Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication: Phone Call Text Message Email In an Emergency Please Notify: Name Phone Number Relationship 1. Main problem you are seeking treatment for today 2. How long ago did this problem begin 3. Have you been given a diagnosis for this problem? 4. What treatment(s) have you received for this problem? 5. Name of Physician/Practitioner: 6. Is this Practitioner aware you are seeking Acupuncture for this condition? Y N Past Medical History Current Medical Condition: Surgeries: Significant Emotional and Physical Trauma(s):
Do you have or have you ever had any infectious diseases? Y N If Yes please describe Medications, including prescription, over the counter, vitamins and supplements, taken in the last three months Allergies: Family Medical History: General Health If deceased, please list age and cause of death Mother: Father: Brother(s): Sister(s): Personal Medical History Childhood Health Issues: Current Emotional Health: Rate on a scale of 1 (none) to 10 (significant amount) Mood Swings Nervousness Mental Tension Rate on a scale of 1 (poor) to 10 (good) Family Life Social Life Work Life Relationship Status: Single Married Partnered Divorced Widowed Quality of Significant Relationship Predominant Current Emotion:
Occupation: Work- related Stress Level (1-10) Other Life Stressors: Hobbies and Recreational Habits: Do you have a regular exercise program, and if so what is it? Y N Smoker: No Former, Quit date Yes, amount/day Alcohol use: None Former, Quit Date Yes, amount/day Have you ever been treated for emotional problems? Y N Have you ever considered suicide? Y N Have you ever attempted suicide? Y N Do you experience a sudden drop in energy during the day? Y N Time? Hours of sleep per night Frequent waking? Y N WOMEN ONLY Age at First Menses Days Between Menses Duration of Menses Check all that apply: Heavy Flow Light Flow Spotting Between Menses Irregular Cycle Clotting Painful Periods Difficulty Conceiving PMS Symptoms Breast Lumps Nipple Discharge Vaginal Discharge Number of Pregnancies Number of Births Miscarriages Abortions Difficulties during pregnancy, labor and delivery Birth Control, type and duration of use: Last Menstrual Period: / / Last PAP Smear: / /
Please Check All That Apply Lung/Large Intestine Meridians/Organ Network Difficulty Breathing Excess Phlegm Frequent Colds Asthma Shortness of Breath Sinus/Rhinitis Wheezing COPD Chest Congestion Cough Allergies Smoker Excessive Sweating Dry Skin Psoriasis Bronchitis Difficulty Concentrating Loose Stools Constipation Mucus in Stool Slow Healing Skin Unable to let go Timidity Sadness Boredom Apathy Low Energy Grieving Heart/Small Intestine Meridians/Organ Network Dream Disturbed Sleep Palpitations Restlessness Dizziness Difficulty Falling Asleep Flushed Face Anxiety Vertigo Waking Still Feeling Tired Hot Flashes Nightmares Phobias Shortness of Breath Cardiac Pain Depression Anemia Mental Confusion Cold Hands Cold Feet Poor Circulation Bitter Taste in Mouth Speech Problems SIBO Excess Laughter Celiac Disease Forgetfulness Sores on the tip of the tongue Spleen/Stomach Meridains/Organ Network Abrupt Weight Gain Excessive Appetite Low Appetite Heartburn Abrupt Weight Loss Acid Reflux Mouth Sores Belching Fatigue After Eating Bad Breath Nausea Vomiting Gurgling Stomach Noises Bloating Hiccups Gas Stomach Pain Hemorrhoids Indigestion Gastritis Irritable Bowel Diabetes Loose Stools Ulcers Crohn s Disease Vaginal Discharge Fatigue Organ Prolapse Weak Muscles Easily Bruised Headaches Over thinking Aching Heavy Limbs Worry Excess Phlegm Poor Memory Difficulty Focusing Feeling Insecure Restless Sleep Cold Knees
Kidney/Urinary Bladder Meridians/Organ Network Dental Problems Kidney Stones Infertility Impotence Easily Broken Bones Low Back Pain Knee Pain Osteoarthritis Lack of Perspiration Night Sweats Hearing Problems Fear Excessive Perspiration Excessive Thirst Hot Feet Fatigue Cold Body Temperature Cold Hands Cold Feet Depression Hot Body Temperature Sciatica Easily Startled Hair Loss Memory Problems Panic Attacks Tinnitus Feel Overwhelmed Premature Gray Hair Decreased Will Power Low Libido Lack of Bladder Control Frequent Night Urination Dark Under Eye Circles Liver/Gall Bladder Meridains/Organ Network One Sided Headache Migraines Easily Angered Frustrated Stiff Neck and Shoulders Depression Irritable TMJD Difficulty Staying Asleep Frequent Sighing Vertigo Tinnitus Bitter Taste in Mouth Acid Reflux Irritable Bowel Nausea Tightness in Chest Vision Problems Belching Bloating Churning Stomach Numbness Twitching Restless Legs Tendonitis Muscle Spasms PMS Fibromyalgia Menstrual Cramps Brittle Hair Brittle Nails Impatience Unable to Plan Nervousness Indecision Unable to Organize Body Pain On a scale of 1 (none) to 10 (worst pain possible), how is your pain today? Does the pain impair your ability to (circle all that apply) Work Exercise Sleep Climb Stairs Drive Walk Concentrate Participate in Hobby Activities of Daily Living (list) What makes the pain worse? Sitting Standing Heat Cold Stress Fatigue Activity What makes the pain better? Rest Heat Cold Massage Activity Other
Nature of the pain (circle all that apply) Dull Distending Heavy Sharp Ache Stabbing Pulling Throbbing Deep Superficial Radiating Hot Numb Tingling Moves Around Local/Fixed Please mark areas of pain on the chart below with an X Please Sign One of the Two Options Below Option #1 I have received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment. Patient Signature Date Option #2 I have NOT received a diagnostic exam by a physician or chiropractor within the last six months regarding the condition for which I am seeking treatment. Ohio law requires that a Licensed Acupuncturist recommend that you receive a diagnostic exam from a physician or chiropractor. I understand this recommendation. Patient Signature Date Licensed Acupuncturist Signature