Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA

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1 Please complete this Health History Form. You may it back to the clinic or print it out and bring it with you to your appointment. Thank You. Name: Date: Address: Phone (day): City/State/Zip: (evening): Date of Birth: Occupation: Emergency Contact (name and phone): Please complete this questionnaire as thoroughly as possible. All of your answers will be held in confidence within lawful limits. Print all information and indicate areas of confusion with a question mark. Please leave the right-hand columns blank. Thank you. Please list the conditions you wish to be treated: 1) 2) 3) 4) 5) Please list any medications (prescribed and over-the-counter), herbs, vitamins, and supplements you are currently taking: Name Dosage/Amount Purpose

2 Current Health (check any that apply): Temperature: Fever Chills Night sweats Spontaneous Sweats Hot Flashes Do you tend to feel: Warmer than others Cooler than others Please leave blank for acupuncturist s notes Thirst: Do you tend to be thirsty? Yes No Temperature drinks you prefer: warm room temperature cool cold / iced Digestion: Changes in Appetite Nausea Vomiting Abdominal Pain Gas Heartburn Belching Other Bowel movements: Frequency: times per day: Formed Loose Liquid (diarrhea) Incomplete times per week: Difficult to pass Urination: Color: Dark yellow Light yellow Clear Amount: Scanty Copious Urgent Frequent Painful Night-time Breathing: Cough Wheezing Shortness of Breath Painful Other Head, Eye, Ear, Nose, and Throat: Headaches: Location: Frontal Sides Back Top Quality: dull and nagging Intense Sharp Eyes: Pain/Strain Tearing Dryness Ears: Ringing Earaches Sinus Congestion Nose Bleeds Frequent Sore Throats TMJ/Jaw Problems Other

3 Cardiovascular: High Blood Pressure Cold Extremities Palpitations Chest Pain Edema Swelling of Ankles Stroke Heart Murmurs Do you have a pacemaker? Yes No Other Please leave blank for acupuncturist s notes Sleep: Hours per night: How long does it usually take you to fall asleep? Insomnia Constant sleepiness Frequent vivid dreams Other Mental State: Irritability Anger Anxiety Depression Mood Swings Other Energy: Fatigue Hyperactivity Immunity: Slow Wound Healing Chronic Infections Frequent colds Allergies Do you have reduced immunity (such as HIV/AIDS, Hepatitis C, scleroderma, or vitiligo) or are you receiving any treatments that may affect your immunity (such as chemotherapy)? Yes No Describe Other Male Reproductive: Erectile Dysfunction Premature ejaculation Lack of interest in sex Penile Discharge Enlarged Prostrate Testicular Pain/Swelling Other:. Female Reproductive: Irregular Cycles Nipple Discharge Heavy Flow Vaginal Discharge (describe) Breast tenderness before period Mood fluctuations before period Painful Periods Bleeding Between Periods Lack of interest in sex Other.

4 Menstrual/Birthing History: Age at first Menses:. Length of Cycle:. # of Days of Menses:. Total # of Pregnancies: Live Births:. Age at Onset of Menopause: Are you pregnant? Yes No If yes, where are you in your pregnancy and what is your due date?. Please leave blank for acupuncturist s notes Neurologic: Dizziness Loss of Balance Paralysis Seizures/Epilepsy Numbness/Tingling Other: Skin: Rashes Hives Acne Eczema Location/Other: Sores/Wounds Surgeries: 1. date: 2. date: 3. date: 4. date: Do you have any other concerns that you would like to discuss? Have you had acupuncture before? Yes sensitivities to needling? Describe: No Do you have any special

5 For Practitioner Pulse: Tongue: Observations: 1 st Treatment: Tx plan: Practitioner Name:

6 Informed Consent to Treat I hereby request and consent to the performance of acupuncture treatments and other Oriental medicine procedures on me (or on the patient named below, for which I am legally responsible) by Lisa M. Blake MAOM, Dipl. O.M., Lic.Ac. I understand that methods or treatments may include but are not limited to acupuncture, moxibustion, cupping, intradermal needles, ear pressballs, bloodletting, electrical stimulation, Tui Na (Chinese massage), Gua Sha, Chinese herbal medicine, and nutritional counseling. Heat therapy using moxa (Artemisia), a dried herb, that is lit and burned on the needles or on the skin, or the use of a heat lamp in conjunction with needle therapy. Moxa is not burned directly on the skin, but on top of a burn ointment which will conduct the heat and prevent burns. On rare occasions, a blister may occur. The practitioner will explain the procedure as it is done and the patient is asked to let them know the status of the heat at all times. Application of stainless steel pressballs onto various points in the ear. These are applied with adhesive tape and may be left in the ear for up to 7 days or as suggested by the practitioner. Electrical stimulation of the needles using a battery operated machine to create a current through the needles may be used. This creates a constant vibration through the needles that would be adjusted according to patient comfort. Cupping is a technique used to resolve muscle tightness or help clear the lungs in respiratory conditions. A glass cup is applied to the skin and then a pump suctions the skin and muscle into the cup. The suction is adjusted according to patient comfort. The cups can leave a reddish or purplish mark on the skin that clears up in a few days, similar to a bruise. Gua sha is a technique similar to cupping where a flat tool is used to scrape the skin to relieve muscle tension and congested blood flow. It leaves a similar bruise-like rash that lasts for a few days. Herbs and nutritional supplements that have been recommended are traditionally considered safe in the practice of Chinese Medicine. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status. If experience any gastro-intestinal reactions to the herbs I will inform the acupuncturist immediately. I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the abovenamed procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I also understand that any evaluation given to me in no way replaces western (allopathic) medical evaluation diagnosis and treatment. I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical treatment, to discuss an emergency situation and/or to share appropriate medical information. My signature gives my practitioner permission to release my medical records for the reasons listed above. I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation. Print Name Signed Name Date

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