Acupuncture & Massage Initial Intake Form

Main Complaint

Please identify the major health concerns for which you are seeking help with in order severity and for how long you have had each problem.

  1. ______How long?______
  1. ______How long?______
  1. ______How long?______
  1. ______How long?______
  1. ______How long?______

How would you rate the quality of your life (1=very poor, 10=excellent)? 1 2 3 4 5 6 7 8 9 10

To what extent do these problems interfere with your daily activities and effect your quality of life?______

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What are your goals in coming to our office?______

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Have you been given a diagnosis for these problems? ______

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What other treatments have you tried and what has been your response? ______

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General Information

Who referred you to us? ______Phone:______

Who is your primary heath care provider/MD? ______Phone:______

In an emergency notify: ______Phone:______

Personal Medical History

Illnesses:______

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Surgeries:______

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Significant Trauma (i.e. motor vehicle accidents, falls…)______

______

Do you or have you ever had any infectious disease?______. If so please describe:______

______

Medicines (Please list all medications, herbs, vitamins, and over the counter drugs you are currently taking):

______

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______

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Allergies/Sensitivities: Please list any foods, drugs, medications, or environmental factors which you are

sensitive or allergic to:______

______

______

Do you have allergic reactions to any oils, lotions, ointments, latex, or other substances applied to your skin? If so please describe:)______

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Family Medical History

Check All Applicable / Mother / Father / Sisters / Brothers / Spouse / Children
Current Age
Arthritis
Asthma
Allergies
Autoimmune Disease
Back pain
Cancer
Constipation
Diarrhea
Diabetes
Digestive Disorders
Emotional Problems
Epilepsy
Headaches/Migraines
Heart Disease
High Blood Pressure
Insomnia
Kidney Disease
Liver Disorders
Reflux
Stress/Anxiety
Other

If any of the above are deceased, what was the cause?______

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Childhood health: ______

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General(please check all that apply)

Poor AppetiteWeaknessSudden Energy Drops

Hearing LossFeversParticular Tastes or Smells

Easy to Bleed or BruiseSweat EasilyFatigue

Strong ThirstPoor SleepChills

TremorsPoor BalanceWeight Loss

Night SweatsCravingsWeight Gain

Changes in AppetitePuffiness or SwellingOther:______

Skin & Hair

RashesItchingDandruff

Skin Ulcers EczemaHair Loss

HivesPimplesRecent Moles

Changes in Hair TexturePoor SleepChills

Head, Eyes, Ears, Nose, and Throat

DizzinessGlassesPoor Vision

CataractsEar RingingSinus Problems

ToothacheTeeth ProblemsTaste/Smell Problems

HeadachesConcussionsEye Strain

Night BlindnessBlurry VisionPoor Hearing

Nose BleedsFacial PainJaw Click

MigrainesEye PainColor Blindness

Ear AchesSpots in Front of EyesRecurrent Sore Throat

Lip or Tongue SoresDecreased HearingFloaters

Cardiovascular

High Blood PressureLow Blood PressureIrregular Heartbeat

Cold Hands or FeetBlood ClotsPalpitations

Swelling of HandsSwelling of FeetChest Pain

PhlebitisFaintingLight Headedness

Respiratory

CoughBronchitisDifficulty Breathing

PhlegmCoughing up BloodPneumonia

Asthma Painful BreathingEasily Winded

Gastro-Intestinal

NauseaConstipationDiarrhea

Bad BreathUlcersAbdominal Pain

Chronic Laxative UseVomitingIntestinal Gas

IndigestionRectal PainBelching

Blood in StoolsHemorrhoidsLoss of Appetite

Urology

Painful UrinationUrgency to UrinateUnable to Hold Urine

Decrease in Urine FlowFrequent UrineBlood in Urine

Cloudy UrineKidney StonesGenital Sores

S.T.D.sPain in Groin AreaFrequent Night Urination

Neuro-Psychological

SeizuresAreas of NumbnessConcussion

TwitchesLack of CoordinationDepression

Bad TemperLoss of BalanceStress

Poor MemoryAnxietyMood Swings

IrritabilityTremorsDizziness

Gynecology

Age of First Menses: ______Irregular PeriodsClots

Duration of Menses: ______Painful PeriodsPMS

Date of Last Menses______Breast LumpsMenopausal

# of Pregnancies: ______SpottingYeast Infections

# of Births: ______Vaginal DischargeFertility Problems

Musculo-Skeletal

Arthritis

Muscle Weakness

Muscle Cramping

Muscle Spasms

Scoliosis

Weak Joints

Please Circle Any Areas of Pain:

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