ACUPUNCTURE MEDICAL HISTORY PATIENT INFORMATION Date: / / Name (Last) (First) (MI) Date of Birth: / / Height: Weight: Month Day Year TREATMENT INFORMATION Please fill this out to the best of your ability: Have you ever been treated with Naturopathy, Acupuncture, Chinese Herbs, Bodywork? Yes No If yes, what condition and by whom (include phone number): What is the purpose of your visit?: What medical diagnosis have you received and by whom?: How long have had this condition?: Was the onset: Sudden Gradual Symptoms are relieved by: Have you had this problem before? Yes No Symptoms are made worse by: Place an X on the line below that best rates the severity/intensity of this complaint on a scale of 1-10: 0 10 Place an X on the line below that best rates your distress level on a scale of 1-10: 0 10 What other treatments have you received recently for this and/or other conditions?: Medications/Supplements Dosage Purpose for taking Page 1 of 7
Family Physician/Internist name: Phone: ( ) Date of last doctor s visit/exam: / / Date of next visit/exam: / / MEDICAL HISTORY Check all that apply AIDS/HIV Alcoholism Asthma Bleeding Disorder Blood Clots Cancer Childbirth Trauma Cytomegalo Virus Diabetes Eczema Emphysema Epstein Bar Heart Disease Hepatitis A/B/C Herpes I/II High Blood Pressure Low Blood Pressure Lyme disease Lymph Node Excision Mononucleosis Multiple Sclerosis Pacemaker Polio Prosthetics Repetitive Strain Injury Rheumatic Fever Rheumatism Scarlet Fever Seizure Disorder Tendonitis Tuberculosis Urinary Tract Infection : Allergies List reactions (such as hives, rash, shock, tongue swelling, breathing difficulty, etc.): None Medications Food Family Medical History (please list any significant family illness): Mother: Father: Siblings: Grandparents: Major injury history (childhood through adulthood): Surgery history (any, including c-section, dental, plastic etc.): Imaging X-Rays, MRI, CT (specify by name and dates of studies & results if known): LIFESTYLE FACTORS Caffeine consumption: Yes No If yes, how often? Alcohol consumption: Yes No If yes, how often? Recreational drugs: Yes No If yes, which substance(s)?: Smoking: Yes No If yes, how many packs/day? Exercise and Energy How is your energy level? What time of the day is your energy?: Highest: Lowest: Do you fatigue easily?: What type of exercise do you participate in and how often?: Page 2 of 7
Emotions and Sleep How do you feel emotionally?: During the past month, have you often been bothered by: Feeling down, depressed or hopeless? Yes No Little interest or pleasure in doing things? Yes No Stress Levels: Please mark with an X on this scale None Unmanageable How many hours of sleep do you get per night? Do you have difficulty falling asleep? Yes No Do you have difficulty staying asleep? Yes No Where do you hold stress?: How do you relax or reduce stress?: How do you feel about your work or profession?: How do you feel about your relationship with your spouse or significant other?: GENERAL Check all that apply Chills Fatigue Fever Night Sweats Weight Gain Weight Loss SKIN AND HAIR Check all that apply Acne Bruising Dryness Hair Loss Hives Itching Premature Graying Rash EYES, EARS, NOSE, THROAT, AND HEAD Check all that apply Bleeding Gums Blurred Vision Double Vision Dry Mucous Membranes Ear Pain Eye Pain Eye Redness Frequent Colds Headache Hearing Loss Hearing Problems Nasal Congestion Nasal Drainage Nose Bleed Oral Ulcers Rhinitis Ringing in the Ears Runny Nose Seasonal Allergies Sinus Pain Sore Throat Tinnitus Vertigo Visual Disturbances Visual Problems Headaches/migraines: Yes No If yes, where on your head the headaches/migraines manifest? Are you aware of any triggers? Page 3 of 7
RESPIRATORY Check all that apply Bloody sputum Chronic Cough Difficulty Breathing Sputum Production CARDIOVASCULAR Check all that apply Abnormal Blood Pressure Chest Pain Cold hands and feet Hypertension Irregular Heart Beat Palpitations Phlebitis Have ever been diagnosed with heart trouble?: Yes No Poor Circulation Swelling of Extremities GASTROINTESTINAL (GI) PROFILE Check all that apply Abdominal Pain Belching Bloating Bloody Stool Constipation Diarrhea Gas Heartburn Hemorrhoids Indigestion Itchiness Laxative Use Pain with Bowel Movement Ulcer Undigested food in stool Vomiting Bowel movements: How often? day/wk Do you frequently have painful bowel movements?: Yes No UROGENITAL Check all that apply Change in urinary stream Difficulty Emptying Bladder Dribbling when sneezing Frequent urination Incontinence Pain on urination Stress Incontinence Urinary tract infection How many times per day do you urinate?: Color : Pale yellow Dark yellow/orange Do you have trouble starting a stream: Yes No How is your sexual energy?: What type of birth control do you use?: Do you have infertility: Yes No What was determined to be the cause of your infertility: MEN Check all that apply Impotence Premature ejaculation Prostatitis Penile blood/mucous discharge I have had a recent prostate exam Page 4 of 7
