LiveWell Chiropractic & Wellness

Transcription

1 LiveWell Chiropractic & Wellness ACUPUNCTURE PATIENT INTAKE PATIENT INFORMATION Date Date Patient Address City State Zip Sex: M F Age: DOB: Single Married Divorced Widowed Separated Patient SS# - - Occupation: Employer: Spouse s Name: Birthdate: SS# - - Occupation: Spouse s Employer: Whom may we thank for referring you? Name of Medical Doctor: Facility Ph. PHONE NUMBERS Home Cell Best time/place to contact you AM PM Home Cell In case of emergency, contact: Name Phone Acupuncture has been explained to me as a treatment consisting of inserting needles through the skin at specific points on the surface of the body, (small amount of electrical current may be applied to the needles). The purpose of acupuncture has been explained as the alleviation or cure of symptoms or disorders. Massage, acupressure, acupuncture, reflexology, preventative or corrective exercise and nutritional or herbal counseling are considered experimental procedures and are not considered a substitute for Western Medicine. Therapies and advice offered shall not be construed by the client to be a diagnosis of treatment of any disease or injury. It is recommended that you CONSULT YOUR PHYSICIAN for any serious conditions and get at least two medical opinions. It is your right and responsibility for your own body. I understand that complications can result from acupuncture treatment. Among these possible complications are areas of anesthesia, fainting, weakness, nausea, hematoma, infection, pain and discomfort, pneumothorax and aggravation to present symptoms. Client further understands and agrees to hold harmless, to indemnify and protect against court action the therapist, management and owners of this clinic, in the unlikely event of accidental injury on these premises. Signed Date

2 FAMILY MEDICAL HISTORY *Place X if applies to you, or indicate; Father, Mother, Brother, Sister, Grandparent Diabetes Stroke Hypertension Low Blood Pressure Heart Disease Cancer Psoriasis Lupus TB/Emphysema Kidney Disease Liver Disease Headache/Migraine Arthritis Osteoarthritis Rheumatoid Arthritis Spinal Problems Asthma IBS M.S. GURD Gout Stomach Ulcers Eye Disease Acid Reflux Mental Illness Epilepsy/Seizures Allergies/Sinus Bleeding Disorders Thyroid Dis. Alcoholism Drug Addiction Miscarriage Is there a possibility you are pregnant? YES NO Due Date MEDICAL HISTORY (Surgeries, Illnesses, Accidents) Year: Description Outcome: MEDICATIONS, VITAMINS, HERBS Medication Reason Year Started PRIMARY COMPLAINT Reason for visit When did symptoms appear? Is condition getting progressively worse? YES NO Unknown Rate the severity of your symptom on a scale of 1 (least) to 10 (severe) Please mark on picture at right to show where your discomfort is. Type of pain: Sharp Dull Throbbing Numbness Other Time of day it is worse AM PM What % of day in pain Does it interfere with Work Sleep Recreation Daily Routine Is there anything you do that relieves the symptom? What makes the symptoms worse? Have you ever had this symptom or condition before? YES NO Have you ever received treatment? YES NO If yes, when? By whom? What was the diagnosis?

3 CONTAGIOUS DISEASE (Check if you have ever had or currently have one of the following): Hepatitis AIDS HIV + Venereal Disease Herpes Other ALLERGIES LIFESTYLE HABITS: Alcohol: None Drinks/week Tobacco: None Cigarettes / Packs (circle one) per day. Caffeine: None Cups of Coffee / Tea / 12 oz. Sodas (circle one) per day. Sugar: Salt: Recreational Drugs: Stress Scale: EXERCISE: Never Little Moderate Heavy Type of exercise? EMOTIONS: Happy Worry Easily Irritable Difficulty making decisions Angry Sad Cry easily Hurry to do things Fearful Anxiety Over think or worry History of Depression DIET (please mark with x all foods eaten and cross off foods you avoid) Beef Eggs Cheese Grains Tofu Pork Bread Margarine Fried Food Yogurt Poultry Milk Ice Cream Sweet Health Bars Fish Butter Vegetables Salads Hot Spicy Other Cravings? Do you eat three meals per day? Yes No Do you eat at regular hours? Yes No what times do you eat? Appetite: Up and Down Poor Constant hunger Loss of taste Normal WEIGHT: Underweight Overweight Recent gain Recent loss Normal ENERGY: Up and Down Low Excess Tired in afternoon Wake up tired Low after eating Normal SLEEP: Difficulty falling asleep Lots of dreams Tired upon rising Awake easily Nightmares Sleep too much Difficulty going back to sleep Restless How many hours of sleep do you prefer? How many do you actually get?

