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

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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

Other therapies tried

Medications

Surgery

Chiropractic

Phys. Therapy

Other

3. Approx. Date Of Onset

Does it interfere with your

Work

Sleep

Daily Routine

Recreation

Other therapies tried

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?

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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

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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

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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

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