Scott Towne Center ~ 2101 Greentree Road, Suite A-204, Pittsburgh, PA ~ [412] /

Transcription

1 Confluence Healing Scott Towne Center ~ 2101 Greentree Road, Suite A-204, Pittsburgh, PA ~ [412] / Patient Identification / Contact Information: At times it may be necessary to communicate to you regarding your appointments, matters relating to your care, or to provide you valuable promotional or event notices. May we contact you regarding appointments or matters pertaining to your care? Yes Are you interested in receiving promotional or event notices? Yes No No Name Date Home Address City State Zip E- Mail Home Phone Cell Phone Work Phone ext. Occupation Primary Physician: Phone: Emergency Contact (EC) Relationship (EC) Home Phone: (EC) Cell Phone: (EC) Work: (Please leave the best two numbers to reach this person) Sex: Male Female Marital Status: Single Married Divorced Widowed Partnered Your Date of Birth Your Age Have you had acupuncture before? Yes No How did you hear about us? Medical Survey Please state briefly, the primary reason you are seeking treatment today. Briefly list any secondary concerns Medical Diagnosis, if provided by M.D. If your primary concern is an injury, how did this occur? When was the onset of your primary medical concern? Have you seen a Medical Doctor concerning your What other forms of treatment have you sought? condition, and if yes, when?

2 List all Prescription Medicines & Nutrient Supplements/ Herbs that you are taking, and why (for prescription drugs). Circle Yes [Y], No [N] or Past [P] regarding use of the following: Coffee/ Tea Y N P Cups per day Alcohol Y N P Frequency Alcohol Addiction Y N P Any Alcohol Treatment Y N P Recreational Drugs Y N P Drug Addictions Y N P Smoking Y N P Packs per day Number of years Laxative Use Y N P List any chronic childhood illnesses or diseases: List any Accidents, Surgeries, or Hospitalizations. Please include approximate dates and reasons. Check any boxes that may apply: Do you have any allergies to medications, chemicals or I have a pacemaker I have a bleeding disorder or use blood thinners My immune system is compromised I currently have suicidal thoughts History of sexual, mental, or physical abuse foods? Please list How do you feel about the following areas of your life? Great Good Fair Poor Bad Great Good Fair Poor Bad Significant Other Family Self Work Diet Exercise Spirituality Hobbies / Leisure Activities /Sports

3 Do you exercise regularly? Yes No If so, what kind and how often? Height Present Weight Ideal Weight Any recent weight loss or weight gain? Amount of Loss? Amount of gain? Quality of Sleep Do you sleep well? Do you wake rested? How many hours per night? If you wake frequently, what is the reason? For Women Age of first period Start date of last period / / Age of menopause # of days in cycle # of days flow Color of flow Clots in flow? Yes No Is your cycle regular? Yes No Do you experience PMS? Yes No Is your period painful? Yes No Check any that apply: Fibroids PID Endometriosis Ovarian Cysts Fibrocystic breasts History of breast cancer Are you pregnant? Yes No Number of live births Any Miscarriages? Family History Please indicate by checking any boxes that apply to you or your blood relative [Grandparent, parent, or sibling ] You Relative You Relative Asthma / Allergies Infectious Disease Migraines High Blood Pressure Heart Attack / Stroke Heart Disease High Cholesterol Kidney Disease Diabetes Cancer Anemia /Blood disorder Autoimmune Disease Osteoporosis Arthritis Pulmonary Disease Epilepsy / Seizures Tuberculosis Mental Illness Hepatitis Eating Disorders Thyroid Disease Emotional Disorders Please list any Medical Conditions you may have that are not previously listed:

