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Transcription:

Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred Phone Email Birth Date (include year) Age Gender Occupation Employer Referred by Emergency Contact: Name Phone Fees: It is our policy that you pay the entire session fee or co-pay at the time of each session. We will provide a minimum of one month s notice of any changes to our fees. Insurance Company Insurance Company Phone Number (Provider Line) ID # Please bring a photocopy of your insurance card (front and back) or bring your card to your first appointment so we can make a copy at the clinic. Cancellation Policy: If you need to change or cancel your appointment please do so with a minimum of 24 hours notice. Failure to do so will result in being charged the equivalent of the cash rate of the missed appointment to your account. I understand the cancellation policy. Signature: Date: / / (continued onto next pages)

Health History Have you had acupuncture before? If so, for what reason? Main issue(s) you are seeking treatment for: Diagnosis from a medical professional (if applicable): Please mark any areas of pain or discomfort: Please check any symptoms that you have experienced in the past or currently experience: General sweating easily during the day fatigue night sweating fevers bleed or bruise easily chills change in appetite weight loss/gain dizziness/vertigo poor sleep Skin & Hair rashes/hives psoriasis eczema loss of hair acne

Head, Ears, Eyes, Nose & Throat earaches/pressure in the ears headaches/migraines ringing in the ears sinus pressure hearing loss nose bleeds eye floaters dizziness/vertigo itchy eyes teeth/jaw clenching blurry vision Cardiovascular/Circulatory chest pain swelling/edema fainting high blood pressure lightheadedness low blood pressure cold hands & feet Respiratory pain on inhaling sneezing chest tightness seasonal/other allergies cough phlegm production asthma Genito-Urinary difficulty urinating urgent/frequent urination blood in urine sores on genitals pain upon urination genital pain

Neurological/Psychological anxiety poor memory depression quick temper loss of balance/coordination easily susceptible to stress areas of numbness/paralysis Digestive heartburn gas belching diarrhea bloating constipation nausea abdominal pain/cramps vomiting mucus in stool chronic bad breath blood in stool sores on lips/tongue hemorrhoids For Women Only: irregular periods breast pain painful periods vaginal discharge bleeding between periods vaginal sores period clots hot flashes menstrual cramping night sweating age of first menses duration of typical period duration of typical cycle date of last PAP # of pregnancies # of live births (+ years) # of miscarriages # of abortions Have you been through menopause? Age? Have you ever taken birth control pills? When and for how long?

For Women Only (continued): Other premenstrual & menstrual symptoms (bloating, breast tenderness, irritability, mood swings, fatigue, loose stools, acne, etc.) For Men Only: erectile dysfunction/impotence ejaculatory pain varicocele BPH Lifestyle Current medications/herbs/supplements: Do you follow any certain diet or way of eating? (vegetarian, gluten-free, paleo, etc.) Current exercise routine:

Do you use tobacco? If so, how often? Do you drink alcohol? If so, how many drinks/week? Are you currently taking any of the following medications? (circle if yes and indicate how often) Advil/Motrin/Ibuprofen Aleve/Naproxen Bayer/Aspirin Celebrex/Celecoxib Prednisone/Prednisolone Are you currently taking any other pain medications? If yes, list name and amounts per day: Allergies (medications/foods/chemicals/etc.): Have you ever had a seizure? If yes, indicate date of last: Please circle any significant illnesses and indicate date: Cancer Hepatitis Diabetes High blood pressure Epilepsy Heart Attack Stroke Ulcer Disease Liver Disease Colon Polyps Other Please list any major surgeries/hospitalizations and approximate dates: _

Family Medical History Cancer Seizures High blood pressure Stroke Diabetes Heart Attack Hepatitis Asthma Other Please list any other relevant information or issues you would like to discuss: Thank you for taking the time to fill out these forms. Please let us know if you have any questions or concerns.

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