Rachel Beth Dorfman, L.Ac., C.M.T.
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1 Rachel Beth Dorfman, L.Ac., C.M.T. Classical Acupuncture, Chinese Medicine and Asian Bodywork Patient Information Name: Today's date: Address: Age: Date of birth: City: State: Zip: Best phone to reach you: Receive texts (please circle): Yes No Marital Status: Gender: Occupation: Referred by, or how you heard of us: Emergency Contact (Name/Phone): Relationship to you: Primary Doctor (Name/Phone): Are you under the care of a physician now? Yes No If so, what for? Current prescriptions, over the counter medications, and/or supplements: Have you had acupuncture before: Yes No Primary reason for seeking acupuncture: How long have you had this condition?
2 Secondary reason for seeking acupuncture: How long have you had this condition? Are you receiving any other treatments for these conditions? (please specify) If known, what seemed to be the initial cause? Please check conditions that you have or have had in the past: Heart disease Stroke Diabetes Asthma Seizures/Epilepsy Alcoholism/Addiction High Blood Pressure Cancer Other: HIV/AIDS Epilepsy Allergies Bleeding disorder Emphysema Hypertension Ulcers Osteoporosis Hepatitis Pneumonia Anemia Thyroid condition Pacemaker TB Autoimmune Other: Do you take anticoagulant medication? Yes No Surgeries/History of hospitalizations: List of broken bones: Smoker: Yes No How much and how often? Exercise: Yes No How much, how often, what type? Alcohol consumption How much, how often? Birth control method? Number of children: Please circle your current level of stress, 1 being lowest and 10 being highest:
3 Temperature/Energy/Sleep Tend to be HOT Night sweats Chills Tend to be Cold Unusual/excess sweating Fatigue Cold hands, feet Excessive thirst Body feels heavy/weak Fever No thirst Feel wired/ungrounded Difficulty falling asleep Restless sleep Disturbing dreams Hours of sleep per night? Daily caffeine intake? Mood/Emotions Anger easily Fear Sadness/grief Anxiety Indecision Stress Depression Irritability Worry Easily startled Mood swings Difficulty concentrating Neuropsychological ADD/ADHD Mental illness Poor memory Bipolar disorder Nervousness Musculoskeletal Back pain: upper/mid/lower Joint pain or weakness: hand/wrist elbow/shoulder/foot/ankle/knee/hip Skin/Hair/Nails Acne Bruise easily Dry skin/itchy skin/oily skin Dry, brittle nails Muscle cramps/spasms Neck pain Weak muscles Hives Rashes/Eczema/Psoriasis Dry hair/oily hair Head/Eyes Dizziness/Vertigo Blurred or failing vision Eye strain or pain Fainting Cataracts Glaucoma Headaches Dry/Itchy/Red/Watery eyes Poor night vision Migraines Ears/Nose/Throat/Mouth Ear infections Sinus problems Dry Mouth Ear ringing Difficulty Swallowing Mouth sores Hearing loss Dry throat Gum problems Hay fever/allergies Sore throat Teeth grinding Nasal congestion Hoarseness/Loss of voice TMJ/Jaw problems Nosebleeds Swollen glands General amount/extent of dental work:
4 Respiratory Asthma or wheezing History of childhood asthma Emphysema Bronchitis Cough w/phlegm or blood Frequent colds Chronic cough Difficulty breathing Pneumonia Shortness of breath Cardiovascular Chest pain/tightness Low blood pressure Rapid/irregular heart beat Hardening of arteries Palpitations Swelling of ankles High blood pressure Poor circulation Varicose veins Gastrointestinal Acid reflux/gerd Diarrhea or loose stool Nausea Bad breath Food allergies/sensitivities Poor appetite Belching Hemorrhoids Excessive appetite Bloating and/or gas Indigestion Stomach pain Blood in stool Liver problem Ulcers Constipation Gall bladder stones/problem Vomiting Bowel movement frequency: Formed or loose: Color: Strong odor: Yes No Genitourinary Blood or pus in urine Urgent urination Lowered sex drive Frequent urination Painful/burning urination Premature Ejaculation Incomplete urination Urinary tract infection Prostatitis Nighttime urination History of UTI Impotence/Erection difficulties Unable to hold urine Kidney stones STD: Gynecology/Reproduction Abnormal PAP smear Mid-cycle bleeding/spotting Previous miscarriage Breast tenderness Painful periods/cramps Vaginal discharge Clots with menses PMS Vaginal dryness Heavy menstrual flow Light menstrual flow Yeast infections Irregular periods Menopausal symptoms Are you pregnant? Average length of cycle: Date of last PAP exam: Date of last period: Duration of flow: Age of menopause: Additional info:
5 Informed Consent Acupuncture is a form of therapy in which fine needles are inserted into specific points on the body. Your treatment may include the application of Moxabustion Therapy, Cupping Therapy, or hands-on massage/bodywork. These will be explained to you at the time of treatment. An Acupuncturist is not able to make a medical diagnosis, provide primary care, or Western (allopathic) medical care. Please see your doctor for those services and for routine check-ups. Acupuncture is generally safe. Serious side-effects are extremely rare. The purpose of Acupuncture is to reduce pain and to aid in bringing the body back to a normal state of balance. Because Acupuncture involves the insertion of needles into the skin, minor side-effects are rare, but may occur. These include bruising, slight bleeding, weakness, drowsiness, intense to subtle sensations during or following treatment, fainting, and increase or aggravation of symptoms during or following treatment. Only sterile, one-time use, disposable needles are used. Needles are not re-used, even on different areas of the body on the same person. Please inform your Acupuncturist: If you have ever experienced a seizure, dizziness, or fainting episode If you have a pacemaker or any other electrical implants If you have a bleeding disorder If you are taking anticoagulants or any other medications If you have damaged heart valves or high blood pressure If you have any form of infection If you are pregnant With this knowledge, I voluntarily consent to receiving Acupuncture. I understand that I can refuse treatment at any time. Signature: Printed name: Date:
6 Financial Policy Payment is expected at time of visit Cash or checks accepted Insurance is not accepted at this time, but a receipt may be provided for you to submit yourself If current fees are the only thing stopping you from scheduling regular treatments, please speak with me regarding the availability of payment options Cancellation Policy Please give 24 hours notice if you need to cancel or reschedule an appointment In cases where appointments are cancelled, or missed altogether without notification: The first time will be free of charge The second time, there will be a charge equaling 50% of the expected treatment fee The third time, there will be a full charge of the expected treatment fee and a consultation as to whether treatments should continue to be scheduled It is understood that emergencies happen. If an emergency causes you to miss your appointment, please speak with me. Signature: Date:
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CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
Acupuncture Patient Health History
Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR P: (541) F: (541)
CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR 97417 P: (541)517-9869 F: (541)543-2220 PATIENT INFORMATION Name: Age: DOB: Sex : Address: City: Zip: Home Phone: Cell
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
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
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac
ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac. 617-835-2512 Patient Information and Health History Date: Name: Date of Birth: Street: City: State: Zip: Phone: (H) (W) )
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:
Name: Date of Birth: Date: Address: Postal Code: Occupation: Telephone: Day: Cell Phone: E-mail address: Emergency Contact: Evening: Telephone: Male Female Where did you hear about Acupuncture for Health?
Mayflower Acupuncture LLC
Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.