What is acupuncture?
Acupuncture is a healing art that involves the stimulation of specific points on the body. I understand that acupuncture serves individuals with a wide range of complaints including both acute and chronic healthcare issues. I understand that I may be treated with the insertion of needles and/or with the application of heat to the skin.

Is there anything your practitioner needs to know?
Apart from medical details, it is important that you let your practitioner know if you have ever experienced fainting; have a pacemaker or any other electrical implants; are pregnant; have a bleeding disorder; are taking anti-coagulants (blood thinners) or any other medication, and have damaged heart valves or have any other risk of infection.

Side Effects/Risks/Complications
Acupuncture is considered a safe method of treatment, but occasionally there may be some bruising, tingling or slight bleeding on or near the needling sites that may last a few minutes, a few hours or even a few days. Burns and/or scarring are potential risk of moxibustion or when treatment involves the use of TDP heat lamps. Bruising is a common side effect of cupping. Temporary pain and/or discomfort may occur as well. There have been rare instances reported in which a patient fainted, experienced a spontaneous miscarriage, experienced nerve damage or sustained a pneumothorax (air in the chest cavity that could cause a collapsed lung). Infection is another possible risk, although sterile, disposable needles are used in a clean safe environment. Conventional medical therapy also may be indicated either in response to an emergency or as deemed necessary at the discretion of a licensed physician.

Patient Responsibility
I understand that it is my responsibility as a patient to inform my practitioner of all aspects of my health and that as services progresses, to inform my practitioner of changes that occur. I will inform my practitioner if I am pregnant/ and or suspect pregnancy at any time. If I experience any pain, discomfort or possible adverse side effects, it is my responsibility to immediately notify my practitioner. If I currently have any infectious disease (cold, flu, intestinal virus, etc.) or rash, I am to notify my practitioner prior to my appointment.

No Guarantees - I know that each person is unique and has ultimate responsibility for his or her own healthcare. I acknowledge that I have not received any guarantees or promises as to the results of success that will be obtained from the services provided. I understand that I am free to discontinue service at any time. Medical Treatment - I recognize that my practitioner is not a substitute for a medical doctor and will not suggest that I discontinue medical treatment. If I am currently under a physician’s care, I should continue as long as my physician and I deem it necessary and that the acupuncturist does not recommend altering medication or other therapies without first consulting my personal physician.

I have read the above information and acknowledge that the purposes, goals, techniques, procedure, limitations and potential risks of acupuncture have been explained to me. By signing below, I am voluntarily consenting to be treated with acupuncture and/or moxibustion, and/or cupping by a licensed acupuncturist at Blueprint Wellness, LLC.

Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. All answers are confidential.

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Basic Information

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Emergency Contact

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Physicians

* No contact will be made without your permission

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Personal Lifestyle Habits

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Medical

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Medicines

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