205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:

Transcription

1 205 W Giaconda Way, Suite 135 Tucson, AZ, (520) info@forever-able.com Name: Birth date: Age: Today s Date: Address: Home phone: Mobile phone: May we add you to our list? yes no Height: Weight: Usual Blood Pressure: Employer: Occupation: Primary Physician Name & Phone: Emergency Contact, Relationship and Phone: Responsible party for patients under 18 yrs of age (Name & Relationship): Have you had acupuncture before? How did you hear about us? CHIEF COMPLAINTS Please list your top three complaints / concerns in order of importance to you Mark an X on the scale to indicate the severity of the condition When did this start? Indicate by circling whether each of the following make it,, or Heat Cold Damp Exercise Rest #1: I I I 1 10 #2: I I I 1 10 #3: I I I

2 Have you been to another health care practitioner for any of the above, and if so, what was your diagnosis? PAIN & PHYSICAL SYMPTOMS Please circle where you are experiencing symptoms: INJURIES & SURGERIES Please indicate what happened to what body part & when: DIET & EXERCISE Do you follow a special diet now or have you in the past? If so, please describe (i.e. vegetarian, vegan, grain-free, etc): Do you exercise? Yes No If yes, please describe what you do and how often: How often and in what amounts do you use the following? Coffee / Tea: Tobacco: Soda / Diet Soda: Marijuana: Alcohol: Other: 2

3 HEALTH HISTORY Please indicate if you or a family member (please specify who) have or have had any of the following conditions: Self Mother s side Father s side Siblings Allergies Arthritis Autoimmune Disease Blood / Bleeding Disorder Cancer / Tumor (specify) Depression / Anxiety Diabetes Food Allergies Hepatitis / Liver Disease Herpes High blood pressure HIV / AIDS Heart Disease / Condition Kidney Disease Mental Illness Osteoporosis Stroke Stomach or Intestinal Disorder Stroke Substance abuse / dependence Thyroid Disease Tuberculosis Seizure Disorder HEALTH QUESTIONNAIRE Please check all symptoms that pertain to you currently or in the past: Palpitations Restlessness Anxiety / Nervousness Dizziness Chest pain / discomfort Depression Insomnia (specify: difficulty falling asleep / staying asleep) Vivid dreams / Nightmares Easily startled Rapid or irregular heartbeat Craves bitter taste / foods Asthma / wheezing Catch colds easily Allergies Chills Fever Persistent cough Sinus congestion Frequent sinus infections Excessive mucus / phlegm Dry mouth, throat, nose, or skin Sore throat Nosebleeds Skin condition (acne, eczema, psoriasis, etc) Difficulty breathing / shortness of breath Stiff neck / shoulders Spontaneous sweats (w/o exertion) Sweats very little (even with exertion) Grief / sadness Craves pungent / spicy foods 3

4 Tight / suffocating feeling in chest Cold hands / feet Bitter taste in mouth Blood shot or dry eyes Hot face / chest Headache / Migraine Numbness Dry skin Skin rashes Numbness of hands & feet Muscle spasms, twitching, cramping Seizures / convulsions / tremors High stress Stress exacerbates symptoms Dizziness Gall stones Red / dry / itchy eyes Poor vision / blurred vision Floaters / spots in vision Night blindness Feeling of lump in the throat Tendonitis Soft / brittle hair &/or nails PMS Irregular period Pain below ribcage Tendency to get angry / loose temper Indecisiveness Craves sour taste / foods Urine is: Normal color Dark yellow Cloudy Excessive Burning Difficult / hesitant Clear Reddish Scanty Bad odor Painful Urgent Sore, cold or weak knees Low back pain or weakness Cold in the bones Frequent urination Urgent urination Get up more than once a night to urinate Lack of bladder control / incontinence Frequent bladder infections / UTIs Edema or swelling of ankles / legs Excessive thirst Absence of thirst Memory problems Hair loss Premature graying of hair Dental problems / cavities Tinnitus / ringing in ears Hearing loss Hot flashes Night sweats Excessive fear Craves salty taste / foods Low appetite Fatigue Excessive appetite Loose stools Thirst with no desire to drink Constipation Alternating constipation & diarrhea / loose stools Abdominal bloating or gas after eating Heartburn / belching / reflux Feeling tired after eating Hemorrhoids Prolapsed organs (previously diagnosed) Bruises easily General feeling of heaviness Mental fogginess / difficult concentration Swollen hands / feet Bad breath Mouth or tongue sores Bleeding, swollen or painful gums Stomach pain Nausea / vomiting Frequent yeast infections / Candida Over-thinking / excessive worry Craves sweets 4

5 Are you sexually active? Yes No Any recent changes in sex drive? Yes No Libido is: Normal Low High / excessive Please check all that apply: Pain with intercourse Pain with orgasm Genital pain Sores on genitals Unusual discharge STD (specify) MEN ONLY: Premature ejaculation Blood in semen Erectile dysfunction Nocturnal seminal emission Unusual discharge Impotence Vasectomy Enlarged prostate Prostate disease Pain / swelling of testicles Please briefly describe the nature of any significant traumatic events you have experienced with approximate dates (i.e. divorce, injury / accidents, death of loved ones, bankruptcy, etc): MEDICATIONS: Please list all medications (prescription & over-the counter), herbs, vitamins and supplements you are currently taking: 5

6 WOMEN ONLY: Please check all that apply to your menstrual cycle: Are you currently pregnant or could you be pregnant? Heavy Light Painful Yes No Irregular Clots PMS Are you currently nursing? Yes No Fatigue Breast tenderness / distention Start date of last period: Bloating Mood changes Average cycle length (i.e. 28 days or other): Cramps (specify when) Typical number of days of flow: Bleeding or spotting between periods Age at first menses: Digestive or bowel changes (specify) Number of pregnancies: Heavy vaginal discharge between periods Number of births: Number of miscarriages: Color of menstrual blood is: Number of abortions: Red Pink Brown Current form of birth control: Very dark / purple 6