PERSONAL INFORMATION (Male intake form)

Transcription

1 Brooke Phillips Diplomate of Oriental Medicine Natural Fertility Program 126 East Third Street, Suite A Rochester, Michigan (248) brooke@rochesteracupuncture.us PERSONAL INFORMATION (Male intake form) Mr. Name: Address: Apt # City: State: Zip: Home Phone: Alternate Phone: Date of Birth: / / Place of Birth: Any known complications at birth: Occupation: Occupational Stress: chemical physical psychological Other: How many hours/week do you work? Are you satisfied with your job? Marital Status: single married divorced widowed mutually committed Have you ever had acupuncture?, when? For what condition? Was it a good experience? How were you referred to us? Can we contact him/her to thank them for the referral?

2 MEDICAL HISTORY What are your reasons/concerns for seeking treatment? When did your health concerns begin? Your condition is improved by Your condition is aggravated by Are you currently under the care of a physician? For what condition(s)? Physician s Name: Address: City: State: Zip: Phone: Date of last medical doctor visit: / / What was the reason for your visit to your medical doctor? Was there a diagnosis offered? 2

3 What other methods of therapy (conventional and alternative) have you used for this condition? Therapy Therapist name Date / / Response Therapy Therapist name Date / / Response Therapy Therapist name Date / / Response Family Medical History (please check all that apply to PARENTS/SIBLINGS): Diabetes Cancer Heart Disease Stroke High Blood Pressure Seizures Asthma Allergies Other Personal Significant illnesses (please check all that apply TO YOU): Allergies To: Cancer Diabetes: Type I (insulin usage) Type II Hepatitis: A B C Heart Disease Stroke Seizures HIV / AIDS Pneumonia Tuberculosis Multiple sclerosis Thyroid Asthma Stomach Ulcers Obesity Depression Shingles Chronic Fatigue Rheumatic Fever High Blood Pressure STD s Other Please list any surgical procedures you have had: Surgery Surgery Date Date 3

4 Surgery Surgery Date Date Please list prescribed medications you are currently taking and for what condition: Please list over-the-counter medications you are currently taking and for what condition: Please list any vitamins, supplements, and herbs you are taking: Product Product Product Product 4

5 Please mark in the following table how often do you experience the listed emotions and what is the usual cause that triggers them: Emotion Happy Peaceful Anxious Relaxed Joy Anger Fear Worry Depression Sadness Never Sometimes Often Always Caused by FERTILITY HISTORY: Have you initiated any pregnancies in the past? When? Have you been evaluated by an urologist? Diagnosis: Have you had a semen analysis? Results: Date: Count (million cell/ml): Motility (%): Morphology (% normal): Other: Are you taking any medications or supplements? Please list and describe for what condition: 5

6 Have you had any Male surgeries? Procedure Date Result Comment Vasectomy Vasectomy reversal Testicular Biopsy Varicocele ligation Hernia repair Undesenced testicle Renoval of testicle Have you had your hormones evaluated? Test Date Result Comment FSH LH Testosterone Antisperm antibodies GENERAL HEALTH HISTORY: How frequent do you have intercourse? # times per week Do you have difficulty obtaining or keeping an erection? Does your penis become warm/hot when aroused? Do you ever experience burning or itching after intercourse? On a scale from 1 to 10, (10 being the best) what is your energy level? Do you tend to be warm or cold? Do you often need extra blankets or sweaters or can you go outside wearing a t-shirt when it is chilly? 6

7 Do you have cold hands and feet? Do you experience night sweats? Do you have hot feet at night? Do you experience sweating upon light exertion? Do you experience difficulties with urination? Urgency Pain with Frequency Do you need to get up more than once per night to urinate? Have you had a history of urinary tract infections? Do you experience regular bowel movements? Daily 2-3 time per day Every other day Frequent loose stool Constipation Alternating diarrhea with constipation Do you tend to be thirsty or experience dry mouth and throat? Do you experience dry eyes? Do you experience ringing in your ears? High pitched Low pitched Do you experience low back pain? Do you have problems falling asleep or staying asleep, or waking nightly at the same time? Do you tend to get sick easily? Number of brothers and sisters: Where are you in the birth order? Oldest Middle Youngest How many years between you and closest siblings? 7

8 Did your mother have any miscarriages? How old was your mother when you were born? How was your mother s pregnancy with you? Were there any major stressful events? DIET, EXERCISE & LIFESTYLE Do you have a regular exercise program?. Please, describe: How many meals do you have per day? How many snacks? Are you or have you ever been on a restricted diet?. What kind? What foods/flavors do you crave? Please describe your average daily diet: Morning Afternoon Evening Dietary preferences: Vegetarian Vegan Raw foods diet Fast food/ burgers/ fries Spicy / hot Sweet 8

9 Low fat diet High protein/low carb Dairy /milk /cheese Eggs Chicken Fish / seafood Red meat Artificial sweeteners Sour Salty Cold drinks Hot drinks Ice chewing Extreme thirst Thirst with no desire to drink Do you take any of the following: Coffee: # /week Regular Decaf Alcohol: # /week What? Soda: # /week Diet Regular Cigarettes: # /day (Brand: ) Recreational Drugs: # /week (Type: ) How is your sleep: I sleep well. It s hard to fall sleep It s hard to stay sleep I wake up every night at I wake up refreshed Γ I wake up tired How many hours/night do you sleep? What time do go to bed? Do you have recurring dreams?. If yes, explain: Do you use any of the following products? anti-perspirant hair dyes/permanents/relaxers cellular phone, #of mins per day computer, # hours per day commercial household cleaning products Mark any of the following symptoms that applies to you in the present or past: 9

10 General symptoms Fatigue Sweat without exertion Night sweats Fever / chills Dizziness / vertigo Bleed / bruise easily Low immunity Digestion Extreme appetite No appetite Cravings Dieting Tired after eating Bloating Gas Acid regurgitation Heartburn/Ulcers Nausea Vomiting Bulimia Irritability or low energy between meals Fall asleep easily Lie in bed with eyes open Wake at specific times Wake repeatedly Wake frequently to urinate Vivid or Lucid Dreams Wake up not feeling rested Nightmares or frightening dreams Need drugs or supplements to fall asleep Head, Eyes, Ears, Nose and Throat Dry eyes Spots / flowery vision Blurred vision Poor vision Eye strain Night blindness Cataracts Macular degeneration Bleeding gums TMJ Sores on tongue or mouth Dry mouth Excess saliva Sinus problems Post-nasal drip Sore throat Headaches Swollen glands Difficulty swallowing Intestinal Daily Bowel movement Diarrhea Constipation Hemorrhoids Anal itching / burning Laxative use Bloody stool Mucous in stool Contain undigested food Anal fissures Intestinal pain/cramping Incomplete evacuation Hard to push out IBS Colitis Gout Gallstones Other Sleep Earaches Tinnitus / ringing Deafness Nosebleed Other Cardiovascular / respiratory Heart palpitations Chest pain Difficulty breathing High cholesterol Varicose veins Blood clots Swollen ankles Heart valve abnormality Shortness of breath Cold hands / feet Dry cough Wheezing Chest tightness Difficult inhalation Difficult exhalation Productive cough (color of phlegm? ) Other Skin / hair Dry skin Rashes / hives Eczema Psoriasis

11 Pimples / acne Fungal infections Brittle nails Ridged nails Hair loss Dandruff Musculoskeletal Spinal pain Joint pain Tendonitis Swelling Arthritis Limited range of motion Vertebral disc degeneration Osteoporosis Numbness Carpal tunnel Neuropsychological Anxiety Irritability Insomnia Depression Easily stressed Poor memory Seasonal mood disorder Tics Tremors Death of someone close Job stress Recent divorce Currently in therapy Financial setback Genito-urinary Urine Clear Urine Cloudy Urine Dark Painful urination Frequent urination Loss of urine when laughing or sneezing Incomplete urination / retention Dribbling Burning urination Blood in urine Wake frequently to urinate Kidney stones Bedwetting Decreased libido / sexual desire Impotency