"Patient Intake Form - Oceanside Acupuncture Clinic"

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Confidential Patient Intake Form
Name:________________________________________
Is this your first acupuncture experience? Yes No
Phone Number:_________________________________
How did you hear about us?
Email:________________________________________
⎕ Website
⎕ Word of Mouth
⎕ Newspaper
⎕ Referral
⎕ Walk/Drive By
⎕ Online Ad
Address:______________________________________
⎕ Other:_______________________________________
Personal Health Number:_________________________
Birth Date & Year:______________________________
**If patient is under 16 years of age**
Occupation:____________________________________
Parent/Guardian:________________________________
Family Physician:_______________________________
Signature:_____________________________________
Emergency Contact:_____________________________
Phone Number:_________________________________
Relationship:________________________________
Witness:______________________________________
Phone Number:______________________________
Main Complaints
Health History
Please list your main health complaints & concerns in order
Please indicate with P (past), C (current), or F (family) if any
of importance.
conditions apply.
1. _________________________________
__Cancer
__Bleeding Disorder
type?___________
__Anemia
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
__ Contagious Illness
__Lyme Disease
How Long:____________________________________
__Diabetes
__Chronic Pain
Other Treatments:_______________________________
__Heart Disease
__Blood Bourne Disease
What makes it better:___________________________
__Pacemaker
__Substance Abuse
__Osteoporosis
__Fibromyalgia
What makes it worse:___________________________
__Seizure Disorder
__Skin condition
__Stroke/TIA
type?________________
2. _________________________________
__Thyroid Condition
__Autoimmune Disease
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Hyper / Hypo
type?________________
How Long:____________________________________
Medications (include herbs & supplements)
Other Treatments:______________________________
_____________________________________________
What makes it better:___________________________
_____________________________________________
What makes it worse:___________________________
_____________________________________________
_____________________________________________
3. _________________________________
_____________________________________________
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Injuries/Surgeries (note when & where on body)
How Long:____________________________________
_____________________________________________
Other Treatments:_______________________________
_____________________________________________
What makes it better:____________________________
_____________________________________________
What makes it worse:____________________________
Confidential Patient Intake Form
Name:________________________________________
Is this your first acupuncture experience? Yes No
Phone Number:_________________________________
How did you hear about us?
Email:________________________________________
⎕ Website
⎕ Word of Mouth
⎕ Newspaper
⎕ Referral
⎕ Walk/Drive By
⎕ Online Ad
Address:______________________________________
⎕ Other:_______________________________________
Personal Health Number:_________________________
Birth Date & Year:______________________________
**If patient is under 16 years of age**
Occupation:____________________________________
Parent/Guardian:________________________________
Family Physician:_______________________________
Signature:_____________________________________
Emergency Contact:_____________________________
Phone Number:_________________________________
Relationship:________________________________
Witness:______________________________________
Phone Number:______________________________
Main Complaints
Health History
Please list your main health complaints & concerns in order
Please indicate with P (past), C (current), or F (family) if any
of importance.
conditions apply.
1. _________________________________
__Cancer
__Bleeding Disorder
type?___________
__Anemia
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
__ Contagious Illness
__Lyme Disease
How Long:____________________________________
__Diabetes
__Chronic Pain
Other Treatments:_______________________________
__Heart Disease
__Blood Bourne Disease
What makes it better:___________________________
__Pacemaker
__Substance Abuse
__Osteoporosis
__Fibromyalgia
What makes it worse:___________________________
__Seizure Disorder
__Skin condition
__Stroke/TIA
type?________________
2. _________________________________
__Thyroid Condition
__Autoimmune Disease
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Hyper / Hypo
type?________________
How Long:____________________________________
Medications (include herbs & supplements)
Other Treatments:______________________________
_____________________________________________
What makes it better:___________________________
_____________________________________________
What makes it worse:___________________________
_____________________________________________
_____________________________________________
3. _________________________________
_____________________________________________
MILD 1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10 SEVERE
Injuries/Surgeries (note when & where on body)
How Long:____________________________________
_____________________________________________
Other Treatments:_______________________________
_____________________________________________
What makes it better:____________________________
_____________________________________________
What makes it worse:____________________________
Do you suffer from needle sensitivity resulting in light-headedness, nausea or fainting? Yes No
How do you sleep? (Trouble falling or staying asleep,
How is your digestion? (Appetite, bowel movements,
dreams, wake often - at specific times, etc?)
bloating, nausea, heart burn, etc?)
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Body Temperature
Not necessarily in degrees, but how you feel relative to others - needing to wear more layers, over-heating regularly, etc.
COLD 1 — 2 — 3 — 4 — 5 — 6 — 7 — 8 — 9 — 10 HOT
⎕ Cold hands & feet
⎕ Thirst but no desire to drink
⎕ Hot hands & feet
⎕ Numbness
⎕ Easily chilled
⎕ Never thirsty
⎕ Always thirsty
location_________
Energy Level
LOW 1 — 2 — 3 — 4 — 5 — 6 — 7 — 8 — 9 — 10 HIGH
⎕ Drop in energy
⎕ Shortness of breath
⎕ Difficulty focusing
⎕ Energy drop after meals
⎕ Body weakness/heaviness
⎕ Poor memory
⎕ Dizziness
time of day?__________
⎕ High or low blood pressure ⎕ Need caffeine or stimulants
⎕ Bleed or bruise easily ⎕ Heart Palpitations
Women Only Are you currently or potentially pregnant? Yes No If yes, how many weeks? ________________
How many pregnancies have you had? _______ Natural births: ________ Cesarian: _______
Please check if any apply. ⎕ PMS
⎕ Heavy menses
⎕ Long menses ⎕ Cramping
⎕ Spotting
⎕ Yeast Infection
⎕ UTI
⎕ Birth Control
⎕ Infertility
⎕ Trying to conceive ⎕ Miscarriage
⎕ Menopause
⎕ Hot Flashes/Night Sweats
⎕ Weight gain
⎕ Vaginal dryness
⎕ Mood Swings
⎕ Anger
⎕ Irritability
⎕ Anxiety
⎕ Fear
⎕ Sadness/Grief
Frequent Emotions
⎕ Depression ⎕ Hyperactivity ⎕ Timid/Shy ⎕ Indecision ⎕ Obsessive thoughts
⎕ Vision loss
⎕ Red eyes
⎕ Itchy eyes
⎕ Floaters or spots in eyes
Eyes, Ears,
⎕ Night blindness
⎕ Tinnitus
⎕ Hearing loss
⎕ Sleep apnea
Nose &
⎕ Phlegm
⎕ Dental issues
⎕ Sore throat
⎕ Seasonal allergies
Throat
⎕ Cold sores, cankers
⎕ Lingering cough
⎕ Sinus congestion ⎕ Asthma
⎕ Sinusitis
⎕Rhinitis
⎕ Dry eyes
⎕ Dry nose, mouth, throat
Lifestyle Do you exercise? Yes No If yes, how often? __________ times per week.
List your physical activities: ________________________________________________________________
What is your stress level like? ⎕ Low ⎕ Moderate ⎕ High ⎕ Off & on
Do you have stress management habits? Yes No If yes, please list: ________________________________
Please describe your diet: __________________________________________________________________
Please list any foods you restrict: ____________________________________________________________
Please give any other information you feel may be of importance: ______________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
The information on this form is accurate to the best of my knowledge:
Signature: _____________________________________________
Date: ______________________________
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