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Transcription:

STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP: Home Phone: Cell Phone: May messages be left on one or both of these numbers? Yes No E-Mail: Social Security # Occupation: Employer:_ Primary Care Physician: Insurance Provider: Policy Number: ID Number: Emergency Contact: (name, telephone, relation): How did you hear about us? Please identify the health concerns (past or present) that have brought you into the clinic: Condition Treatments Received 1. 2. 3. 4. 5.

5. Please list any foods, medications, or drugs you are hypersensitive or allergic to (including reactions): Please list any medications, vitamins or supplements you are currently taking (including dosages): Do you have any reason to believe you may be pregnant? Yes No If yes, how far along are you? Do you have any infectious diseases? Yes No If yes, please identify: Blood Pressure: What was your most recent reading? /_ When was this taken? Height: Weight (Current): Past Maximum: When? Male Only: a. Prostate concerns? e. Impotence? PSA level, if applicable: b. Painful urination? f. Testicular Pain/Swelling: c. Decreased stream? d. Discolored urine? _ Any other male concerns your practitioner should be aware of? Female Only: Gynecological History: a. Age of First Menses: b. Number of Days of Flow: c. Length of Cycle: d. Date of last menstruation:

f. Menstrual cramping? g. PMS? k. Number of Pregnancies: l. Number of Live Births: m. Number of Miscarriages: n. Number of Abortions: o. Birth Control Type: s. Onset of Menopause: Any other gynecological information your practitioner should be aware of? Hospitalizations and Surgeries: Reason When Reason When Family History: Father Mother Brothers Sisters Grandparents Cancer _ (Please note type) Diabetes _ Heart Disease _ High Blood Pressure _ Stroke _ Mental Illness _ Asthma _ Lifestyle: a. Do you typically eat three meals per day? Y / N If no, how many? b. Do you feel you have a healthy diet? Y / N c. Do you have particular food cravings?

d. Exercise routine: e. On average, how many hours per night do you sleep? Do you wake rested? g. Do you smoke? How much? h. What is your caffeine intake? i. How much alcohol do you consume? _ For the conditions listed below, please CIRCLE any that you have now and UNDERLINE any you have experienced in the past: EMOTIONAL Mood Swings Anxiety Depression Stress ENERGY & IMMUNITY Fatigue/Low Energy Chronic Fatigue Syn. Insomnia Frequent colds and flu Slow Wound Healing MUSCULOSKELETAL Neck/Shoulder Pain Muscle Tension Muscle Spasms Back Pain Headaches Fibromyalgia Joint Pain Stiffness Restless Legs Leg Cramps Sprains/Strains Tendonitis Arthritis EYE, EAR, NOSE AND THROAT Impaired Vision Poor Night Vision Floaters Eye Pain/Strain Glaucoma Glasses/Contacts Excessive Tearing Redness/Dryness Ringing In The Ears Ear Aches Sinus Problems Allergies Frequent Sore Throats Teeth Grinding TMJ CARDIOVASCULAR Heart Disease Chest Pain Palpitations/Fluttering High Blood Pressure Stroke Heart Murmurs Varicose Veins DVT Cold Hands and Feet Anemia GASTROINTESTINAL Ulcers Low Appetite Excessive Hunger Nausea/Vomiting Abdominal Pain Flatulence Bloating Acid Reflux Belching Chronic Constipation Chronic Diarrhea IBS

Hemorrhoids Food Sensitivities Night Sweats Low Libido GENITAL/URINARY TRACT Painful Urination Frequent/Urgent Urination Frequent UTI Burning/Pain with Urination Blood in Urine Kidney Disease Kidney Stones Wake At Night to Urinate Irregular Menses Heavy Bleeding Complications with Pregnancy Infertility Impotence NEUROLOGICAL Vertigo Dizziness Numbness/Tingling Loss of Balance Seizures Trigeminal Neuralgia Stroke Shingles MS RESPIRATORY Asthma Shortness of Breath Wheezing Emphysema Bronchitis ADDICTIONS Alcohol Cigarettes Narcotics Marijuana OTHER ENDOCRINE Hypothyroid Hyperthyroid Diabetes

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