Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
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1 Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency contact: Phone: What is your reason(s) for seeking acupuncture? Symptom #1 Symptom #2 Symptom #3 What makes it better/worse? What makes it better/worse? What makes it better/worse? Have you been given a diagnosis for this issue(s)? Have you tried other treatments to address this issue(s)?
2 Medical History. Please list the following information: Illnesses Surgeries Significant trauma (motor vehicle accidents, fractured bones, etc.) Medications/Supplements (please list all meds, herbs, vitamins and OTC drugs) Allergies/Sensitivities (please list any foods, drugs, medications, environmental factors, chemicals or materials you are allergic to) Do you have, or have you ever had the following conditions? Please circle all that apply: alcoholism allergies arthritis asthma anxiety chronic fatigue diabetes fibromyalgia heart disease high blood pressure hypo/hyperglycemia HIV impotence infertility IBS kidney disease Lyme disease osteoporosis Raynaud s seizures/epilepsy stroke thyroid disease hepatitis (type: ) cancer (type: ) mental illness (type: ) Do you have any medical devices in your body (pace-maker, knee replacement, etc.)? 2
3 Lifestyle. Please provide the following information: Do you exercise? Type/frequency/duration? Do you smoke? How often? Do you drink caffeine? How often? Do you drink alcohol? How often? Do you observe any dietary restrictions? What foods do you crave? Or avoid? How many hours a night do you sleep? Do you wake up rested? Musculoskeletal pain. Please mark any painful or distressed area(s) on the diagram below. On a pain scale of 1 (no pain) to 10 (maximum pain), what is your pain level today? Recent Condition or Symptoms. Please check the boxes for any of these items that you may have experienced in the last three (3) months. If the issue is of a chronic or persistent nature, please circle the item as well. 3
4 General bleed/bruise easily change in appetite chills cravings fatigue fevers localized weakness night sweats sweat easily poor appetite poor sleeping strong thirst weight gain weight loss tremors Skin/Hair eczema dandruff dryness loss of hair hives pimples itching rashes recent moles Head/Nose/Throat headaches blurred vision ear infections dizziness eye inflammation hearing loss swollen glands poor night vision ringing in ears strep throat spots/floaters itchy ears Cardiovascular chest pain/tightness palpitations rapid heart beat poor circulation shortness of breath low blood pressure swollen ankles cold hands/feet Gastrointestinal nausea diarrhea indigestion constipation stomach pain excessive hunger blood in stool hemorrhoids gallbladder disorder heartburn gas ulcer Respiratory chronic cough coughing up phlegm difficulty breathing wheezing/asthma frequent colds bronchitis pneumonia sinus infections Neurological seizures numbness/tingling limbs loss of balance poor memory hard to focus/concentrate 4
5 Urogenital painful urination urinary urgency incontinence weak urinary stream kidney stones wake at night to urinate Men s Health enlarged prostate impotence fertility issues erectile dysfunction low libido Women s Health painful periods menopause issues fibroids/ovarian cysts endometriosis PCOS frequent yeast infections fertility issues history of miscarriage PMS Emotional depression anxiety/worry easily stressed out panic attacks mood swings grief/sadness irritable/angers easily insomnia 5
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