PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient

(1)

Date Name

Address

City State Zip

Sex:  M 

F Age Birthdate



Single



Married



Significant Other



_Widowed



_Separated



_Divorced

Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner’s Name Birthdate SS# Occupation Spouse/Partner’s Emp.

Whom my we thank for referring you?

PATIENT INFORMATION

PHONE NUMBERS

GENERAL INFORMATION

H W Cell

Best time/place to reach you Email Address:

IN CASE OF EMERGENCY CONTACT

Name Relationship

Home phone Work phone

Have you had acupuncture before?



Yes



No Have you used Chinese herbal medicine?



Yes



No Are you currently under the care of physician?



_Yes



_{No If yes, for what?}

Physician’s name Phone Who is responsible for this account? ___________________ Relationship to Patient _____________________ Insurance Co. ____________________________ Group #

Is patient covered by additional insurance?



Yes



No Subscriber’s Name

Birthday SS#

Relationship to Patient Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage with and assign directly to all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature

Relationship Date

Is condition due to an accident?



_Yes



_No

Date

Type of accident



_Auto



_Work



_Home



_Other

To whom have you made a report of your accident? _{Auto Insurance Employer Worker Comp }_Other Attorney Name (if applicable)

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1. Approx. Date Of Onset Does it interfere with your



_Work

_

_Sleep

_

_{Daily Routine}



_Recreation

Other therapies tried



Medications



Surgery



Chiropractic



_{Phys. Therapy}



_Other

2. Approx. Date Of Onset

Does it interfere with your



_Work

_

_Sleep

_

_{Daily Routine}



_Recreation



Medications



Surgery



Chiropractic



_{Phys. Therapy}



_Other

3. Approx. Date Of Onset

Does it interfere with your



Work



Sleep



Daily Routine



Recreation



Medications



Surgery



Chiropractic



Phys. Therapy



Other

Please list all medications that you are currently taking (or have used in the past two months), with dosages:

1. 4.

2. 5.

3. 6.

Please list any vitamins, minerals or homeopathic remedies that you are currently taking:

1. 4.

2. 5.

3. 6.

Please list all allergies that you have to any of the following:

Drugs Foods

Other (i.e. pollen, paint, etc.)

Past Medical History: Please list past injuries, broken bones, surgeries & hospitalizations, with approx dates:

PRESENT HEALTH CONCERNS

ORIENTAL MEDICINE INTAKE FORM

Name Date

HEALTH HISTORY

FAMILY INFORMATION

Work Activity:



_Sitting _{% of time}



_Standing _{% of time}



_{Light labor} _{% of time}



_{Heavy labor} _{% of time}

Exercise:

Do you exercise regularly?



_Yes



_No

If yes, describe & tell how often:

Do you have children?



Yes



No

If yes, how many? Ages Are you, or could you be currently pregnant?



_Yes



_{No Due date}

Personal Habits:



_Tobacco _packs/day



_Alcohol _drinks/wk



_{Coffee/tea/cola} _cups/day



_{Recreational drugs times/wk}



_{High Stress Level Reason}

Do you follow any diet regimens/restrictions?

(3)

GENERAL

Please check if you have had (in the last three months)



_{Poor appetite}



_{Fevers/Chills}



_Tremors



_{Heavy appetite}



_{Sweat easily}



_{Poor Sleeping}



_{Changes in appetite}



_{Localized weakness}



_{Heavy Sleeping}



_{Weight Loss/gain}



_{Bleed / bruise easily}



_{Dream disturbed sleep}



Cravings



Sudden energy drop (time?)



Night sweats



_{Strong thirst}



_Fatigue



_Dizziness



_{Rashes / hives}



_Ulcerations



_{Fungal infections}



_Itching



_{Exzema/Psoriasis}



_{Recent moles}



Dry Skin



Loss of hair



Changes in hair or skin texture



_Dandruff



_Pimples/Acne

Other hair or skin concerns:



_Concussions



_{Spots in front of eyes}



_{Swollen glands}



_{Glasses/Contacts}



_{Earaches/infections}



_{Sores on lips/tongue}



_{Eye strain/pain}



_{Ringing in ears}



_{Dry mouth}



_{Red eyes}



_{Poor heating}



_{Excessive saliva}



Itchy eyes



Sinus problems



Teeth problems



_{Dry eyes}



_{Post Nasal Drip}



_{Gum problems}



_{Excessive tearing}



_{Excessive phlem}



_{TMJ disorder}



_{Poor/blurry vision} _color



_{Grinding teeth}



_{Night blindness}



_{Nose bleeds}



Cataracts/Glaucoma



Recurrent sore throats



_{Headaches (location, triggers, severity)?}

Other head and neck concerns:



High blood pressure



Palpitations



Swelling of feet



_{Low blood pressure}



_Fainting



_{Blood clots}



_{Chest pain}



_{Cold hands/feet}



_Phlebitis



_{Irregular heartbeat}



_{Swelling of hands}

Other heart or blood vessel concerns:



_Cough



_{Pain with deep breath}



Coughing blood



Shortness of breath



_Wheezing



_{Tight chest}



_Asthma



_{Production of phlegm - color}



_Bronchitis

_{Is it}



_thick



_thin



_Pneumonia

Other lung related concerns:

SKIN AND HAIR

RESPIRATION

HEAD, EYES, EARS, NOSE AND THROAT

(4)

GASTROINTESTINAL



Nausea



Belching



Abdominal pain



_Vomiting



_{Bad breath}



_{Itchy anus}



_Diarrhea



_{Blood in stools}



_{Burning anus}



_Constipation



_{Mucus in stools}



_{Hemorroids/fissures}



_Gas/Bloating



_{Mucus in stools}



_{Hemorroids/fissures}



Hiccups



Acid regurgitation

History of chronic laxative use?

Other concerns with your general digestion:



_{Pain on urination}



_Bedwetting



_{Premature ejaculation}



Frequent urination



Kidney stones



Nocturnal emissions



_{Blood in urine}



_Impotency



_{Sores on genitals}



_{Urgency to urinate}



_{Increased libido}



_{Frequent urinary tract infections}



_{Unable to hold urine}



_{Decreased libido}



_{Chronic yeast infections}



_{Decrease in flow}

If you wake to urinate, how often?

Other concerns with genitals or urinary system:



_{Neck pain}



_{Muscle weakness}



_{Knee pain}



_{Upper back pain}



_{Cramps/spasms}



_{Foot / ankle pain}



_{Lower back pain}



_{General joint pain / stiffness}



_{Hip pain}



_{Hand/wrist pain}



_{Shoulder pain}



_{Joint with limited range}



Muscle pains

of motion

Other muscle, joint or bone concerns:



_Seizures



_{Memory loss}



_{Easily susceptible to stress}



_{Loss of balance}



_Concussion



_{History of emotional /}



_{Areas of numbness}



_Depression

_{Physical abuse}



_Ticks



_Anxiety



Lack of coordination



Irritability

Have you ever been treated for emotional problems?



Yes



No Have you ever considered or attempted suicide?



Yes



No Other neurological or psychological concerns:

Age of first menses If no longer menstruating, approx date ceased First day of last menses Length between menses: days Duration of period days



Unusual flow



Heavy



Light



Vaginal discharge



Vaginal sores



Painful periods color



Hot Flashes



Irregular periods



Vaginal odor



Breast lumps/soreness



Clots in flow



Vaginal dryness

GYNECOLOGY

NEUROLOGICAL

GENITOURINARY

(5)

Changes in body or psyche prior to menstration (“PMS”)

Date of last PAP: Results were



_Nornal



_Abnormal



_Unsure

If you use birth control, what type and for how long?

Have you ever used hormonal methods for contraception or period regulation? (i.e. the pill, Depo-Provara, etc.)

Other gynological concerns:

Number of pregnancies: Births Miscarriages Abortions Were your births relatively normal? Explain:

Other related concerns:

Please let us know of any concerns you would like to address:

GYNECOLOGY (cont)

PREGNANCY HISTORY

COMMENTS

FAMILY HISTORY

Addiction (alcohol/drugs) Cancer

Cardiac disorders (heart disease, high blood pressure, stroke)

Diabetes

Digestive /Gastro- intestinal disorders Immune disorders (hepatitis, HIV, etc.) Mental Illness

Respiratory disorders (asthma, allergies, etc.) Skin disorders (eczema, pso-riasis, etc.)

Seizure disorders