Helen Spieth LAc, M.Chem
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- Cora Fisher
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1 Helen Spieth LAc, M.Chem 1221 SE Madison St., Portland, OR ph: (503) fax: (503) Name: Date: Address: City: State: Zip Code: Phone (h): (c): (w): address: Quarterly E-Newsletter? Yes No Age: Date of Birth: Marital Status: Married Separated Divorced Widowed Single Partnership Live with: Spouse Partner Parents Children Friends Alone Occupation: Hours per week: Retired Employer: Physician: Phone: Address: Who may we thank for referring you? In Emergency Notify: Relationship to patient: Phone: Please list your main health concerns in order of importance to you:
2 What is your present level of commitment to address underlying causes of your signs and symptoms that relate to your lifestyle? (Rate from 0 to 10, with 10 being 100% committed) What behaviors or lifestyle habits do you currently engage in that you believe are unsupportive of your health? What potential obstacles do you foresee in addressing the lifestyle factors or changes that may be recommended? Wheel of Balance Wellness is a balance of many factors. Using the circle, shade your level of satisfaction in each area as it relates to you. For example, if you are extremely happy in your career, shade the entire pie shape for career. Typical Food Intake Family & Friends Personal Growth Physical Environment Do the same for each area, starting from the center point Fun & 50% 80% Significant Other/ radiating outwards. Recreation Romance Breakfast: Lunch: Dinner: Snacks: Number of caffeinated drinks per day: Number of alcoholic drinks per week: Number of times per week alcohol consumed: How often do you eat out? Career Money Health 60% 80% Example: 90% 70% 100% 80% Do you smoke? Yes No Past Amount:
3 Exercise #of days per week: Length of workout: Type of activity: Sleep Bedtime: Wake time: Difficulty falling asleep? Yes No Night time waking? Yes No if yes, what time? Wake up feeling rested? Yes No General Height: Weight: lbs. Weight 1 year ago: lbs. Maximum Weight: When: When during the day is your energy the best? Worst? Personal History Please check any conditions or symptoms you have now Arthritis Liver/Gallbladder Disease Stroke Heart Disease High/low Blood Pressure Hypo/Hyperglycemia Kidney Disease Elevated Blood Cholesterol Cancer Diabetes Food Allergies/Intolerances Diverticulitis/IBS Ulcer Seizures Hepatitis Raynaud s Disease Chronic Fatigue Anemia Thyroid Imbalance Respiratory Allergies Alcoholism Lyme Disease Chronic Pain Condition Impotence Gastritis/Pancreatitis Asthma Infertility Emphysema Family Medical History Please check any condition that applies to your immediate family. Put an F (father), M (mother), S (sister), B (brother), GM (grandmother), GF (grandfather) next to choice Diabetes Seizures Heart Disease Stroke High Blood Pressure Allergies Cancer Asthma Other
4 Childhood Illnesses Please check any condition you had as a child Scarlet fever Diphtheria Rheumatic fever Mumps Measles German measles Hospitalization, Surgery, Imaging What hospitalizations, surgeries, X-Rays, CAT Scans, EEG, EKG s have you had? Year Year Year Allergies Any drugs? Any foods? Any environmental or chemicals? Current Medications Please check any of the following medications that you take or use Laxatives Pain relievers Antacids Cortisone Appetite suppressants Antibiotics Tranquilizers Thyroid medication Sleeping pills Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking: 1) 5) 2) 6) 3) 7) 4) 8)
5 Please check the first box if you had this issue in the past but do not any longer. Please check the second box if you currently/recently have any of these symptoms. General Fevers Poor sleeping Muscle weakness/fatigue Sweats easily Chills Fatigue Localized weakness Tremors Night sweats Bleed/Bruise easily Poor balance Cravings Dental/Gum problems Weight loss Peculiar tastes/smells Strong thirst (hot/cold drinks) Weight gain Sudden energy drop Skin and Hair Rashes Dermatitis Change in skin/hair texture Itching Ulcerations Hives/allergic dermatitis Loss of hair Eczema/Psoriasis Dandruff Acne Recent moles Skin discoloration Weak or ridged nails Warts Face flushing Fungal infection Head, Eyes, Ears, Nose and Throat Dizziness Difficulty swallowing Headaches Glasses Eye strain Migraines Poor vision Night blindness Eye pain Cataracts Blurred vision Color blindness Ringing in ears Poor hearing Earaches Sinus problems Nose bleeds Spots in front of eyes Grinding teeth Facial pain Recurrent sore throat/colds Dental problems Jaw clicks/locks Sores on lips/tongue Cardiovascular Chest pain Irregular heart beat Palpitations at rest Fainting Cold hands/feet Swelling of hands/feet Spontaneous sweating Phlebitis Shortness of breath Varicose/spider veins Pressure in chest High blood pressure Low blood pressure Blood clots Dizziness Respiratory Cough/Wheezing Coughing blood Tight sensation in chest Bronchitis Pneumonia Pain with deep inhalation Asthma Difficult inhale/exhale Difficulty breathing when lying down Production of phlegm: What color?
6 Gastrointestinal Nausea Abdominal pain/cramps Vomiting Gas Constipation Diarrhea Indigestion Black stools Loose stools (>2 per day) Bloating Blood in stools Rectal pain Bad breath Excessive appetite Hemorrhoids Acid reflux/gerd Poor appetite Chronic laxative use Belching Changes in appetite Significant thirst Hernia IBS/Crohn s disease Genito-Urinary Frequent urination Urinary tract infection Kidney stones Painful urination Blood in urine Premature ejaculation Urgent urination Sores on genitals Nocturnal emission Unable to hold urine Herpes Impotence Copious flow STD s Pain in testicles Scanty flow Decreased libido Prostatitis Dribbling after urination Excessive libido Night urination: What time? How often? Gynecological/Reproductive - Females Difficult/painful intercourse Ovarian cysts Age of first menses Vaginal dryness Endometriosis Date of last menses Vaginal sores Uterine fibroids Date of last PAP/Pelvic Vaginal discharge Fibrocystic breast tissue # of pregnancies Irregular menstruation Polycystic ovarian disease # of ectopic pregnancies Painful menstruation Infertility # of live births PMS # of miscarriages Do you practice birth control? # of abortions What type? How long? Musculoskeletal Neck pain Shoulder pain Muscle pain Knee pain Hand/wrist pain Muscle weakness Hip pain Carpal Tunnel Sciatica Foot/ankle pain Tendonitis Bursitis Rotator cuff pain Sprains/strains Soreness/weakness in lower Back pain: Low Middle Upper body (back, knee, hip, ankle, foot) Neuropsychological Seizures Concussion Nervousness Areas of numbness ADD/ADHD Anxiety/Panic attacks Loss of balance Bad temper/irritable Depression Vertigo/Dizziness Poor memory Manic depression Lack of coordination Easily susceptible to stress Seasonal Affective Disorder
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Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered
Lucas D. Brown, L.Ac. (312)
Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt:
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
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Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT
Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT 801 623 8253 1291 South 1100 East #202 Salt Lake City, UT 84105 www.peakacupunctureclinic.com info@peakacupunctureclinic.com CLIENT INFORMATION Client Name: If Patient
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
Average Daily Diet: Morning Afternoon Evening
Average Daily Diet: Morning Afternoon Evening Habits: Cigarettes Coffee Tea Cola Alcohol Drugs Sugar Salt Other Family Medical History: Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizure