"Acupuncture Intake Form"

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Acupuncture Intake Form
Please complete this questionnaire carefully. The information you provide will assist me in creating a complete
health profile for you. All of your answers are absolutely confidential. If you have any questions, please ask.
Patient Information (Please Print)
Name: _____________________________________
Date of First Visit:____________________________
Date of Birth: _____________________ M / F
Occupation: ______________________________________
Address:________________________________________________________Postal Code: ______________
Phone: (H) ______________________ (W) _____________________ (Cell) _________________________
Email Address___________________________________ Preferred method of contact: �� Home
Cell
E-Mail
Family Doctor: _______________________________________________Phone________________________
Emergency Contact Name: _____________________________________Phone: _______________________
How did you hear of us?_____________________________________________________________________
Have you ever had Acupuncture before?
YES
NO
What is your primary reason(s) for treatment today?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you visited a medical doctor for this condition? YES
NO
If yes, did you receive a diagnosis? NO
YES: _________________________________________________
Are you currently receiving any other treatments for this condition?
YES
NO
If yes, please describe treatments and how effective they have been: _________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please list any current medications (prescription and over the counter), vitamins, supplements, herbs
or homeopathic remedies that you are taking, including dosage if you know it
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
For females: Are you pregnant? NO Possibly YES How far along? __________
Do you have a contagious disease at this time? NO
YES: _____________________________________
Acupuncture Intake Form
Please complete this questionnaire carefully. The information you provide will assist me in creating a complete
health profile for you. All of your answers are absolutely confidential. If you have any questions, please ask.
Patient Information (Please Print)
Name: _____________________________________
Date of First Visit:____________________________
Date of Birth: _____________________ M / F
Occupation: ______________________________________
Address:________________________________________________________Postal Code: ______________
Phone: (H) ______________________ (W) _____________________ (Cell) _________________________
Email Address___________________________________ Preferred method of contact: �� Home
Cell
E-Mail
Family Doctor: _______________________________________________Phone________________________
Emergency Contact Name: _____________________________________Phone: _______________________
How did you hear of us?_____________________________________________________________________
Have you ever had Acupuncture before?
YES
NO
What is your primary reason(s) for treatment today?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Have you visited a medical doctor for this condition? YES
NO
If yes, did you receive a diagnosis? NO
YES: _________________________________________________
Are you currently receiving any other treatments for this condition?
YES
NO
If yes, please describe treatments and how effective they have been: _________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please list any current medications (prescription and over the counter), vitamins, supplements, herbs
or homeopathic remedies that you are taking, including dosage if you know it
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
For females: Are you pregnant? NO Possibly YES How far along? __________
Do you have a contagious disease at this time? NO
YES: _____________________________________
If you are seeking treatment for a painful condition, please describe the pain and shade in
areas of pain on the diagram below
Pain Condition #1
Degree of pain (please circle 1=low, 10=high)
1 2 3 4 5 6 7 8 9 10
Nature of the Pain
O Constant
O Comes and goes
O Fixed
O Moves
O One side
O Both sides
O Sharp
O Dull
O Burning
O Aching
O Spastic
O Numb
Does the pain get better, or worse with?
O Heat
better worse
O Cold
better worse
O Motion
better worse
O Rest
better worse
O Pressure better worse
O Better in AM or PM?
Pain Condition #2
Degree of pain (please circle 1=low, 10=high)
1 2 3 4 5 6 7 8 9 10
Nature of the Pain
O Constant
O Comes and goes
O Fixed
O Moves
O One side
O Both sides
O Sharp
O Dull
O Burning
O Aching
O Spastic
O Numb
Does the pain get better, or worse with?
O Heat
better worse
O Cold
better worse
O Motion
better worse
O Rest
better worse
O Pressure better worse
O Better in AM or PM
Do you have any of the following?
