New Patient Intake. How did you hear about Presidio Acupuncture? Friend (who?) Emergency Contact: Relation: Phone #:

Transcription

1 New Patient Intake Name Age Date Birth Date / / Address: City: State: Zip: Phone(cell) address: How did you hear about Presidio Acupuncture? Friend (who?) Internet MD/Midwife Other Emergency Contact: Relation: Phone #: Regular Medical Doctor: Other Specialist / PT / Chiro / ND: Occupation: Employer: Chief Complaint (Please identify your major health concerns): 1. Since Age: 2. Since Age: 3. Since Age: General Questions Have you ever had acupuncture before? Y N Are you now or could you be pregnant? Y N Date of conception Do you have a history of miscarriage? Y N Do you have a pacemaker, heart arrhythmia, or other heart condition? Y N Have you ever had blood-clotting problems or problems with bleeding? Y N Are you on blood thinning medications? Y N Do you take aspirin regularly? Y N Have you ever been diagnosed with Hepatitis? HIV? AIDS? TB? Y N When?

2 Surgical History: Please list all surgeries and approximate age: Hospitalizations and approximate date: Specific allergies and reaction: Major Accidents/Injuries (include head injuries, fractures, deep cuts, serious sprains, etc.) Indicate date or age: What were the conditions surrounding your birth: Family Medical History (any medical conditions that run in your family) Diabetes Cancer High Blood Pressure Heart Disease Stroke Depression/Mental Illness Alcoholism/Drugs Other Medication History List all medications and supplements you are currently taking: 3

3 Pain PAIN: please indicate on the figures below the areas of the body you experience pain: How would you characterize your pain (circle all that apply): dull/achy sharp/stabbing burning tingling numbness electrical superficial deep shooting The pain is (circle all that apply): better/worse with heat better/worse with cold better/worse with pressure better/worse with movement better/worse with rest worse in am/pm Exercise, Diet & Energy: On a scale of 1-10 please rate your energy level. What time of day is your energy: Highest? Lowest? Do you fatigue easily? Please list some of your favorite foods: Circle all the foods/flavors you enjoy and eat often: spicy sweet salty bitter fresh/raw foods fried food dairy canned foods frozen foods/microwave meals fast food sodas coffee red meat white meat How often do you exercise? What kind of exercise do you do? Do you sweat when active? Sweat when inactive? Night sweats? Height Weight Weight 1 year ago Highest Weight 4

4 Emotions & Sleep: Do you have (circle all that apply): panic/anxiety attacks bad/short temper nervousness sadness crying spells tendency to worry poor memory difficult concentration Briefly describe a typical night of sleep for you. How long do you normally sleep? hours per night Do you take naps? How often? I have difficulties with (circle all that apply): falling asleep staying asleep dream-disturbed sleep Do you often experience waking up and not being able to fall asleep again? No Yes, usually at am/pm Number of times per night you get up to use the restroom On a scale of 1-10 please rate your stress level How do you relax? How do you feel about your work? Are you in a relationship? How do you feel about your relationship? What is your most predominant emotion? Please check the box next to any conditions that apply to you, past and/or present Head and Face Heart and Chest Skin Headaches High Blood Pressure Acne Dizziness Low Blood Pressure Dryness Memory Loss Chest Pain Moles that Change Other Chest Tightness Lumps Difficulty Lying Down Excessive Sweating Eyes Other Night Sweats Blurry Vision Rarely Sweat Eyelid Twitching Circulation Other Floaters Easy Bruising Pain Easy Bleeding Neurological Cold Limbs-Hands or Feet Nervousness/Anxiety Nose Body Temp Runs Cold Numbness or Tingling Tremors Body Temp Runs Hot Lack of Coordination Frequent Colds Nerve Pain Sinus Trouble Gastrointestinal Bleeding Always Thirsty Never Thirsty Mouth Excessive Appetite Dental Problems Low Appetite Gum Problems Gas/Bloating Teeth Grinding/TMJ Stomach or Abdominal Pain Unusual Tastes Nausea Other Diarrhea/Loose Stools Constipation Throat Rectal Bleeding Sore Throat Colon Problems Hoarseness Difficulty Swallowing Urination Dryness Frequent Other Difficult 5

5 Well-Woman History Have you ever had an abnormal pap smear? Yes No Have you ever had a cervical biopsy, operation, cauterization or conization? Yes No Have you ever had a venereal disease? Yes No What kind? Do you get yeast infections regularly? Yes No Do you have chronic vaginal discharge? Yes No Do you douche regularly? Yes No With what? Do you use vaginal lubricants? Yes No Which Ones? Do you use tampons? Yes No Do you sleep with one in? Yes No Do you ever experience pain with sex? Yes No Age at which menses began menses stopped Are your periods painful? Yes No How many days do you normally bleed? How heavy is the bleeding? Light Normal Heavy What color is the blood? Light red Red Dark red Purple Brown Black Is there clotting? Yes No Does your face break out before or during your period? Yes No Do your breasts become tender when you are premenstrual? Yes No Do you get premenstrual low back pain? Yes No Do you bleed or spot between periods? Yes No How many days are there from one period to the next? Date of last menstrual period Have your cycles changed since they began? Yes No Do you ovulate on your own? Yes No On what day of your cycle? Do your breasts become tender at ovulation? Yes No Do you experience pain at ovulation? Yes No Do your bowel movements become loose at the beginning of your period? Yes No Have you ever been diagnosed with uterine fibroids or polyps? Yes No Have you ever had pelvic inflammatory disease? Yes No Were you treated for it? Yes No Have you ever been diagnosed with endometriosis? Yes No Have you been diagnosed with pelvic abnormalities? Yes No Have you had surgeries besides a D&C? Yes No When? What kind? How many pregnancies have you had? How many children do you have? Were there complications during your pregnancies? Yes No If yes, what? How many abortions have you had? How many miscarriages have you had? How many times has a D & C been performed? 6

6 Informed Consent I,, hereby authorize the licensed acupuncturist at Mama Lounge to administer any style of Chinese Medicine relevant to my diagnosis and treatment, including but not limited to the following: Insertion of disposable, stainless steel acupuncture needles of various sizes into my body at different depths and locations. Heated moxibustion treatment using the herb Artemisia vulgaris, or a heat lamp may be placed on or near any part of my body. There is also indirect moxibustion treatment where the herb may be placed on the head of a needle or on ginger or salt which rests on the skin. The heat might cause slight discomfort or leave a small scar or blister on the skin. With any type of heat, there is risk of burn. A vigorous massage technique called gua sha may produce redness, tenderness or slight bruising of the skin that will last from 1-5 days. Cupping may be used to promote circulation. Suction from the cups may produce red or purple spots that can last 1-5 days. Electrical Stimulation may be used to enhance the treatment at various acupuncture points. I have been informed that I have the right to refuse any form of treatment. I understand the nature of the treatment, have been informed of the risks and possible consequences involved with this treatment, and was given an opportunity to ask questions pertaining to my treatment. I also understand there is always the possibility of unexpected complications and I understand that no guarantee can be made concerning the results of treatment. Patient Signature: Print Name: Date: Before Treatments Bring a list of all medications and supplements you are taking DO NOT wear perfumes or any other strong scents Be prepared to undress down to your undergarments Do not drink coffee the day of your visit Have a light meal or snack before visit. A full stomach or empty stomach could cause nausea or dizziness Drink plenty of water day of treatment Do not eat or drink anything that changes the color of your tongue and try not to brush your tongue Do not have any alcohol or drugs in your system from the night before After Treatments Do not drink alcohol Do not eat greasy, spicy, or cold foods Do not exercise Spend the rest of the day relaxing! Patient Signature: Print Name: Date: THANK YOU FOR YOUR COOPERATION IN THOROUGHLY COMPLETING THIS FORM 7