CONFIDENTIAL CLIENT INTAKE FORM - ACUPUNCTURE

TO DETERMINE THE BEST TREATMENT PLAN FOR YOU, PLEASE, FILL OUT AS COMPLETE AS POSSIBLE, EVEN IF YOU DO NOT FEEL CERTAIN QUESTIONS PERTAIN TO YOUR PRESENT CONDITION.

Name: ___________________________________ Gender assigned at birth: M F Date: ________

Home Address: _________________________ City: ____________________ State: ________ Zip: _________

Email: __________________________________________________________________ Age: ________ DOB: ________

If under 18, person responsible for your account: ______________________________________________________

Home phone: ___________________ Work phone: ____________________ Cell phone: ___________________ Emergency Contact: Name:__________________________________________ Contact phone:_____ ______________ Marital Status: ___ single ___ married ___ divorced ___ widowed ___ significant other

Are you a caregiver for dependents? YES NO If yes, how many children? ____ How many adults____

Occupation:_____________________________________________ Number of years in this type of work: ____ Retired: Number of years in retirement: ____ Occupation when in workforce: ______________________


Primary care physician

Name: _______________________________________ Phone: ______________________

Insurance coverage circle one: None Workers’ Comp Auto Injury Health Insurance Company

*We do not accept insurance at this time, but can provide you with a statement for submissions to your company. How did you hear about us? Please circle one and write the name Current patient:____________________________________ Friend:______________________________ Doctor: _____________________________________________ Insurance:__________________________ Advertisement: ____________________________________ Other:_______________________________


Have you had acupuncture before? YES NO

If yes, with whom?______________________ When___________For what condition?__________________________

CHECK IF YOU CURRENTLY EXPERIENCE ____ hepatitis ____ HIV ____ high blood pressure ____ seizures ____ pacemaker ____ pregnancy

____ blood-thinning meds ____ Surgically implanted joint/bone replacement or stabilizers

Are you currently under the care of any other health care provider?

i.e. physician, chiropractor, therapist, massage therapist, etc.? YES NO

If yes, please provide the name and title of the practitioner(s), the condition being treated and the length of time you have been receiving this treatment: ____________________________________________ Practitioner Condition Length of treatment to present: _______________________________________________ ______________________________________________________________________________________________________________ Please list all past medical conditions for which you were hospitalized and/or received surgery (include the dates): _______________________________________________________________________________________

CURRENT HEALTH CONDITIONS Please list your health concerns in order of priority: 1. ____________________________________________ 2.____________________________________________

3. ____________________________________________ 4.____________________________________________

5. ____________________________________________ 6.____________________________________________ What do you believe is causing your most important health concerns?______________________________________________________________________________________________________________

What is your main reason for today’s visit? ________________________________________________________

How long have you had this condition? ________________________________________________________ How does it impact your quality of life? ________________________________________________________ Have you seen a physician or other health practitioner about this? YES NO When? _________________ What was the diagnosis (if any)? ________________________________________________________ Describe any treatment you received and the results:_________________________________________________ ______________________________________________________________________________________________________________

What aggravates this condition? ________________________________________________________ What improves this condition? _________________________________________________________


HABITS AND LIFESTYLE Do you smoke? YES NO If yes, what?______________ How much/often? _____ Since when? _____

Do you drink alcohol? YES NO If yes, what?_______________ How much/often?_________________________

Do you exercise regularly? YES NO If yes, please describe what you do: ______________________________

Emotional stress scale Please circle 1 2 3 4 5 6 7 8 9 10 No Stress Moderate Extremely Stressed What do you do when you want to release stress and/or just relax?__________________________________

How many hours do you usually sleep per night?____________ When do you go to bed?_______________ Do you wake feeling refreshed? YES NO

What is your height?________ What is your present weight?________

What was your weight one year ago? __________ What is the most you have ever weighed?__________ How often do you have a bowel movement?________________________ When?__________

NUTRITION: Do you drink coffee? YES NO If yes, how much per day? ____________________ Do you drink caffeinated tea? YES NO If yes, how much per day?_____________________ Do you drink soda pop? YES NO Do you have regular eating habits? YES NO Do you eat while engaged in other occupations? YES NO

Do you eat more when under stress or feeling depressed? YES NO

Do you experience sudden drops in energy? YES NO Please describe a typical day’s diet for you with times:

Breakfast: Lunch: Dinner: Snacks:

FAMILY HISTORY Please describe your family’s health, including current age or age at death, and major illness, and chronic illness history (diabetes, heart disease, osteoporosis, cancer, allergies, mentalillness, ect) Member Mother: Father Sisters/Brothers: Maternal Grandmother:

Maternal Grandfather:

Paternal Grandmother:

Paternal Grandfather:

WOMEN ONLY please circle response as appropriate Are you currently experiencing any gynecological symptoms or problems? YES NO

Are you currently sexually active? YES NO If yes, partner(s) is/are M F If sexually active, do you perform safe sex practices? Any problems related to sexual function? YES NO Do you have any history of sexually transmitted diseases? YES NO Do you have any history of cervical, ovarian, or breast cancer? YES NO Do you perform regular breast self-exams? YES NO How old were you at onset of first menses? If you are of menstruating age, date of last period: Periods generally last _____ days and occur every_____ days bleeding is __ heavy __moderate __light List any PMS symptoms: If you are menopausal or perimenopausual: Are you taking hormone replacement therapy? YES NO List and symptoms or concerns:

