Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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1 Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Appt reminders via text? Y N via ? Y N Date of Birth: Age: Gender: M F Relationship Status: Physician: Physician Phone: Employer: Occupation: Hrs/Wk: Who may we thank for referring you? Have you ever had acupuncture before? Y N If so, where? Emergency contact: Phone: Relationship: If patient is a minor or under legal guardianship: Guarantor Name: Relationship to Patient: Guarantor Address: Guarantor Phone: Insurance Information Primary Insurance Company: Subscriber ID#: Group #: Subscriber Name: Relationship to Patient: Birthdate: Secondary Insurance Company: Subscriber ID#: Group #: Subscriber Name: Relationship to Patient: Birthdate: Revised 7/2014 Page 1
2 Patient Health History Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this to the best of your ability. What is the main reason you are seeking treatment today? (Please mark any areas of pain on diagram) 1. Chief Complaint Date of onset Please list any major accidents, surgeries, or hospitalizations and include approximate dates. Chronic Illnesses: Allergies/Sensitivities (seasonal, chemical, environmental, food, drugs, etc.): Medications (prescribed/over-the-counter) and supplements you are currently taking. (Continue on back if you require more space). Medication/Supplement Reason Dosage How Long Prescribed by Revised 7/2014 Page 2
3 Family Medical History: (M=mother, F=father, GP = grandparent, S =sister, B=brother) Camas Acupuncture & Nutrition YOU RELATIVE WHO YOU RELATIVE WHO Allergies Alcoholism Alzheimer s Disease Arthritis Asthma Autoimmune Disease Cancer Diabetes Heart Disease Hepatitis High Blood Pressure High Cholesterol Infectious Diseases Mental Illness Osteoporosis Seizures Stroke Thyroid Disease Lifestyle Caffeine Tobacco Alcohol Soda Water intake Exercise (describe) Nutrition YES NO AMOUNT Meals/day Snacks/day Food cravings Special Diet? Y N Breakfast: Dinner: General Lunch: Snacks: Height: Weight: Maximum Weight: When? Interests & Hobbies: Spiritual Practice: Are you in a supportive relationship? Y N If not, what about it is not supportive? Have you experienced any major traumas? (Whatever you consider to be a traumatic event in your life) Y N Explain: Revised 7/2014 Page 3
4 Wellness Rating Health and wellness is a balance of many factors. Using the scale below, choose your level of satisfaction in each area of your life on a scale from 1-10 (1 = not happy, 10 = very satisfied). Physical Health Financial Health Spiritual Health Family Health Social Health Career Health Sexual Health Mental Health Please check any symptoms you have had in the past 3 months. General Poor appetite Poor sleeping Night sweats Localized weakness Fevers Chills Cravings Poor balance Sweat easily Tremors Change in appetite Weight gain Bleed or bruise easily Weight loss Strong thirst Peculiar taste/smell Sudden energy drop Fatigue Skin & Hair Rashes Eczema Recent moles Itching Hair loss Dandruff Hives Ulcerations Change in skin/hair texture Acne Head, Eyes, Ears, Nose & Throat Dizziness Concussions Migraines Glasses Eye strain Eye pain Poor vision Night blindness Color blindness Cataracts Blurry vision Ear aches Ringing in ears Poor hearing Spots in front of eyes Sinus problems Nosebleeds Grinding teeth Recurrent sore throats Facial pain Teeth problems Jaw clicks Headaches Cardiovascular High blood pressure Low blood pressure Chest pain Phlebitis Fainting Cold hands or feet Swelling of hands Swelling of feet Blood clots Irregular heartbeat Palpitations Respiratory Cough Pneumonia Bronchitis Difficulty breathing Asthma Coughing blood Pain with deep breath Phlegm Revised 7/2014 Page 4
5 Gastrointestinal Nausea Chronic laxative use Diarrhea Constipation Vomiting Belching Black Stools Indigestion Bad breath Blood in stools Hemorrhoids Abdominal cramps Gas Acid reflux Genitourinary Nighttime urination Frequent urination Blood in urine Urgent urination Incontinence Kidney stones Decreased flow Genital sores Strong smelling urine Dark urine Painful urination Female Reproductive Pregnant Trying to get pregnant Breast self-exams Menopause Hysterectomy Fibrocystic breasts Breast tenderness Fibroids Endometriosis Irregular periods Decreased libido PMS Yeast infections Bleeding between periods Painful periods Ovarian Cysts Age at first period # of pregnancies Last gynecological exam # days between periods # of live births Last mammogram Date of last menstrual period # of miscarriages Last bone density exam # Days of flow # of abortions Last colonoscopy Male Reproductive Prostate problems Premature ejaculation Testicular pain Urination problems Erectile dysfunction Decreased libido Date of last prostate exam Date of last colonoscopy Musculoskeletal Neck pain Muscle pain Knee pain Back pain Muscle weakness Foot/ankle pain Hand/wrist pain Shoulder pain Hip pain Numbness Tingling Neuropsychological Seizures Loss of balance Poor memory Lack of coordination Anxiety Depression Bad temper Easily susceptible to stress Is there anything else you would like me to know? Revised 7/2014 Page 5
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611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
Integrative Health and Fitness
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New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy
Patient Contact Information Form Your privacy is being protected per HIPPA guidelines. No information will be given out without your expressed consent. Please indicate any of the following methods of communication
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician