Acupuncture Form

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.

Date:

Name:

Gender assigned at birth: MALE FEMALE

Age:

DOB:

If under 18, person responsible for your account:

Emergency Contact:

Marital Status: SINGLE MARRIED DIVORCED WIDOWED SIGNIFICANT OTHER

Are you a caregiver for dependents? YES NO

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 & their phone:

*We do not accept insurance at this time, but can provide you with a statement for submissions to your company. Have you had acupuncture before? YES NO

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

Name & title of the practitioner(s), condition being treated, & how long you've received: Please list all past medical conditions for which you were hospitalized and/or received surgery: 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?

Describe any treatment you received and the results:

What aggravates this condition?

What improves this condition?

HABITS AND LIFESTYLE Do you smoke? YES NO What? How much/often? Since when?

Do you drink alcohol? YES NO What? How much/often?

Do you exercise regularly? YES NO Please describe:

Emotional stress scale Please circle 1 2 3 4 5 6 7 8 9 10

NO STRESS MODERATE STRESS HIGH STRESS 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

Height:

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 How much per day? Do you drink caffeinated tea? YES NO 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 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 COVERED IN THIS FORM: