Eastern Body Therapy

Transcription

1 2310 Eastern Body Therapy 6th Avenue San Diego, CA (619) Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) Social Security #: Date of Birth: Drivers License# Employer/school Full time Part time Occupation: Spouse s name: Work phone: ( ) Referred By Preferred Language: Have you had acupuncture before? yes no Is your condition a result of a work injury? yes no Automobile accident yes no Responsible Party Information Responsible party: Date of birth: Relationship to patient: self spouse other SS#: Responsible party s home phone: ( ) Work phone: ( ) Address: Apt. City State Zip Employer s name: Phone number: ( ) Occupation: If patient is a child, other parent s name: Home address: Apt. City State Zip: Home phone: ( ) Work phone: ( ) Occupation: Patient s Insurance Information PRIMARY insurance company name: Insurance address: City: State: Zip: Name of insured: Date of birth: Relationship to patient: self spouse parent other _ Insurance ID #: Group #: SECONDARY insurance company name: Insurance address: City: State: Zip: Name of insured: Date of birth: Relationship to patient: self spouse parent other _ Insurance ID #: Group #:

2 Emergency Contact Name:_ Relationship: Address: : Apt. City State Zip Home phone: ( ) Work Phone: ( ) ASSIGNMENT OF BENEFITS FINANCIAL AGREEMENT Assignment and release: I authorize payment of benefits be made directly to the healthcare provider. I understand that I am responsible for any and all charges not paid by my insurance. I authorize the Eastern Body Therapy release of any information required by my insurance companies to process this claim, including medical records and dates of service. New Patient Intake Form Name Signed: SS# Date: History of current complaint Reason for today s visit How long have you had these symptoms? What other treatment have you had for this condition? What seems to make it better? What seems to make it worse? Please list other conditions for which you are under the care of a physician: What medications are you taking? (Please include over the counter medications, herbs, and vitamins as well as prescription medications) Do you know what your blood pressure usually is? yes no if yes: / Lifestyle Information Appetite low high moderate Are you vegetarian? yes no Do you have cravings for specific foods? yes no If yes, what do you crave? How many glasses of water do you drink in a typical day? _ Regular Exercise Type How often

3 Medical History Please check any of the following conditions you currently have or have previously had: Now Previous Now Previous Now Previous Alcoholism Diabetes Pacemaker Allergies to what Anemia Appendicitis Arteriosclerosis Asthma Cancer type Chicken Pox Chronic Fatigue Depression Epilepsy Pneumonia Fibromyalgia Polio Gout Rheumatic Fever Heart Disease Scarlet Fever Hepatitis Seizures Herpes Stroke High Blood Pressure Thyroid Disorders HIV/AIDS Tuberculosis History of Abuse Ulcers Measles Venereal Disease Mental Illness Other (Please Multiple Sclerosis explain) Mumps Please list dates and types of all surgeries you have had: Please list any major traumas and accidents you have had: Family Medical History Please check any of the following that someone in your immediate family (sisters, brothers, parents, grandparents, aunts, uncles) has had Condition Who has it? Condition Who has it? Allergies Diabetes Asthma Heart Disease Alcoholism High Blood Pressure Cancer Seizures

4 Poor appetite Heavy appetite Prefer cold drinks Prefer hot drinks Recent weight gain/loss General Symptoms Poor sleep Heavy sleep Dream disturbed sleep Fatigue Lack of strength Bodily heaviness Cold hands or feet Poor circulation Shortness of breath Fever Chills Night sweats Sweat easily Muscle cramps Vertigo or dizziness Bleed or bruise easily Peculiar taste in mouth Glasses Eye strain Eye pain Red eyes Itchy eyes Spots in eyes Poor vision Blurred vision Night blindness Glaucoma Cataracts Head, Eyes, Ears, Nose, Throat Teeth Sinus problems problems Grinding Excessive teeth phlegm TMJ Recurrent Facial pain sore throat Gum Swollen problems glands Sores on lips Lumps in or tongue throat Dry mouth Enlarged Excessive thyroid saliva Nose bleeds Ringing in ears Poor hearing Earaches Headaches Migraines Concussions Other: Difficulty breathing when lying down Respiratory Shortness of breath Tight chest Asthma Wheezing Wet cough Dry cough Coughing blood High blood pressure Blood clots Low blood pressure Fainting Cardiovascular Chest pain Difficulty breathing Rapid heart beat Heart palpitations Phlebitis Irregular heart beat Nausea Vomiting Gastrointestinal Acid regurgitation Gas Hiccup Bloating Bad breath Diarrhea Constipation Laxative use

5 Black stools White, chalky stools Bloody stools Mucous in stools Intestinal pain or cramping Itchy anus Burning anus Rectal pain Hemorrhoid Anal fissures Neck/should er pain Muscle pain Upper back pain Musculoskeletal Low back pain Joint pain Rib pain Limited range of motion Muscle weakness Rashes Hives Ulcerations Eczema Psoriasis Skin and Hair Acne Dandruff Itching Hair loss Change in hair/skin texture Fungal infections Seizures Numbness Tics Poor memory Neuro/psychological Depression Abuse Anxiety survivor Irritability Considered/ Easily attempted stressed suicide Seeing a therapist Pain on Frequent Urgent Blood in urine Genito-urinary Unable to hold urine Incomplete Venereal disease Bedwetting Wake to urinate Increased libido Decreased libido Kidney stones Impotence Premature ejaculation Nocturnal emission Age menses began Gynecology

6 Number of Light flow Breast Age at days in Clotted flow tenderness menopause cycle PMS Breast lumps Duration of flow Vaginal discharge Pregnancies # Date of last PAP Irregular (color Live births periods ) # Date last Painful periods Vaginal sores Premature births period began Heavy flow Vaginal odor # Is there anything else you feel we should know about you? Thank you for taking the time to help us to help you!