Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced Separated Widow Occupation Employer Emergency contact Relationship Phone number Primary Care provider Phone How do you want to be contacted? Home phone Work phone Cell phone Email How did you hear about us? Medical Complaint Reason for your visit: For how long have you had this condition? What makes it better? What makes it worse? Have you being treated for this condition by another health care practitioner? Have this treatment helped? Do you have a medical diagnosis? Have you had acupuncture before?
Do you currently have an infectious disease Yes No Possibly Health Information Hospitalizations/Surgeries Allergies (Medications, foods, environmental) Prescription medications, dosage and frequency Over the counter medications, dosage, frequency
Medical History Head Ears, nose, throat Eyes Neurological Headaches Change in Impaired vision Dizziness Migraines hearing Eye pain Vertigo Bell s Palsy Ear ringing Blurred vision Fainting Facial pain Earache Tearing Loss of balance Hair loss Ear infections Dryness Seizure Jaw pain/tmj Allergies Cataracts Poor memory Nose Glaucoma Insomnia congestion Redness Numbness/ting Runny nose Glasses/contacts ling Frequent Paralysis colds Tremors Nose bleeds Night Sinus problems headaches Difficulty swallowing Hoarseness Frequent sore throats Respiratory Cardiovascular Gastrointestinal Urinary/Kidney Frequent High blood Bad breath Kidney Disease colds pressure Changes in Kidney Stones Asthma Low blood appetite Bladder/Kidney Difficulty pressure Belching infections breathing Heart disease Nausea/vomiting Painful Emphysema Chest pain Heartburn Cough Palpitations Gastro esophageal Frequent Tuberculosis Irregular reflux (GERD) heart beat Indigestion Recurrent UTI Pacemaker Bloating Cloudy urine Varicose veins Gas Blood in urine Edema Constipation Frequent Stroke Loose stools Taking Diarrhea Incontinence Coumadin/ Irritable Bowel Urgency Warfarin syndrome (IBS) Nighttime Taking Aspirin Crohn s Disease Ulcerative colitis Hemorrhoids Gall Bladder
disease Liver disease Endocrine Muscular- skeletal Emotional Skin Hyperthyroid Joint pain Depression Hypothyroid Joint stiffness Anxiety Diabetes Arthritis Anger Hypoglycemia Muscle cramps Fear Excessive Back pain Grief/sadness sweating Carpal tunnel Worry/overthinking Night sweats Osteoporosis ADHD Feeling Fibromyalgia Panic Attacks hot/cold Aggression Acne Dry skin Slow wound healing Easy bruising Rashes Psoriasis Itching Sleep Difficulty falling asleep Difficulty staying asleep Grinding teeth Nightmares Sleep apnea Other Fatigue Allergies Weight loss Weight gain Anemia For Men Impotence Vasectomy Date: Testicular pain/redness/swelling Prostate problems Seminal emissions Low libido Excess libido Painful intercourse For Women Are you pregnant? Yes No Trying Maybe Method of birth control: Age at first period Start date of last menses Age at menopause Typical length of menses (days) Length of cycle (from 1 st day of menses to the 1 st day of next month menses) Number of pregnancies Births Abortions Miscarriages
Hysterectomy yes No Date Check if apply: Painful periods Irregular cycles Scanty flow Heavy flow Clotting Inter- cycle bleeding Endometriosis PMS Fibroids Low libido Excess libido Painful intercourse Infertility Vaginal discharge Moodiness Fibrocystic breasts Breast tenderness Ovarian cysts Nipple discharge Abnormal PAP smear Family History Asthma Cancer Diabetes Heart disease High Blood pressure Stroke Lifestyle How is your diet? Great Good Fair How many meals do you eat per day? How many snacks? Are you a vegetarian or a vegan? What kind of foods make up your primary diet? What kinds of foods do you usually exclude from your diet? Do you exercise regularly? What form? How often? Do you drink alcohol? Yes No How often? How much? Do you smoke? Yes No How much?
For how long have you been a smoker? Do you use recreational drugs? Yes No What kind and how often? How is your energy? Great Good Fair Poor How is your sleep? Great Good Fair Poor How is your level of stress? Low Moderate High Source of stress: Work Financial Family/relationship other Patient Signature Date