication?

YesNoNot Sure
How is your blood pressure?

HighLowNormalNot Sure
Average BP: (mm/Hg)
Please include all prescription and nonprescription medications, herbs and supplements you are taking. Upload a separate sheet if more convenient.

.
Drug Name Purpose Dosage How often How long
Medication list

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Allergies:*

MilkEggTree nutSeafoodSoyWheatPenicillinNone
Other Allergies:
Personal Medical History

Please list any hospitalization, operations and significant traumas that have occurred in the past five years. Attach separate sheet if necessary.
Date Event Treatment and outcome
Past Medical History - check all previously experienced medical conditions

Anemia - HemolyticAnemia - Iron deficientAnemia - PerniciousAnxiety disorderAppendicitisArteriosclerosisAsthmaBird fluBronchitisCarpal tunnelChronic fatigue syndromeCoeliac diseaseColitisCOPDDepressionDiabetes type 1Diabetes type 2Disc degeneration - Cervical spineDisc degeneration - Lumbar spineDisc degeneration - Thoracic spineEating disorderEmphysemaEpilepsy/seizuresFibromyalgiaGastritisGoutGraves' diseaseGuillain–Barré syndromeHashimoto's thyroiditisHeart diseaseHenoch–Schönlein purpuraHepatitis BHepatitis CHerpes simplexHIVHypertensionHyperthyroidHypotensionHypothyroidKidney stonesMeningitisMental illnessMigrainesMonoMultiple sclerosisMumpsMyasthenia gravisNeuropathyOsteoarthritisPacemakerParkinson’s diseasePolioPolycystic kidney diseasePolycystic liver diseasePolymyalgia rheumaticaPTSDRestless leg syndromeRheumatic feverRheumatoid arthritisRhinitisScarlet feverSciaticaSclerodermaSinusitisSystemic lupus erythematosus
Family History

please indicate family member and age of onset
Addictions
Cancer (include type)
Diabetes
High blood pressure
Heart disease
Psychological disease
Stroke
Thyroid disease
Other
My Constitution

This info provides the holistic information of how your body-mind uniquely manifests health and disease. This information is very important to how treatment is individualized to meet your needs.
My body temperature runs:*

HotWarmNormalCoolCold
I really dislike ______ weather.*

HotColdWindyDryHumid
My hands feel cold _______*

AlwaysFrequentlySometimesRarely/never
My hands feel hot/sweaty _______*

AlwaysFrequentlySometimesRarely/neverAt night
My feet feel cold _______*

AlwaysFrequentlySometimesRarely/never
My feet feel hot/sweaty _______*

AlwaysFrequentlySometimesRarely/neverAt night
I sweat _______*

Easily/frequentlyHardly everWhen I exerciseAt night
I have a bowel movement _______*

1x/day2-3x/daymore than 3x/day1x/2-3 daysless than 1/2-3 days
My stool is ________ (check all that apply)*

Formed/solidLooseDryPebble-likePainful or difficult to passIrregular (mix of loose and dry or constipated)BloodyOther
How many times do you urinate per day?
How many times do you urinate per night?*
The color of my urine is

ClearLight yellowYellowDark yellowRed/brownCloudy
Thirst

Strong thirst for cold drinksObvious thirst for room temp or warm drinksLow thirst, drink littleThirsty but don't like to drinkModerate thirstDrink only because I know I should
Appetite

PoorHungry but don't feel like eating because I often feel uncomfortable afterwardsModerateStrongHungry immediately after eatingOther
Self-care
Do you have a regular eating habit?

YesNoSometimes
Please provide us with a general idea of your daily diet along with the time of meals and snacks.
Breakfast
Lunch
Dinner
Snacks
Do you crave certain tastes or foods? If so, what?
Are you a vegetarian/vegan? If so, what are your main protein sources?
How much of your diet consists of cold/raw foods?
Raw vegetables, fruits, smoothies, ice cream, yogurt, etc...
Do you eat organic foods? If yes, which foods do you focus on?
Have you ever undertaken a restricted diet? If yes, please describe diet and indicates dates.
gluten free, intermittent fasting...
Are you an emotional eater? If so, what are the emotions that cause you to eat excessively or stop you from eating?
How many glasses of water do you drink/day?
Do you consume any of the following? If yes, how much and how often?
Cigarettes/cigars
frequency: number/day, week, month
Alcoholic beverages
frequency: number/day, week, month
Other recreational drugs
frequency: number/day, week, month
Coffee/caffeinated beverages
frequency: number/day, week, month
Do you exercise regularly? If yes, please describe type and frequency.
Please list one or two emotions that seem predominant in your life and when they occur.
Please list any personal or occupational stress factors you may be experiencing.
(physical, psychological, chemical)
How many hours a week do you work?
Do you enjoy what you do?
Do you have a mindfulness practice? If yes, please share the name or describe. If not, how do you manage stress?
How would you rate the quality of your sleep?

Poor/disturbed/wake during the nightInconsistent/variesrestfulOther
How many hours do you usually sleep each night?
What time do you generally go to bed, fall asleep and wake?
Do you have difficulty staying asleep? If so, what causes you to wake and is there a certain time you always wake?
Do you have difficulty waking up? Once up, do you feel well rested from your sleep?
Do you dream a lot when you sleep? If so, are the dreams vivid or disturbing and do you usually remember them?
Please describe your overall energy for the day, and any extreme peaks or dips in energy.
Current Health

Check all symptoms you’ve experienced in the past 3 months.
Head, Eyes, Ears, Nose & Throat Symptoms

HeadhachesMigrainesConcussionDizzinessVertigoFoggy headedDry eyesCataractsPoor night visionDifficulty focusingRed eyesFloatersBlurry visionEye strainGlasses/contactsEarachesEar ringing: High pitchEar ringing: Low pitchLoss of hearingTMJGrinding teethMouth sores/ulcersObstructed sinusNose bleedsDental problemsExcess salivaBleeding gumsDry mouthFeeling of lump in throatSore throat
Gastrointestinal Symptoms

BloatingAbdominal pain/crampsIndigestionNauseaVomitingBelchingFlatulenceHiccupBad breathAcid refluxHemorrhoidsAnal fissuresRectal painPeptic ulcersPancreatitisGastric ulcersInflamed gallbladderProlapsed stomachGallstonesInguinal herniaAbdominal herniaHiatal herniaSplenomegalyHepatomegallyWeight gainWeight loss
Respiratory Symptoms

Dry coughWet coughPneumoniaPost-nasal dripPhlegmyNasal congestionShortness of breathLabored breathingPain upon breathing deeplyTightness in chestBreath feels hotBronchitis
Cardiovascular Symptoms

Irregular heart beatRapid heart beatHeart palpitationsFaintingSwelling of hands/feetLeft arm painChest painVaricose veinsPhlebitisPericarditisPoor circulationRaynaud’s syndrome
Integumentary Symptoms

Dry skinItchy skinHivesHerpes zoster (Shingles)GranulomaSevere acneEczemaPsoriasisEdemaContact dermatitisAllergic dermatitisBruise easily
Urinary Symptoms

Incomplete urinationDecreased flowLack of bladder controlPain during urinationBurning urinationBedwettingSmelly urineProlapsed bladderKidney stones
Musculoskeletal/Neurological Symptoms

Muscles weaknessMuscle tightnessFull body aches/painsParalysisLoss of balanceLack of coordinationTremors
What areas are painful?

HeadNeckShoulderUpper backMiddle backLower backRibsWristsElbowHandsFingersHipsUpper legSide of legLower legKneeAnkleFootToesGroinButtocks
In which areas do you experience numbness?

Face/headShoulder/armHand/FingerHip/legFoot/toe
Psychological/Emotional Symptoms

DepressionAnxietyPanic attacksSuicidal thoughtsFrequent worryManic episodesMemory lossObsessions/compulsionsADHDAnger management issuesUnresolved grief
Reproductive Health
Are you sexually active?

YesNo
Have you been tested for STIs in the past 6 months?

YesNo
Do you have a history of STIs? If yes, please list:
Men's Reproductive Health
Check all you have experienced in the past 6 months.

Discharge from penisErectile dysfunctionWet dreamsPainful ejaculationPremature ejaculationLow sperm countImpotenceLack of sexual driveHigh sexual driveSore on penisPain/cold in genital areaEnlarged prostateTesticular lumpHydroceleVaricoceleBreast lumpProstatitisInfertileGenital soreGenital itchingTesticular pain
Women's Reproductive Health
Are you pregnant?*

YesNoNot sure
Are you trying to get pregnant?*

YesNo
# of pregnancies:*
# of live births:*
# of miscarriages:*
# of abortions*
# of caesarean sections:*
Do you have vaginal discharge? If yes, please describe the amount, coloration, consistency and odor?
Menstruation: If you are peri-menopausal or no longer menstruating, please indicate what a normal period was like for you in the past.
Age of first menses:
Length of period:
number of days
Length of cycle:
number of days
Date of last menses:

MonthDayYear
Date
Do you experience any of the following symptoms with your period? Check all that apply.

Spotting between periodsMissed periodsIrregular periodsPain with period
Describe your period discharge
Average number of pads/tampons used per day; Color changes on different days: Black , Dark Brown, Purple, Dark Red, Normal Red, Bright Red, Pale Red; Consistency: Watery, Thin, Thick, Clotting
PMS: Check all that apply.

IrritabilityTendency to cryCramps before periodMoodinessBloating/swellingCramps after periodLow back painFatigueBreast tendernessCrave sweetsCrave carbsCrave meat
General GYN: Check all that apply.

Lack of sexual driveVaginal mucosa dryPainful intercourseVaginal itchingUTIsVaginal infectionsYeast infectionsVaginal OdorConception difficultyUse hormonal birth controlHysterectomyFibroidsPIDEndometriosisFibrocystic breastsOvarian cystsPolycystic ovary syndromeBreast cancerMonthly breast self examFibrous breastHistory of mammogramBreast reductionBreast implantsAbnormal mammogramNipple dischargeBreast feed your childInfertility problems
Age of menopause:
Last Period:
Did you experience any of the following symptoms during Menopause?

MoodinessHot flashesVaginal drynessBrain fogUse of hormonal therapy
Upload any additional forms, information, pictures of your tongue here

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Any additional questions or comments?
Should be Empty:

Clinical Intake form

Personal Identification Information:

Insurance Provider Information

POLICIES FOR CANCELLATIONS AND LATE APPOINTMENTS

I have obtained a copy of this office’s HIPAA/Privacy policies (download from EWIW FORMS or have requested a copy to be emailed to me).

INFORMED CONSENT TO TREATMENT

PATIENT ADVISORY TO CONSULT A PHYSICIAN

COMMUNICATIONS PRIVACY POLICY

FINANCIAL HARDSHIP POLICY

TEACHING CLINIC ASSOCIATES

Agreement to Arbitration

Credit Card Authorization

HEALTH HISTORY EVALUATION

Health Goals

Medical Information

Medications

Personal Medical History

Family History

My Constitution

Self-care

Current Health

Reproductive Health

Men's Reproductive Health

Women's Reproductive Health