Mind + Body Acupuncture & Wellness

8700 Menchaca Rd Suite 203 · Austin, TX 78748 · (512) 541-9673 · mindplusbodyacu.com

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Personal information
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Main complaint
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Medical history — check all that apply
Additional history
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Occupation & lifestyle
Recent medicines & supplements
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Diet & nutrition
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Symptoms in the past 3 months — check all that apply
General
Head, eyes, ears, nose & throat
Cardiovascular
Respiratory
Skin & hair
Gastrointestinal
Genitourinary
Neuropsychological
Pregnancy & gynecology
Painful or distressed areas

Tap or click any area to mark it as painful or distressed. Use the view tabs for detail. Tap again to deselect.

Front view
Front body mapClickable front body regions Head Neck L shoulder R shoulder Chest Abdomen Lower abdomen L arm L elbow L forearm L wrist L hand R arm R elbow R forearm R wrist R hand L hip Groin R hip L thigh L knee L shin L ankle L foot L toes R thigh R knee R shin R ankle R foot R toes
Back view
Back body mapClickable back body regions Head Neck L shoulder R shoulder Upper back Mid back Lower back Sacrum / tailbone L glute R glute L arm L elbow L forearm L wrist L hand R arm R elbow R forearm R wrist R hand L hamstring L knee L calf L ankle L heel R hamstring R knee R calf R ankle R heel
Head detail
Head detail mapHead regions including tongue Scalp Forehead L temple R temple L eye R eye Sinuses / nose L cheek / jaw R cheek / jaw L ear R ear Mouth / lips / teeth Occiput / base of skull Neck / throat Tongue
Hands detail
Hands detail mapIndividual finger, wrist, and palm regions Left hand Right hand — Palm / back view — Left palm Right palm Knuckles Knuckles L wrist Thumb Index Middle Ring Pinky L palm R wrist Thumb Pinky Ring Middle Index R palm L palm (back) L knuckles R palm (back) R knuckles
Feet detail
Feet detail mapIndividual toe, arch, heel, and ankle regions Left foot Right foot — Sole / bottom view — Left sole Right sole L ankle L foot top L ball Big toe 2nd 3rd 4th Pinky R ankle R foot top R ball Big toe 2nd 3rd 4th Pinky L arch / sole L heel R arch / sole R heel
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Selected / painful
Selected areas
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Texas acupuncture scope-of-practice notice

Prior to providing acupuncture services, Texas acupuncturists are required by state law to determine that a patient has been evaluated for the condition being treated by a physician or dentist within the last 12 months, or referred by a chiropractor within the last 30 days.

(Pursuant to 22 TAC §183.7 of the Texas State Board of Acupuncture Examiners' rules relating to Scope of Practice and Tex. Occ. Code Ann., §205.351)

I have been evaluated by a physician or dentist for the condition being treated within the last 12 months. I recognize that a physician should evaluate me for the condition being treated by my acupuncturist.
Please select Yes or No
— OR —
I have received a referral from my chiropractor within the last 30 days for acupuncture.
Please select Yes or No
Notice of privacy practices & consent to share health information

I acknowledge that I have been provided access to Mind + Body Acupuncture & Wellness PLLC's Notice of Privacy Practices. I understand that I have the right to review the Notice of Privacy Practices prior to signing this form.

I understand that Mind + Body Acupuncture & Wellness staff may need to contact me with information related to my treatment. If this contact is made by phone and I am not available, a message will be left on my voicemail if possible. I understand that if I wish my health care information to be disclosed to any other individual, I must give written permission to do so below.

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Permission to disclose health information to other parties optional

Complete only if you want your health information shared with someone else. This authorization is voluntary.

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Cancellation, reschedule & no-show policy

At Mind + Body Acupuncture & Wellness, we understand that your time is valuable, and ours is too. No-shows and last-minute cancellations make it difficult to provide the best care for you and our other patients. We are always happy to work with you to reschedule whenever necessary, and having sufficient notice allows us to better serve you.

Cancellations, no-shows, and rescheduled sessions are subject to a FULL charge if not received at least 48 hours in advance. This is necessary because your appointment time is held exclusively for you. You will be responsible for the entire session fee if you cancel with less than 48 hours' notice. Please note that insurance does not reimburse for missed appointments.

Please initial each item below to acknowledge and accept this policy:

I agree to place a valid, active credit or debit card on file at Mind + Body Acupuncture & Wellness, PLLC.
If I do not request cancellations or rescheduled sessions with at least 48 hours' advance notice, I give Mind + Body Acupuncture & Wellness permission to charge my card on file for the full fee for the scheduled service.
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