Cathryn Aiken, L.Ac. 530 Traffic Way Arroyo Grande, CA 93420 T: 805.489.8592 F: 805.489.9509 www.arroyograndehealthandwellness.com aghealthandwellness@gmail.com PLEASE PRINT LEGIBLY TODAY S DATE: M / F / / LAST NAME FIRST NAME MI SEX BIRTH DATE ADDRESS CITY STATE ZIP ( ) - ( ) - PHONE CELL PHONE E-MAIL ADDRESS DRIVER S LICENSE NO. CURRENT OCCUPATION - IF RETIRED, WHAT WAS YOUR PREVIOUS OCCUPATION? EMPLOYER ( ) - WORK PHONE EMPLOYER S ADDRESS SPOUSE or PARENT ADDRESS PHONE REFERRED BY: NAME OF PRIMARY HEALTH CARE PROVIDER AND PRACTICE (M.D., CHIROPRACTOR, ETC.) ARE YOU CURRENTLY UNDER THE CARE OF THIS HEALTH CARE PROVIDER? YES NO HAVE YOUR COMPLAINTS PREVIOUSLY BEEN GIVEN A PARTICULAR MEDICAL DIAGNOSIS? YES NO PLEASE EXPLAIN ARE YOU CURRENTLY TAKING ANY PRESCRIBED MEDICATIONS, VITAMINS, SUPPLEMENTS, HERBS? PLEASE LIST: PRESENT COMPLAINT / SYMPTOMS: WHEN AND HOW DID PROBLEM START? WHAT MAKES IT BETTER? WHAT MAKES IT WORSE? PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY: DIABETES HEPATITIS A B C HYPERTENSION PREGNANCY TB CHEM /RAD SEIZURES HEMOPHILIA PACEMAKER HIV / AIDS
DESCRIBE YOUR GENERAL ENERGY LEVEL: PLEASE RATE GENERAL ENERGY LEVEL ON SCALE OF 1-10: 1 = EXHAUSTED & 10 = GREAT: WHAT TIME OF DAY DO YOU FEEL BEST? WORST? HISTORY OF PARTICULAR EMOTIONAL EPISODES: HOBBIES / INTERESTS: WHAT ARE YOUR MOST COMMONLY EXPERIENCED EMOTIONS? PLEASE X ANGE R FRUSTRATION WORRY SADNESS FEAR EXCITEMENT JOY WHAT EMOTIONS DO YOU HAVE A DIFFICULT TIME EXPRESSING? PLEASE X ANGE R FRUSTRATION WORRY SADNESS FEAR EXCITEMENT JOY IF YOU COULD CHANGE 3 THINGS ABOUT YOUR LIFE / SELF, WHAT WOULD THEY BE? WHAT IS YOUR HISTORY FOR MAJOR ADULT ILLNESSES: SURGERI ES: CHILDHOOD ILLNESSES: PRESCRIBED MEDICATIONS:
PLEASE PROVIDE A BRIEF FAMILY HISTORY. INCLUDE ANY INCIDENCES OF ALCOHOLISM/SUBSTANCE ABUSE, ARTHRITIS, ASTHMA, CANCER, DIABETES, HEART DISEASE, HYPERTENSION, NERVOUS DISORDERS, SEIZURES, SKIN DISEASE, STROKE, TB, ETC. FATHER MOTHER SIBLING SIBLING SIBLING MATERNAL GRANDFATHER GRANDMOTHER PATERNAL GRANDFATHER GRANDMOTHER OTHER WOMEN OF FIRST PERIOD: LAST PAP: RESULTS: LENGTH of FULL MONTHLY CYCLE: DAYS DURATION of FLOW: DAYS IS CYCLE REGULAR? ANY SPOTTING? PAIN? PMS? VAGINAL DISCHARGE? OTHER? DIFFICULTIES DURING TEENS (PAIN, FLOW, REGULARITY, CRAMPS, HEADACHES, ETC.): BIRTH CONTROL HISTORY (METHOD & DURATION OF USE): OBSTETRIC HISTORY NO. OF PREGNANCIES: NO. OF BIRTHS: NO. OF MISCARRIS: NO. OF ABORTIONS: OTHER: MENOPAUSE? YES NO? STDs (HERPES, WARTS, ETC.): MEN HISTORY OF IMPOTENCE, PREMATURE EJACULATION, FERTILITY DIFFICULTIES, DISCHARGE FROM PENIS, VASECTOMY, ETC. STDs (HERPES, WARTS, ETC.) ANY CHILDREN? YEAR of BIRTH
DAILY HABITS (HOW MUCH OF EACH OF THE FOLLOWING DO YOU CONSUME DAILY?) CIGARETTES / TOBACCO: ALCOHOL / IN WHAT FORM: COFFEE / TEA/ CAFFEINATED BEVERS: DAIRY PRODUCTS (MILK, CHEESE, BUTTER, YOGURT, ICE CREAM, ETC.): MEAT / FISH / POULTRY: BREADS / GRAINS: COOKED VEGETABLES: RAW FRUITS / RAW VEGETABLES: SPECIFIC FOOD / FLAVOR CRAVINGS: TYPICAL DAY S MENU (INCLUDE CONTENT AND TIME YOU NORMALLY EAT) TIME CONTENT BREAKFAST: LUNCH: DINNER: SNACKS: EXERCISE (TYPE, DURATION, NUMBER OF TIMES PER WEEK): WHICH OF THE FOLLOWING MAKE YOU FEEL BAD / WORSE? COLD HEAT DAMP DRY WIND HUMIDITY FOG WHICH OF THE FOLLOWING MAKE YOU FEEL GOOD / BETTER? COLD HEAT DAMP DRY WIND HUMIDITY FOG DO YOU HAVE ANY INTOLERANCE TO HEAT OR COLD (FOOD, DRINKS) OR AREAS OF THE BODY THAT ARE HOT OR COLD? PLEASE TELL ME ABOUT ANY PREVIOUS TREATMENTS YOU HAVE TRIED FOR YOUR CONDITION (ACUPUNCTURE, HOMEOPATHY, MASS, NUTRITION, M.D., ETC.) AND THE RESULTS:
PLEASE X ANY THAT ARE LONG TERM SYMPTOMS or THAT YOU HAVE EXPERIENCED IN LAST 3-6 MONTHS ( )ACID REGURGITATION ( )HAIR DRY /DULL ( )SKIN - YELLOWING ( )ALLERGIES ( )HAIR LOSS ( )SLEEP - ALWAYS SLEEPY ( )ALTERNATING FEVER / CHILLS ( )HAIR PREMATURE GRAY ( )SLEEP - CAN T FALL ASLEEP ( )APPETITE - ALWAYS HUNGRY ( )HEART ATTACKS ( )SLEEP - CAN T STAY ASLEEP ( )APPETITE - POOR ( )HEAVINESS OF BODY ( )SLEEP - EXCESSIVE DREAMING ( )ASTHMA ( )HEAVINESS OF LIMBS ( )SNEEZING ( )BAD BREATH ( )HEMORRHOIDS ( )SPASMS - WHERE ( )BEARING-DOWN IN GROIN / SCROTUM ( )INDIGESTION ( )STIFFNESS - WHERE ( )BELCHING or HICCUPS ( )INFERTILITY ( )STOOL - BURNING ( )BLADDER or KIDNEY STONES ( )IRREGULAR HEARTBEAT ( )STOOL - CONSTIPATION ( )BLOATING of ABDOMEN ( )LUMPS / MASSES / TUMORS ( )STOOL - DIARRHEA - ACUTE ( )BLOOD CLOTS ( )MEMORY FORGETFULNESS ( )STOOL - DIARRHEA - CHRONIC ( )BREATH DIFFICULT TO INHALE ( )MEMORY - LOSS OF MEMORY ( )STOOL - DIFFICULT TO PASS ( )BREATH SHORTNESS OF BREATH ( )MEMORY - POOR MEMORY ( )STOOL - DRY STOOL ( )BREATH SIGHING ( )MENSES CLOTS ( )STOOL - INCONTINENCE ( )BREATH WHEEZING ( )MENSES CRAMPING DURING ( )STOOL - LOOSE STOOL ( )BRITTLE NAILS ( )MENSES HEAVY FLOW ( )STOOL - UNDIGESTED ( )BRONCHITIS ( )MENSES HEADACHES: ( )STROKE ( )BRUISE EASILY ( )MOUTH BLEEDING GUMS ( )SWEAT - EASILY WITH EXERTION ( )BURNING RECTUM / ANUS ( )MOUTH PAINFUL GUMS ( )SWEAT - NIGHT SWEATS ( )CHEST / ARM PAIN ( )MOUTH - SORES ON GUMS ( )SWEAT - SPONTANEOUS DAY SWEAT ( )CHEST FULLNESS ( )MOUTH - SORES ON LIPS ( )TEMPERATURE - ALWAYS COLD ( )CHILLS AND FEVER ( )MOUTH - SORES ON TONGUE ( )TEMPERATURE - ALWAYS HOT ( )CLEARING THROAT OFTEN ( )MOUTH - TOOTH LOSS ( )TEMPERATURE - BETTER WITH COLD ( )CONVULSIONS ( )NASAL DISCHARGE COLOR ( )TEMPERATURE - BETTER WITH HEAT ( )COUGH ( )NASAL - DRY NOSE ( )COLD AREAS ( )COUGHING MUCUS: COLOR ( )NAUSEA ( )HOT AREAS ( )CRAMPING ( )NUMBNESS WHERE ( )TEMPERATURE - HOT AT NIGHT ( )DESCENDING / SINKING in AB ( )PAIN ABDOMINAL ( )TEMPERATURE - HOT PALMS / SOLES ( )DISCHARGE CLEAR ( )PAIN - BODY ACHES ( )TEMPERATURE - OTHER ( )DISCHARGE MILKY ( )PAIN - DULL ACHE ( )THIRST - ALWAYS THIRSTY ( )DIZZINESS / VERTIGO ( )PAIN HEADACHES ( )THIRST - FOR