ACUPUNCTURE INTAKE FORM
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- Clifford Byrd
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1 ACUPUNCTURE INTAKE FORM This questionnaire is CONFIDENTAL and used to gather information to give you the most effective treatment possible. Name Address City State Zip Phone Home Work Cell Birth date Age Sex Marital Status Employer Job Primary physician Address Phone Date of last physical examination Other Medical Practitioner (if applicable ie: Ob/Gyn, PT, OD, etc): Address Phone In emergency: Contact Relationship Phone Referred by Insurance policy and group# Have you ever had acupuncture before: Yes No MAJOR COMPLAINT (Reason for Visit) Have you ever had this condition before? Yes No Have you received treatment for this condition? If yes, when? By whom? Did it help? 1
2 What was the medical diagnosis? Describe what caused it or how it started: PERSONAL MEDICAL HISTORY: (Include date) Major Surgeries including Ob/Gyn if applicable, Accidents Please check if any of the following statements are true for you: I am taking anticoagulants I have a pacemaker I am pregnant I have allergies: MEDICATIONS, HERBS or SUPPLEMENTS YOU ARE PRESENTLY TAKING: Condition/Illness How Often HABITS: How Often Cigarettes Sugar Salt Recreational Drugs Alcohol Coffee Tea Soda Other EXERCISE: Never Little Moderate Heavy Type of Exercise 2
3 HOBBIES or INTERESTS: STRESS LEVEL: Minimal Moderate High Very High Main Source of Stress: How long have you been under this stress? EMOTION HEALTH: Happy Easily Irritable Difficulty making decisions Angry Cry easily Hurry to do things Depression Stressed Restless Overwhelmed Anxious Obsessive Uninterested Even tempered Other: RESPIRATORY: Shortness of breath Difficulty breathing Difficulty inhaling Sigh a lot Dry cough Cough with phlegm Cough with blood Tightness in chest Wheezing Normal Allergies Sudden Sadness/Grief Other CARDIOVASCULAR - CIRCULATION Palpitations Chest pain Low blood pressure High blood pressure High cholesterol Murmur Irregular heart beat Varicose veins Ankle or Hand swelling Numbness in extremities Other DIGESTION: Indigestion Bloating/Gas Heartburn/Acid reflux Nausea Vomiting Full feeling Belching Abdominal pain or cramps Food Sensitivities Difficulty digesting fatty or oily foods Bitter taste Excessively worry O Other BOWELS Loose stool Diarrhea Hemorrhoids Constipation Pain or cramps Use laxatives/fiber Normal Other 3
4 URINATION (three to four times per day is normal): Frequent Burning Bladder infections Urgency Nighttime Incontinence Kidney stones or infections Normal THIRST: Less than normal Excessive Thirsty but do not drink Prefer cold drinks Prefer hot drinks Prefer room temperature Normal APPETITE: Always Hungry or eats excessively Minimal to No Appetite Loss of taste 3 meals a day Less than 3 meal More than 3 meals Do you eat at regular hours? Yes No Cravings: Sweet Salty Spicy Bitter Carbohydrates DIET (Typical Foods): Dairy: Cheese Yogurt Butter Milk Ice Cream How many times/day? Any Sensitivity or Allergy to Casein? Carbohydrates: Whole Grains White Bread Cakes Pasta Rice Potatoes Vegetables How many times/day for each? Have you ever been tested for Sensitivity or Allergy to Gluten or Corn? Protein: Beef Fish Poultry Beans Seeds/Nuts Vegetables: Green/Leafy (cooked) Green/Leafy (raw/salads) Other veggies regularly eaten: Fruits: type, how much and how often: Special Diet/Food Lifestyle: Vegetarian Vegan Diabetic Gluten Free Dairy Free Other WEIGHT: Normal Underweight Overweight Recent gain Recent loss Difficulty Losing Weight 4
5 ENERGY: Inconsistent Low Normal Excess Low after eating Tired in the afternoon Other BODY TEMPERATURE: Warm Cold Flushed face Feel warmer late afternoon Sweats Easily Night sweats Warm Palms Alternate chills and fever Profuse Perspiration Cold hands and feet Warm soles Normal SLEEP: Difficulty falling asleep Dream often Tired when get up in morning Awake easily Nightmares Sleep too much Difficulty going back to sleep Restless Normal Average # hours of sleep: HEADACHES - DIZZINESS: Headaches Vertigo Bend down and stand up and get dizzy Dizziness Motion sickness Poor balance Faint easily Migraines Poor memory SKIN: Dry Hives Itching Oily Acne Bruise easily Eczema Normal Rashes Cuts heal slowly Normal Hair: Dry Oily Dandruff Falling out Early grey Normal NAILS: Soft Spots Grow slowly Ridges and lines Purple Yellow Break easily Pale Normal Other EYES: Wear glasses/ contacts Eyelids swollen Red Dry Itch Poor night vision Twitch Painful Sensitive to light Color blindness Tear easily Normal Other 5
6 EARS: Poor hearing Ringing (high pitch) Ringing (low pitch) Discharges Ear aches Normal Other NOSE: Stuffy nose Sneeze a lot Environmental sensitivity Bleeding Loss of smell Sinusitis Normal Other MOUTH & THROAT: Dry Gum problems Difficulty swallowing TMJ Feel lump in throat Mouth sores Grind teeth Normal Other FAMILY MEDICAL HISTORY: Mother Father Sibling Children Other Illness/date ***** FOR FEMALES ONLY ***** Are you or might you be pregnant? Yes No Not Sure If yes, date of conception? # of Pregnancies: Births Miscarriages Stillborn Abortions Any Pregnancy or Childbirth Complications? Do you use Birth Control? Yes No Type and for how long: In what menstrual stage are you in? pre-menopausal menopausal post menopausal Any menopausal symptoms? Are you experiencing reduced sex drive? Yes No Other difficulties? EXPLAIN: 6
7 When was your last gynecological exam? Findings? Vaginal Discharge: Yellow Thick Bad Odor White Clear Other Do you have regular breast exams? Monthly Yearly Never Last mammography: Do you have facial hair or excess body hair? Yes No MENSTRUAL CYCLE AND FERTILITY: (Please check and explain as applicable) Age started Days of flow Age stopped Date last period How many days from the beginning of your period to the start of your next period? Irregular Painful Heavy flow Scanty flow Dark Color flow Light color flow Clotting Spotting between periods Water Retention Abdominal bloating Painful or tender breasts Breast lumps Emotional changes Lump in throat feeling Constipation and/or diarrhea Tightness in chest Hormonal problems Backache Pinching in lower abdomen with Ovulation Have you been unsuccessfully trying to conceive and/or been diagnosed with Infertility? Have you and your partner been evaluated by a Fertility Specialist? Yes No If Yes, what were the findings? Are you scheduled or in the process in Fertility Treatments? Yes No What is the Fertility Treatment Plan? GYNECOLOGICAL HISTORY AND OPERATIONS: ***** FOR MALES ONLY ***** Swollen Testes Testicular Pain Premature Ejaculation Low or Irregular Sperm Count Date last tested: Feelings of coldness or numbness in external genitalia Decreased Libido Latest Prostate Exam/Results: Other: 7
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FAMILY MEDICAL HISTORY:
NAME DATE PHONE(home) (work) cell E-mail (for office use only) ADDRESS CITY/STATE ZIP AGE HEIGHT WEIGHT SEX MARITAL STATUS BIRTH DATE OCCUPATION EMPLOYERS NAME EMPLOYERS ADDRESS PERSONAL PHYSICIAN DATE
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What do you believe is causing your most important health concern?
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New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip
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Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:
Consultation Intake Form Date: Name: Age: Sex: M F T Address: Phone: (day) (evening) e-mail: Birth date: What would you like help with at this time? Present physical complaints: Onset and length of symptoms:
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)
! 30 E Padonia Rd, #305, Timonium, MD 21093 Phone: (410) 560-7404 Fax: (443) 705-0228 Email: info@waynebonliemd.com Today s Date: Patient Information Name: DOB: / / Address: City/Town: State: Zip: Home
What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Acupuncture &Traditional Chinese Medicine Intake Form
SACRAMENTO 2801 K Street Suite 502 Sacramento, 95816 (916) 887-4660 SutterIntegrativeHealth.org Acupuncture &Traditional Chinese Medicine Intake Form Name: Have you had acupuncture before? Yes No Date
PATIENT INFORMATION. Name Today s Date. Address. City State Zip. Primary Phone # (h, w, c) Secondary Phone # (h, w, c)
PATIENT INFORMATION THANK YOU FOR CHOOSING BEAUTIFUL AMA! We are excited to work with you to balance your body and emotions naturally. These questions will help us develop an individualized diagnosis and
PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS
Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR 97838 Phone:541-371-3700 Fax:541-515-7022 PERSONAL INFORMATION: First Name: Last Name: Middle Initial: Email for doctor communications: