6365 Shier Rings Road, Suite A Dublin, OH fax Acupuncture Form
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1 6365 Shier Rings Road, Suite A Dublin, OH fax Acupuncture Form Name Date of Birth Gender: M F Address City State Zip Cell Phone Employer Work Phone X Work Address Occupation Social Security # Marital Status: Sin Mar Div Sep Wid Emergency Contact: Phone number: Relation: Address Number of Children Ages Main Concerns Please tell me about your major health and wellbeing concerns in order of how important they are to you. It will help if you include when and where you first noticed them and to what extent they affect your daily life now. Have you received a diagnosis for your concerns? If yes, what was the diagnosis? What kind(s) of treatment(s) have you tried or are currently using related to these concerns? What results have you seen from the above treatment(s)?
2 Please mark the severity of your chief concern on the following scale. Not a problem Worst imaginable Please mark the greatest degree of severity of your chief concern that you have EVER experienced. Not a problem Worst imaginable Personal Medical History Please mark all that apply and explain as necessary. Allergies Heart disease Seizures Asthma Hepatitis Stroke Cancer High blood pressure Thyroid disease Diabetes HIV/AIDS Other Please date and describe all hospitalizations and surgeries: Please date and describe all significant traumas: What do you know about your birth (prolonged labor, forceps, premature, etc)? List all known allergies (food, chemicals, drugs, seasonal, insects, etc): Have you undergone a course of antibiotics lately? Have you been under the care of a licensed health care professional in the past year? If so, for what reasons?
3 Family Medical History Please mark all that apply and explain as necessary, indicating which family member. Allergies Drug/Alcohol abuse Seizures Asthma Heart disease Stroke Cancer High blood pressure Thyroid disease Diabetes Mental disorder Other Review Of Symptoms General Catch cold easily Recurrent infections Night sweats Bleed or bruise easily Organ prolapsed Strong thirst (hot or cold) Fatigue /low energy Sudden drops of energy Time of day Sudden change in weight Sleep Difficulty in falling asleep Wake up easily at night Times per night? Particular time? Wake up too early in am What time? Nightmares Vivid dreams Grinding teeth Talking in Sleep Circulation Cold hands or feet Swelling in hands/feet Blood clots Varicose veins Edema/swollen ankles Puffy eyes Nervous System Loss of taste/smell/touch Tingling sensations/numbness Tremors Where? Lack of coordination/balance Paralysis or seizures Stroke Concussion Other Skin and Hair Dry skin/scalp/hair Rashes/hives Itching Eczema Warts Acne Change in moles Hair loss/thinning hair Graying of hair Other Mind and Emotions Poor memory Difficulty concentrating Depression Often stressed Lose control of emotions Substance abuse Anxiety/nervousness Manic behavior Panic attacks Easily angered Aggressive behavior Other Chest Pain in chest Tightness or pressure in chest Pain with breathing Difficulty breathing Shallow breathing Shortness of breath Recurrent/chronic cough Coughing up blood Coughing up phlegm Asthma/wheezing Production of phlegm High blood pressure Low blood pressure Heart palpitations or rapid heartbeat Irregular heartbeat Other Muscles and Joints Neck pain Shoulder pain Back pain Where? Hand/wrist pain Knee pain Foot/ankle pain Muscle pain/weakness Tremors/tics in muscles Osteoporosis Herniated disc Sciatica Other
4 Head, Ears, Eyes, Nose, Throat Headaches Where? When? Migraines Dizziness/Vertigo Fainting spells Earache Change in hearing Ringing in the ears Blurry vision Night blindness Color blindness Spots before eyes Dry eyes Eye pain/sore eyes Excessive tearing Glasses/contacts Facial pain Facial paralysis Nosebleeds Blocked nose/sinuses Sinus infections Jaw pain Teeth/gum problems Recurrent sore throat Hoarseness/loss of voice Tonsillitis/swollen glands Sores on lips/mouth/gums Strange taste in mouth Oral ulcers Other Urinary Pain with urination Urgent urination Frequent urination Blood in urine Cloudy urine Dribbling urination Urinary incontinence/retention Incontinence at night Do you wake to urinate? How many times? Bladder/kidney infections Recurrent yeast infections Kidney stones Digestion Little appetite Strong appetite Hunger but no desire to eat Food cravings Belching Nausea Vomiting Heartburn Indigestion Abdominal pain Regurgitation Weight loss Weight gain Loose stools/diarrhea Dysentery Strong smelling stools Blood in stools Constipation (<1 bm/day) and dry stools with difficulty Alternating constipation and diarrhea Gas/Flatulence Hernia Rectal pain/prolapsed Hemorrhoids Anorexia nervosa Bulimia Bad breath Other Male System Prostate Problem Change in Sexual Drive Rashes/itching Genital Discharge Erection Difficulty Low Sperm count/ mobility Female System Premenstrual irritability Clots in menstrual blood Color of blood Irregular menses Painful menses Heavy/prolonged bleeding Missed menses Spotting/abnormal bleeding Vaginal discharge Vaginal dryness Genital sores Ovarian cysts Fibroids Endometriosis Breast lumps Breast swelling or redness Nipple discharge Abnormal PAP smear Infertility Other Are you currently pregnant? Is it possible that you are currently pregnant? Are you trying to get pregnant? Do you practice birth control? What type and for how long? Number of pregnancies Number of births Number of premature births Number of Abortions Age of first menses Duration of menses Number of days in cycle Age of menopause Date of last pap
5 EDUCATION AND EXPERIENCE 6365 Shier Rings Road, Suite A Dublin, OH Ph: Disclosure Statement Chris Cooper graduated from American Institute of Alternative Medicine (AIAM) in January AIAM is a three year program with a curriculum strongly emphasizing Traditional Chinese Medicine as well as Acupuncture. In June 2014, he gained his certification of Diplomate in Acupuncture (Dipl. Lac) as issued by the National Council of Colleges for Acupuncture and Oriental Medicine (NCCAOM). Ohio State Acupuncture License was awarded August Included in this certification is a course in Clean Needle Technique and First Aid/CPR. Chris s education also included adjunct therapies such as moxibustion, cupping, gua sha, tuina, auriculotherapy, electro-acupuncture, and lifestyle and Traditional Chinese Medical (TCM) nutritional counseling. Chris holds a Masters Degree in Clinical Counseling from University of Dayton. This clinic uses only single-use, disposable, factory-sterilized needles and complies with the rules and regulations promulgated by the Ohio Department of Public Health and Environment concerning proper cleaning and sanitation measures. FEE SCHEDULE: Initial Acupuncture Consultation and Treatment $90.00 Fertility Acupuncture/Wellness Consultation and Treatment $ Follow-up Acupuncture Treatment $70.00 Cupping Treatment $70.00 (If added to acupuncture treatment) ($15.00) I understand that if I need to reschedule an appointment for any reason, I will give at least 24 hours notice or be responsible for half of the session fee. If I don t call, or show up, I will be responsible for the full session fee. PATIENT S RIGHTS The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. The patient may seek a second opinion from another health care professional or may termination therapy at any time. The practice of acupuncture is regulated by the Ohio State Medical Board. I have read and understand this document. Patient s Signature (or Signature of Guardian) Date
6 6365 Shier Rings Road, Suite A Dublin, OH Ph: STATEMENT OF INFORMED CONSENT I hearby request and consent to the performance of acupuncture and other treatments within the scope of practice of an acupuncturist to be performed by Chris Cooper, L. Ac., representing Dublin Family Chiropractic, on me (or, if the patient is a minor, on the patient named below, for whom I am legally responsible. I understand that there are minor risks associated with acupuncture treatment, including, but not limited to, slight bleeding and/or bruising of the skin. I understand that the risk of infection is negligible when using single use, disposable needles. I have had the opportunity to discuss with the acupuncturist the nature and purpose of acupuncture. I understand that results are not guaranteed. I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications. I wish to rely on the acupuncturist to exercise good judgment during the course of the procedure, based on the facts then know, and act in my best interest. I have read the above consent, or have had it read to me. I have had an opportunity to ask questions about its content, and by signing below, I agree to the above named procedures. I intend for this consent form to cover the entire course of treatment for my present condition, as well as any future conditions for which I may seek treatment. Following your treatment: Occasionally, a person may feel light headed after an acupuncture treatment. If this happens to you, please sit for a while in the designated area. You should feel fine within a few minutes. PAYMENT WILL BE REQUESTED FOR CHANGES OR CANCELLATIONS OF LESS THAN 24 HOURS Please sign and date below to indicate that you have read and understand this form. Patient s Signature (or Signature of Guardian) Date Printed Name Phone Number Address City, State Zip
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*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Worthington Optimal Wellness Acupuncture Patient Health History Form
Worthington Optimal Wellness Acupuncture Patient Health History Form Rita Ghodsizadeh, L.Ac, Dipl.Ac. B.A. 6180 Linworth Rd., Worthington, OH 43085 Office # 614-848-5211 ; cell # 614-309-1898 www.acupuncturehealscolumbus.com
Birch Wellness Center
Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age:
Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA
Please complete this Health History Form. You may email it back to the clinic (LBlakeLac@gmail.com) or print it out and bring it with you to your appointment. Thank You. Name: Date: Address: Phone (day):
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
GENERAL INFORMATION FOCUS. 1 P age. Today s Date. Address City State Zip.
1 P age GENERAL INFORMATION Today s Date Name Date of Birth Address City State Zip Home Phone Mobile Phone Work Phone Occupation Email Emergency Contact Contact Number Family Physician Physician Phone
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
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Symptom Review (page 1) Name Date
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Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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Lucas D. Brown, L.Ac. (312)
Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt:
Healing Arts Acupuncture & Traditional Chinese Medicine
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Naturopathic Medicine Intake Form Adults (16+)
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