Mountain Spirit Acupuncture 12201 Pecos Street Suite 100 Westminster, CO 80234 303-929-7334 Pregnancy Intake Name: Birth Date: / / Age: Address: City: State: Zip: Preferred Phone #: Home Cell Work Ok to leave messages? Yes No How did you hear about Mountain Spirit Acupuncture? Friend (Who?) Internet Mail-out MD / Midwife Other Emergency Contact: Relation: Phone #: Successful health care is only possible when the practitioner has a thorough understanding of the patient physically, mentally and emotionally. Please complete the following questionnaire as thoroughly as possible. Are you currently receiving health care? Yes No If yes, where and from whom? If no, when and where did you last receive health care? MAIN HEALTH CONCERNS PRIMARY COMPLAINT: Symptoms: How long have you had this? Is your condition: Getting worse Staying constant Coming & going Have you had this in the past? Yes No How did it begin? What aggravates it? What relieves it? What other healthcare practitioners have you seen about this? Type of care given? Was it effective? SECONDARY COMPLAINT: Symptoms: How long have you had this? Is your condition: Getting worse Staying constant Coming & going Have you had this in the past? Yes No How did it begin? What aggravates it? What relieves it? What other healthcare practitioners have you seen about this? Type of care given? Was it effective? Are your complaints affecting your ability to work or otherwise be active? No effect Yes Some physical restrictions Need limited assistance Need assistance often Can't care for self Is today's visit due to a Motor Vehicle Collision? Yes No If yes, when? Have you ever had acupuncture before? Yes No Do you have any chronic infections diseases? Yes No If yes, explain: Are you suffering from any chronic illnesses? Yes No If yes, explain:
Significant diseases, injuries, hospitalizations, surgeries, x-ray/ct/mri/nmr Reason Date Results (if applicable) Please list any prescription medications, over the counter medications, vitamins or supplements that you are currently taking, and give your dosage. Medication/Vitamin/Supplement Dosage Frequency Reason Please list any foods, drugs, substances or medications you are hypersensitive or allergic to: Please check any immunizations that you have had: Polio Tetanus Measles/Mumps/Rubella (MMR) Pertussis Diphtheria Hepatitis B Influenza Other: Family History Mother Father Brother(s) Sister(s) Age if living Health G = Good, P = Poor Age at death if deceased Cause of death Family Illnesses Mother Father Brother(s) Sister(s) Allergies Cancer Diabetes Heart Disease High Blood Pressure Kidney Disease Stroke Mental Illness PLEASE FILL IN WHAT APPLIES TO YOU I am pregnant This is my first pregnancy I'm carrying one twins more: I'm due: I'm weeks Starting maternity leave: (approx date) I'm planning on having a month maternity leave. I have birthed one or more babies in the past Youngest <-----------------------------------------------------------------------------------------------------------> Oldest Birth date: Child's age: Cesarean birth: < 38 wks gestation Birth was induced CURRENT &/OR PAST PREGNANCIES Please indicate any pregnancy complications that you have experienced (miscarriage, ectopic pregnancy, premature labor, (pre) eclampsia, gestational diabetes, etc):
Please indicate any conditions you have experienced either in this pregnancy (first box, C) or if you have experienced this condition prior to pregnancy (second box, P): C / P C / P C / P C / P Muscle cramps Varicose veins Vulvar varicosities Other pain: Headaches Sinus concerns Hemorrhoids Carpal tunnel pain Anxiety/Depression Neck pain Sciatica Fatigue Upper back pain Constipation/Gas Nausea Mid back pain Restricted breathing Stress Low back pain Cramping/bleeding Swelling (edema) High/low blood pressure Pelvic pain Breech General Symptoms C / P C / P C / P Poor appetite Poor Sleep Poor circulation Large appetite Dream disturbed sleep Vertigo or dizziness Strongly like cold drinks Heavy sleep Fatigue Strongly like hot drinks Bodily heaviness Lack of strength Peculiar taste Chills Shortness of breath Cravings Fever Muscle cramps Sweats easily Bleed or bruise easily Anemic Night sweats Cold hands or feet History of Cancer Prolapsed organs What type: When: Endocrine and Metabolic Disorders Hypothyroidism Hyperthyroidism Hypoglycemia Adrenal burnout / fatigue Diabetes Mellitus Night sweats Sweats easily Weight gain Weight loss Head, Eyes, Ears, Nose, Throat Headaches Glaucoma Grinding teeth Migraines Night blindness Sinus problems Facial pain Sores on lips or tongue Enlarged thyroid Glasses or Contacts Swollen glands Excessive phlegm Poor vision Dry mouth Ear aches Blurred vision Excessive saliva Ringing in ears Eye strain Recurrent sore throat Poor hearing Red eyes Lumps in throat Gum problems Itchy eyes TMJ problems Eye pain Spots or floaters in eyes Teeth problems Concussions Respiratory Difficulty breathing when lying down Color of phlegm Pneumonia Shortness of breath Frequent colds Tight chest Coughing blood Persistent cough Cough Wet or dry (circle one) Asthma / Wheezing Cardiovascular High blood pressure Fainting Irregular heart beat Tight chest Difficulty breathing Heart disease Chest pain Heart palpitations Blood clots Pace maker Low blood pressure Are you currently taking Coumadin, Warfarin or any other blood thinners? Yes No Genito-Urinary Pain when urinating Frequent urination Wake to urinate Blood in urine Bed wetting Incomplete urination Venereal disease Unable to hold urine Kidney stone Increased libido Decreased libido Incontinence Urgency to urinate Difficulty urinating Urinary output equal to liquid intake? Yes No
Gastrointestinal C / P C / P C / P Bowel movements: Itchy anus Hemorrhoids Frequency: Anal fissures Nausea Texture/Form: Black stools Vomiting Color: Bloody stools Acid regurgitation / Heart burn Odor: Gas Bad breath Diarrhea Bloating Frequent hiccups Constipation Intestinal pain or cramping Gallbladder disease Laxative use Burning anus Liver disease Mucous in stool Rectal pain Incomplete bowel movement Undigested food in stool Fatigue after eating Skin and Hair Rashes Change in hair / skin texture Fungal infections Eczema Hives Ulcerations Dandruff Psoriasis Acne Hair loss Itching Neuropsychological Seizures Numbness Anxiety Poor Memory Depression Abuse survivor Irritability Easily stressed Mental fogginess Stroke Mood swings Loss of balance Mental tension Anger easily Paralysis Considered or attempted suicide Tics When: Musculoskeletal pain Please fill out the Pain Management Intake. Your diet Appetite: Low Strong Too busy to notice Coffee (#/day) Artificial sweeteners Energy Drinks Soft drinks (#/day) Red meat Dairy Water (#/day) How frequently: How frequently: Frequent thirst Decreased thirst Yesterday's breakfast: Lunch: Dinner: Snacks: Is this a typical day? Yes No Your lifestyle Alcohol Marijuana Tobacco How often? How often? How much? Occupational hazards Other recreational drug use Exercise Type: Frequency: Stress Cause: Occupation: Hours/week: Do you enjoy your job? Yes No Your sleep Difficulty falling asleep Difficulty staying asleep Wake feeling rested Vivid dreams Good sleep quality Poor sleep quality Frequent waking What time: For how long:
Menstrual History Age menses began: Number & years: Age menopause began: Pregnancies: Date of last menstrual period: Children: Are you pregnant, or is there a chance you are pregnant? Yes No Abortions: If yes, how many weeks? Miscarriages: Are your periods painful? Yes No D&C or D&E: If so, how many days does the pain last? Complications: What is the quality of pain? Sharp Dull Burning Cramping Fixed Moving How many days do you typically bleed? Do you get yeast infections regularly? Yes No How heavy is the bleeding? Light Moderate Heavy Have you ever had a venereal disease? Yes No What day is the heaviest? Have you ever been diagnosed with Chlamydia? Yes No What color is the blood? Light red Red Dark red Do you have chronic vaginal discharge? Yes No Brown Black If yes, what color? Is there clotting? Yes No if yes, what size: Does it have a smell? Yes No Average number of days in your cycle? If yes, what does it smell like? Do you bleed or spot between periods? Yes No Have you ever had pelvic inflammatory disease? Yes No Do you have premenstrual tension? Yes No If yes, were you treated for it? Yes No Does your face break out before your period? Yes No Treatment method: Does your face break out during your period? Yes No Do you have premenstrual breast tenderness? Yes No Have you ever been diagnosed with uterine Do you retain water during your period? Yes No fibroids or polyps? Yes No Do you get premenstrual low back pain? Yes No Have you ever been diagnosed with endometriosis? Yes No Do you have loose bowel movements at the Have you been diagnosed with pelvic adhesions beginning of your period? Yes No or abnormalities? Yes No Have your cycles changed since they began? Yes No Have you been diagnosed with PCOS (Poly Cystic If yes, describe: Ovary Syndrome)? Yes No Have you taken any medications other than Do you ovulate on your own? Yes No contraceptives for gynecological conditions? Yes No On what day of your cycle? Medication Reason How long? Do your breasts get tender at/during ovulation? Yes No Date of last pap smear: Have you ever had an abnormal pap smear? Yes No Is there anything else about you or your health history you feel we should know about?