4 General Symptoms BODY TEMPERATURE: Warm natured Cold natured Cold hands and feet Flushed face Warm palms/warm soles Feel warm late afternoon or night PERSPIRATION: Very little Easily Night sweats Profuse Palms Bad smell Without exertion Feet DIGESTION AND BOWELS: Indigestion Nervous Stomach Bloating Heartburn Nausea/Vomiting Full feel or distention Belch/burp Stomach noises Abdominal pain or cramps Gas Bad breathe Difficulties with fatty/oily food Bitter taste in mouth Gallstones Weight problems Ulcers BOWELS: How frequent do you have a bowel movement? times daily Loose stool Blood in stool Undigested food in stool Diarrhea Small amount of stool Stool with very bad smell Formed stool Black stool Constipation: for how long? Hard Stool Mucous in stool Anus itch Colon problems Burning anus Hemorrhoids Intestinal worms/parasites Pain or cramps Use of laxative URINATION: Frequent Burning Bladder infections HISTORY OF: Nighttime Blood Incontinence Kidney Stones Profuse Pus Strong smell Kidney infections Cloudy Scanty Painful Urgency Not normal color Genital pain Dribble urine Prostate problems Dribble urine during urination THIRST: Less than normal Prefer cold drinks Prefer hot/warm drinks Excessive thirst

5 HEADACHES - DIZZINESS: Headaches Vertigo Bend down/up dizziness Dizziness Motion sickness Poor balance Faint easily Migraines Poor memory SKIN: Dry Hives Clammy Oily Bruise easily Body odor Rashes Cuts heal slowly Boils Itching Yellow skin Eczema HAIR: Dry Dandruff Early grey Oily Falling out EYES: Wear glasses/contacts Cataracts Red Spots or lines in vision Glaucoma Dry Poor night vision Pain Itch Sensitive to light EARS: Poor hearing Ringing (high pitched) Discharges Ear ache Ringing (low pitched) NOSE: Current stuffy nose Hay fever/allergies Sneeze a lot Mucous Bleeding Loss of smell Sinusitis Rhinitis Date or season of last cold or flu

6 MOUTH AND THROAT: Dry Gum problems TMJ/Grind Hoarseness Sores in mouth/on tongue Thyroid problem Swollen glands Feel lump in throat Teeth problem RESPIRATORY: Shortness of breath Difficulty inhaling Cough with blood Chest pain Difficulty exhaling Dry cough Asthma Difficulty breathing when lying down Cough with Bronchitis Tightness in chest phlegm Sigh a lot CARDIOVASCULAR CIRCULATION: Diagnosed heart problems Low blood pressure High blood pressure Murmur Slow heart beat Irregular heart beat Palpitations High cholesterol Varicose veins Bruise easily Numbness of extremities History of anemia

7 FOR FEMALES ONLY: Are you pregnant? Yes No Maybe If yes, what is the approximate date of conception? Do you have regular Pap test? Yes No How regular? Do you do regular breast exams? Yes No How regular? GYNECOLOGICAL HISTORY AND OPERATIONS: Ovaries Breast Uterus Vagina Fallopian tubes Other What method of birth control do you now use? What method of birth control have you used in the past? PREGNANCIES: Total Number: Number of c hildren: Pregnancy or Childbirth complications: MENSTRUAL CYCLE: Age started: Age stopped: How many days between periods? How many days of flow? Describe flow: Does it begin as bright red or as a dark brownish red? What is the coloring at the end? PMS SYMPTOMS Irregular Clotting Backache Water retention Dark color flow Sigh a lot Light color flow Scanty flow Lump in throat feeling Abdominal bloating Heavy flow Constipation and/or diarrhea Painful or tender breast Painful Spotting in between cycle Breast lumps Tightness in chest Hormonal problems Emotional changes VAGINAL DISCHARGE: White Yellow Thick Bad Odor Clear OVULATION SYMPTOMS: Are you aware when ovulation occurs? Yes No If so, please describe the symptoms or sensations Menopausal problems? Yes No Please describe: