"Acupuncture Patient Medical History Intake Form - Acupuncture Arts East"

ADVERTISEMENT
ADVERTISEMENT

Download "Acupuncture Patient Medical History Intake Form - Acupuncture Arts East"

186 times
Rate (4.5 / 5) 10 votes
PATIENT MEDICAL HISTORY INTAKE FORM
Patient Name: ____________________________________________
Date: __________________________
Date of Birth: ______________________________________________
Medical History:
(Please check box if you have ever had the following)
� arthritis
� kidney or bladder problems
Primary Health Concerns: _________________________________
� asthma
� gallstones
� bronchitis
� ulcers
__________________________________________________________
� pneumonia
� gastric reflex
� allergies
� eating disorder
__________________________________________________________
� anemia
� high blood pressure
� heart problems
� chronic fatigue
__________________________________________________________
� chronic pain
� hepatitis
� migraine headache
� alcoholism
__________________________________________________________
� eye disorder
� substance abuse
� cancer
� jaundice
Secondary Health Concerns: ______________________________
� diabetes
� female reproductive disorders
� epilepsy
� sudden weight loss
__________________________________________________________
� stroke
� sudden weight gain
__________________________________________________________
Family History:
(Please list any major medical conditions that your
parents have or had that you know of)
Date of onset of symptoms: _______________________________
__________________________________________________________
Pain from this condition is: � minimal
� moderate
� slight
� severe
__________________________________________________________
Have you had this condition in the past? ___________________
__________________________________________________________
What makes it better? _____________________________________
Are your currently receiving care from:
� chiropractor
� massage therapist
What makes it worse? _____________________________________
� medical specialist
� nutritionist
� physical therapist
� therapist
Is your condition: � getting worse � comes and goes
� constant
� don’t know
Have you had acupuncture before? Yes
No
Medications you are currently taking: ______________________
If yes, for what condition? ___________________________________
__________________________________________________________
Do you use any of the following?
� Alcohol
Amount/Wk ______________________________
__________________________________________________________
� Tobacco
Amount/Wk ______________________________
� Coffee
Cups/Day _______________________________
List surgeries/procedures: ________________________________
� Carbonated sugar drinks (Pepsi, Coke, etc.)
Servings/Day ____________________________
__________________________________________________________
� Foods labeled “Diet”
� Processed Foods
__________________________________________________________
How many glasses of water do you drink per day? __________
Have you been injured in an accident? Yes
No
What exercise do you do on a regular basis?
If yes, please describe: _____________________________________
� walking
� gym workout/training
� jogging
� exercise classes
__________________________________________________________
� bicycle
� yoga
� hiking
� Pilates/Core/Barre
Date of last physical exam: ________________________________
� rowing/kayaking
� dance
� sports
� other ________________________
Please complete reverse
|
|
|
Acupuncture Arts East
62 Brown Street, Merrimack Medical Center, Suite 402, Haverhill, MA 01830
t: 978-372-4771
susan@acupunctureartseast.com
PATIENT MEDICAL HISTORY INTAKE FORM
Patient Name: ____________________________________________
Date: __________________________
Date of Birth: ______________________________________________
Medical History:
(Please check box if you have ever had the following)
� arthritis
� kidney or bladder problems
Primary Health Concerns: _________________________________
� asthma
� gallstones
� bronchitis
� ulcers
__________________________________________________________
� pneumonia
� gastric reflex
� allergies
� eating disorder
__________________________________________________________
� anemia
� high blood pressure
� heart problems
� chronic fatigue
__________________________________________________________
� chronic pain
� hepatitis
� migraine headache
� alcoholism
__________________________________________________________
� eye disorder
� substance abuse
� cancer
� jaundice
Secondary Health Concerns: ______________________________
� diabetes
� female reproductive disorders
� epilepsy
� sudden weight loss
__________________________________________________________
� stroke
� sudden weight gain
__________________________________________________________
Family History:
(Please list any major medical conditions that your
parents have or had that you know of)
Date of onset of symptoms: _______________________________
__________________________________________________________
Pain from this condition is: � minimal
� moderate
� slight
� severe
__________________________________________________________
Have you had this condition in the past? ___________________
__________________________________________________________
What makes it better? _____________________________________
Are your currently receiving care from:
� chiropractor
� massage therapist
What makes it worse? _____________________________________
� medical specialist
� nutritionist
� physical therapist
� therapist
Is your condition: � getting worse � comes and goes
� constant
� don’t know
Have you had acupuncture before? Yes
No
Medications you are currently taking: ______________________
If yes, for what condition? ___________________________________
__________________________________________________________
Do you use any of the following?
� Alcohol
Amount/Wk ______________________________
__________________________________________________________
� Tobacco
Amount/Wk ______________________________
� Coffee
Cups/Day _______________________________
List surgeries/procedures: ________________________________
� Carbonated sugar drinks (Pepsi, Coke, etc.)
Servings/Day ____________________________
__________________________________________________________
� Foods labeled “Diet”
� Processed Foods
__________________________________________________________
How many glasses of water do you drink per day? __________
Have you been injured in an accident? Yes
No
What exercise do you do on a regular basis?
If yes, please describe: _____________________________________
� walking
� gym workout/training
� jogging
� exercise classes
__________________________________________________________
� bicycle
� yoga
� hiking
� Pilates/Core/Barre
Date of last physical exam: ________________________________
� rowing/kayaking
� dance
� sports
� other ________________________
Please complete reverse
|
|
|
Acupuncture Arts East
62 Brown Street, Merrimack Medical Center, Suite 402, Haverhill, MA 01830
t: 978-372-4771
susan@acupunctureartseast.com
PATIENT SYMPTOM SURVEY
Patient Name:
Date:
GENERAL
REPRODUCTIVE SYSTEM
CHEST
ARMS & HANDS
PAST NOW
PAST NOW
PAST NOW
PAST NOW
� � fatigue
� � painful intercourse
� � chest pain
� � pain in upper arm
� � sleep problems
� � prostate problems
� � shortness of breath
� � pain in forearm
� � swollen glands
� � sexual problems
� � pain in hands
� � pain around ribs
� � hot/cold intolerance
� � loss of sex drive
� � pain in fingers
MUSCULOSKELETAL
� � frequent headaches
� � genital infections
� � pinched nerve in arm
� � weight loss
birth control method: ________
� � pinched nerve in hand
� � joint swelling
� � weight gain
� � pins & needles in arm
� � muscle cramps
WOMEN ONLY
� � fever or chills
� � pins & needles in hand
� � neck pain
� � cramps
� � allergies
� � fingers go to sleep
� � shoulder pain
� � PMS
� � hands cold
� � tennis elbow
EMOTIONAL
� � irregular periods
� � swollen joints in fingers
� � arm pain
� � nervousness
Are you pregnant?
� � arthritis in fingers
� � hand sensations
� Yes � No
� � anxiety or worry
� � loss of grip
� � loss of grip strength
date of last period ____
� � frequent crying
� � mid-back pain
HIPS, LEGS & FEET
# pregnancies ________
� � irritability
� � rib pain
# of miscarriages ______
� � anger
� � low back problems
� � pain in buttocks (R/L)
� � difficult labor
� � tension
� � hip pain
� � pain in hip joint (R/L)
� � breast problems
� � mood swings
� � foot problems
� � pain down leg (R/L)
� � fear
� � leg cramps
� � pain down both legs
HEAD
� � restlessness
� � knee pain
� � leg cramps
� � confusion
� � headache
� � ankle weakness
� � pins & needles in legs
� � depression
� � entire head
� � tingling foot
� � numbness of leg (R/L)
� � suicidal thoughts
� � back of head
� � numbness of feet (R/L)
LOW BACK
� � forehead
� � numbness of toes
NERVOUS SYSTEM
� � temples
� � low back pain
� � feet feel cold
� � dizziness
� � migraine
� � low back pain is worse
� � cramps in feet (R/L)
� � head feels heavy
� � fainting
when:
� � swollen ankles (R/L)
� � paralysis
� � loss of memory
� working
� � swollen feet (R/L)
� � tremors
� � light-headedness
� lifting
� � painful joints in toes
� � numbness/tingling
� � fainting
� stooping
� � pain in foot (R/L)
� � convulsions
� � light bothers eyes
� standing
� � pain in knee (R/L)
� � loss of smell
� � memory loss
� sitting
HEART/LUNG
� � muscle weakness
� � loss of taste
� bending
� � loss of balance
� coughing
� � chest pain
GASTROINTESTINAL
� � dizziness
� � pinched nerve
� � high blood pressure
� � change in appetite
� � slipped disk
� � low blood pressure
EYES, EARS, NOSE, THROAT
� � thirst
� � muscle spasms
� � persistent cough
� � nausea
� � eye pain
� � arthritis
� � hard to breathe
� � vomiting
� � dry eyes
� � coughing blood
MID BACK
� � diarrhea
� � blurred vision
� � coughing phlegm
� � earache
� � constipation
� � mid back pain
� � irregular heartbeat
� � gas
� � ear discharge
� � pain between shoulder
� � varicose veins
� � ringing in ears
� � hemorrhoids
blades
� � ankle swelling
� � belching
� � hearing loss
� � sharp stabbing pain
SKIN
� � nosebleeds
� � heartburn
� � muscle spasms
� � abdominal pain
� � hoarseness
� � easy bruising
SHOULDERS
� � bloody/black stools
� � problems swallowing
� � dry skin
� � indigestion
� � sore throat
� � pain in shoulder joint
� � itching
� � jaw tight or sore
� � pain across shoulders
� � boils
URINARY
� � dental problems
� � bursitis (R/L)
� � rashes
� � painful urination
� � arthritis (R/L)
� � excessive sweat
NECK
� � frequent urination
� � tension in shoulders
� � hair changes
� � difficult urination
� � pain in neck
� � pinched nerve
� � incontinence
� � pain with movement
� � limited range of motion
� � bed wetting
� � pinched nerve in neck
� � dark urine
� � stiff neck
� � muscle spasms in neck
� � frequent infections
� � prostate problems
� � arthritis in neck
PATIENT SIGNATURE
|
|
|
Acupuncture Arts East
62 Brown Street, Merrimack Medical Center, Suite 402, Haverhill, MA 01830
t: 978-372-4771
susan@acupunctureartseast.com
Page of 2