Inner Balance Acupuncture

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Transcription:

Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth: / / Occupation: Home Address: City: State: Zip: Home phone: Cell phone: Work phone: E-mail: May we call you at either of the above phone numbers? Yes No May we leave a message? Yes No Emergency contact: (name) (phone) (relation) Referred by: 1

Are you under the care of a physician now? Yes No If yes, what for: Physician s name: Physician s phone number: Reasons for today s visit: Reason #1 How long have you had this condition: Are you receiving other treatments for this condition? (please specify): Reason #2 How long have you had this condition: Are you receiving other treatments for this condition? (please specify): Reason #3 How long have you had this condition: Are you receiving other treatments for this condition? (please specify): Have you had Acupuncture before? Yes No Have you used Chinese Herbs before? Yes No Is your condition getting worse? better? What seemed to be the initial cause? Please list current medications you are taking, including vitamins, herbs, etc.: 2

Family Medical History: Heart Disease Stroke Diabetes Asthma Seizures Alcoholism High Blood Pressure Cancer other: Your Past Medical History: HIV/AIDS Alcoholism Allergies Appendicitis Asthma Cancer Chicken Pox Diabetes Emphysema Epilepsy Goiter Heart Disease Hepatitis Hypertension Multiple Sclerosis Mumps Pacemaker Pneumonia Seizure Stroke Thyroid TB Typhoid Fever Ulcers other: List any hospitalizations you ve had during the past 5 years: Surgeries: (list) Your Lifestyle: Alcohol Marijuana Stress Tobacco Drugs Occupational Hazards Regular Exercise: Yes No Type: How Often: General Symptoms: Poor Appetite Dream disturbed sleep Shortness of breath Excess Appetite Fatigue Fever Strongly like cold drinks Lack of Strength Chills Strongly like hot drinks Peculiar taste in mouth Night Sweats Recent weight loss Body feels heavy Sweat Easily Recent weight gain Cold feet Sleep too much Bleed or bruise easily Cold hands Muscle Cramps Poor sleep Poor circulation Vertigo or dizziness 3

Head, Eyes, Ears, Nose, Throat: Glasses Headaches Red Eyes Itchy Eyes Spots in Eyes Poor Vision Blurred Vision Dry Eyes Night Blindness Glaucoma Cataracts Teeth Problems Grinding Teeth TMJ Facial Pain Gum Problems Dry Mouth Excess Saliva Sinus Problems Swollen Glands Lumps in Throat Enlarged Thyroid Nose Bleeds Poor Hearing Ringing in Ears Sores on Lips/Tongue Recurrent Sore Throat Excessive Phlegm (color of phlegm: ) Respiratory: Difficulty Breathing Lying Down Shortness of Breath Tight Chest Asthma/Wheezing Pneumonia Cough Cough up Blood Cardiovascular: High Blood Pressure Irregular Heart Beat Phlebitis Low Blood Pressure Blood Clots Palpitations Difficult Breathing Chest Pain Fainting Are you taking blood thinners/aspirin: Yes No Gastrointestinal: Nausea Vomiting Gas Acid Regurgitation Hiccups Bloating Bad Breath Diarrhea Constipation Use Laxatives Black Stools Bloody Stools Mucus in Stools Itchy Anus Burning Anus Rectal Pain Hemorrhoids Anal Fissures Intestinal Pain or Cramping Bowel Movements Frequency Formed or Loose Color Strong odor: Yes No 4

Musculoskeletal Neck/Shoulder Pain Upper Back Pain Joint Pain Muscle Pain Low Back Pain Rib Pain Limited Range of Motion Sciatica Paralysis Numbness >> Mark areas of pain on the diagram >> Skin and Hair Rashes Eczema Dandruff Hives Ulcerations Psoriasis Itching Acne Hair Loss Fungal Infections Change in Hair/Skin Texture Other: Neuropsychological Seizures Poor Memory Irritability Depression Easily Stressed Anxiety Tics Abuse Survivor Seeing a Therapist Considered or Attempted Suicide Other: Genitourinary Pain on Urination Blood in Urine Venereal Disease Increased Libido Frequent Urination Incontinence Bedwetting Decreased Libido Urgent Urination Kidney Stone Wake to Urinate Impotence Incomplete Urination Other: 5

Gynecology Age Menses Began: Duration of Flow: Length of Cycle: Date Last Period Began: Age of Menopause: Date of Last PAP Exam: Irregular Periods Vaginal Sores Breast Lumps Painful Periods Vaginal Odors # pregnancies Clots Vaginal Discharge # live births PMS color # abortions Breast Self Exam # premature births Other: Is there anything else that you feel we should know relevant to your condition(s)? 6

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