Patient s Name Date Address Phone City/State/Zip Work Phone Gender Age Weight Height Date of Birth SS# Email Address Insurance Carrier Policy Holder Policy Holder DOB Emergency Contact Phone Family Physician Phone Specialist (if relevant) Phone How did you hear about us? Current Medical History Primary Reason for Visit Other concerns you would like to address How long have you had your problem? Has a physician given you a diagnosis? Have you had MRI, XD ray, lab tests for this condition (if you have had any of the above, please bring the written report to your initial visit, if possible, to assist in a complete evaluation. If there are metal implants, fusions, screws, etc. please bring the actual films) What was the initial cause? Is it getting worse? How so? What makes your condition better? What makes it worse? Is it worse at certain times of year? Certain weather? What treatments are you currently using? Are they effective? What treatments have you tried in the past? Were they effective? Current Medications/Supplements Past Medical History Surgeries/Medical Procedures (include dates)
Past Physical Traumas (e.g. car accident, fall, childhood injuries) Past Emotional Traumas (e.g. divorce, death in family, childhood trauma) Past Medications (e.g. Chemotherapy, Steroids, Childhood antibiotics) Check any of the following conditions you have currently or have had in the past Auto- immune Depression Mumps Appendicitis Emphysema Nervous disorder Alcoholism Gall bladder disorder Osteoporosis Allergies Glaucoma Pacemaker Antibiotic use Gout Parasites Appendicitis Heart disease Phlebitis Arthritis Headaches Pneumonia Asthma Hepatitis Seizures Birth trauma Herpes STD s Bleeding disorder Hypertension Stroke Blood clots IBS Thyroid disorder Bronchitis Jaundice Tuberculosis Chicken pox Kidney disorder Vascular disease Cancer (specify) Liver disorder Ulcers Measles Other (Specify) Mononucleosis Diabetes Multiple Sclerosis Family Medical History Father: Alive/Age Deceased/Age Father health issues Mother: Alive/Age Deceased/Age Mother health issues Your birth order (e.g. 3 rd child of 5) Siblings (total #/health issues) Other relevant family information
Lifestyle Occupation Hours per week Stress level Physical or other stressors form occupation Married/partnered Single Hobbies/activities Exercise (what type, how often) After exercise, do you feel: Better Worse About the same Energy level in general (1-10) Time of day more energy Time of day less How much sleep on average Night owl Morning person Alcohol frequency Tobacco frequency Caffeine frequency Recreational drugs frequency Social support (family, friends, social organizations) Nutrition Your appetite: Good Fair Poor Fluctuates Hungry w/no app Do you eat: 3 meals/day More frequent small meals irregular meals Do you eat breakfast? Are you a vegetarian? Times/week you eat out What do you eat on a typical day? Breakfast Lunch Dinner Snacks Cravings Sweet Chocolate Pasta Salty Cheese Other (specify) Sour Bread Please provide any additional information about your diet that you feel is relevant (foods you feel are best for you, foods you have adverse reactions/allergies/sensitivities to, foods you dislike, etc.)
Circle the number that best applies to you: Psychological/Emotional Rarely Neutral Often Wood/Liver Depressed 1 2 3 4 5 Angry 1 2 3 4 5 Easily irritable 1 2 3 4 5 Lack of courage 1 2 3 4 5 Indecisive 1 2 3 4 5 Fire/Heart Laughs easily 1 2 3 4 5 Anxious, restless 1 2 3 4 5 Easily frightened 1 2 3 4 5 Earth/Spleen Happy, content 1 2 3 4 5 Compulsive caretaker 1 2 3 4 5 Worry, overthinking 1 2 3 4 5 Obsessive 1 2 3 4 5 Metal/Lung Melancholy, sad 1 2 3 4 5 Grief 1 2 3 4 5 Water/Kidney Fearful 1 2 3 4 5 Introverted 1 2 3 4 5 Lack of will 1 2 3 4 5 Please check any of the following conditions that you have or have had in the past: General General Body Temperature: Cold Cool Temperate Warm Hot Qi Tired, fatigued Tired after exercising Spontaneous sweating Wake up tired Yang Extreme fatigue Chilled easily Cold sweats
Qi Palpation Shortness of breath upon exertion Feeble cough Shortness of breath with exertion Catch colds easily Aversion to wind Spontaneous sweating General fatigue Bloating after eating Tired after eating Loose stools/diarrhea Weakness in limbs Poor appetite Bleed/bruise easily Heavy menstrual bleeding Prolapsed organs Hemorrhoids Low back pain Knee pain Frequent urination Bone fractures, weakness Dental problems Difficulty inhaling a deep breath Rapid and weak breathing Asthma Qi Mental depression Irritability Sighing Flank pain and pain below ribs Foreign body sensation in throat Dysmenorrhea Breast distension Heart Lung Spleen Kidney Liver Yang Cold limbs Blue lips (Yin?) Dry cough Dry mouth and throat Afternoon fever Night sweating Prefer warm food Abdom pain better with pressure and warmth Diarrhea Chilly with cold limbs Loose stool with undigested food Frequent urination at night Clear urine Swollen ankles, legs Impotence Loose stool w/ undigested food Diarrhea in early morning Fire Pain in head Eye redness, swelling, pain Bitter taste in mouth Irritable
Yang rising Headache Dizziness Liver (con t) Wind Itching Pain that moves to various parts Liver and Gallbladder (Damp- heat) Scanty yellow urine Bitter taste in mouth w/ poor appetite and nausea Yin Feel warm in afternoon Feel warm in evening Hot flashes Deep heat in body Low grade fever in PM Night sweats Heat in palm of hands Heat in soles of feet Flushed face Thirsty for cold drinks General Heart Yellow whites of eyes and skin Swelling, burning in genitals Blood Dizziness/vertigo Dry skin, hair, nails Numbness/tingling in hands or feet Blurred or weak vision Insufficient lactation Scanty or infrequent period Difficulty staying asleep Mental restlessness Anxiety esp that builds later in day Difficulty falling asleep Poor memory Confusion Lung Dry cough Dry throat Cough w/blood Dry eyes Heat in palms/soles of feet Liver Rashes or hives Itchy skin Blurry vision Numbness of limbs Muscle twitches Spasms of tendons Dry brittle nails Poor night vision Floaters/spots in vision Tremor, shaking
Yin Insomnia Tinnitus Dizziness Poor memory Low back/knee pain Night sweats/hot flashes Kidney Dampness/Phlegm Foggy/sluggish thinking Headaches like a band around the head Ear discharge Cysts Difficulty getting up in morning Sweaty hands/feet Nodules Acne Lung Sinus discharge Chest congestion Productive cough Shortness of breath or wheezing Post- nasal drip Sinus infections Difficulty breathing lying down Spleen Nausea Weight gain Aversion to greasy food Cysts Yellow sweating (stains) Fungal infections Swollen feet/ankles/legs Swollen joints Kidney
Gastro- Intestinal Acid reflux Nausea Belching Flatulence Stomach/abdominal pain Flank pain Frequency of bowel movements per day (or per week if less) Loose stool Blood in stool Incomplete bowel movements Genito- Urinary How many times do you normally urinate per day? What color is your urine normally (without taking vitamins)? Painful urination Incomplete urination Discharge Frequent urination Strong- smelling urine Bedwetting Urgent urination Cloudy urine Incontinence Dribbling after urination Kidney stones Blood in urine Dribbling while coughing or jumping Genito- Urinary Male Prostate problems Genital pain Impotence Low sperm count Swollen testicles Erectile dysfunction Discharges Cold, numb genitals Sex drive (1-10) Other (describe) Genito- Urinary Female Age menses began Number of pregnancies Birth control (specify Age menopause Number of abortions type and how long) Number of days in cycle Number of miscarriages Duration of flow Pregnant currently? Infertile Fibroids Endometriosis Fibroids Vaginal discharge Pain during intercourse Cysts Yeast infections Sex drive (1-10) Menstrual Cycle Irregular (specify) Spotting Cramping, pain PMS Clots, dark blood Headaches before period Mid- cycle bleeding Headaches after period Water retention, bloating
Peri- menopausal symptoms Depression Anxiety Crying spells Spotting Hot flashes Vaginal dryness Additional information you feel is relevant: Musculo- skeletal Neck pain, stiffness Multiple joint pain Hip pain Shoulder pain Sore muscles Sciatica Upper back Arthritis Low back Foot pain Muscle weakness? Muscle stiffness? Limited range of motion? Limited use/function? Where? Where? Where? Where? Please indicate on the drawings below any areas of pain, discomfort