Rachel Beth Dorfman, L.Ac., C.M.T.

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Transcription:

Rachel Beth Dorfman, L.Ac., C.M.T. Classical Acupuncture, Chinese Medicine and Asian Bodywork Patient Information Name: Today's date: Address: Age: Date of birth: City: State: Zip: Email: Best phone to reach you: Receive texts (please circle): Yes No Marital Status: Gender: Occupation: Referred by, or how you heard of us: Emergency Contact (Name/Phone): Relationship to you: Primary Doctor (Name/Phone): Are you under the care of a physician now? Yes No If so, what for? Current prescriptions, over the counter medications, and/or supplements: Have you had acupuncture before: Yes No Primary reason for seeking acupuncture: How long have you had this condition?

Secondary reason for seeking acupuncture: How long have you had this condition? Are you receiving any other treatments for these conditions? (please specify) If known, what seemed to be the initial cause? Please check conditions that you have or have had in the past: Heart disease Stroke Diabetes Asthma Seizures/Epilepsy Alcoholism/Addiction High Blood Pressure Cancer Other: HIV/AIDS Epilepsy Allergies Bleeding disorder Emphysema Hypertension Ulcers Osteoporosis Hepatitis Pneumonia Anemia Thyroid condition Pacemaker TB Autoimmune Other: Do you take anticoagulant medication? Yes No Surgeries/History of hospitalizations: List of broken bones: Smoker: Yes No How much and how often? Exercise: Yes No How much, how often, what type? Alcohol consumption How much, how often? Birth control method? Number of children: Please circle your current level of stress, 1 being lowest and 10 being highest: 1 2 3 4 5 6 7 8 9 10 11+

Temperature/Energy/Sleep Tend to be HOT Night sweats Chills Tend to be Cold Unusual/excess sweating Fatigue Cold hands, feet Excessive thirst Body feels heavy/weak Fever No thirst Feel wired/ungrounded Difficulty falling asleep Restless sleep Disturbing dreams Hours of sleep per night? Daily caffeine intake? Mood/Emotions Anger easily Fear Sadness/grief Anxiety Indecision Stress Depression Irritability Worry Easily startled Mood swings Difficulty concentrating Neuropsychological ADD/ADHD Mental illness Poor memory Bipolar disorder Nervousness Musculoskeletal Back pain: upper/mid/lower Joint pain or weakness: hand/wrist elbow/shoulder/foot/ankle/knee/hip Skin/Hair/Nails Acne Bruise easily Dry skin/itchy skin/oily skin Dry, brittle nails Muscle cramps/spasms Neck pain Weak muscles Hives Rashes/Eczema/Psoriasis Dry hair/oily hair Head/Eyes Dizziness/Vertigo Blurred or failing vision Eye strain or pain Fainting Cataracts Glaucoma Headaches Dry/Itchy/Red/Watery eyes Poor night vision Migraines Ears/Nose/Throat/Mouth Ear infections Sinus problems Dry Mouth Ear ringing Difficulty Swallowing Mouth sores Hearing loss Dry throat Gum problems Hay fever/allergies Sore throat Teeth grinding Nasal congestion Hoarseness/Loss of voice TMJ/Jaw problems Nosebleeds Swollen glands General amount/extent of dental work:

Respiratory Asthma or wheezing History of childhood asthma Emphysema Bronchitis Cough w/phlegm or blood Frequent colds Chronic cough Difficulty breathing Pneumonia Shortness of breath Cardiovascular Chest pain/tightness Low blood pressure Rapid/irregular heart beat Hardening of arteries Palpitations Swelling of ankles High blood pressure Poor circulation Varicose veins Gastrointestinal Acid reflux/gerd Diarrhea or loose stool Nausea Bad breath Food allergies/sensitivities Poor appetite Belching Hemorrhoids Excessive appetite Bloating and/or gas Indigestion Stomach pain Blood in stool Liver problem Ulcers Constipation Gall bladder stones/problem Vomiting Bowel movement frequency: Formed or loose: Color: Strong odor: Yes No Genitourinary Blood or pus in urine Urgent urination Lowered sex drive Frequent urination Painful/burning urination Premature Ejaculation Incomplete urination Urinary tract infection Prostatitis Nighttime urination History of UTI Impotence/Erection difficulties Unable to hold urine Kidney stones STD: Gynecology/Reproduction Abnormal PAP smear Mid-cycle bleeding/spotting Previous miscarriage Breast tenderness Painful periods/cramps Vaginal discharge Clots with menses PMS Vaginal dryness Heavy menstrual flow Light menstrual flow Yeast infections Irregular periods Menopausal symptoms Are you pregnant? Average length of cycle: Date of last PAP exam: Date of last period: Duration of flow: Age of menopause: Additional info:

Informed Consent Acupuncture is a form of therapy in which fine needles are inserted into specific points on the body. Your treatment may include the application of Moxabustion Therapy, Cupping Therapy, or hands-on massage/bodywork. These will be explained to you at the time of treatment. An Acupuncturist is not able to make a medical diagnosis, provide primary care, or Western (allopathic) medical care. Please see your doctor for those services and for routine check-ups. Acupuncture is generally safe. Serious side-effects are extremely rare. The purpose of Acupuncture is to reduce pain and to aid in bringing the body back to a normal state of balance. Because Acupuncture involves the insertion of needles into the skin, minor side-effects are rare, but may occur. These include bruising, slight bleeding, weakness, drowsiness, intense to subtle sensations during or following treatment, fainting, and increase or aggravation of symptoms during or following treatment. Only sterile, one-time use, disposable needles are used. Needles are not re-used, even on different areas of the body on the same person. Please inform your Acupuncturist: If you have ever experienced a seizure, dizziness, or fainting episode If you have a pacemaker or any other electrical implants If you have a bleeding disorder If you are taking anticoagulants or any other medications If you have damaged heart valves or high blood pressure If you have any form of infection If you are pregnant With this knowledge, I voluntarily consent to receiving Acupuncture. I understand that I can refuse treatment at any time. Signature: Printed name: Date:

Financial Policy Payment is expected at time of visit Cash or checks accepted Insurance is not accepted at this time, but a receipt may be provided for you to submit yourself If current fees are the only thing stopping you from scheduling regular treatments, please speak with me regarding the availability of payment options Cancellation Policy Please give 24 hours notice if you need to cancel or reschedule an appointment In cases where appointments are cancelled, or missed altogether without notification: The first time will be free of charge The second time, there will be a charge equaling 50% of the expected treatment fee The third time, there will be a full charge of the expected treatment fee and a consultation as to whether treatments should continue to be scheduled It is understood that emergencies happen. If an emergency causes you to miss your appointment, please speak with me. Signature: Date:

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