Patient Intake Form
Name_________________________________________________
Date__________________________________________________
301 W 29th Street | Baltimore, MD 21211
Address ____________________________________________City____________________________State_______Zip_________________
Home Phone___________________________Work Phone_____________________Cell________________________________________
Email___________________________________Date of Birth_____/____/_________Age_________Place of Birth__________________
Relationship Status
❍ Married
❍ Single
❍ Divorced
❍ Separated
❍ Partner
❍ Widowed
Height_________Weight____________
Name of Partner/Spouse____________________________Years w/ Partner/Married_______________________________________
Emergency Contact Name_____________________________________________Telephone Number_________________________
Children (Names & Ages)__________________________________________________________________________________________
Education____________________________________________Pets__________________________________________________________
Occupation(s)________________________________________Employer_____________________________________________________
Name of Physician__________________________________________Physician Telephone___________________________________
Date of Last physician appointment________________________________________________________________________________
How did you hear about us? __________________________________________________________________________
May we have your permission to add you to our mailing list? ❍ Yes ❍ No
List any other type of therapies or treatments that are a part of your overall approach to wellness
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Have you ever been treated with acupuncture and/or Chinese herbal medicine? ❍ Yes
❍ No
Comments ________________________________________________________________________________________________________
1)
2)
3)
4)
5)
____________________________________________________________________________________________________________________
Surgeries/Hospitalizations____________________________________________________________________________________________
Trauma (Physical/Emotional/Any)________________________________________________________________________
____________________________________________________________________________________________________________________
Recent Tests (w/in the last 2 years) Including; Physical, Cholesterol, Other blood, Food Allergies/Sensitivities, Prostate,
HIV/STD, Lyme, Other(s) _____________________________________________________________________________________________
____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
1
Food Log (Example of typical day of eating)
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Time
Time
Time
Time
Time
Time
Crave Sugar ❍ Yes ❍ No ❍ Niether
Crave Salt ❍ Yes ❍ No ❍ Niether
Thirst for water ❍ Yes ❍ No ❍ Niether
Alcohol # of drinks/day_______/wk________
Tobacco Frequency__________________________________________
Marijuana Frequency_____________________
Other drugs Type___________________Frequency_______________
Coffee # of cups/day_______/wk__________
Soft Drinks ❍ Yes ❍ No # of drinks/day_________/wk __________
❍ Yes ❍ No
If yes, which kind? ________________________
Diet Beverages
❍ Yes
❍ No How often?___________________
Exercise Type(s) ______________________Frequency______#/wk______ Water # of cups or ounces/day_______/wk________
List all medications and supplements (Alert your practitioner immediately if anything changes)
Medication/Supplement
Specify reason taking
Medication/Supplement
Specify reason taking
1)________________________
_______________________
4)________________________
_______________________
2)________________________
_______________________
5)________________________
_______________________
3)________________________
_______________________
6)________________________
_______________________
Have you taken antibiotics or steroids within the last year? ❍ Yes ❍ No
If so, frequency?_______________________ For what condition? __________________________________________________________
Please check any previously diagnosed conditions or health history (include the year)
__Asthma
__Diabetes
__Meningitis
__Fibromyalgia
__Glaucoma
__AIDS/HIV
__Gout
__Syphilis
__Measles
__Lupus
__Alcoholism
__Goiter
__Gonorrhea
__Mumps
__Ulcerative Colitis
__Arteriosclerosis
__Thyroid Disorder
__Paralysis
__Mononucleosis
__Chrohns Disease
__Bronchitis
__Heart Disease
__Stroke
__Pacemaker
__Kidney Stones
__Cancer Type______
__High Blood Pressure
__Migrains
__Pneumonia
__Gall Stones
__Chicken Pox
__Hepatitis
__Vein Condition
__Polio
__Lyme
__Epilepsy
__Herpes
__Multiple Sclerosis
__Tuberculosis
__Emphysema
__Pancreatitis
__Parkinsons
__Rheumatic Fever
Other(s)___________________________________________________________________________________________________________
FAMILY MEDICAL HISTORY
Father
Mother
Sibling
Sibing
Child
Child
Age
Alive
Deceased
Health History
2
Please check any that apply by writing “P” for past or “C” for current next to the word
Kidney/Bladder Function
____Wake to Urinate
____Tinnitus
____Early graying of hair
____Need excessive sleep
____Easily defeated or disgruntled
____Dark circles under eyes
____Phobias
____Hair Loss
____Hearing Loss or trouble hearing
____Urgency or frequent urination
____Lack of bladder control
____Stress incontinence
____Crave Caffeine or Stimulants
____Thin hair
____Warm/hot at night
____Night sweats
Heart Function
____Bedwetting
____Palpitations or Fluttering at rest
____Easily startled
____Irregular Heart beat
____Pacemaker
____Palpitations
____Anxiety
____Panic attacks
____Spontaneous sweating
If so, where________________________
Liver/Gall Bladder Function
____Tend toward numbness in extremities
____Nearsighted
____Floaters
____Blurry vision
____Muscle cramps or tight muscles
____Brittle nails
____Vertigo
____Cold Feet
____Dream disturbed sleep
____Feel better after exercise
____Rib-side or breast
distention/pain
____Dry, itchy or irritated Eyes
____Watery Eyes
____Cataracts
____Anger easily
____Frustration or irritability
____Dizziness/light-headed when standing
____Frequent dreams
____Lump in throat/trouble swallowing
____Headache on top or side of head
____Neck and Shoulder tension
____Seizures
____Dry Skin
____Trouble falling asleep
____Light sleeper
____Dry hair, nails or skin
____Emotional Sensitivity
____Ever Fainted
____Muscle spasms
____Numbness/Tingling
____Anemia
Overall Energy/Immune Funtion
____Fatigue during the day
____General weakness
____Easily catch colds or other illness
____Prolonged recovery from illness
____Aversion to talking
____Get cold easily
____Feel worse after exercise
____Frequent sore throats
____Poor healing Skin
____Vomiting
Large/Small Intestine Function
____Bowel movement #/day____
or #/wk______ Formed? Yes/No
____Loose stools
____Diarrhea
____Constipation
____Dry stool
____Incomplete feeling
____Blood in stool
____Mucous in stool
____Undigested food in stool
____Alternating diarrhea/constipation
Overall Temperature
____Cold hands/feet
____Sweaty hands/feet
____Feel generally more hot
____Feel generally more cold
Sexual/Endocrine Function
____Normal Libido
____High Libido
____Low Libido
____Flushed feeling any time of day
____Feel heat in hands, feet and/or chest
____Thirsty, drink in gulps
____Lack of perspiration
____Alternating chills & fever
____Scanty yellow urination
____Nose bleeds
____Dry cough
____Skin Rashes
Lung Function
Stomach/Spleen Function
____Vericose Veins
____Low appetite
____Abrubt weight gain/loss
____Abdominal bloating after eating
____Gurgling noises in stomach
____Fatigue after eating
____Prolapsed organs
____Hernias
____Hemorrhoids
____Easily bruise
____Worry, Over-thinking
mind is scattered or suddenly blank
____Poor memory recall
____Insomnia
____Feeling Overwhelmed
____Lack of strength in four extremities
____Excessive Saliva
____Abdominal gas
____Snoring
____Large appetite/insatiable
____Mouth (canker) sores
____Bad breath or bad taste in mouth
____Bleeding, swollen or painful gums
____Burning sensation after eating
____Ulcer
____Belching
____Hiccoughs
____Nausea If so, when____________
MEN ONLY
____ Prostate complications
Describe_________________________
__________________________
____ Lack of Semen
____ Premature ejaculation
____ Impotence
____ Swollen testicles
Blood Physiology
____Palpitations or Heart Fluttering
____Absent Minded
____Bulimia/Anorexia
____Headache over
forehead
____Aversion to strong
____Sadness, melancholy, grief
____Sinus congestion
____Seasonal allergies (If so, when_____)
____Nasal discharge (Color_____________)
Fluid Physiology
____Itchy Skin
____Cough when laying down
____Thirsty with no desire to drink
____Mental sluggishness or fogginess
____Swollen hands, feet, joints
____Chest congestion
____Thirst for Water Very/Normal/Not at all
____Dry mucous membranes
____Productive cough (Color__________)
____Dry mouth, nose, throat
Other
____Swollen Glands
____Grinding teeth
____TMJ
____Depression
____Unable to adapt to stress
____Wake up feeling tired or unrested
____Shortness of breath
____Asthma
____Abdominal cramping
____Stomach ache/pain
____Restlessness
____Chest pain or discomfort
____Overall Achy feeling
____Migraines If so, how often_______
____Tremors
____Paralysis
____ Testicular pain
____ Feeling of coldness in genitals
____ Pain/itching
____ Nocturnal Emissions
3
CONSENT FORM
Consent to Services: By signing below, I do hereby voluntarily
consent to be treated with acupuncture, moxibustion,
aromatherapy oils, and/or herbs and medicinal substances
by my practioner, licensed acupuncturist. I have read and
understand the potential risks of these services described below.
I have the right to consent to or refuse any proposed treatment
or course of treatment. I understand that I am free to discontinue
treatment services at any time.
Acupuncture/Moxibustion Treatment:
I understand that acupuncture serves individuals with a wide
range of complaints including both acute and chronic health
care issues. I understand that I may be treated with the insertion of
thin sterilized needles through the skin and/or with the application
of heat to the skin (moxibustion), Aromatherapy or the application
of Oils to the skin, cupping & Gua Sha techniques and/or Zero
Balancing techniques. I understand that my acupuncturist is not a
licensed dietitian, however may provide dietary guidance based
upon Chinese Medical principles of nutrition.
Risks/Possible Side Effects: While adverse side effects are rare,
I understand that they may include but are not limited to: local
bruising, minor bleeding, fainting, temporary pain and discomfort,
infection, and temporary aggravation of symptoms existing prior
to treatment. If direct moxibustion is used as part of therapy, there
is a risk of burning or scarring from its use.
No Guarantees: I know that each person is unique and has
ultimate responsibility for his or her own wellness and healthcare.
I acknowledge that I have not received any guarantees or
promises as to the results or success that will be obtained from the
services provided.
I understand that my
Moxibustion and Essential Oils for Clinical use. Her graduate
level degrees include a Master’s in Acupuncture from Maryland
University of Integrative Health, formerly the Tai Sophia Institute,
She has also obtained her license to practice from the Maryland
State Board of Acupuncture. I have the right to ask for copies of
Infectious Disease Prevention: I understand that infectious
diseases are carried through the air, through physical contact,
universally prescribed precautions and procedures (such as clean
needle technique and hand washing) to prevent the spread of
the use of clean needle technique (CNT).
Client Responsibilities: I understand that it is my responsibility
as a client to inform my practitioner of all aspects of my health
and as treatment services progress, inform my practitioner of
changes that occur. I will inform my practitioner if I am pregnant
and/or suspect pregnancy at any time, and if I am being treated
for cancer or epilepsy. If I experience any pain, discomfort or
possible adverse side effects, it is my responsibility to immediately
notify my practitioner.
Medical Treatment: I recognize that my practitioner is not
a substitute for a medical doctor and will not suggest that I
discontinue medical treatment. I understand that if I am currently
under a physician’s care, I should continue as long as my
physician deems necessary. It is my responsibility to consult with my
physician before altering any medications or medical treatments.
I understand that my practitioner may request a physical exam if
it has been over a year since my last exam. I am free to consult
a medical doctor or any other licensed practitioner at any time.
I understand that if there is an emergency, or a worsening of my
health condition, or if a new ailment or condition arises, that I
should consult a licensed physician.
I acknowledge
that I received a copy of Lola Manekin’s Notice of Privacy
Practices which describe the practitioner’s policy of respecting
information will not occur without written consent. If you would
like to request a restriction or release, please request a Restriction/
Release Disclosure Request Form to specify.
Fees & Cancellation Policy: I have been informed of the fees
for service, and I understand that payment is due when the
services are provided. If I do not cancel an appointment at least
24 hours (medical emergencies excluded) in advance, then I am
responsible for paying the full treatment fee.
I have carefully read and understand all of the above information. I understand that I may ask my practitioner any questions or
further explanations necessary before signing this consent form. By signing below, I give my permission and consent to treatment.
Client Signature: _____________________________________________
Date: _____________________________________________
Patient Name (print):_________________________________________
Signature of Guardian:_____________________________
(If under the age 18)
301 W 29th St | Baltimore, MD 21211
Patient Registration
Patient’s Name:____________________________________________________ SS# (optional):________________________
First Name
MI
Last Name
Date of Birth:________________________
__Male __ Female
__Single __Married
__Widowed __ Divorced __ Separated
Street Address :____________________________________________________________________________________________
City/State/Zip Code:_______________________________________________________________________________________
Home Phone:_____________________________________
Cell Phone:_______________________________________ Fax:________________________________
E-mail Address:_______________________________________________________
Can this be used for communicating with you? Yes__ No__
Spouse’s Name:_______________________________________________ SS #:______________________________________
Spouse’s Employer:______________________________________ Spouse’s Work Phone #:___________________________
Patient’s Employer:____________________________________________________
Work Phone w/Area Code:____________________________________________
Responsible Party:______________________________ Relationship: __Self __Spouse __Parent __Other:__________
If patient is a Minor, are parents __Married __Divorced Custodial Parent:__________________________________
Custodial Parent’s Home Phone :________________________ Work Phone:_____________________________________
In case of emergency, contact (not living with you):_________________________________________________________
Phone Number:_________________________________
Relationship to Patient:_________________________________
Is this work-related? __Yes __No If yes, date of injury?_______________Claim #:_______________________________
Is this auto accident related? __Yes __No If yes, date of injury? ___________Claim #:__________________________
Insurance Company to be billed____________________________________________________________________________
Adjuster’s Name & Phone
#______________________________________________________________________________________________
Attorney’s Name & Phone
#______________________________________________________________________________________________
Referring Physician’s Name & Phone
Number:_______________________________________________________________________________
PLEASE PRESENT INSURANCE CARD(S) & PHOTO ID FOR COPYING AND COMPLETE THE REQUESTED INFORMATION
Insurance Company # 1:________________________________________ Phone #:__________________________________
Primary Insured’s Name:________________________________________ Date of Birth:______________________________
Policy #:____________________ Group #:__________________________ Relationship:______________________________
Address:___________________________________________________________________________________________________
Insurance Company # 2:________________________________________ Phone #:_________________________________
Primary Insured’s Name:_________________________________________ Date of Birth:_____________________________
Policy #:____________________ Group #:_________________________ Relationship:______________________________
Address:___________________________________________________________________________________________________
◊
◊
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I hereby authorize the payment of medical benefits to LM at BlueGreen, LLC for services rendered. I
understand that I am financially responsible for any services not covered by my insurance carrier. I
permit a copy of this authorization to be used in place of the original.
I further agree to pay all collections costs, attorney fees, and other collections costs that may be
incurred to enforce the collection of any amounts outstanding.
I hereby authorize LM at BlueGreen, LLC to release any medical information necessary to complete
and process my insurance claims.
X _________________________________________________________________________________________________________
Patient’s OR Insured’s Signature (If patient is a Minor, must have Responsible Party Signature)
Date
I authorize LM at BlueGreen, LLC to treat me and use my personal health information for healthcare operations.
X __________________________________________________________________________________________________________
Patient’s Signature (OR Parent if patient is a Minor)
Date
Billing Policy & Acknowledgement of HIPAA Privacy Policy
The following sets forth the general billing policy of LM at BlueGreen, LLC. Please review this information and
sign where indicated.
 I understand that it is my responsibility to provide the office of Leonora Manekin, M.Ac., L.Ac. accurate
billing information at the time of check in and to notify the provider of any changes in this information.

I understand that it is my responsibility to know my co-pay and to pay it at the time that services are
being rendered. I understand that this is a contractual agreement that I have with my health plan and
that the provider also has a contractual agreement with my health plan to collect co-pays at the time
of service, and they are required to report to the carrier any enrollees failing to pay the co-pay.

I understand that if I present an insufficient funds check (NSF check) for payment on my account that I
will be charged a $25 NSF fee. I further understand that to rectify my account, I will be required to pay
with either cash, a money order, cashier’s check, or credit card.
 I understand that I will be billed for any amounts due by me (co-payments/coinsurance amounts/
deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be
provided with two (2) statements for any balance due after insurance payment. I further understand
that if I have not made payment prior to the second statement being mailed, that the second
statement will be marked as “Final Notice” and may be sent to an outside collection service if I do not
fulfill my financial obligations. I also understand that I will be responsible for any collection, interest or
legal expenses associated with the collection efforts.
 I understand that the provider will obtain the necessary prior authorizations prior to rendering treatment.
I further understand that prior authorization is not a guarantee of payment, and that I am responsible for
any bills not paid by my insurance carrier.

I have received a copy of the Notice of Privacy Practices as required by HIPAA from LM at BlueGreen,
LLC and understand my rights with regard to my personal health information disclosure.
My signature below confirms that I have read and understand these billing policies, privacy practices and my
financial obligation as pertains to the health care provider, LM at BlueGreen, LLC.
.
________________________________
Patient’s Signature
____________________________________________________________
Legal Guardian to Patient (if patient is minor or incapable of signing)
Date