Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT

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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 is a Minor, Guardian s Name: Date of Birth: Age: Address: City: State: Zip: Primary Telephone Number: Secondary # Email (please write legibly): Emergency Contact Information : Name: Telephone Number: Relationship: Date of last physical exam: / / Physician: Have you ever received acupuncture before? What other type of treatment are you currently receiving? REASONS SEEKING TREATMENT There will be ample time during your initial intake to elaborate on the following questions. 1. What are the main health problems for which you are seeking treatment? How long have you had this condition? The onset was sudden gradual Medical diagnosis, if any? Please rate the extent which your current complaint affects daily life (1 = minor; 10 = major) What other forms of treatment have you sought, and what were your results? 2. What are the main health problems for which you are seeking treatment? How long have you had this condition? The onset was sudden gradual Medical diagnosis, if any? Please rate the extent which your current complaint affects daily life (1 = minor; 10 = major) What other forms of treatment have you sought, and what were your results? - 1 -

MEDICATIONS Please list any medications, supplements, herbs or vitamins you are taking, including all over the counter medications: Medications/ Supplement Duration of usage Dosage/ Frequency Treating which condition? HEALTH HISTORY Please describe any significant injuries, surgeries, or illnesses: Childhood: Age Adolescence: Age Age Adulthood: Year Cancer or tumors Diabetes Hepatitis HIV/ AIDS Other Infectious Disease Multiple Sclerosis Blood or Bleeding Disorders Seizures High Blood Pressure Heart Disease Stroke/ Blood Clots Thyroid Disorder Osteoporosis Lyme Disease Alcoholism Depression or mental illness Age of death Self Mother Father Sibling Spouse - 2 -

Please assign a number of severity (1 = lowest, 10 = highest ) to any symptoms you have experienced in the last three month. Place a P to any symptoms you have experienced in the past. Head and Neck Headaches Migraines Stiff Neck Low Back Pain Gastrointestinal Belching Nausea Vomiting Stomach pain Gas Acid regurgitation Heartburn Indigestion Excessive hunger Poor appetite Bloating after meals Hemorrhoids Irregular bowel movements Diarrhea Constipation Loose Stools Blood in stool Undigested food in stool Average Number of Bowel Movements? Per Day Per Week Respiratory, Nose, Throat and Mouth Asthma Allergies Frequent colds (3 or more per year Chronic cough Coughing blood Chronic runny nose Frequent sore throat Difficulty swallowing Dry mouth Sinus infections Excessive phlegm Nasal congestion Nose bleeds TMJ Cold sores Bleeding gums Difficulty Inhaling Wheezing Shortness of breath Emphysema Neurological Dizziness Fainting Loss of balance Lack of coordination Areas of numbness Poor memory Tremors Numbness or tingling Epilepsy/seizures Concussion Vertigo Ears and Eyes Ear pain Ringing in ears: high / low pitch Clogged / popping ears Decreased hearing Red eyes Poor vision See spots Skin and Hair Dry skin Acne Bruise easily Skin rashes Psoriasis Itching Eczema Changes in moles or lumps Hair loss Premature graying Night sweating Excess sweating Cardiovascular High blood pressure Low blood pressure Palpitations Chest pain Irregular heartbeat Varicose veins Poor circulation Anemia History of heart attack - 3 - Genito-Urinary Pain on urination Frequent urination Urgent urination Blood in urine Incomplete urination Decreased libido Impotence Premature ejaculation Nocturnal emission Lumps in testicles Pain/ itching of genitalia History of sexually transmitted disease: self/ partner Gonorrhea Chlamydia Syphilis Herpes: _ Oral/ _ Genital Sleep What time do you go to bed? What time do you wake? Do you feel refreshed when you wake? Do you have trouble Falling asleep Staying Asleep Nightmares Disturbed Sleep

LIFESTYLE Food and Drink: Please Describe Typical Meals: Breakfast: Lunch: Dinner: Snacks: Do you have any food cravings? List any food intolerances: What % of your diet is organic? On average, how often are you consuming? Red meat Fast food All vegetables Leafy green vegetables Products made of wheat flour Dairy Days per week? More then once a day? In ounces, how much plain water are you drinking? ounces (A typical glass is 8oz, a Nalgene bottle is 32 oz) What else are you drinking? Caffeine # of coffees per day # of teas per day # of sodas per day Tobacco # of cigarettes/cigars per day Age began use? Alcohol Average drinks per day? Per Week? Age began use? Marijuana Specify Frequency Age began use? Hard drugs (cocaine, crack, heroin, LSD, etc.) Specify Frequency Age began use? Systems Energy and Temperature: What is your energy level (From 1 = lowest to 10 = highest)? What time of day is your energy: Highest? Lowest? What kind of exercise do you do? On average how often do you exercise? minutes/hrs days per week. In general, does your core feel hot or cold? Cold Hands & Feet? - 4 -

Muscles, Joints and Bones: Please indicate where you are experiencing pain. What is the current level of pain, from 1-10? Onset? The pain feels worse with: The pain feels better with: The pain is please check all that apply: Constant Dull Tingling Aching Comes and goes Superficial Numb Fixed Sharp Deep Burning Moves around Women: At what age did you start menstruating? Age at onset of menopause Number of days in your cycle? Duration of flow? Color? Clots? Quality? (thick, thin) PMS Symptoms Are you currently pregnant? Yes No Number of pregnancies? Number of deliveries? Abortions/Miscarriage(s)? Are you presently trying to get pregnant? Yes No Have you taken any medications to enhance fertility? Medication? Dates/ Duration Have you undergone any fertility treatments? Procedures/ dates of procedues: 1. 3. 2. 4. CHECK any current symptoms. CIRCLE any symptoms that have affected you in the past. Heavy flow Irregular menses Uterine Fibroid No flow Discomfort following menses Reoccurring yeast infections Light flow Discomfort before menses Reoccurring UTIs Spotting between menses Discomfort during menses Breast lumps Date of last pap smear? Results of the last 2 pap smears? - 5 -

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