Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA Patient Intake Form
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1 Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA Patient Intake Form Name (last, first) Date Address City / State / Zip Birth Date Home phone Work Phone Cell Phone Occupation Emergency contact (name & phone) Referred by Single Married Divorced Significant Other Widowed Caregiver for dependent Children Have you ever had acupuncture? If yes, when/where? For what condition? Are you currently under the care of a physician? If so, who, and for what condition(s)? Main reason(s) for seeking acupuncture? Are you working with an attorney for your condition? Yes or No How long have you experienced symptoms? Your condition is improved by: Your condition is aggravated by: List all current medications, prescribed or over the counter List all current vitamins, herbs and other supplements 1
2 Significant illnesses (please check all that apply) Cancer Diabetes Hepatitis 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 surgeries you ve had including dates Please list any Allergies Please list any major emotional or physical traumas you ve experienced Lifestyle (please check all that apply, and note frequency of use) Tobacco Alcohol Recreational drugs Caffeinated beverages Do you exercise? Please list types of activity and frequency: Dietary preferences Vegetarian Raw foods diet Low fat diet High protein/low carb Dairy /milk /cheese Eggs Chicken Fish / seafood Red meat Artificial sweeteners Fast food/ burgers/ fries Spicy / hot Sweet Sour Salty Cold drinks Hot drinks Ice chewing Extreme thirst Thirst with no desire to drink 2
3 General symptoms Fatigue Sweat without exertion Night sweats Fever / chills Digestion Extreme appetite No appetite Cravings Dieting Tired after eating Bloating Gas Acid regurgitation Heartburn/Ulcers Dizziness / vertigo Bleed / bruise easily Low immunity GERD Nausea Vomiting Bulimia Anorexia Irritability or low energy between meals Other How many meals per day? How many snacks per day? Intestinal Diarrhea Constipation Hemorrhoids Anal itching / burning Laxative use Bloody stool Mucous in stool Anal fissures Rectal prolapse Sleep Falls asleep easily Lie in bed with eyes open Wake as specific times Wake repeatedly Wake frequently to urinate Head, Eyes, Ears, Nose and Throat Dry eyes Spots / flowery vision Blurred vision Poor vision Eye strain Night blindness Cataracts TMJ Sores on tongue or mouth Dry mouth Excess saliva Sinus problems Intestinal pain/cramping Incomplete evacuation IBS Colitis Crohn s Disease Gout Celiac Disease Gallstones Other Vivid or Lucid Dreams Wake up not feeling rested Nightmares or Frightening dreams Need drugs or supplements to fall asleep Swollen glands Earaches Difficulty swallowing Headaches Tinnitus / ringing Nosebleed Bleeding gums Post-nasal drip Sore throat Deafness 3
4 Cardiovascular / respiratory Heart palpitations Chest pain Difficulty breathing High cholesterol Varicose veins Blood clots Swollen ankles Heart valve abnormality Shortness of breath Skin / hair Dry skin Rashes / hives Eczema Psoriasis Pimples / acne Fungal infections Musculoskeletal Spinal pain Joint pain Tendonitis Swelling Arthritis Limited range of motion Neuropsychological Anxiety Irritability Insomnia Depression Easily stressed Poor memory Seasonal mood disorder Tics Tremors Death of someone close Cold hands / feet Dry cough Wheezing Chest tightness Difficult inhalation Difficult exhalation Productive cough (color of phlegm?) Other Brittle nails Ridged nails Hair loss Dandruff Disc degeneration Osteoporosis Numbness Carpal tunnel Fibromyalgia Job stress Recent divorce Currently in therapy Financial setback Emotional stress scale no stress moderate stress extremely stressed Rate your stress level regarding: Work Health Love Money Family The future 4
5 Genito-urinary Frequent urination Loss of urine when laughing or sneezing Incomplete urination / retention Dribbling Burning urination Blood in urine Men only Enlarged prostate/prostatitis Prostate cancer Testicular cancer Testicular pain or swelling Wake frequently to urinate Kidney stones Bedwetting Bladder prolapse Decreased libido / sexual desire Erectile dysfunction Impotency STD s Women only Age menses began Age menses ended (if applicable) Date of last ob/gyn exam Hysterectomy? partial full Hormone replacement therapy Live births Miscarriage Abortions Infertility Birth control pills Breast cancer Ovarian cysts Fibroids Endometriosis Candida / yeast Vaginal discharge Vaginal odor Vaginal sores Herpes Human Papilloma Virus positive Uterine prolapse STD history (chlamydia, PID, etc) Fibrocystic breast Period lasts days Usual number of days in cycle Headaches before menstrual cycle during cycle after cycle Pain at ovulation Cramps / low back pain Acne associated with period Constipation associated with period Diarrhea associated with period Menstrual flow is: Clotting Brownish Watery, thin and bright red Depression or irritability with period Bleeding outside of normal menstrual cycle No period / skipped cycles Irregular cycle Normal red Flooding and trickling Stop and start flow If you have been evaluated for infertility, what was your diagnosis? 5
Patient Intake Form. Name (last, first) Date. Address. City / State / Zip. Home phone Work Phone. Cell Phone . Occupation Birth Date Age
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Patient Intake Form. Name (last, first) Date. Address. City / State / Zip. Home phone Work Phone. Cell Phone . Occupation Birth Date Age
Patient Intake Form Anne Kinchen, Licensed Acupuncturist Water Tower Plaza 25200 Chagrin Blvd #103 Beachwood, OH 44122 (216) 292-9698 clevelandacupuncture.com Name (last, first) Date Address City / State
Health History Form Nancy T. Moore, M.Ac., L.Ac Larrabee Ave., #206, Bellingham, WA (360)
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PERSONAL INFORMATION (Male intake form)
Brooke Phillips Diplomate of Oriental Medicine Natural Fertility Program 126 East Third Street, Suite A Rochester, Michigan 48307 (248) 841-1570 - brooke@rochesteracupuncture.us www.rochesteracupuncture.us
PERSONAL INFORMATION (Female intake form)
Brooke Phillips Diplomate of Oriental Medicine Natural Fertility Program 126 East Third Street, Suite A Rochester, Michigan 48307 (248) 841-1570 - brooke@rochesteracupuncture.us www.rochesteracupuncture.us
Eastern Body Therapy
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
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~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
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Health History New England Community Acupuncture Name: Contact - Cell: Street: Home: City: Work: State: Zip: Email: DOB: Height: Occupation: Age: Weight: Physician: Emergency Contact - Name & Phone Number:
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No
ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **
Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer
PATIENT MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information: