Health History Form Nancy T. Moore, M.Ac., L.Ac Larrabee Ave., #206, Bellingham, WA (360)
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1 Health History Form Nancy T. Moore, M.Ac., L.Ac Larrabee Ave., #206, Bellingham, WA (360) Name (last, first) Date Address City / State / Zip Home phone Work Phone Cell Phone Occupation Birth Date Age Emergency contact (name & phone #) Referred by Insurance (type, ID #, phone number on card) Single Married Divorced Significant Other Widowed Caregiver for dependent children (how many)? for elderly person(s)? Have you ever had acupuncture? If yes, when? for what condition? by whom? Are you currently under the care of a physician? If so, who, and for what condition(s)? Have you seen any other medical care provider for this condition? If so please explain diagnosis: Main reason(s) for seeking acupuncture today How long have you experienced symptoms? Your condition is improved by Your condition is aggravated by
2 List all current medications, prescribed or over the counter, vitamins, herbs, and other supplements Significant illnesses (please check all that apply) Cancer HIV/AIDS Pneumonia Tuberculosis Diabetes Multiple Sclerosis Thyroid Asthma Hepatitis Stomach Ulcers Obesity Depression Heart Disease Shingles Chronic Fatigue STDs Stroke Rheumatic Fever Seizures Emphysema Other Please list any surgeries you ve had, including dates: Please list any allergies: Please list any major emotional or physical traumas you ve experienced Lifestyle (please check all that apply, and note frequency of use) Tobacco Alcohol Recreational drugs Caffeine (cigs per day ) (drinks per day ) (type/amt ) (beverages per day ) Do you exercise? Yes No Please list types of activity and frequency: Nutrition Please check if any of these apply to you: Vegetarian Vegan Raw foods diet Low fat diet High protein/low carb (Atkins) Other 2 Do you eat the following foods? red meat X per week artificial sweeteners X per week fast food X per week salads eggs fish X per week coffee X per week white flour breads, pretzels, etc. cooked vegetables Gastro-Intestinal Extreme appetite No appetite Nausea Bulimia Anorexia Cravings Dieting Tired after eating Bloating Gas Heartburn/GERD Gurgling Ulcers Extreme thirst Constipation Celiac Diarrhea Loose stools Hemorrhoids Gallbladder disease Mucus in stool Bloody stools Anal fissures Diverticulitis IBS Ulcerative colitis Crohn s Disease Gout
3 Incomplete evacuation Laxative use Polyps Gallstones Rectal prolapse Fatigue between meals/low blood sugar Other Sleep Fall asleep easily Lie in bed with eyes open Wake at specific times Wake repeatedly Wake frequently to urinate Nightmares Dream-disturbed sleep Need drugs or supplements to fall asleep Skin, Hair Dry skin Rashes / hives Eczema Psoriasis Pimple/acne Fungal infections Brittle nails Ridged nails Hair loss Dandruff Other Head, Eyes, Ears, Nose and Throat Dry eyes Floaters/spots Blurred vision Poor vision Eye strain Night blindness Cataracts Glaucoma Itchy eyes Macular degeneration Excess tearing Dry mouth TMJ Excess saliva Canker sores Cold sores Sinus problems Post-nasal drip Frequent sore throats Headaches Swollen glands Difficulty swallowing Earaches Nosebleeds Tinnitus/ringing Hearing impairment Other Cardiovascular/Respiratory Palpitations Chest pain Difficulty breathing High cholesterol Varicose veins Hypertension Swollen ankles Shortness of breath Wheezing Chest tightness Dry cough Productive cough Cold hands/feet Blood clots Heart valve abnormality Other Musculoskeletal Low back pain Joint pain Tendonitis Swelling Arthritis Disc degeneration Osteoporosis Numbness Neck pain Shoulder pain Hip pain Knee pain Mid back pain Upper back pain Elbow pain Jaw pain Carpal tunnel Limited range of motion Other Neuropsychological Anxiety Irritability Insomnia Depression Easily stressed Poor memory Tics Tremors Job stress Recent divorce Financial setback Mood swings Difficulty concentrating Seasonal mood disorder Death of someone close Currently in therapy Formerly in therapy Other Emotional stress scale no stress moderate extremely stressed Rate your stress level regarding the following areas (1 is low, 10 is high) Work Health Love Money 3
4 4 Family Friends Future Living conditions Isolation Responsibilities Past Weight Genito-urinary Frequent urination Dribbling Burning Blood in urine Incomplete urination Kidney stones Bedwetting Bladder prolapse Genital pain Loss of urine when laughing, sneezing, or coughing Decreased libido/sexual desire Other Men only: Enlarged prostate Prostate cancer Testicular cancer Herpes Impotency Erectile dysfunction Testicular pain/swelling STD Women only: Date of last OB/GYN exam Hysterectomy? partial full Painful intercourse Live births Miscarriage Abortion(s) Infertility Birth control pills Breast cancer Herpes Fibroids Endometriosis Candida/yeast PMS Vaginal discharge Vaginal odor Vaginal sores Dry vagina HPV positive Fibrocystic breast Ovarian cyst Prolapse Hormone replacement Hot flashes Nightsweats Mood swings STD Age menses began Age menses ended (if applicable) Period lasts days Usual number of days in cycle Bleeding/spotting outside of normal menstrual cycle Irregular cycle No period/skipped cycles Menstrual flow: Heavy Light Watery/thin Fresh red blood Brownish Purplish/dark Clots Flooding & trickling Headaches before menstrual cycle during cycle after cycle Associated with cycle: Pain at ovulation Pain at start of period Pain during period Low back pain Irritability Weepiness/depression Diarrhea Constipation Acne Breast tenderness Nausea Insomnia Cramps
5 5 Please note any other concerns that may have been missed on this form: Please mark specific areas of pain on the diagram below.
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
Minister Medical ^Acupuncture
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
Who is filling out this intake form? Self Spouse Parent Guardian
Office Use Only: Reviewed with Patient Data Entry Scan & File Date: Date: Date: Initials: Initials: Initials: Today s Date: Who is filling out this intake form? Self Spouse Parent Guardian If you are not
New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip
About You Pulley Chiropractic & Acupuncture, LLC Janine Pulley, D.C., L.Ac. 102 Peters Street, Suite 1, North Andover, MA 01845 P: 978-237-5106 * F: 978-420-4399 drjanine@pulleychiropractic.com * www.pulleychiropractic.com
WELCOME to Naturopathic Medicine at Vivo!
1 WELCOME to Naturopathic Medicine at Vivo! What You Can Expect: 1 st Appointment: Your first appointment is up to 1 hour and 30 minutes; this includes a detailed patient intake, a complete health history,
If you have any questions, feel free to contact us at 475- WLNS (9567) or
UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH
Have you ever been diagnosed with any of the following? The patient has a history of the following conditions: Glaucoma
PALMETTO PHYSICAL MEDICINE 10 FINANCIAL BOULEVARD ANDERSON, SC 29621 PHONE (864) 437.8930 FAX (864) 309.8004 Have you ever been diagnosed with any of the following? Palpitation/Flutter Feelings Edema/Swelling