Piedmont Acupuncture & Wellness Clinic
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- Millicent Brooks
- 6 years ago
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1 Patient Information : Address: Street City State Zip Phone: Age: DOB: Marital Status: Occupation: Employer: Emergency Contact: Relationship Primary Physician Ob/Gyn Other Provider Other Provider Referred By: 1
2 Health History Patient Date Reason for Visit: Please list 4 major health concerns in order of importance and indicate level of impairment on a scale of 1-10 (1= no symptoms, 10=worst ever), how long you have been experiencing this, and if there is anything that makes it better or worse (ie. cold/hot, movement/rest etc.) Please provide any additional information below: 2
3 Patient Date Have you had acupuncture before? Y / N Date: Are you taking any anti-coagulant medication? Y / N Are you pregnant or trying to become pregnant? Y / N Please list any diagnoses you may have been given: Please list any Medications you are currently taking (Include dosage and frequency) Please list any Vitamins or Supplements you are currently taking: Please list any Food or Drug allergies and reactions you have: Do you have any Diet Restrictions? If so please describe: Please list any Surgeries & Hospitalizations (type and dates): Please indicate your level of Stress on a scale of 1-10 (1=none, 10=worst ever) I I I I I I I I I I How does stress manifest for you (please list any physical/emotional symptoms): What makes your stress worse: What makes your stress better: 3
4 Psychological/ Behavioral Depression Nervousness Anxiety Panic Attacks Irritable Easily Angered Aggressive Behavior Fearful Grief Indecision Poor Concentration Over Thinking Poor Memory/ Forgetful ADD/ADHD Bi-Polar Seasonal Affective Disorder Difficulty Expressing Emotions Frequent Sighing/ Yawning Easily Stressed Lose Control of Emotions Other: Musculoskeletal Please check all that apply: Pain Numbness Tingling Broken Bones Sprain/Strain Joint Swelling Edema Carpal Tunnel Tendonitis Restricted Movement Sciatica Herniated disk Osteoporosis Other: Head Neck Shoulders Arms Elbows Wrists Hands/Fingers Upper Back Middle Back Lower Back Hips Legs Knees Ankles Feet/Toes (Please circle areas of concern) Seizures / Epilepsy Tremors Paralysis Neurological Nerve Damage Concussion Peripheral Neuropathy Significant Lack of Coordination Loss of Balance Vertigo/Dizziness Sleep Sleep: hrs/ night Difficulty Falling Asleep Difficulty Staying Asleep Excessive Sleep Not Enough Sleep Sleep Walk/Talk Disturbing Dreams Restless Sleep Wake: x/night Not Rested Upon Waking Wake Too Early Sleep Apnea Grind Teeth Snoring Night Sweats Wake to Urinate Energy Please indicate on a scale of 1-10 your general level of energy and check all that apply Low I-----I-----I-----I-----I-----I-----I-----I-----I-----I High Fatigue Wired Energy drop after eating Energy Drop: Time of Day: Other: 4
5 Cardiovascular Shortness of Breath Slow Heart Rate Fast Heart Rate Palpitations Irregular Heart Beats Palpitations Varicose/Spider Veins Blood Clots Hand/Feet Swelling Fainting Bleed/Bruise Easily Chest Pain/Pressure Anemia Phlebitis High Blood Pressure Low Blood Pressure Other: Pain with Breathing Difficulty Breathing Shallow Breathing Wheezing Production of Phlegm Recurrent/ Chronic Cough Shortness of Breath Chest Tightness Respiratory Frequent Colds Frequent Fevers Cough Blood Bronchitis Emphysema Pneumonia Asthma Gastro-Intestinal Bowel Movement: How often? x/ day(s) Indigestion Nausea/Vomit Bloating Gas Feel a lump in the throat Heartburn/Reflux Belching Bad Breath Excessive Saliva Poor Appetite Excessive Hunger Hunger but No Desire to Eat Hemorrhoids Bowel Incontinence Ulcer Hiatal Hernia IBS/Crohns Disease Blood in Stool Rectal Pain Abdominal Pain Stomachaches Tired after BM BM Difficult to Pass Cramps w/ BM Incomplete BM Alternate Constipation/ Loose Stool Loose Stool Diarrhea Dry Stool Constipation Excessive Weight Gain Excessive Weight Loss Genito-Urinary Dark Urine Clear Urine Cloudy Urine Burning Urine Scanty Urine Profuse Urine Frequent Urine Urgent Urine Blood in Urine Painful Urination Nocturnal Urination Difficult Start/Stop Frequent UTI Kidney Stones Incontinence Hair, Skin, Nails Rashes Acne Dandruff Itching Warts Eczema Psoriasis Dermatitis Face Flushing Hives Thick Skin Scaly Skin Thin Skin Dry Skin Dry Nails Dark Under-eyes Abscesses/Infections Hair Loss Dry/Brittle Hair Premature Greying Weak Nails Ridged Nails Change in Hair/Skin Texture Other Dry I-----I-----I-----I-----I-----I-----I-----I-----I-----I Oily 5
6 Migraines Headaches Facial Pain Heavy Headed Light Headed Dizziness Poor Vision Blurry Vision Night Blindness Glasses Spots in Eyes Eye Strain Eye Pain Red Itchy Eyes Color Blindness Excessive Tearing Head, Eyes, Ears, Nose, Throat Nose Bleeds Poor Smell Sinus Problems Nasal Discharge Poor Hearing Earaches Ear Ringing Excess Ear Wax Dry Lips/Mouth Dry Throat Difficulty Swallowing Sore Throats Lip/Mouth Sores Tongue Sores Grinding Teeth Lock Jaw/ Clicks Cold Hands & Feet Cold in the bones Chills Thirst for Cold Drinks Excessive Thirst Thirst for Hot Drinks Thirst, No desire to Drink Absence of Thirst Temperature & Thirst Hot Hands Hot Feet Hot Chest Hot Flashes Hot in Afternoon Hot at night Night Sweats Unusual Sweats Other: Decreased Libido Excess Libido Premature Ejaculation Erectile Dysfunction Rashes/ Itching Jock Itch Male Reproductive Health Nocturnal Emission Testicular Pain Genital Pain Herpes Prostate Disease Vasectomy Hernia Genital Sores Other: Infection Screening Have you ever tested Positive? Please indicate when HIV Tuberculosis Lymes Disease Mono/ Epstein Bar Hepatitis Herpes (oral/ genital) Gonorrhea Syphilis Other: The information on this form is correct to the best of my knowledge. Signature: Date: 6
7 Gynecology First Day of Last Menses: At what age did you start menstruating? Length of your cycle? (ex days): Duration of Bleeding: Are you Currently Pregnant? Y / N How would you describe your flow? Light Medium Heavy Irregular Other: What Color is the Blood? Bright Red Dark Red Pale Red Purplish Brownish Are there clots? Y / N Dime Size Quarter Size Form of Birth control: How long with this method? Number of Pregnancies? Deliveries: Cesareans: Abortions: Miscarriages: Please list any symptoms you have before/ during or after your period: Irregular Periods Painful Periods PMS Menopausal Syndrome Abnormal Pap Smear Polycystic Ovarian Syndrome (PCOS) Pelvic Inflammatory Disease (PID) Pain with Intercourse Post Coital Bleeding Fibroids Endometriosis Infertility Pain at Ovulation Genital Sores Vaginal Dryness Vaginal Discharge Vaginal Soreness Spotting Between Periods Breast lumps Nipple discharge Other: The information on this form is correct to the best of my knowledge. Signature: Date: 7
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HEALTH HISTORY QUESTIONNAIRE Healing Arts of Memphis 1541 Overton Park Ave. (Rear) Memphis, TN 38112 901 726 1485 Name Date Street City ST Zip Home Phone Cell Email Age Date of Birth Male Female HT WT
Johanna M. Hoeller, DC PS
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CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
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Greg Garcia ND, LAc S.W. Watson Ave., Beaverton OR ~ Office: ~ Office Fax: ~
Greg Garcia ND, LAc 4720 S.W. Watson Ave., Beaverton OR 97005 ~ Office: 503.526.0397 ~ Office Fax: 503.643.4633 ~ www.drgreggarcia.com Patient Intake Form Name: Date Address: City: State: Zip Code: Phone
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:
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Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
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Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA PHONE: FAX:
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