HOT? ( ) FOR COLD? ( ) ( )EAR DEAFNESS ( )PAIN INTERMITTENT ( )THIRST - NO THIRST ( )EAR - LOW-HUMMING ( )PAIN - JOINT PAIN ( )THROAT - CHRONIC HOARSENESS ( )EAR RINGING ( )PAIN - LOW BACK AND / OR KNEES ( )THROAT - FREQUENT SORE THROAT ( )EMOTIONS ANXIETY ( )PAIN HEADACHES - MIGRAINE ( )SENSATION OF OBJECT STUCK IN THROAT ( )EMOTIONS DEPRESSION ( )PAIN - MUSCLE PAIN ( )ULCERS - ( )EMOTIONS EASILY STARTLED ( )PAIN - OTHER ( )ULCERS - STOMACH ( )EMOTIONS FEAR ( )PAIN - BACK WHERE ( )URINE - BLOOD IN URINE ( )EMOTIONS GRIEF / SADNESS ( )PAIN SHARP ( )URINE - BURNING URINE ( )EMOTIONS HYSTERIA ( )PALPITATIONS ( )URINE - CLOUDY URINE ( )EMOTIONS INDECISIVENESS ( )PARALYSIS ( )URINE - DARK URINE ( )EMOTIONS IRRITABLE ( )PMS ABDOMINAL DISTENTION ( )URINE - DIFFICULT URINE ( )ENERGY CAN T STOP GOING ( )PMS - BREAST TENDER / SWOLLEN ( )URINE - DRIBBLING URINE ( )ENERGY EASILY FATIGUED ( )PMS CRAMPING ( )URINE - INCONTINENCE ( )EYES - DRY EYES ( )PMS - EMOTIONAL ( )URINE - SCANT URINE ( )EYES EXCESSIVE TEARING ( )PMS - HEADACHES ( )URINE - URGENT ( )EYES FLOATERS ( )PNEUMONIA ( )URINE - AWAKE TO URINATE ( )EYES BLURRY VISION ( )PROLAPSE - WHERE? NO of TIMES PER NIGHT ( )EYES - POOR VISION ( )SEIZURES WHAT TIME? ( )EYES - RED / PAINFUL ( )SEXUAL - IMPOTENCE ( )VOICE - HARD TO PROJECT ( )FACE FLUSHED CHEEKS ( )SEXUAL - LOW SEX DRIVE ( )VOICE - HOARSENESS ( )FACE - PALE COMPLEXION ( )SEXUAL - NIGHT TIME EMISSIONS ( )VOMITING ( )FACE - PALE LIPS ( )SEXUAL - PREMATURE EJACULATION ( )VOMITING CLEAR FLUIDS ( )FACE - RED FACE ( )SKIN - DRY / ITCHING ( )WATER RETENTION ( )FEVERISH AT NIGHT ( )SKIN - LARGE RED PATCHES ( )WEIGHT GAIN ( )FEVERISH DURING DAY ( )SKIN - OTHER ( )WEIGHT LOSS ( )FREQUENT COLDS ( )SKIN - RED PAINFUL RASH
Cathryn Aiken, L.Ac. 530 Traffic Way Arroyo Grande, CA 93420 T: 805.489.8592 F: 805.489.9509 www.arroyograndehealthandwellness.com aghealthandwellness@gmail.com PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below: INSURED OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services rendered. I understand that cancellations made without 24 hours notice and appointments missed without notice of cancellation will be billed for the amount of the appointment. I understand that my insurance does not cover this amount. Payment is required at the time of treatment. For patients with insurance the insured should verify benefits available for the patient, as well as co-payments, deductibles and remaining benefits for the plan s year. Co-pays and deductibles are due at the time of treatment. Benefits are not guarantee of payment. Many insurance companies only pay for a portion of the total fee. Your insurance will be billed as a courtesy, however fees due are your responsibility. Your insurance will be billed for a period of three months after services are rendered. After this time, you will be responsible for payment. SIGNED: DATE: