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

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Transcription:

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email Address Ok to contact via phone? email? text? Age Date of Birth Place of Birth Height Weight Employer Name Job Family Physician Referred By Emergency Contact Phone Have You Been Treated By Acupuncture or Oriental Medicine Before?: Yes No Main Problem(s) you would like help with How long ago did this problem begin (be specific)? To what extent does this problem interfere with your daily activities (work, sleep, etc)? Have you been given a diagnosis for this problem: If so, what? What kinds of treatment have you tried? Past Medical History (please include date): Cancer Diabetes Hepatitis High Blood Pressure Heart Disease Rheumatic Fever Thyroid Disease Seizures Venereal Disease HIV/AIDS Other Surgeries (type of and date) Significant Trauma (auto accidents, falls, etc) Significant Dental Work (type and date) Allergies (drugs, chemicals, foods/result) Family Medical History (check): Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizures Asthma Allergies Other

Medicines taken within the last two months (vitamins, drugs, herbs, etc) Name of Medication/Supplement Reason for Taking It Occupational Stress (physical, chemical, psychological, etc) Do you have a regular exercise program? Yes No Please Describe Have you ever been on a restricted diet? Yes No What Kind? Please describe your average daily diet: Morning Afternoon Evening How many packs of cigarettes do you smoke per day? How much coffee, tea or cola do you drink per day? How much alcohol do you drink per week? Please describe any use of recreational drugs

Please check any you have had in the last three months: General Poor appetite Fevers Sweat easily Localized weakness Bleed or bruise easily Peculiar tastes or smells Strong thirst (cold or hot) Thirst, no desire to drink Sudden energy drop what time of day? Poor sleep Chills Tremors Poor balance Fatigue Night sweats Cravings Change in appetite Weight gain Weight loss Skin and Hair Rashes Itching Change in hair or skin Ulcerations Eczema Loss of Hair Hives Pimples Recent moles Other hair or skin problems Head, Eyes, Ears, Nose, and Throat Glasses Poor vision Cataracts Ringing in ears Sinus problems Grinding teeth Teeth problems Concussions Eye strain Night blindness Blurry vision Poor hearing Nose bleeds Facial pain Jaw clicks Migraines Eye pain Earaches Recurrent sore throats Sores on lips or tongue Headaches - where and when Other head or neck Cardiovascular High blood pressure Irregular heartbeat Cold hands or feet Blood clots Low blood pressure Swelling of hands Chest pain Fainting Swelling of feet Difficulty in breathing Other heart or blood vessel Respiratory Cough Bronchitis Difficulty breathing Production of phlegm Coughing blood Pneumonia Asthma Pain with a deep breath Other lung problems Approximately when was your last cold or flu? Gastrointestinal Nausea Constipation Black stools Bad breath Abdominal pain or cramps Chronic laxative use Vomiting Gas Blood in stools Rectal pain Diarrhea Belching Indigestion Hemorrhoids Other stomach or intestinal Urinary Pain on urination Urgency to urinate Frequent urination Unable to hold urine Impotency Blood in urine Kidney stones Sores on genitals Other urinary system problems Do you wake up to urinate? Yes No. How often? Any particular color to your urine? Sexual and Reproductive Number of pregnancies Number of births Premature births Miscarriages Abortions Infertility Impotency/ Erectile dysfunction Genital sores

Age at first menses Days between menses Duration First day of last menses Unusual character (heavy or light) Painful periods Vaginal discharge What color? Changes in body/psyche prior to menstruation Clots Irregular periods Last Pap Breast lumps Are you sexually active? Do you practice birth control? Yes No N/A What type and for how long? Other sexual or reproductive concerns Musculoskeletal Neck pain Back pain Hand/wrist pain Muscle pain Muscle weakness Shoulder pain Knee pain Foot/ankle pain Hip pain Neuropsychological Seizures Areas of numbness Concussion Bad temper Lack of coordination Depression Easily susceptible to stress Loss of balance Poor memory Anxiety Other neurological or psychological problems

Please note the severity of your problem now: No Problem Worst Imaginable Please note the severity of your problem within the last week: No Problem Worst Imaginable Comments (please mention any other problems you would like to discuss): Indicate painful or distressed areas:

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