4 Review of Mind / Body Symptoms Regarding this next section: Please indicate by checking next to any symptom you regularly experience, or have experienced in the last two weeks. You may also circle any symptoms which are particularly troublesome. Symptoms may appear more than once, so check for each time they appear. Poor or variable appetite Hard to gain, lose, or regulate weight Tiredness / fatigue /lethargy Abdominal distention or bloating after meals Excessive gas Worry, over-think, or obsess Difficult to focus, poor memory Cravings for sweets Lack of muscle tone or strength Tip of nose often feels cold Easily bruises Feeling cold easily Diarrhea w/ partially digested food Asthma or wheezing Low, soft voice Weak voice Shortness of breath Perspires VERY easily or for no reason, spontaneously Frequent colds, allergies Weak cough Watery nasal discharge Prolonged feelings of grief or sadness Prolapse of organs Hemorrhoids Vericose veins Bearing down or sinking feeling in lower abdomen Water retention or swelling of legs/ankles, abdomen Puffy eyes, face or hands Feelings of heaviness in body, limbs, or head Excessive saliva, drools easily Lack of thirst or thirst but no desire to drink fluids Nausea or vomiting Soft, unformed, or loose stools Loose stools with offensive odor Burning sensation with bowel movements Scanty, frequent urine Mental fog Sweetish taste in mouth Headaches like a tight band around the head Weeping skin lesions Lethargic in humid weather Wheezing Barking cough Sticky, thick mucus Yellow, green, or brown mucus or foul smelling discharges Copious clear or white mucus Mucus worse in the A.M. Frequent nasal congestion Internal nodules or cysts External nodules or cysts Nausea or vomiting Severe Vertigo, room spinning Feel worse when eating greasy, oily foods, dairy, sugar Pain or full feeling in the ribs Feeling like it is hard to take in a full or satisfying breath Cold fingertips or toes Frequent sighing Frequent belching Feeling like a lump in throat or difficulty in swallowing Depression or moodiness Easily frustrated or quick to anger Irritability Pebble like stools Constipation Alternating constipation or diarrhea Gas pains, cramps, tension in stomach or abdomen Sensitive stomach or intestinal problems related to stress Acid reflux or indigestion Irregular menstrual periods PMS, breast swelling, tenderness Severe menstrual cramps with dark blood or blood clots Mottling, numbing, or chilling of hands, feet, or limbs Poor circulation Angina or diagnosed heart disease Fixed, stabbing like pain on any part of the body Painful hemorrhoids, cysts, lumps Pain aggravated at night or from Inactivity Purplish lesions or areas on body

5 Intense thirst for cold water Red face, ears Red, burning eyes High pitched ringing in ears Intense headaches Dark yellow urine Burning sensation with urination Bitter taste in mouth Mouth or tongue ulcers Restless dream disturbed sleep or nightmares Easily agitated, quick to anger Easily overheated or easily sweats Constipation w/ very dry stools Bleeding or painful gums Constant hunger & appetite Acid reflux or bitter regurgitation Feeling feverish that s worse in afternoon or evening Heat sensations in the palms or soles of the feet Menopausal hot flashes or night-sweats Thirst, especially at night Vaginal dryness Low back pain or weakness Tendency for knee or foot weakness, pain, or injury Hair loss or early graying Fertility problems Early menopause Loosening or loss of teeth Decline of memory, vision, or hearing Congenital problem with bones Emaciation or atrophy of tissues Sudden Vertigo or dizziness Migraines or intense pounding headaches High pitched ringing in ears Hypertension Blurry vision Tendency for angry outbursts Seizures, stroke or T.I.A. s Feeling agitated or worse in windy, fast changing weather Tremors of hands, feet, or head Disequilibrium, incoordination Spasms, ticks, twitches, cramps, of nerves or muscles Anemia Poor skin healing Vague, or mild dizziness Thinning of hair Forgetfulness, poor memory Mild numbness or tingling in limbs Pale complexion, lips, nails Dry skin, hair, eyes Dull headache Muscle cramps Poor night vision, floaters in vision Scanty or infrequent menstruation Brittle or thin weak nails Very dry, straw-like hair Tight, contracted muscles, esp. of the shoulders, head, neck, or jaw Insomnia and/ or anxious sleep Heart palpitations or fluttering Cold hands Restless Fatigue Anxiety or dread Easily startled and jumpy Acute abdominal pain or diarrhea brought on by cold foods or drink Stomach ache relieved by heat Palpable cold areas on the body Craving for warm, cooked foods and hot drinks Body or joint pain aggravated by cold temperatures Groin pain or history of hernia Pale, purplish skin, nail beds, lips or tongue Fever or chills Sweating associated w/ cold or flu symptoms Body aches associated w/ cold or flu Sore, scratchy throat Swollen glands Sinus or ear pain Nasal congestion or runny nose Cough with chest congestion Dry, barking cough Puffiness around eyes, dark circles Profound exhaustion or lack of stamina and endurance Low back pain, or soreness Weakness of back, feet or knees Cold feeling in back, buttocks, hips, belly, or limbs Diminished libido Diminished motivation, apathy Puffiness/swelling of ankles/feet Tendency to be overweight Cravings for salt Low humming or buzzing in ears Disorders of urination Frequent night-time urination Diarrhea before daybreak

6 Body Pain Chart Please indicate by placing: XXX s in any areas you experience pain and / or 000 s in any areas you experience numbness or tingling. Left Side Right Side