What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition?
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- Lora Randall
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1 Name Date What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition? Do you bruise or bleed easily? q Yes q No Pain l r b = left, right, both past current q q head q q lower arm l r b q q upper back q q shin l r b q q jaw q q wrist l r b q q mid-back q q ankle l r b q q neck q q hand l r b q q lower back q q foot l r b q q throat q q fingers l r b q q hip q q heel l r b q q shoulder l r b q q chest q q thigh l r b q q toes l r b q q upper arm l r b q q rib/flank l r b q q knee l r b q q elbow l r b q q abdomen q q calf l r b [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ [ q q nausea q q gas q q diarrhea q q vomiting q q abdominal bloating q q constipation q q belching q q abdominal pain q q blood in stools / black stools q q heartburn q q decreased appetite q q pus in stools q q bad breath q q indigestion q q hemorrhoids q q bleeding gums q q low energy / fatigue q q anal fissures q q ulcers q q crave sweets q q rectal pain q q excessive appetite q q decreased ability to taste or smell q q nose bleeds q q change in appetite q q sweet taste in mouth q q recurring sore throat q q often feel pensive / thoughtful q q difficulty swallowing q q edema q q laryngitis / hoarse voice q q frequent colds q q asthma q q dry skin q q sinus infection q q bronchitis q q itching q q cough q q pneumonia q q acne q q cough with blood q q chronic obstructive pulmonary disease q q rashes q q production of phlegm q q often feel sad q q hives q q hay fever or allergies q q crave pungent foods q q eczema q q psoriasis Other current related symptoms S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S S q q frequent urination q q frequent urinary tract infections q q impotence q q urgency to urinate q q frequent vaginal infections q q premature ejaculation q q pain on urination q q pelvic inflammatory disease q q testicular lumps q q urine / bowel incontinence q q abnormal PAP smear q q prostatitis q q weak urine stream q q irregular periods q q blood in urine q q premenstrual syndrome q q genital itching / pain q q kidney stones q q painful menstrual periods q q genital lesions / discharges q q low back pain q q abnormal bleeding q q decreased libido q q sore / weak knees q q menopause symptoms q q crave salty foods q q breast lumps q q ear ringing low pitch q q often feel afraid q q ear ringing high pitch q q decreased hearing q q ear infections 1
2 Total Pregnancies Living Ectopic Miscarriages Induced Abortions Family History -- Complete for each family member placing an X in the appropriate box: Self Mother Father Sister Brother Spouse Child Allergies Blood Disorder / Anemia Diabetes Cancer/Tumor, Type: Seizures High Blood Pressure Kidney or Bladder Disorder Stomach or Intestinal Disorder Drug/Alcohol Use Tuberculosis Heart Disease Stroke Depression / Mental Illness Other Age at Death Allergies ( ex., food, hay fever, pollen, drugs, medication, etc.) q q dry eyes q q insomnia q q migraine q q red eyes q q excessive / vivid dreams q q dizziness q q eye inflammation q q grinding teeth q q fainting q q blurred vision q q depression q q seizures q q poor night vision q q anxiety / stress q q localized weakness q q floaters (spots in visual field) q q irritability q q numbness or tingling of limbs q q visual changes q q treated for emotional / q q tremors q q glasses / contact lenses psychological problems q q poor coordination q q cataracts q q indecisiveness q q paralysis q q crave sour foods q q often feel angry q q aversion to wind q q tendonitis q q gallstones q q high blood pressure q q chest pain or pressure q q blood clotting disorders q q low blood pressure q q jaw, neck, shoulder or arm pain q q phlebitis q q palpitations q q nausea q q poor memory q q irregular heart beat q q swollen hands or feet q q crave bitter foods q q usually feel happy q q fevers q q chills q q headache q q frequent or strong thirst q q cold hands / feet q q neck stiffness q q tend to feel warmer than others q q tend to feel colder than others q q concussion q q night sweats q q cold sweats q q enlarged lymph glands q q sweat easily q q prefer warm food and drink q q prefer cold food and drink Tumors or lumps 2
3 t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t Past or current infections What is your ethnic heritage? How many generations have you been in this country? Please provide a list of the significant places you have lived in your life and the duration of time you lived in each place. Location Date(s) In/Out or Duration of Stay Please list your family members (partners, siblings, parents, etc.) Major Hospitalizations Please list any hospitalizations or surgeries you have undergone. Year Operation or Illness Name of Hospital City and State Medicines, Herbs and Supplements Check any medications you are currently taking q aspirin q antacids q blood thinners q sleeping pills q ibuprofen q fiber or other laxatives q blood pressure pills q tranquilizers q acetaminophen (Tylenol) q diet pills q insulin q anti-depressants q oral contraceptives q allergy medication q other, please list 3
4 Western Drugs Drug Dosage Frequency Herbs & Supplements Type Brand Dosage Frequency Habits Please check any habits which apply to you now or in the past Yes No # per day / week Age started Age quit Coffee Other Caffeine (tea) Tobacco Marijuana Alcohol Other Drugs Please describe any restricted diet you follow(ed) now or in the past (ex. no red meat, vegan, vegetarian). Please describe your typical diet. TIME DESCRIPTION Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack How many 8 oz. cups of water do you drink daily? 4
5 How is your dental health? (Do you have receding gums, gingivitis, etc.? Do you floss and/or use mouth wash, etc.?) When was your last visit to the dentist? Please describe any regular program of exercise. Do you have any religious or spiritual practice? If so, please describe. What are the top priorities in your life? What are your goals for your health? Please provide any additional information about yourself or your condition not covered by the above questions. Are you seeing other practitioners? q Yes q No If yes, please provide practitioner(s) contact information and any specialties they may have. Would it be all right to contact this/these practitioner(s) regarding your care? q Yes q No 5
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