Noa Health and Acupuncture, LLC

37 Franklin Street Suite 1, Westport, CT. 06880

Iris Netzer-Greenfield, L.Ac.


Patient Intake Form

Please note, the information you are asked to provide is pertinent within the scope of Chinese Medicine. If you have any questions regarding any content on this intake form, feel free to ask. I will be happy to explain. Noa Health and Acupuncture LLC complies with HIPAA privacy requirements.

Name (last, first) _____________________________________ Date ______________ Address________________________________________________________________City/State/Zip___________________________________________________________

Home phone _____________________ Work Phone ____________________

Cell Phone _____________________ Email __________________________
Occupation ______________________Birth Date ______________________
Emergency contact ________________________________________

                                                  (name & phone)

Referred by _____________________________________________________
Single ___ Married ___ Divorced ___ Significant Other ___ Widowed____

Caregiver for dependent number of children ________
Have you ever had acupuncture? _______ If yes, when? _____________________________________________________________
For what condition? ________________________________________________
Are you currently under the care of a physician? _____If so, who________________

For what condition(s)? __________________________________________________

Main reason(s) for seeking acupuncture ____________________________________________________________________ ____________________________________________________________________

How long have you experienced symptoms? _______________________

Your condition is improved by ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Your condition is aggravated by


List all current medications, prescribed or over the counter ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all current vitamins, herbs and other supplements __________________________________________________________________________________________________________________________ _____________________________________________________________ __________________________________________________________________________________________________________________________

Significant illnesses (please check all that apply)

___ Cancer
___ Diabetes
___ Hepatitis
___ Heart Disease ___ Stroke

___ Seizures ___ HIV / Aids ___ Pneumonia

___ Tuberculosis
___ Multiple sclerosis ___ Thyroid
___ Asthma
___ Stomach Ulcers ___ Obesity
___ Depression

___ Shingles
___ Chronic Fatigue
___ Rheumatic Fever ___ High Blood Pressure ___ Sexually Transmitted Diseases
___ Other ___________

Please list any surgeries youÕve had including dates __________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

Please list any allergies ___________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________

Please list any major emotional or physical traumas youÕve experienced ___________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________

Lifestyle (please check all that apply, and note frequency of use) ___ Tobacco
___ Alcohol
___ Recreational drugs

___ Caffeinated beverages

Do you exercise? _______ Please list types of activity and frequency ___________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________

Dietary preferences

___ Vegetarian
___ Vegan
___ Raw foods diet
___ Low fat diet
___ High protein/low carb ___ Dairy /milk /cheese ___ Eggs

___ Chicken

General symptoms

___ Fatigue
___ Sweat without exertion

___ Fish / seafood
___ Red meat
___ Artificial sweeteners ___ Fast food/ burgers/ fries
___ Spicy / hot
___ Sweet
___ Sour

___ Night sweats
___ Fever / chills
___ Dizziness / vertigo

___ Cold drinks
___ Hot drinks
___Ice chewing ___Extreme thirst ___Thirst with no desire to drink

___ Bleed / bruise easily ___ Low immunity
___ Other


___ Extreme appetite ___ No appetite
___ Cravings
___ Dieting

___ Bloating
___ Gas
___ Acid regurgitation ___ Heartburn/ulcers ___ Nausea

___ Vomiting
___ Bulimia
___ Irritability or low energy between meals ___Other ______________

___ Tired a"er eating
How many meals per day? _______ How many snacks per day? _______


___ Diarrhea
___ Constipation
___ Hemorrhoids
___ Anal itching / burning

___ Laxative use ___ Bloody stool


___ Fall asleep easily
___ Lie in bed with eyes open ___ Wake at specific times
___ Wake repeatedly
___ Wake frequently to urinate

Head, Eyes, Ears, Nose and Throat

___ IBS
___ Colitis
___ Gout
___ Gallstones
___ Other

___ Dry eyes
___ Spots / Flowery vision ___ Blurred vision
___ Poor vision
___ Eye strain
___ Night blindness
___ Cataracts
___ Macular degeneration

___ Bleeding gums
___ TMJ
___ Sores on tongue or mouth ___ Dry mouth
___ Excess saliva
___ Sinus problems
___ Nosebleed
___ Post-nasal drip

___ Sore throat
___ Headaches
___ Swollen glands
___ Difficulty swallowing ___ Earaches

___ Tinnitus / ringing
___ Deafness
___ Other _______________

___ Mucous in stool
___ Anal fissures
___ Intestinal pain/cramping ___ Incomplete evacuation ___ Nausea

___ Vivid or lucid dreams
___ Wake up not feeling rested
___ Nightmares or frightening dreams
___ Need drugs or supplements to fall asleep


___ Heart palpitations ___ Chest pain
___ Difficulty breathing ___ High cholesterol ___ Varicose veins

___ Blood clots ___ Swollen ankles

Skin and Hair

___ Dry skin
___ Rashes / hives ___ Eczema
___ Psoriasis


___ Spinal pain ___ Joint pain ___ Tendonitis ___ Swelling ___ Arthritis


___ Anxiety
___ Irritability
___ Insomnia
___ Depression ___ Easily stressed ___ Poor memory

___ Heart valve abnormality
___ Shortness of breath ___ Cold hands/feet ___ Dry cough
___ Wheezing
___ Chest tightness

___ Pimples / acne ___ Fungal infections ___ Brittle nails
___ Ridged nails

___ Limited range of motion ___ Vertebral disc degeneration
___ Osteoporosis

___ Seasonal mood disorder ___ Tics
___ Tremors
___ Death of someone close ___ Job stress

___ Difficult inhalation ___ Difficult exhalation ___ Productive cough (color or phlegm?) ___Other ______________

___ Hair loss
___ Dandruff
___ Other

___ Numbness
___ Carpal tunnel
___ Other ______________

___ Recent divorce
___ Currently in therapy ___ Financial setback
___ Other _______________

Emotional stress scale
1 2 3 4 5 6 7 8 9 10

Rate your stress level regarding
Work ____
Health ____ Money ___ Love____ Family___

extremely stressed

The future ___ General___


___ Frequent urination
___ Loss of urine when laughing or sneezing ___ Incomplete urination/retention
___ Dribbling
___ Burning urination
___ Blood in urine

___ Wake frequently to urinate ___ Kidney stones
___ Bedwetting
___ Decreased libido/sexual desire ___ Impotency

___ Infertility
___ Other _______________________

Men only

___ Prostate problems

Women only

___ Erectile dysfunction ___ Herpes

Age menses began ____
Date of last OB/GYN exam __________
Hysterectomy? ___ Partial ___ Full ___ Hormone replacement therapy

Age menses ended (if applicable) ____ Headaches ____ before menstrual cycle ___ during cycle ___ a"er cycle

___ Abortion(s)
___ Miscarriage
___ Live births
___ Birth control pills ___ Breast cancer ___ Ovarian cysts ___ Fibroids

___ STD history (chlamydia, PID, etc) ___ Fibrocystic breast
___ Pain at ovulation
___ Cramps/low back pain

___ Acne associated with period
___ Constipation or diarrhea associated with period ___ Emotional irritability or depression associated with period
___ Bleeding outside of regular menstrual cycle
___ No period/skipped cycles
___ Irregular cycle

Period lasts ____ days. Usual number of days between periods _______

___ Candida/yeast
___ Vaginal discharge
___ Vaginal odor
___ Vaginal sores
___ Herpes
___ Human Papilloma Virus positive

Menstrual Flow ___ Clotting___ Watery, thin and bright red ___ Flooding and tricking  ___ Brownish____ Normal Red____ Start and Stop Flow____


If you have been evaluated for infertility, what was your diagnosis?


Iris Netzer-Greenfield, L.Ac.

Acupuncture is NOT a substitute for conventional medical diagnosis and treatment. Techniques commonly employed in the application of acupuncture:

Acupuncture needling – treatment will consist of the insertion of sterile disposable needles at specific sites on the body. Stimulation of said needles may be by manipulation, electrical stimulation or the application of warming substances (moxa) on the needle itself.

Auxiliary / Associated therapies – massage, assisted stretching, topical application of liniments.

There is no guarantee that acupuncture will help any condition. Certain medications and social habits may decrease the beneficial effects of acupuncture. These include the use and abuse of alcohol, tobacco, steroids, painkillers, narcotics, stimulants, antidepressants, psychopharmaceuticals and illegal drugs.

(Print Name)
I, ______________________________________, certify that I have read and

understood the statements above. I also certify that I have informed my acupuncturist of all known physical, mental and medical conditions and medications, and I will keep her updated on any changes.

Signature: _________________________ Date:__________________


Iris Netzer-Greenfield, L.Ac.

37 Franklin Street, Suite 1 Westport, CT P: 203-635-5151 E:


Payments can be made by Visa, Master Card, American Express, Discover, check or cash. Make checks payable to Acupuncture Remedies, P.C.. Full payment is expected at the time the services are rendered. There are no refunds for unused package sessions. All sales are final.

Explanation of Insurance Coverage: Many insurance policies do cover acupuncture care but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner.

If you must cancel your appointment, please notify us as soon as possible. In order to uphold our high standard of care, we must adhere to a standard 24-hour cancellation policy. Please note that you will be charged the full amount for less than '24-hour cancellations' and/or 'no-shows.

(Print Name)
I, ______________________________________, certify that I have read and

understood the statements above and agree to abide by them. Signature: _________________________ Date:__________________

Credit Card Payment Form
Name as it appears on the card:______________________________________________________

Billing address of the card:

______________________________________________________ ______________________________________________________

Visa MasterCard Amex Discover
Expiration date: ______________ Security Code: ___________

Credit Card Number:____________ Type of card:______________


Iris Netzer-Greenfield, L.Ac.

37 Franklin Street, Suite 1 Westport, CT P: 203-635-5151 E:

Notice of Privacy Practices

This Notice together with the Practices Regarding Disclosure of Health Information, describe how health information about you may be used and disclosed. They also describe how you can gain access to your health information. Please review this information carefully.

Understanding Your Health Record

A record is made each time you visit the office for treatment. This record includes symptoms, clinician observations, diagnosis and treatment. The record may also contain other pertinent information provided by you or another of your health care practitioners with whom we may have spoken.

Your Health Information Rights

This office owns your health record, however, the content is always available to you for your review. You have the right to request a review of your file and to obtain copies of documents contained in your file. You also have the right to request that amendments be made to you record. In addition, you may request that the use of your information be restricted from certain uses and disclosures and to request a list of individuals of entities to whom your information has been disclosed. You may revoke any authorizations you have given regarding disclosure of you health information at any time. This revocation must be provided to this office in writing.

Our Responsibilities

We are required to maintain the privacy of your health information and to provide you with a copy of the Notice of our privacy practices. We will follow the terms of this Notice and advise you if we are unable to comply with a request you may make regarding the use of your health information. We reserve the right to amend our privacy policies and we use our best efforts to notify you of any such amendments. Other than for reasons stated in this Notice, we will not use or disclose your health information without your consent.

I, _____________________________________, have received a copy of the Notice of Privacy Practices and a copy of (Print Name)

the Practices Regarding Disclosure of Patient Health Information. I understand my health information will be used and disclosed consistent with these Notices.

________________________ ________________________ __________________ Patient Signature Print Name Date

Iris Netzer, L.Ac. Acupuncture Remedies, P.C.
201 E.56th Street New York, NY 10022 (917)744-4403

Standards and Practices Privacy of Patient Information

Iris Netzer, L.Ac.
is committed to treating all patients with appropriate care and respect. Information that patients provide to use in connection with their treatment, Protected Health Information (PHI), is subjected to standards of security and confidentiality as defined under Federal Law, the Health Information Portability and Accountability Act (HIPAA). These Standards and Practices set forth the procedures in insure compliance with the requirements of HIPAA.


1.      Written or electronic files containing PHI must be stored in secure facilities. Written files will be maintained in

locked file cabinets and electronic files will be stored in secure databases only accessible through password- protected codes. Computer screens will be positioned so that they are not viewable by persons other than personnel authorized to access that information. All personnel shall use discretion when discussing PHI in conversations.

2.      A Notice of Privacy Practices together with the statement of Practices Regarding Disclosure of PHI will be provided to all patients at the time of their initial visit. All patients will be requested to sign a statement acknowledging receipt of this information. The acknowledgement will be kept on file for seven years.

3.      Patients will be requested to advise the office whether it may contact them by phone or in writing regarding their care. It is our practice to call to remind patients of their appointments and to send billing and related information to patients homes.

4.      PHI may be routinely used for treatment, billing, payment and quality control purposes. PHI may also be used without the patients consent for the following purposes:

1.      uses and disclosures required by law

2.      uses and disclosures for public health activities

3.      disclosures about victims of abuse, neglect or domestic violence

4.      disclosures for judicial and administrative proceedings

5.      disclosures for law enforcement purposes

6.      uses and disclosures about decedents

7.      uses and disclosures for cadaver or organ donation purposes

8.      uses and disclosures to avert a serious threat to health or safety

9.      disclosures for workers compensation

10.    disclosures to a State Licensing Board or other professional oversight entity

5.      Patients have the right to request restrictions on the use of their PHI although, we are not always able to abide by such requests. All such requests must be submitted in writing on our Restriction Request Form. We will take all such requests under advisement and notify the patient in writing of our determination. A copy of the determination will be maintained in our files. If the request is granted then it will be observed, except in the event of an emergency or in the event we terminate the agreement.

6.      State law pertaining to parent/guardian authorization will apply in the case of a minor. When state law is silent, we reserve the right to use our professional judgment.

7.      Non-routine requests for PHI will be reviewed in the normal course and may require specific patient authorization.

8.      Patients may request an account of all PHI disclosures made in the prior six years. Such an accounting will not include disclosures:


1.      for treatment, payment and healthcare operations

2.      to the patient

3.      to persons involved in the patients care

4.      for national security or intelligence purposes

5.      to correctional institutions of law enforcement agencies

6.      disclosures made prior to the enactment of HIPAA

In some instances PHI may be used once it has been stripped of all elements of personally identifying information. Identifiers that may be stripped include:

1.      name

2.      all address information

3.      email addresses

4.      dates (other than year)

5.      Social Security number

6.      medical record numbers

7.      health plan beneficiary numbers

8.      account numbers

9.      certificate numbers

10.    license numbers

11.    vehicle identification numbers

12.    facial photographs

13.    telephonenumbers

14.    device identifiers

15.    urlÕs

16.    ip addresses

17.    biometric identifiers

18.    zip code, if the geographic unit includes less than 20,000 persons

19.    any other unique data which when used alone or in combination with other information might identify

the individual who is the subject of the information

9.      We are required to act on written requests for onsite review of PHI within thirty days of our receipt of the request. If copies are requested we may charge a reasonable copying fee. Patients do not have the right to access:

1.      psychotherapy notes

2.      information relating to criminal, civil or administrative procedures

3.      PHI lawfully prohibited from release because it is subject to or exempted from Clinical Laboratory

Improvements Amendments (CLIC)

4.      information created by someone other than us given to use under a promise not to release

10.    Patients have a right to request amendments to their PHI. Requests to amend must be made in writing, clearly stating the requested amendment and the reason for the request. We will provide a written response within 60 days. If un-amended information had previously been provided to third parties, we will undertake to advise any such person of the amendment. If the request is denied we will provide a written statement setting forth the basis for the denial.

11.    Amendment Rights do not apply in the following circumstances:

1.      the information is not part of the patient file

2.      the information is accurate and complete

3.      the information was not created by us

12.    We shall designate a person who shall be responsible for developing and implementing out HIPAA policies and procedures. This person shall also be responsible for training all staff in these policies and procedures. All employees will be required to sign an Employee Agreement Form acknowledging that they have been trained and they understand their obligations. Employee infractions of HIPAA will result in discipline and may result in termination of employment. Similarly, any third party vendor who has access to PHI will be required to


acknowledge that they are HIPAA compliant in all services provided to our business.

13.    We shall not adversely treat any patient who exercises his/her rights under HIPAA. The staff is expressly prohibited from intimidating, threatening, coercing, discriminating, or retaliating against any patient who exercises their HIPAA rights.

14.    Any patient wishing to appeal a determination or to file a complaint regarding HIPAA should contact the Secretary of DHHS within 180 days of the alleged violation. All personnel shall fully cooperate with any resulting investigation. Complaints are to be filed with:

Office for Civil Rights
U.S. Department of Health and Human Services 200 Independence Avenue, SW
Washington DC, 20201

800-368-1019 Hotline


Practices Regarding Disclosure of Patient Health Information

Your health information will be routinely used for treatment, payment and quality monitoring. Your consent is not required in these circumstances.

Treatment – Information obtained by us will be entered into your treatment record and used in the course of your treatment. Your health information may be shared with other health practitioners as we, in the exercise of our professional judgment, deem appropriate. Information regarding our assessment of your health and information regarding consultations may also be retained in your file.

Payment – Your record will be used to receive payment for services. A bill or other payment information may be mailed to your home or to a third party provider. That information will likely contain diagnostic determination, practitioner impressions and treatment procedures.

Quality Monitoring – We will use your health information to assess the care you have received and to compare outcomes. This information may also be used in conjunction with various scientific studies regarding your specific condition or Oriental Medicine itself.

The following disclosures are required by law and do not require your consent:

Food and Drug Administration (FDA) – We are required to disclose health information to the FDA related to any adverse effects of food, supplements, products, and product defects for surveillance to enable produce recalls, repairs or replacements.

Workers Compensation – We will release health information to the extent required under the workers compensation law.

Public Health – We are required to disclose health information to public health entities or legal authorities responsible for tracking birth and morbidity, communicable disease, injury or disability and matters relating to organ/cadaver donations.

Law Enforcement – We are required to provide your health information to law enforcement and professional oversight personnel under state and federal law. Similarly, we will disclose such information in the event we believe there is a risk of harm to yourself or others.

We also consider the following uses as routine use and disclosure. If you do not want your health information used in the following circumstances, please advise us in writing.

Business Associates – Professionals and others whose services we require in the normal course of our business. Examples include our accountant, lawyer and pharmacy. We require these individuals to follow the same procedures and standards as our staff.

Communication with family – We may contact a family member or some other person designated by you to assist them in enhancing your well-being.

Marketing and Fundraising – We may periodically send information to you regarding treatment alternatives and other health related benefits we believe may be useful to you. We may also request your charitable support on behalf of alternative medicine research projects or other medically related chartable events. This contact will not disclose information regarding your specific medical condition.