Mary Helen Robert, LAc
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- Vanessa Malone
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1 Mary Helen Robert, LAc Acupuncture Center 6212 Dayton Blvd., Suite B Hixson, TN Date: Name: Date of Birth: Address: Phone: Gender: Height: Weight: Married ( ) Single ( ) Widowed ( ) Divorced ( ) Separated ( ) Other ( ) In case of an emergency please contact (include name and phone number): Occupation: Who referred you to this office? Have you had an acupuncture treatment before? Primary reason for your visit today? Present symptoms: Are you currently working with any other health care practitioners (please list)? Other areas of pain or concern: List ALL significant hospitalizations, surgeries, accidents, traumas (include dates):!1
2 Please list current medications including over the counter and prescription (attach separate sheet if necessary): Name Dosage/ Frequency/ Duration For what reason are you taking this? Supplements/vitamins/herbs currently used (attach separate sheet if necessary): Name Dosage/ Frequency/ Duration For what reason are you taking this? Level of daily stress: 1 (least) 1O (most). Have you recently had any unusually stressful experiences (i.e. divorce, death of someone close, bankruptcy, loss of job, illness, injury, etc...)? Please describe. What are the main stress factors in your life? What are the main ways you relax and reduce stress? What types of exercise do you presently participate in (How often)? How many hours per week do you work/volunteer? Are you satisfied with your primary relationship and/or your support system? What would you describe as the dominant emotion(s) in your life right now? Please describe your health and any other additional comments:!2
3 Family History: Relationship Alive/Deceased (age) Present health or cause of death Father Mother Siblings (gender) (Check all that apply to you & indicate with a P those symptoms experienced in the past): Energy level/temperature: low energy feel cold cold hands fatigue intolerance of heat/cold cold feet sleepy during the day feel hot hot palms/feet/chest head/face feels hot Lung/Large Intestine & Associated CM functions cough (dry/with sputum) shortness of breath sore throat nasal problems difficulty breathing sensitive/dry skin sinus issues/congestion allergies rashes/hives/eczema catch colds easily asthma sadness/grief/unresolved loss history of bronchitis fever/chills tobacco use Spleen/Stomach & Associated CM functions less than one bowel movement per day gas/bloating bad breath diarrhea/loose stools pain or discomfort after eating hemorrhoids constipation/dry stools low or excessive appetite bruise easily undigested food in stool organ prolapse edema blood or mucus in stool general feeling of heaviness in the body crave sweets nausea/vomiting bleeding/painful/swollen gums tends to overthink indigestion/heartburn facial swelling/pain tends to worry abdominal pain diabetes!3
4 Please indicate an example of (1) your diet when you have time and energy to prepare meals and (2) a typical diet when stressed or pressed for time. Please include beverages. (1) Breakfast Lunch Dinner Snack (time of day) (2) Breakfast Lunch Dinner Snack (time of day) How many meals do you typically eat per day? How often do you eat at restaurants? Please list any dietary restrictions: How much of the following do you drink per day? Coffee (cups) Teas (cups) Water (oz) Soft drinks (oz) Wine (glass) Beer (oz) Liquor (oz) Liver/Gallbladder & Associated CM Functions: headaches/migraines irritable/frustrated discomfort/tightness/tension around ribcage dizziness/vertigo feel tense itching/pain in genitals dry/red/itchy eyes difficulty making plans/decisions alternating constipation/diarrhea blurred vision trouble with vision high stress level easily angered bad temper heat in head/face lump in throat muscle tension/cramps/spasms/tremors gall stones seizure/convulsions Heart/Small Intestine and Associated CM Functions: palpitations insomnia/sleep problems tongue sores rapid/irregular heart beat light sleeper cries a lot pacemaker dream-disturbed sleep numbness/tingling at extremeties chest pain mental confusion difficulty concentrating nightmares poor memory anxiety!4
5 Kidney/Bladder and Associated CM Functions: low back pain/weakness dribbling sexual/reproductive issues hearing problems weak/sore knees blood in urine infertility ringing in ears cold sensation in low back painful urination adrenal exhaustion cold sensation in knees cloudy urine night sweats joint pain urgent urination hormonal imbalances wake at night to urinate profuse/scanty urination increased libido kidney stones clear/dark urine decreased libido bladder/kidney infection excessive hair loss/balding craves salt loss of bladder control frequent broken bones tend to be fearful retention of urine dental problems lacks willpower Other: cancer heart disease COPD CVA (stroke) thyroid disorder hepatitis autoimmune disease For Women Are you pregnant (if so, how many months)? Trying to become pregnant? Maybe? Method of birth control? Age of First Menses Date of Last Menses Age of Menopause Hysterectomy (Date)? Typical Length of Menses (Days You Bleed) Typical Length of Cycle (From the 1st Day of One Cycle to 1st Day of the Next) Check all that apply to you (*Please indicate with a P symptoms you experienced in the past): hot flashes PCOS irregular menses infertility fibroids vaginal infections change in menstrual flow uterine bleeding ovarian cysts vaginal yeast menstrual pain breast lumps abnormal PAP test vaginal discharge clotted blood in menses breast discharge endometriosis vaginal itch PMS breast pain/tenderness PID vaginal dryness water retention!5
6 Pregnancies (please include losses/terminations): Year Vaginal/C Section Sex Complications/Other things you might want to mention For Men Are you currently experiencing any of the symptoms below (*Please indicate with a P symptoms you experienced in the past): prostate problems nocturnal emissions testicular pain delayed stream premature ejaculation groin pain incontinence impotence Do you have any diseases, conditions or problems not listed above (Please describe)? _ Pain (Please indicate on the diagram any areas of pain or numbness)!6
7 * Our office policy requires payment on the day of your visit. * Kindly allow 24-hour minimum notice for change or cancellation of appointment. No shows will owe for full value. We absolutely forgive emergencies. * There will be a $30.00 fee for returned checks. I, the undersigned, have read and understand the above policies: Signature Date!7
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NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
Holistic Health Care New Patient Intake Form
Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past
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611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
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Minister Medical ^Acupuncture t^wellness Clinic What is acupuncture? Acupuncture is a therapy in which fine needles are inserted into specific points on the body. Is acupuncture safe? Acupuncture is generally
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records