Welcome to Our Community!

Please take a moment to print out this form, read it and sign it, and bring it in with you to your first visit. If you have any questions, give us a call at (518) 615-0505.

About the Acupuncture Studio

•We treat in a community setting

Here at the studio we offer Community Acupuncture. Although all discussion regarding your personal information takes place in a private setting, the treatment itself happens in a communal room. In our clinic we use recliners in a large, quiet, soothing space.  Treating patients in a community setting has many benefits: it’s easy for friends and family members to come in for treatment together; many patients find it comforting; and it often seems to make individual treatments more powerful.  This style of acupuncture allows patients to keep their needles in as long as they want, and the “right” amount of time varies from patient to patient and treatment to treatment. Most people learn after a few treatments when they feel ‘done”; this can take from twenty minutes to a couple of hours! Many people fall asleep, and wake feeling refreshed. 

•Our Commitment to You

We want to make it possible for you to receive acupuncture regularly enough and long enough to get better and stay better. We want to give you the tools to take responsibility for your own health. We provide a safe, comfortable environment with skilled practitioners.

What We Need From You

•Responsibility

The Acupuncture Studio does not provide primary care medicine. Acupuncture is a wonderful complement to Western medicine, but it is not a substitute for it.  If you are concerned you might have a serious infection, a malignant growth, or an injury that won’t heal, or if you need someone to go over the details of your medical history with you, you need to see a primary care physician (MD, or DO).  Although we cannot diagnose something serious, we can provide complimentary care for conditions which require a physician’s attention-for instance, we often treat patients for the side effects of chemotherapy.  But we need you to take responsibility for your own health. 

•Flexibility

The community setting requires some flexibility from you.  For instance, many patients have a favorite recliner.  When we are busy, someone may be sitting in yours.  Similarly, we have a few patients who snore.  Other patients who dislike snoring should bring earplugs, a cd player or ipod to the treatment. Some of our patients even bring favorite pillows or blankets from home with them, because they prefer theirs to ours.  That’s fine with us.  Please participate in making yourself comfortable in the community room before treatment. If you need to limit your treatment time, please let the receptionist know. If you are asleep we will not typically wake you up.

•Community-Mindedness

The soothing atmosphere in our clinic exists because all of our patients create it by relaxing together.  We appreciate everyone’s presence! This kind of collective stillness is a rare and precious thing in our rushed and busy society.  Maintaining this reservoir of calm requires that no one talk in the clinic space. Also PLEASE turn OFF your phone!  If you would like to speak to a practitioner one-on-one at any length, please let us know.  We will need to schedule that separately and you might need to do it by phone.

Unfortunately we can’t always explain what every point does, or how acupuncture works, while we are treating you—these are very large topics. We do offer a wonderful Resource Center. If you have questions, we’ll be happy to give you plenty to read!

•Commitment

Acupuncture is a PROCESS.  It is very rare for any acupuncturist to be able to resolve a problem with one treatment.  In China, a typical treatment protocol for a chronic condition could be acupuncture every other day for three months!  Most of our patients don’t need that much acupuncture, but virtually every patient requires a course of treatment, in order to see the results they are looking for from acupuncture.

On your first visit, your acupuncturist will suggest a course of treatment, which can be anything from ‘we’d like to see you once a week for six weeks” to “we’d really like to see you every day for the next four days”.  Each treatment plan is as individual and varied as our clients! This suggestion is based on our experience with treating different types of conditions.  If you don’t come in often enough or long enough, acupuncture probably won’t work for you. If you have questions about how long it will take to see results, please ask us, or if you think you need to adjust your treatment plan, please let us know.  We need you to commit to the process of treatment in order to get good results.

One big reason that we are able to keep our prices so low is because of the extraordinary amount of marketing our patients do on our behalf—we don’t have to advertise.  We cannot express how grateful we are for this.  Our patients are such effective marketers because they have first-hand experience of how well acupuncture works.  All of our satisfied patients basically made a commitment to a course of treatment.

•Appointments

Part of our success is that our patients learn the “routine” and take on a lot of responsibility for the appointments.  Re-scheduling and making payment happens at the front desk BEFORE each treatment, allowing you to relax and enjoy the treatment.  Please take all personal belongings with you into the treatment room.  And of course, please turn off your cell phone.

Your appointment time is reserved specifically for you.  In the event of a missed appointment or an appointment cancelled with less than 24 hours notice you will be charged for the full session.

Layout and wording used with permission from Working Class Acupuncture, Portland, OR.