O
O
O
Pacemaker
Hemophilia
Latex allergy
O
O
O
Surgical replacements
Sensitive skin
Nut allergy
O
O
Implants
Fear of needles
O
Other allergy __________________________________________________________________
Is There Family History of:
O
O
O
Alcoholism
Depression
Mental illness
O
O
O
Allergies
Diabetes
Seizures
O
O
O
Asthma
Heart disease
Stroke
O
O
Bleeding disorders
High blood pressure
O
O
Cancer
Kidney disease
O
Other___________________________________________________________________________
How much do you consume per day of:
Water _______ Coffee _______ Tea _______ Soda _______ Alcohol ______ Cigarettes ______
□ �� w arm �� d rinks �� �� �� �� �� �� �� �� □ �� c old �� d rinks
□ �� r oom �� t emperature �� d rinks? ��
Generally, do you prefer
□ �� a lways �� t hirsty �� �� �� �� □ �� r arely �� t hirsty �� o r �� �� �� �� �� □ �� t hirsty �� f or �� s ips �� l ater �� i n �� t he �� d ay? �� ��
Do you find that you are
What are your typical eating habits?
O
O
O
Skip Meal(s)___________
Eat too Fast
Excess Hunger
O
O
O
Eat in a Rush
Cannot eat when
No Desire to Eat
Worried/Stressed
O
O
Eat When Not Hungry
Eat late at night
O
Craving specific food(s)___________________________________________________________
O
Other: ________________________________________________________________________
What are your typical sleeping habits?
O
O
O
Hours slept/night ______
Trouble staying asleep
Disturbing dreams
O
O
O
Fall asleep quickly
Deep sleeper
Wake at same time every
O
O
night ________
Trouble falling asleep
Light sleeper
O
O
Difficulty waking up
Frequent dreaming
O
Other __________________________________________________________________________
How would you describe your energy levels?
O
O
O
High
Normal
Hyperactive
O
O
O
Low
Lethargic
Changes from day to day
O
Other _________________________________________________________________________
Do you have aversion to any of the following?
O
O
O
Cold
Dampness
Loud Noises
O
O
O
Wind
Heat
Crowds
O
Other _________________________________________________________________________
What is your Average Body Temperature?
O
O
O
O
Hot
Cold Hands &
Hotter @ Night
5 Center Heat
Feet
O
O
O
Cold
Colder @ night
Hot Joints
O
Other _________________________________________________________________________
General Information
O
O
O
Anorexia/Bulimia
Lupus
Mumps
O
O
O
Chronic Fatigue
Lyme disease
Tuberculosis
O
O
O
Chicken Pox
Meningitis
Thyroid Disease
o
Overactive
O
O
Chronic Pain
Scarlet Fever
o
underactive
O
O
Fibromyalgia
Mononucleosis
O
Measles
O
O
Hepatitis ______
Multiple Sclerosis
O
Pneumonia
O
O
HIV
Rheumatoid Disease
O
Tonsillitis
O
O
Herpes/Cold Sores
Rheumatic Fever
O
Cancer: ___________________________________________________________________
O
Other: ____________________________________________________________________
Head, Eyes, Ears, Nose and Throat
O
O
O
Bitter taste
Grinding of teeth
Ringing in ears
o High pitch
O
O
Blurred vision
Goiter
o Low pitch
O
O
Cataracts
Gum problems
O
Sinus issues
O
O
Concussions
Headaches
O
Spots in eyes
O
O
Dry mouth / nose
Hearing aids
O
Swollen glands
O
O
Ear aches
Itchy eyes
O
Teeth issues
O
O
Excess phlegm
Migraines
O
TMJ Syndrome
O
O
Eye pain or strain
Nose bleeds
O
Trigeminal neuralgia
O
O
Facial pain
Poor hearing
O
Watery eyes
O
O
Glasses or contacts
Red or dry eyes
O
Glaucoma
O
Other: ____________________________________________________________________
Respiratory:
O
O
O
Asthma/Wheezing
Cough + Phlegm
Cough + blood
O
O
O
Frequent colds
Emphysema
Difficult breathing
O
O
O
Allergies
Heavy Chest
Tight Chest
O
O
O
Bronchitis
Pneumonia
Short of Breath
O
O
Cough
COPD
O
Other: __________________________________________________________________________
Cardiovascular:
O
O
O
Anemia
Fainting
High blood pressure
O
O
O
Arteriosclerosis
High cholesterol
Irregular heart beat
O
O
O
Easily bruised
Low blood pressure
Pace maker
O
O
O
Poor circulation
Palpitations
Phlebitis
O
O
O
Blood clots
Chest pain
Stroke
O
Heart Disease: ___________________________________________________________________
O
Other: __________________________________________________________________________
Gastrointestinal
O
# Bowel Movements/day___
O
O
O
Normal Stool
Pain after BM
Bad breath
O
O
O
Loose stool
Heartburn/acid reflux
Rectal pain/itching
O
O
O
Constipation
Abdominal pain
Hemorrhoids
O
O
O
Diarrhea
Appendicitis
Hernia
O
O
O
Undigested food in stool
Bloating
Liver Disorder
O
O
O
Mucous in stool
Celiac Disease
Ulcer
o H. Pylori Negative
O
O
Blood in stool
Gas
o H. Pylori Positive
O
O
Strong odour
Hiccups
o Not Tested
O
O
Pain before BM
Nausea/vomiting
O
Other: __________________________________________________________________________
Genito-Urinary
O
O
O
Bed wetting
Urgent urination
Libido issues
O
O
O
Bladder infections
Wake to urinate
Yeast infection
O
O
O
Bloody urine
Pale urine
Impotence
O
O
O
Frequent urination
Dark urine
Prostate Disorder
O
O
O
Painful urination
Cloudy urine
Premature ejaculation
O
O
O
Incomplete urination
Kidney stones
Nocturnal emissions
O
O
Incontinence
Kidney Disease
O
Other: __________________________________________________________________________
Gynecological
PMS – headaches
O
O
O
Menopause
Genital discharge
PMS – back aches
O
O
O
Oral Birth control pills
Genital swelling
PMS – mood swings
O
O
O
Intra-Uterine Device IUD
Hysterectomy
O
O
O
Breast lumps
Endometriosis
# Pregnancies ________
O
O
O
Genital burning
Fibroids
# Miscarriages_________
O
O
Genital itching
Cysts
Menstruation Information:
Describe the menstrual blood:
O
O
O
Heavy periods
Pain After
Thin/Watery
O
O
Light periods
Very thick
O
Dark Red
O
O
Irregular periods
Clots?
O
Bright Red
O
o Size ________
Pain Before
O
Pale Red
o Color ________
O
Pain During
O
Brownish
# Days between periods __________ # days of period__________
Other Information: _________________________________________________________________________
Skin and Hair
O
O
O
Acne
Fungal infection
Itchy/dry skin
O
O
O
Burning skin
Hair loss
Psoriasis
O
O
O
Dandruff
Hot flashes
Rashes
O
O
O
Dermatitis
Heavy sweating
Shingles
O
O
O
Discolorations
Not able to sweat
Warts
O
O
Eczema
Hives
O
Other: __________________________________________________________________________
Neuro-Psychological
O
O
O
ADD/ADHD
Epilepsy
Poor coordination
Parkinson’s �� D isease ��
O
O
O
Addiction
Irritability
O
O
O
Anxiety
Mental illness
Poor memory
O
O
O
Depression
numbness
Seizure
“Foggy” �� f eeling ��
O
O
O
Easily stressed
Vertigo/Dizziness
O
Other: __________________________________________________________________________
Musculoskeletal:
O
O
O
Osteoarthritis
Limited motion
Neck pain
O
O
O
Rheumatoid arthritis
Limited use
Rib pain
O
O
O
Atrophy
Back pain
Scoliosis
O
O
O
Body heaviness
Muscle pain
Weight gain
O
O
O
Joint pain
Muscle cramps
Weight loss
O
Broken Bones: ___________________________________________________________________
O
Other: ______________________________________________________________________
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