Number of pregnancies and your age at each:

Number of live births and your age at each:

Natural deliveries? YES NO C-sections? YES NO

MEN ONLY please circle response as appropriate Are you currently sexually active? YES NO sexually active, do you perform safe sex practices? YES NO If yes, partner(s) is/are M F Are you currently trying to conceive? YES NO Do you have any history of sexually transmitted diseases? YES NO Have you ever had a diagnosis of prostate enlargement or cancer? YES NO Do you ever experience trouble with urination (frequency, hesitancy, pain, dribbling)? YES NO

Do you ever experience trouble with sexual function/libido? YES NO

SYMPTOMS

For each symptom you currently have, please rate its severity from 1 to 5, 5 being the worst. Leave blank if not applicable

Liv/GB(wood)

______ irritability/anger ______ depression/stress ______ headaches/migraines

______ visual problems ______ red/dry/itchy eyes ______ gall stones ______ dizziness

______ blurred vision ______ feeling of lump in throat ______ clenching of teeth at night

______ muscle cramping/twitching ______ tension ______ joints/neck/shoulder pain

______ poor circulation ______soft/brittle nails ______ emotional eater ______ ringing in ears ______ eczema ______Shingles ______ herpes simplex ______ indecisive ______ fullness below ribs

______ shoulder/neck tension ______ insomnia 11pm-3am Lu/LI (Metal) ______ dry cough ______ cough with sputum ______ nasal discharge ______ post-nasal drip ______ sinus trouble ______ itchy/red/painful ______dry mouth/throat/nose ______ skin rashes/hives ______snoring ______ grief/sadness ______ shortness of breath ______ asthma/allergies ______ low resistance to colds or flu ______sneezing ______mild fever comes and goes

______smoke cigarettes ______bronchitis Ht/SI (Fire) ______ heart palpitations ______chest pain ______insomnia/sleep problems ______easily startled ______ restlessness/agitation ______vivid dreams ______ lack of joy in life ______dry scalp ______ skin rash ______ cysts/tumor ______ ear infection ______ sore throat ______ lymph swelling ______ hot palms/soles ______ aversion to heat ______ bitter taste in mouth ______ gum problems ______ nose bleed______ facial redness ______ itchy/burning skin ______ thirst ______ dark blue ______ night sweats ______excess joy Kid/UB (Water) ______urinary problems ______bladder problems ______lack of bladder control

______weakness/pain in lower back ______decreased bone density ______feel cold easily ______low sex drive______excess sexual drive ______poor memory______loss of hair ______hearing problems ______cavities/tooth loss ______craving/avoiding salty foods ______fear ______hot flash/night sweating ______dark under eyes ______weak leg/knees ______rapid weight change ______emotional instability ______thyroid problems Sp/ST (Earth) ______ heaviness anywhere in body ______ fatigue/worse after eating

______ hard to get up in morning ______ edema (swelling) ______ muscles feel tired often

______ easily bruising and bleeding ______ bad breath ______ decreased/increased appetite

______ crave sweets ______hypoglycemia ______difficulty digesting oily foods ______nausea/vomiting ______ gas/belching ______insulin sensitivity ______hemorrhoids ______constipation ______ diarrhea ______ abdominal pain ______ indigestion/heartburn ______ over-thinking ______ tendency to gain weight ______ brain foggy ______ food allergy ______ excess worry Other ______fatigue ______arthritis ______sciatica ______nerve pain ______carpal tunnel ______numbness ______cold hands/feet ______bursitis/tendonitis


MEDICATIONS/SUPPLEMENTS Please list any medications and supplements you are currently taking, along with doses and the reason you are taking them.

Medications:

Reasons: Date Began: Dose:

Does it help? YES NO

Supplements:

Reason: Date Began: Dose:

Does it help? YES NO


DESCRIBE ANY OTHER HEALTH CONCERNS NOT PREVIOUSLY COVERED IN THIS FORM _____________________________________________________________________________________________________

Everything I have written and answered in this form is true to the best of my knowledge.

I will update this office when there are significant changes. Signature_________________________________________________________________ Date____________________


ACUPUNCTURE INFORMED CONSENT TO TREAT

*FORM MUST BE SIGNED BY ALL PARTICIPANTS.

*IF PARTICIPANT IS UNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND

HIS/HER PARENT/GUARDIAN.

I hereby request and consent to the performance of acupuncture treatments and other procedure within the scope of practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Dr. Patricia Bruder and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with Orenda Holistic Health.

I understand that methods of treatment may include, but are not limited to: acupuncture, moxibustation, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.

I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects including: bruising, numbness or tingling near the needle sites that may last a few days and dizziness or fainting. Burns and /or scarring are a potential risk of moxibustation and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include: spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pnuemothorax). Infection is another possible risk, although sterile disposable needles are used with all patients to maintain the safest and most sterile treatment environment possible.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomach ache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.

I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, and I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Printed Name of Participant:____________________________________________________________________ Signature of Participant:_________________________________________________ Date:__________________


MINOR INFORMATION Name of Parent/Legal Guardian:__________________________________________ Age (If A Minor)__________ Signature of Parent/Legal Guardian:_______________________________________ Date:___________________