Prices subject to change without notice.

Last, but not least….enjoy the space.  We do, and hope that the Acupuncture Studio can be an important part of your community.

Thank You

The Acupuncture Studio Staff

Notice of Privacy Policies

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Each time you visit the Acupuncture Studio, a record is made of your visit.  This record contains your health history, current symptoms, examination results, oriental medical diagnosis and treatment plans.  This information serves as:

oA basis for planning your care and treatment

oA legal document describing the care you received, written in a format appropriate to Acupuncture and Oriental Medicine.

oA tool to assess the appropriateness and quality of the care you receive.

Your rights under Federal Privacy Standard

Although your health record is the physical property of the Acupuncture Studio, you have certain rights with regard to the information contained therein.  You have the right to:

oRequest restrictions on the use and disclosure of your health information for treatment, payment, and health care operations.  Health care operations consist of activities necessary to carry out the operation of the Acupuncture Studio.  This right does not include those required by law such as reporting of communicable disease such as tuberculosis.

oYou may ask us to communicate with you by alternative means, and, if the method is reasonable, we must grant your request.

oYou have a right to receive and keep a copy of this notice of privacy practices.  If you do request a copy, the law requires you to acknowledge the receipt of your copy.

oYou have the right to inspect and copy your health information upon request.

oYou have the right to request a correction of your health information unless we did not create the record or if the record is accurate and complete.

oYou have the right to obtain an accounting of non-routine uses or disclosures.

oYou have the right to revoke authorization to use or disclose your health information at any time.

Our responsibility, under the Federal Privacy Standard

In addition to providing you with your rights, the federal standard requires the Acupuncture Studio to:

oMaintain the privacy of your health information, including implementing reasonable and appropriate physical, administrative, and technical safeguards to protect the information.

oProvide you with this notice as to our legal duties and privacy practices with respect to individually identifiable health information that we collect and maintain about you.

oAbide by the terms of this practice.

oTrain our personal concerning privacy and confidentiality.

oImplement a sanction policy to discipline those who breach privacy/confidentiality policies.

oLessen the harm of any breach of privacy or confidentiality.

I understand that I have been given, and have the right to review the Acupuncture Studio’s Notice of Privacy practices prior to signing this document.  The Notice of Privacy Practices is also provided at the front desk This Notice of Privacy Policies also describes my rights and the duties of my practitioners and the Acupuncture Studio with respect to my identifiable health information.  The Acupuncture Studio reserves the right to change information contained in the Notice of Privacy Practices at any time.  I may obtain a revised Notice of Privacy Practices by requesting the most current notice during any office visit.  I understand that there may be other treatment alternatives, including treatment offered by a licensed physician.  I have carefully read and understand all of the above information and am fully aware of what I am signing.  I understand that I may ask my practitioner for a more detailed explanation.  I give my permission and consent to treatment. 

_________________________________   _____________________

Signature of Patient or RepresentativeDate

______________________________________________________

Printed NameDate of Birth

________________________________________________________________

Address

**************************************************************************

I have thoroughly read the above pages regarding community acupuncture, my responsibility in receiving treatment and the financial policies. It was a good read! If I have any questions, I will ask a staff member at the Acupuncture Studio.

__________________________________________________________

Signature of Patient or RepresentativeDate

**************************************************************************

Sign below ONLY if you requested and received more detailed information

I requested and received, in substantial detail, further explanation of the procedure or treatment, other procedures or methods of treatment, and information about the material risks of the procedure or treatment.  I give my permission and consent to treatment.

________________________________________________________________

Patient’s signature   Explained by me and signed in my presence.

Kevin Campopiano, L.Ac.

Acupuncture Health History Questionnaire

In order to better help you at the Acupuncture Studio, we ask that you take the time to fill out this Health History Questionnaire.  The more information you provide, the better able we will be to serve you. 

All answers will be held completely confidential.  If there is anything not covered by this form that you would like to address, please note it on the back or tell one of our practitioners.

Thank you,

The Acupuncture Studio

Date: ___________________

Name:_____________________________________________________________________

Address:______________________________________________________________________

______________________________________________________________________

Emergency Contact: _______________________Emergency Phone Number: ________________

Age:_____________________________Date of Birth: ____________________________

Marital Status: ___________________ Height: ______________ Weight:_____________________

Family Physician: _________________________Physician Phone Number: __________________

Occupation:_______________________________

Home Phone________________________  Cell Phone_______________________

May we contact you via telephone for scheduling issues? Yes /  No

E-mail address: _____________________________________________________________________

Periodically, we send information about Acupuncture Studio events and health tips. 

May we add you to our mailing list via your e-mail address?Yes / No

Is there any chance you may be pregnant?Yes / No

How did you hear about the Acupuncture Studio?

Have you tried acupuncture before?

What can we help you to address today? 

When did this problem begin? 

How does this interfere with your daily activities?

Have you been given a diagnosis for this problem?  If so, what?

Past Medical History

Surgeries

Significant Trauma(auto accidents, falls, etc.)

Allergies (seasonal, drugs, foods, chemicals)

Family Medical History

  Diabetes     Cancer     High Blood Pressure     Heart Disease    Stroke    Seizures

  Asthma     Allergies     Other:

What medicines are you currently taking?

What occupational stress or hazards do you face?

Do you have an exercise program?  If yes, please describe.

Have you ever been on a restricted diet? If yes what kind?

Do you smoke?  If so, how much?

How much caffeinated coffee, tea, or soda do you drink per week?

How much water do you drink per day?

Please describe any non-prescription or recreational drug use.

How much alcohol do you drink per week?

For the following sections, please check if you have had in the last three months:

                                                                      General

Fevers

Sweats easily

Peculiar tastes and smells

Poor sleeping

Chills

Strong thirst

Fatigue

Night Sweats

Weight Gain

Bleed or bruise easily?

Sudden energy drop-what time?

                                                                 Skin and Hair

Rashes

Itching

Dandruff

Change in hair or skin texture

Ulcerations

Eczema

Loss of hair

Hives

Pimples

Recent Moles

Psoriasis

Any other skin Problems?

Head, Eyes, Ears, Nose, Throat

Dizziness

Glasses

Poor vision

Blurred Vision

Cataracts

Ringing in the ears

Sinus problems

Grinding teeth

Teeth problems

Concussions

Eye strain

Night Blindness

Blurry vision

Poor hearing

Nose bleeds

Facial Pain

Jaw clicks

Migraines

Eye Pain

Color Blindness

Earaches

Spots in front of eyes

Recurrent sore throats

Sores on lips or tongues

Any headaches? Where and when?

Any other Head, Ears, Eyes, Nose, Throat problems?

                                                                Cardiovascular

High blood pressure

Irregular Heart beat

Cold hands or feet

Blood clots

Low blood pressure

Difficulty in breathing

Swelling of hands

Phlebitis

Chest pain

Fainting

Swelling of feet

Any other heart problems?

                                                                  Respiratory

Cough

Bronchitis

Difficulty breathing while lying down

Coughing blood

Pneumonia

Production of phlegm

Asthma

Pain with a deep breath

                                                               Gastrointestinal

Nausea

Constipation

Black stools

Bad breath

Abdominal pain or cramps

Vomiting

Gas

Blood in stools

Rectal pain

Anal fissure

Chronic laxative use

Diarrhea

Belching

Indigestion

Hemmorroids

How many bowel movements do you have per day?_____

Any other problems with your stomach or intestines?

                                                                Genito-urinary

Pain upon urination

Urgency to urinate

Decrease in flow

Do you wake to urinate?   _____

How often? ___

Frequent urination

Unable to hold urine

Color of urine:_____

Blood in urine

Sores on genitals

Impotency

Kidney stones

Any other problems with your genito-urinary system?

                                                                Muskuloskeletal

Neck pain

Back pain

Hand/wrist pain

Muscle pain

Muscle weakness

Shoulder pain

Knee pain

Foot/ankle pain

Hip pain

Any other bone or muscle problem?

                                                             Neuropsychological

Seizures

Areas of numbness

Concussion

Bad temper

Dizziness

Lack of coordination

Depression

Easily susceptible to stress

Loss of balance

Poor memory

Anxiety

Have you ever been treated for emotional problems?

Have you ever attempted to commit suicide?

Any other neurological or psychological problems?

Reproduction and gynecology

Age of first menses:

Duration of menses:

Changes in body prior to menstruation:

Date of last PAP

Do you practice birth control?  If so, what type?

Number of Pregnancies:

Live Births:

Abortions:

Premature births:

Miscarriages:

Period between menses

Unusal character of menses (heavy, light)

Irregular periods

Painful periods

Clots

Vaginal discharge

Vaginal sores

Breast lumps

Menopause? Age of onset: ____

Is there anything else you would like to mention about your health?  Please write anything you feel will be helpful to your treatment.