New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
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1 New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Marital Status: Married Single Divorced Widowed Partnered Number of children Sex: Male Female Trans MTF FTM Weight Height Birthdate Age Emergency Contact: Relation Phone Have you received acupuncture therapy before? Y N With whom? When There are times when it is necessary for there to be communication between your acupuncturist and physician in order to discuss the best treatment and method of care. It is important that patient, physician, and acupuncturist work together. Physicians will not be contacted without written signature and consent. Who is your primary care physician? Phone Are you under the care of any other doctors? Who? Contact info Name Phone_ Name Phone_ May I contact your physicians on your behalf? Y N Signature Date I agree to administer payment at the time of treatment in the form of cash or check Y N Initials I would like to be updated on news, events, & classes for Calandra Acupuncture and Miessence Initials I have received a copy of, read, reviewed, understand and agree to the 24 hour cancellation policy Initials Signature Date 1
2 Please indicate any significant illnesses you or a blood relative (Grandparent, parent or sibling) have had: Illness You relative Approx. Date Illness You relative Approx. Date Diabetes Heart Disease Asthma Lung Disease Cancer Arthritis Emotional Disorder Allergies Hepatitis High Blood Pressure Rheumatic Fever Infectious Disease Seizures Childhood diseases/ yr: Measles Mumps Chicken Pox Sexually Transmitted Disease: Gonorrhea Syphilis HIV HPV Chlamydia Herpes Date Check the Box if any of the following statements are true: I have a pacemaker/ joint replacements I have a stent or shunt Where I am taking Coumadin/Warfarin I am taking Lithium (Eskalith, Lithonate, Lithotabs) Please indicate the use and frequency of the following: Yes No Amount Yes No Amount Yes No Amount Coffee/black tea Tobacco Water Intake Non-medical/drugs Alcohol Soda Please list all medication, vitamins, supplements and over the counter drugs. 2
3 What are the main health problems for which you are seeking treatment? What other forms of treatment have you sought? Clinical Notes To be completed by practitioner List any other health problems you now have. List any known allergies, food sensitivities or food craving that you have. List any accidents, surgeries or hospitalizations (include date). Lab results: (please include copies) 3
4 OB/ Gyn History Age of 1 st period (menarche) Are you pregnant? Yes N # of pregnancies Age of last period (menopause) # of live births # of abortions # miscarriages Date of last: Gynecologic exam Pap Mammogram Bone density scan Results_ Number of days between periods Number of days of flow Color of flow Clots? Yes No Color Average number of pads you use per day: 1 st day 2 nd day 3 rd day 4 th day +days Have you been diagnosed with: Fibroids Fibrocystic Breasts Endometriosis Ovarian Cysts PID PCOS Other Location of pain: Low abdomen Lower back Thighs Other Nature of pain (please indicate before, during or after menses) menses: Other symptoms related to Cramping Stabbing Discharge Vaginal dryness Headache Burning Aching Nausea Constipation Diarrhea Dull Bloating Swollen breasts Mood swings Ravenous appetite Consistent Intermittent Poor Hot flashes Night sweats Bearing down sensation Increased libido Decreased libido Insomnia 4
5 Urogenital History Date of last prostate check up PSA results Manual prostate exam results Lab results Frequency of urination: Daytime nighttime Color of urine: clear murky odor: Symptoms related to prostate prostate problems delayed stream post void dribbling incontinence retention of urine erectile dysfunction (ED) increased libido decreased libido premature ejaculation impotence back pain groin pain testicular pain decreased force of stream BPH/ enlarged prostate other 5
6 Symptom Survey Please check the symptoms or conditions you experience frequently excessive appetite insomnia cough low back pain eye problems loose stool/diarrhea palpitations shortness of breath knee problems jaundice digestive problems, cold hands and feet decreased sense of hearing impairment difficulty indigestion smell digesting oily foods vomiting nightmares nasal problems ear ringing gall stones belching, burping mentally restless skin problems kidney stones light-colored stool heartburn/reflux laughing for no reason claustrophobia decreased sex drive soft/brittle nails stomach bloating chest pains colitis/diverticulitis hair loss easily angered obsession in work, poor memory constipation urinary problems difficulty in relationships, etc. making blood in stool easily bruised decisions lack of appetite sadness hemorrhoids dental problems high cholesterol recent use of antibiotics nighttime urination bitter taste fatigue edema asthma allergies dizziness get sick easily headaches I usually feel warm I usually feel chilled 6
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