Worthington Optimal Wellness Acupuncture Patient Health History Form

Similar documents
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Inner Balance Acupuncture

Health History Questionnaire Date: / /.

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

Health History Questionnaire

NEW PATIENT HEALTH HISTORY

Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History

2. Approx. Date of Onset: 3. Approx. Date of Onset:

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM

Eastern Body Therapy

Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042

Acupuncture & Herbal Therapies

Patient Health History Questionnaire

Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **

Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?

New Patient Information

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip

CURRENT MEDICAL HISTORY

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Oriental Medicine Questionnaire

Avery Acupuncture & Natural Medicine New Patient Registration

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Headache Follow-up Visit Form

New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

Average Daily Diet: Morning Afternoon Evening

ACUPUNCTURE QUESTIONNAIRE

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520)

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION

Mayflower Acupuncture LLC

HIPAA Acknowledgement and Appointment Reminder Form

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

PATIENT INFORMATION. GENERAL INFORMATION Have you had acupuncture before? Yes No Have you used Chinese herbal medicine? Yes No

New Patient Medical History Intake Form

Medical History Form

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

stoneburner acupuncture

Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

Medical History Form

55 S. Main Street, Driggs, ID (208)

Emotional Relationships Social Life Sexually Recreation

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

Mayflower Acupuncture LLC

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:

ACUPUNCTURE INTAKE FORM

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Patient Intake Form for Acupuncture Treatment at Infinite Healing

RHEUMATOLOGY PATIENT HISTORY FORM

Symptom Review (page 1) Name Date

Patient Health History

If you have any questions, feel free to contact us at 475- WLNS (9567) or

Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060

Initial Consultation

Laser Vein Center Thomas Wright MD Page 1 of 4

Patient Health History Form

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

What do you believe is causing your most important health concern?

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

Health History Intake Form;

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

New Patient Specialty Intake Form Department of Surgery

To: New patients for acupuncture and Oriental medicine

205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:

Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac

Patient History (Please Print)

Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Name: Age: Gender: Name: Age: Gender: Name: Age: Gender:

MEDICAL DATA SHEET For Patients 18 years of age and older

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

Questionnaire for Lipedema Patients

Chiropractic Patient Admittance Form

Patient History Form

Amarillo Surgical Group Doctor: Date:

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR P: (541) F: (541)

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Scottsdale Family Health

Placer Private Physicians: Patient Health Questionnaire [2]

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

* CC* PATIENT QUESTIONNAIRE

Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA PHONE: FAX:

Essential Health Acupuncture Susana Byers, Lic..Ac. COMPREHENSIVE HEALTH HISTORY QUESTIONNAIRE

Patient History Form

Patient Intake Form for Allegany Ear, Nose, & Throat

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Transcription:

Worthington Optimal Wellness Acupuncture Patient Health History Form Rita Ghodsizadeh, L.Ac, Dipl.Ac. B.A. 6180 Linworth Rd., Worthington, OH 43085 Office # 614-848-5211 ; cell # 614-309-1898 www.acupuncturehealscolumbus.com Today s Date Your Name Gender: M F Mailing Address City, State & Zip Code Cell Phone # Date of Birth Current Age Email Address Primary Care Physician PCP Phone # Emergency Contact Phone # Referred by Consent to Treat: I, the undersigned, understand acupuncture treatments to involve the use of needles, moxibustion, acupressure, tui na (Chinese massage), cupping, gua sha, electrical stimulation, oils/lotions, TDP lamp etc. The risks for acupuncture, although limited, include: puncturing organs in the abdomen or chest cavities. Acupuncture may affect people on all levels: physical, emotional, mental and spiritual, because it works with the whole body to create balance. The duration of treatment varies from person to person depending on the specific illness and their constitution. I fully understand that there is no stated or implied guarantee of success or effectiveness after a specific treatment or a series of treatments. Patient s Signature(or guardian if minor): Dated: ************************************************************************************************* 1. Chief Concern/Reason for Seeking Treatment: How long? 2. Have you been given a diagnosis for this problem? If so, what? 3. What kinds of treatments have you tried? Have they helped? Past Medical History Last Medical Exam: Reason & Date Have you had an infectious disease? Specify Surgeries and Dates Significant trauma (auto accidents, falls) 1

Medicines/Drugs you are currently taking including dose and reason for taking them: Herbs/Vitamins you are currently taking including dose and reason for taking them: Allergies (drugs, foods, environmental or other): Do you wear any electrical device: ear implants pacemaker other Check if you or any blood relative has been diagnosed with the following: You Blood Relative You Blood Relative AIDS/HIV Hernia Anemia Hypertension Alcoholism Hyperthyroidism Allergies Hypothyroidism Asthma Insomnia Irritable Bowel Bleeding Disorders Synd./Crohn s Cancer Kidney Stones Diabetes Lung Disease Depression Multiple Sclerosis Ovarian Epilepsy Cysts/fibroids Endocrine Disorder Pyelonephritis Fibromyalgia Stroke (CVA) Gallstones Tuberculosis Gout Chronic UTIs Heart disease Childhood Fevers Hepatitis Childhood Illnesses 2

Personal History Current Emotional Health Current Quality of Life Current Relationship/Quality Occupation Stress level Have you had any unusual stresses recently? Have you travelled abroad in the past year? If so, where? Diet & Lifestyle Smoke cigarettes (how many/day)? Drink alcohol (how often)? Recreational drugs (how often)? Drink coffee (how often)? Drink soda (how often)? Drink water (how much)? Exercise (kind & amount)? What do you do to relieve stress? Review of Systems Please put a check next to conditions you have experienced within the last 3 months. Indicate the length of time you have had this condition. GENERAL Fever Fatigue Poor sleep/insomnia Chills Sudden Energy drop Dream Disturbed Sleep Fainting Localized weakness Change in appetite Dizziness Disorientation Weight loss Headaches Depression Weight gain Migraines Mania Night Sweating/hot flashes Seizures Easily Angered Abnormal Day Sweating Concussion Anxiety Sudden Thirst for hot or cold drinks Poor Memory Moodiness Peculiar taste or smell ADD/ADHD Panic Attacks Phobias Poor Balance Easily Susceptible to Stress Bleeding or Bruising Lack of coordination Tremors Restless Legs Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Any other neurological or psychological problems? Any nervous habits? 3

REPRODUCTIVE AND GYNECOLOGIC Are you PREGNANT: Yes No Age of first menses First day of last menstrual cycle / / Menopause (age) Date of last pap smear / / Length of menstrual cycle days Vaginal discharge Irregular menses Painful menses Duration Days Heavy Light Color Clots Number of Pregnancies Number of births Miscarriages Abortions Difficult Births? Fertility Problems Birth Control What Type? How long? Experience changes in body and/or psyche prior or during menstruation (please circle: mood changes, cramps, breast tenderness, lower back pain) Other Bleeding/spotting in between menstrual cycles SKIN AND HAIR Rashes Ulcerations Boils Itching Dry Skin Scaly Skin Dandruff Hair loss Recent moles Acne Eczema Changes in hair or skin texture: Specify EYES, EARS, NOSE, THROAT Blurry Vision Night Blindness Dry Eyes Floaters Ringing in ears Poor Hearing Ear discharge Eye discharge Sinusitis Recurrent Sore Throats Nosebleeds Facial Pain/Paralysis Sores on lips/tongue Grinding teeth TMJ Gum Bleeding CARDIOVASCULAR Palpitations Irregular Heart Beat High Blood Pressure Low Blood Pressure Chest Pain Chest Tightness Poor Circulation Cold Hands & Feet Swelling of Feet Swelling of hands Difficulty in breathing Phlebitis Feel cold Other RESPIRATORY Cough Bronchitis Difficulty breathing when lying down Coughing up blood Pain with deep inhalation Asthma Pleurisy 4

Pneumonia GASTROINTESTINAL Poor appetite Hungry all the time Nausea Vomiting Diarrhea Phlegm (profuse/scanty) color Bad Breath Gas/Bloating Belching Acid Reflux Indigestion Other Constipation Stomach pain Abdominal pain/cramps Hemorrhoids Chronic Laxative Use Cravings Taste in Mouth Thirst GENITO-URINARY Pain on urination Frequent urination Urgency to urinate Incontinence Difficult urination Dribbling Cloudy urine Bloody urine Kidney Stones Sores on Genitals Loss of Sex Drive Frequent UTIs Number of times you wake up at night to urinate Color of Urine MALES ONLY: Prostate trouble Erectile Dysfunction Impotence MUSCULOSKELETAL (Indicate Side:R=Right, L=Left, B=Both) Muscle pain Muscle Weakness Osteoporosis Neck pain Upper back Mid-back pain Lower back pain Knee pain Hip Pain Feet/Ankle Pain Wrist/Fingers Pain Shoulder/Elbow Pain Other Referred Pain, Paralysis, Numbness, Tingling or Burning. Location: 5

Pain Diagram: Please indicate any areas of pain or discomfort on the pictures below. R Please circle any answers below that apply to your pain. Is the pain: Dull Sharp Stabbing Burning Aching Fixed Moving What makes the pain better? Cold Heat Massage Rest Movement 6

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback