*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City: State: Zip code: Home phone: Work Phone: Cell: Date of Birth: Age: Email: Legal Guardian name (if under 18 years old) Emergency Contact info: (Name Relationship Phone) Gender: Height: Weight: Relationship status: Employer: Occupation: 1
Have you had Acupuncture before? If so where? How did you hear about our office? Major Complaints What are your major health concerns for which you are seeking treatment and approximate date they started? 1. (Date) 2. (Date) 3. (Date) Medical History Do you have any known Allergies? Please List any Surgeries and approximate date of occurrence? Please list any other traumas/ accidents/ injuries? Have you experienced any emotional trauma s (abuse, loss of a loved one, divorce etc.) please explain? 2
Please check any conditions that you have experienced in the past: Asthma HIV Mumps Bleeding Disorder Jaundice Nervous Disorder Cancer Kidney Disease Paralysis Chicken Pox HIV Pneumonia Diabetes Liver Disease Polio Emphysema Lung Condition Rheumatic Fever Epilepsy Measles STD Glaucoma Meningitis Stroke Hepatitis Migraines Thyroid Condition Heart Disease Mononucleosis Tuberculosis High Blood Pressure Multiple Sclerosis Vein Condition Please check all symptoms you currently experience: General Temperature: Hot body sensation Cold Body Sensation Heat in hands, feet Hot flash Cold hands/feet Night sweats Perspires easily Thirst Energy Levels: Low energy Difficult keep eyes open (daytime) Shortness of breath General weakness Blood Function: Worse with exertion Dizziness Brittle nails Numbness Tingling sensation Heart function: Palpitations Anxiety Restlessness Sores on tip of tongue Chest pain Mental Confusion Spleen function: Abdominal gas Low appetite Bruise easily Abdominal bloat Crave sweets Overthink / Worry Loose stools Gurgling sounds Hemorrhoids Weight gain Weight loss Fatigue after eating Prolapsed organs Undigested food particles in stool 3
Stomach function: Heartburn Acid reflux large appetite Bad breath Canker/ mouth sores Belching Hiccups Vomiting Ulcer Swollen, painful, bleeding gums Stomach pain Burning feeling after eats Intestine Function: Constipation Incomplete stools Blood in stool Mucous in stool Diarrhea Dampness in the body: General heaviness Swollen hands Swollen feet Swollen joints Mental heaviness Mental fogginess Mental sluggishness Chest Congestion Lung function: Frequent colds Cough Chills/ fever Sinus Congestion Difficult breathing Dry Skin Dry nose Dry mouth Dry throat Sneeze Sore throat Sadness/ Grief Skin rashes Tightness in chest Kidney/ Bladder function: Low Back pain Weak knees Sore knees Breaks bones easily Poor memory Fear Low pitched ringing in ears Lack of bladder control Kidney Stones Wakes during night to urinate Bladder infections Easily startled Frequent urine Urgent urine Blood in urine Scanty urine Difficult urine Profuse urine Cloudy urine Painful urine Dark yellow urine Pale Urine Low sex drive Craves salty foods Loss of hearing Excessive hair loss Discharge Liver/ Gallbladder function: Frustration Angers easily Irritable Depression Muscle spasms Muscle twitch Muscle cramps Seizure Bitter taste Headache (top of head) Tension headache Neck tension Sensation of lump in throat High pitched ring in ears shoulder tension Gallstones Nausea Increased stress Limited Range of Motion Convulsions/Tremors Pale stools 4
Eye function: Dry Itchy Blurry Red Watery Vision problems Hot Gritty Spots/ floaters Please differentiate and indicate any areas of pain or scar locations: Nature of pain: Some relief through: Dull Achy Pressure Heat Sharp Burning Cold Exercise Cramping Fixed Other Moving Numbness Pins/Needles Other Symptoms worsen with: Pressure Cold Heat Other: 5
Sleep Habits How many hours a night do you sleep? Do you experience any of the following? Difficulty falling asleep Waking 1 or more times during the night Insomnia Dietary/ Lifestyle Habits Please describe what you typically eat for breakfast, lunch, dinner? Feeling not rested or groggy upon waking Awaking too early Do you drink coffee? Amount per week? Do you drink soda/pop? Amount per week? How much water do you drink in a day? Do you drink alcohol? Amount per week? Do you smoke cigarettes? Amount per week? Recreational drug use? Amount per week? Do you Exercise? Amount per week? Do you have any hobbies? For Men Only: Do you experience any of the following? Impotence Pre-mature ejaculation Swollen testes Cold or Numbness in groin area Nocturnal emissions Testicular pain Date of last prostate exam? PSA number? 6
For Women Only: Are you pregnant or do you think you may currently be pregnant? Age of first menstruation? Do you have Regular cycles? How many days does your period last? Do you experience vaginal discharge? How many days is your entire cycle? Number of pregnancies? Births? Abortions? Miscarriages? Age of Menopause? (If applicable) Have you experienced bleeding between periods? Do you experience any of these PMS symptoms? Breast Swelling Breast tenderness Depression Nausea Vomiting Irritability Anxiety Headaches Migraines Food cravings Bloating Change in bowels Dull pain Sharp pains Have you been diagnosed with any of the following? Fibroids PCOS PID Endometriosis Cysts Menses chart Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Color (pale, bright red, brown, rusty, dark, purple, other) Amount of flow (normal, heavy, light) Clotting ( small, large, red, purple, black, other) Pain/ Cramping (location, dull, sharp) Other 7
Please list any Medications/Supplements/Vitamins you currently take: Date started Medication/ Vitamin/ Supplement Reason for taking Dosage Amount Frequency 8