Lily's TCM Center

Acupuncture, Chinese Herbs & Beyond

Forms

Please download, print and complete the correct forms, bring them with you in order to save your time.

You need to have a copy of Acrobat Reader on your computer to open these files. The reader is available free of charge from the Adobe website.

Please fill this form, in order to save your time at your first visit:

Patient Confidential Information

ASH (American Specialty Health) Forms

UHC(United Health Care) Forms

Top

ASH (American Specialty Health) Forms

(If your acupuncture treatment is covered by ASHP, please use the questionary form with * (mandantory) below and the ones related your condition the most, bring them with you at 1st treatment).
1. ASHP - Patient Health Questionnaire*
2. ASHP - Neck pain evaluation
3. ASHP - Back pain evaluation
4. ASHP - Whole body description
5. ASHP - General pain description
6. ASHP - Back and legs pain scoring
7. ASHP - Headache scoring
8. ASHP - Dizziness scoring

Progress evaluation modules
(If your acupuncture treatment is covered by ASHP/Kaiser, Please download and fill up the following forms, bring them with your 6th treatment).
9. Kaiser patient progress report form*
10. ASHP - Treatment renewal*

Satisfaction survey modules.
11. ASHP - Survey

General scoring modules
12. ASHP - General Health Scoring-1
13. ASHP - General Health Scoring-2
14. ASHP - Fear Scoring
15. ASHP - Accident Questionnaire

Top

UHC(United Health Care) Forms

(If your acupuncture treatment is covered by UHC, Please download and fill up the form with * and the ones related your condition the most, bring them with you at your 1st treatment).
1. UHC -Patient Health Questionnaire*
2. UHC - Neck pain evaluation
3. UHC - Back pain evaluation
4. UHC - Arm/Shoulder/Hand pain evaluation
5. UHC - Hip/leg/foot pain evaluation