WOMEN Check all that apply Absence of Menstruation Clots Dysmenorrhea (painful menses) Heavy Menstrual Cycle Hot Flashes Infertility Light Scanty Cycle Menstrual Irregularities Moodiness/Irritability Night Sweats Spotting between periods Vaginal Discharge Vaginal itching/burning I am or may be PREGNANT I have had a recent pelvic exam (PAP) I have had a recent mammogram or breast exam Please indicate current or previous menstrual conditions even if now menopausal: At what age did you start menstruating?: Number of days between cycles: Number of days of menstrual flow: Color of flow: Do you have any vaginal discharge?: Y N Amount: Color: Frequency: Do you have any blood or mucous breast discharge?: Y N Amount: Frequency: PMS symptoms: Menopausal symptoms: Number of pregnancies: Number of deliveries: Abortion (s)/miscarriage: MUSCLES, JOINTS, AND BONES Check all that apply Back Pain Decreased Range of Motion Joint Pain Joint Swelling Muscle Pain Neck Pain Do you have pain, tenderness, or tightness?: Y N If yes, where?: Is your pain worse or better with heat or cold?: Is your pain worse in the AM PM What makes your pain symptoms BETTER? What makes your pain symptoms WORSE? NEUROLOGICAL Check all that apply Auras Muscle Twitching Numbness Tingling PSYCHIATRIC Check all that apply Anxiety Depression Difficulty Concentrating Difficulty Sleeping Easily Irritated Fearful Memory Loss Nervousness Panic Attacks ENDOCRINE Check all that apply Cold Intolerance Libido Change Sexual Dysfunction HEMATOLOGY Check all that apply Easy Bleeding Easy Bruising Page 5 of 7
PAIN Check all that apply Sharp Burning Aching Dull Numbness Superficial Tingling Deep Tingling On the following drawings, please shade in areas you feel should be addressed. Page 6 of 7
INFORMED CONSENT FOR ACUPUNCTURE & ORIENTAL MEDICINE TREATMENT Washington State Law (18.06.130 RCW) requires East Asian medicine practitioners to use this document to inform the public of the practitioners scope of practice and qualifications. Each patient must receive this in writing prior to or at the time of the initial patient visit. (246-803-300 WAC) CERTIFICATION & LICENSES Washington State East Asian Medicine Practitioner (EAMP), License #AC60571985, 2015-present Colorado Department of Regulatory Agency, Acupuncture License, #ACU.0002054, 2014-2015 Iowa Board of Medical Examiners, Licensed Acupuncturist, #A-50, 2007 2014 Council of Colleges of Acupuncture and Oriental Medicine. Clean Needle Technique Certificate, 2006 National Commission for the Certification of Acupuncture and Oriental Medicine, Diplomat in Acupuncture, 2007 American Association of Acupuncture & Oriental Medicine member (AAAOM) No License, certificate, or registration in a health care occupation has been revoked by any local, state, or national health care agency. INFORMED CONSENT FOR ACUPUNCTURE & ORIENTAL MEDICINE TREATMENT I hereby request and consent to the performance of acupuncture treatments and other East Asian Medicine procedures, including various modes of physiotherapy on me (or the patient named below, for whom I am legally responsible) by the acupuncturist named below. I understand that methods of treatment may include, but are not limited to: acupuncture, moxibustion, cupping, gua sha, electrical stimulation, breathing techniques, exercise therapy, heat and cold therapies, tui-na (East Asian bodywork), herbs and nutritional counseling. I have been informed that acupuncture is a safe method of treatment, but that it may have side effects including but not limited to: bruising, numbness or tingling near the needling sites, and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Infection is another possible risk, although the acupuncturist below uses sterile disposable needles and maintains a clean safe environment. I understand that other side effects and risks may occur. I do not expect the acupuncturist to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the acupuncturist to exercise judgment during the course of treatment which the acupuncturist thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. Patients with bleeding disorders or pacemakers should inform the practitioner prior to receiving treatment. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Rachel S. Weissman, LAc regarding cure or improvement of my condition. I have had an opportunity to ask questions. I hereby release Rachel S. Weissman LAc from any and all liability, which may occur in connection with the above-mentioned procedures, except for failure to perform the procedures with appropriate medical care. I intend this consent form to cover the entire treatment for my present condition ad for any future condition(s) for which I seek treatment. I understand that I am free to withdraw this consent and to discontinue participation in these procedures at any time. Date: / / Patient- Age 18 or older Date: / / Signature of Patient, Parent or Legal Guardian) proclub.com (425) 895-6505 Page 7 of 7