Heidi von Brockdorff, Dipl. OM, L.AC Eugene OR 97401 PATIENT INTAKE FORM Date: NAME: PHONE:HOME WORK STREET: AGE: HEIGHT: WEIGHT: CITY: BIRTHDATE: SEX: STATE: ZIP: OCCUPATION: EMPLOYER S NAME AND ADDRESS: MARITAL STATUS: # OF CHILDREN: PERSONAL PHYSICIAN: DATE OF LAST PHYSICAL EXAM: INSURANCE COMPANY: POLICY NUMBER: EMERGENCY CONTACT: RELATIONSHIP: PHONE: REFERRED BY: FAMILY MEDICAL HISTORY: Cancer Diabetes High/Low Blood Pressure Heart Trouble TB Allergies Kidney Disease Epilepsy Asthma Liver Disease Ulcers Sinus Problems Eye Disease Arthritis Alcholism Spinal Problems Mental Disorders Drug Addiction Other:
Age Parents Died: Mother Father PERSONAL MEDICAL HISTORY (Include date) Major surgeries Illnesses Diseases Accidents CONTAGIOUS DISEASES (Check if you have had one of the following): HIV+ AIDS Hepatitis Venereal Disease Herpes Other ALLERGIES (Drugs, chemicals, food, animals, seasonal, etc.) MEDICATIONS PRESENTLY TAKING: HABITS; Cigarettes (Tobacco) Soft Drinks Salt Coffee Alcohol Recreational Drugs Black Tea Sugar Stress EXERCISE: Never Little Moderate Heavy EMOTIONAL: Happy Easily Irritable Difficulty making decisions Angry Cry Easily Hurry to do things Depression Stressed Restless DIET: (Typical Foods): Beef Eggs Cheese Grains Tofu Pork Bread Margarine Fried Foods Yogurt Poultry Milk Ice Cream Sweets Health Foods Fish Butter Vegetables Salads Hot Spicy Food Cravings Do you eat 3 meals per day? Do you eat at regular hours?
APPETITE: Up and Down Poor Good Hungry a lot Loss of Taste WEIGHT: Normal Underweight Overweight Recent Gain Recent Loss ENERGY: Up and Down Low Normal Excess Low after eating Tired in the afternoon MAJOR COMPLAINT, INJURY OR ILLNESS DATE BEGAN: HOW DID THE CONDITION START: HAVE YOU HAD THIS CONDITION BEFORE? HAVE YOU RECEIVED TREATMENT FOR THIS CONDITION? IF YES, WHEN? BY WHOM? WHAT WAS THE DIAGNOSIS? WHAT WERE THE RESULTS FOR THE TREATMENT? HAS THE CONDITION GOTTEN: Better Worse Is about the same WHAT MAKES IT BETTER? WHAT MAKES IT WORSE? BODY TEMPERATURE: Warm natured Flushed face Feet warmer late afternoon and night Cold Natured Warm Palms Alternate chills and fever Cold Hand and Feet Warm Soles Normal PERSPIRATION: Very Little Easily Night sweats Profuse Palms Bad smell Without exertion Feet Normal
DIGESTION: Indigestion Nervous stomach Bloating Heartburn Nausea/Vomiting Full feeling or distention Belch or burp Stomach noises Abdominal pain or cramps Gas Bad breath Difficulty digesting fats & oils Bitter taste in mouth Gallstones Weight problems Normal Other BOWELS: Loose stool Blood in Stool Undigested food in stool Diarrhea Hemorrhoids Stool with bad smell Constipation Anus Itch Mucous in stool Colon problems Burning anus Small amount of stool Black stool Hard Stool Intestinal worms Pain or cramps Use laxatives Normal URINATION; (three to four times per day is normal): Frequent Burning Bladder infections Urgency Nightime Blood Incontinence Kidney stones Profuse Pus Strong smell Cloudy Scanty Painful Not normal color Kidney infection Normal THIRST: Less than normal Prefer cold drinks Thirsty but do not drink Prefer hot drinks Excessive Normal SLEEP: Difficulty falling asleep Lots of dreams Wake up tired in a.m. Awake easily Nightmares Sleep too much Difficulty going back to sleep Restless Normal
HEADACHES DIZZINESS; Headaches Vertigo Bend down and stand up getting dizzy Dizziness Motion sickness Poor Balance Faint easily Migraines Poor memory SKIN: Dry Hives Clammy Oily Pimples Bruise easily Rashes Moles Cuts heal slowly Itching Warts Yellow skin Eczema Boils Normal Ulcers Body odor HAIR: Dry Oily Dandruff Falling out Early grey Normal NAILS: Soft Break easily Spots Grow slowly Pale Grow fast Ridges and lines Purple Normal EYES: Wear glasses or contacts Eyelids swollen Cataracts Red Spots or lines in vision Inflammation Glaucoma Dry Pale under eyelids Yellow sclera Blink Itch Poor night vision Failing vision Twitch Pain Sensitive to light Sty history Strain Normal Color blindness Blurry vision Tear easily EARS: Poor hearing Ringing (high pitch) Discharges Ear aches Ringing (low pitch) Normal MOUTH AND THROAT: Dry Gum problems Hoarseness Frequent sore throats Sores in mouth/tongue Frequent colds Difficulty swallowing TMJ Dry cracked lips Thyroid problems Hiccups Drool a lot
Swollen glands Grind teeth Normal Feel lump in throat Teeth problems RESPIRATORY: Shortness of breath Difficulty inhaling Sigh a lot Chest pain Difficulty exhaling Dry cough Asthma Difficulty breathing Cough with phlegm Bronchitis when lying down Cough with blood Tightness in chest Cough a lot Normal Other CARDIOVASCULAR: Diagnosed heart problems Palpitations Broken blood vessel/capillaries Low blood pressure Bleed easily Purple palms and fingers High blood pressure High cholesterol Ankle swelling Murmur Varicose veins Facial swelling History of anemia Chest pain Hand swelling Slow beating of heart Bruise easily Irregular heart beat Numbness in extremities Normal PAIN: Low back Shoulder Muscle weakness Sciatica Hands or wrists Muscle cramps Upper back Hips Muscle twitching or spasm Mid back Knees Damp weather Neck Foot or ankle Nerve Spine Arthritis Flank pain ANY OTHER PROBLEMS YOU WOULD LIKE TO DISCUSS FOR MALES ONLY: (Please check or explain if applicable) Reduced sex drive Premature ejaculation Seminal emission Impotence Discharges Genital pain
Prostate problems Pain or burning urination Dribbling If you are male, congratulations you have just completed this form. If you are female, please continue. ARE YOU OR MIGHT YOU BE PREGNANT? Yes No Maybe IF YES, THE APPROXIMATE DATE OF CONCEPTION? ARE YOU EXPERIENCING REDUCED SEX DRIVE? YES NO OTHER DIFFICULTIES? Yes No EXPLAIN DO YOU HAVE REGULAR PAP TESTS? YES NO DATE OF LAST DO YOU HAVE REGULAR BREAST EXAMS? YES NO DATE OF LAST DO YOU HAVE FACIAL HAIR OR EXCESS BODY HAIR? YES NO MENSTRUAL CYCLE: (Please check and explain as applicable) Age started Days of flow Age stopped HOW MANY DAYS FRFOM THE BEGINNING OF YOUR PERIOD TO THE START OF YOUR NEXT PERIOD? Irregular Painful Heavy Flow Scanty flow Dark Color flow Light Color flow Clotting Fluid retention Abdominal bloating Painful or tender breasts Breast lumps Emotional changes Spotting between periods Lump in throat feeling Constipation or diarrhea Tightness in chest
Hormonal problems Backache Sigh a lot VAGINAL DISCHARGE: Yellow Thick Bad odor White Clear Other OVULATORY SYMPTOMS: MENOPAUSAL SYMPTOMS: PREGNANCIES: Total number Number of live births Number of miscarriages Number of therapeutic abortions PREGNANCY OR CHILDBIRTH COMPLICATIONS: GYNECOLOGICAL HISTORY AND OPERATIONS: METHOD OF BIRTH CONTROL USED? DATE:
CHIEF COMPLAINT: Location: Quality: Duration: Intensity: (1-10 scale, 10 being worse) Frequency: Onset: Radiation: Timing: Paliative/Aggravating factors: PHYSICAL EXAM: BLOOD PRESSURE: TONGUE: PULSE: Rate: Rhythm: Right: Left: DIAGNOSIS: TCM DIAGNOSIS:
TREATMENT PLAN: Next scheduled treatment date: Next schedules examination date: ACUPUNCTURE PRESCRIPTION; HERBAL PRESCIPTION: MODALITIES USED: (Including Tui Na, Gua Sha, Electro-stimuation, Cupping, Moxabustion) Patient Instructions: Provider signature: Date: