American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ 85741 (520) 544-6603 Notes for new Patients: Your first session * Can you imagine not having to wait at a doctor's office? Well, your time is as valuable as ours. We have a no-wait policy. You will be seen within minutes of your arrival. your appointment. clothing if possible. Ideally, there should be easy access to your legs up past the knee, arms past the elbows, and abdomen. Feel free to bring such clothes to change into before your treatment. remove them for the Iridology exam. d a case, as you may be asked to Name Birth date Age Sex Address City State Zip Telephone (Home) Cell) E-mail Address Have you been treated by Acupuncture or Oriental Medicine before? Referred to us by (Dr., Friend, Internet, Other): Your Health Care Provider/MD? Phone In Emergency Notify Relationship Phone Main Problem Is this visit the result of an accident or injury? Yes No If yes, please explain How long ago did this problem begin? Have you been given a diagnosis for this problem? If so, What?
What kinds of treatment have you tried? Are you currently receiving treatment for your problem? If so, please describe: Does anything improve your problem? Past Medical History (please include date): Illnesses: Surgeries: Significant Trauma (auto accidents, falls, etc.): Do you have any implants or prosthetics? If so, please describe: Do you have, or have you ever had, any infectious diseases? If so, please describe: Medicines: (prescription and over-the-counter drugs, vitamins, herbs, etc. taken within the last three months Allergies: Family Medical History (General Health): (If deceased, cause of death) Mother s side: Father s side: Number of Siblings: Personal birth history: (prolonged labor, forceps delivery, etc.) Current Emotional Health: Current Quality of Life: Current Relationship/Quality: Current Predominant Emotion:
Occupation: Stress level Have you had any unusual stresses recently? Favorite time of year: Worst time of year Hobbies and Recreational Habits: Do you have a regular exercise program? Please describe: Travel abroad within the past year? Where? Have you ever been on a restricted diet? Please describe: Please describe your average daily diet: Morning Afternoon Evening Proportion of raw food to cooked food Do you get any cravings? If so, what? When? Preferred Tastes: Bitter Spicy Sour Salty Sweet Do you smoke? How many packs of cigarettes do you smoke a day? How much coffee, tea or cola do you drink per week? How much alcohol do you drink per week? How are you today? (Scale of 1-10) Great OK Bad I0 5 1 How committed are you to getting well? (10 is 100% Committed.) 0 5 10
Do you or your family; have a history of any of the following? Cancer Thyroid Disorders Asthma Heart Disease High Blood Pressure HIV Diabetes Rheumatic Fever Allergies Seizures Herpes Addictive Disorders Stroke Hepatitis Mental Illness Put a check mark by the symptoms that pertain to you over the last month. Cold hands Cold feet Feverish in the Afternoon or flushes Heat sensation in hands, feet, chest Day sweats Night sweats Thirsty Catch colds easily Shortness of breath Swelling of hands Cough Cough blood Nasal discharge Nose bleeds Sinus congestion Dry mouth, throat, nose, nose or skin Allergies Sneezing Feel achy Sore throat Difficult breathing Asthma Shortness of breath Phlegm, color Chest congestion Fatigue General weakness Sweat easily Feel worse after exercise Poor balance Dizziness See floating black spots Restlessness Stiff neck/shoulders Palpitations Irregular heart beat Chest pain Chest pain traveling to shoulder Anxiety Insomnia Dream disturbed sleep Mental confusion Emotional changes Sore in lips, tongue Sores on tip of tongue Teeth problems Grinding teeth Facial pain Chills alternating with fever Headache Fever Chills Low appetite Large appetite Change in appetite Constipation Abdominal bloating and/or gas after eating Fatigue after eating Prolapsed organs (previously diagnosed) Bruise easily General feeling of heaviness in body Mental heaviness, sluggishness or fogginess Nausea Loose stools, diarrhea Diarrhea alternating with constipation Hemorrhoids Blood in stool Parasites Indigestion Heartburn Belching Stomach pain Vomiting Ulcers Hernia Burning sensation after eating Bad breath Mouth (canker) sores Feel better after exercise Bleeding, swollen or painful gums Chest pain Tight feeling in chest Bitter taste in mouth Blood shot eyes Anger easily Headache at top of head Hot flashes Dry eyes Irritability; easily susceptible to stress Depression High blood pressure Numbness of hands and feet Muscle spasms, twitching, cramping Seizures Tremors Convulsions Sore, cold or weak knees Low back pain Swollen feet Memory problems Ringing in the ears
Musculoskeletal: General aches Muscular atrophy Muscular weakness Arthritis Joint instability Muscle cramps Joint Pain Recent sprains Injuries or falls Urine is: Normal color Cloudy Difficult Scanty Urgent Has odor Clear Dark yellow Reddish Burning Painful Spasms Kidney stones Frequent urination (Urgent urination) Do you get up more than once at night to urinate? Lack of bladder control Genital sores Libido (sexual drive) is: Normal Low High Low blood pressure Phlebitis Poor hearing Mania Weight loss Blood clots Concussion Itching Eczema Hives Pimples Dandruff Dry skin Rash Recent moles Hair loss Please circle on the diagram areas of pain or injury. Please describe the type and quality of the pain. Burning A Pressure-like Crampy Other
WOMEN ONLY Please answer each question or check as appropriate. Are you pregnant? Yes No Number of children Number of pregnancies Your age at first period Are your menses cycles regular? Yes No Number of days between periods? Average days of flow? The flow is: Normal Heavy Light The color is: Normal Dark Pale Bright red Brown Are there blood clots: Yes No Do you have pain/cramps? Yes No Before During or After period Do you have nausea or vomiting? Yes No Before During Do you experience any of the following before your period each month? Water retention Breast tenderness Breast swelling Irritability Mental depression Food cravings Low back pain Migraines Do you bleed between periods? Yes No Do you have vaginal discharge between periods? If yes, describe consistency, color, and smell: MEN ONLY Please check questions as appropriate Feeling of coldness or numbness in the external genitalia? Pain or swelling of testicles? Premature ejaculation? Impotence? Number of children? *Copies of our policies are available to download online at our website www.ahatucson.com or view a copy in our office reception area. Or we can print you a copy upon request. By signing your name in the space provided below, affirms you have read and received a copy of the American Health Acupuncture LLC s Notice of Privacy Practices, Payment, Cancellation, & Refund Policies and agree to its terms. Signature of Patient: Name: Date: Signature is required.