TodayÕs Date ____/____/____
New Patient Intake Form
_________________________________________________ ____/____/____ ________
First Name (Print) Last Name Birth Date Age
_____________________________________ _________________ ______ _________
Address City State Zip
_______________________ _______________________ ______ ______ _____
Phone (home) Phone (work) Height Weight Sex
____________________________________________________________________
How did you hear about us? (DoctorÕs name, Nurse , Drs office staff, website, flyer, postcard etc)
If you were referred by your doctor, may contact him/her to thank them? ______________________
____________________________________________ ____________________________
Emergency Contact Name and Phone Email Address
Have you had acupuncture before?_______ For what?______________________________________
Chinese Herbal Medicine?______ Name of acupuncturist/herbalist ___________________________
Are you currently under the care of a physician? _______ For what?____________________________
PhysicianÕs Name and Phone ___________________________________________________________
Below, describe all of your complaints on the left side of the page starting with your primary reason for todayÕs visit, then list how long you have had them and how you are treating them directly opposite on the right side. Be sure to mention any drugs, vitamin supplements, or other medicinal substances you are taking.
Complaints: |
How Long? |
Treatment: |
Brief Health History (list major diseases, surgeries, etc.): How many times per year do you get a cold or the flu? ______ |
Diet (summarize how you eat; list any special diet such as high protein, raw food, etc.): |
Family Medical History: |
Emotions:
q Normal q Problem
q Depression q Sadness q Panic attack q Sensitive q Worries q Overly excited
q Anger q Anxiety
Describe: _____________________________________________________________________
_____________________________________________________________________________
Energy:
q Normal q Problem
q Low q Up and down q Exhausted q Hyperactive q Nervous energy q Abundant
Describe: _____________________________________________________________________
_____________________________________________________________________________
Sleep Pattern:
q Normal q Insomnia
Falling Asleep: q Sometimes Difficult q Always difficult
q Sometimes very difficult q Always very difficult
q Sleep in daytime q Take naps
Waking up: ___ Times per night q Wake up too early
q Wake up at night and cannot go back to sleep again
Sleep Quality:
q Deep q Light q Bad
q Many dreams q Bad dreams q Grinding teeth q Talking in sleep q Other
Describe: _____________________________________________________________________
_____________________________________________________________________________
Temperature:
q Normal q Abnormal
q Feel cold easily q Cold Hands q Cold feet q Alternating hot and cold
q Feel hot easily q Hot flash q Sensitive to weather changes
Describe: _____________________________________________________________________
_____________________________________________________________________________
Sweating:
q Normal q Abnormal
q Too easily q Too much q Difficult q Too little q Night Sweats q Other
Describe: _____________________________________________________________________
_____________________________________________________________________________
Sensitivity and Allergies:
q No q Yes
q Cold q Hot q Dampness q Light q Noise
q Airborne particles q Food q Drugs q Other
Describe: _____________________________________________________________________
_____________________________________________________________________________
Appetite and Digestion:
q Normal q Abnormal
q Rapid Hungering q Poor appetite q Nausea q Anorexia q Bloating q Gas
q Hungry, but no desire to eat q Other
Describe: _____________________________________________________________________
_____________________________________________________________________________
Bowel Movement:
q Normal q Abnormal Time of day: __________
q Constipation q Diarrhea q Loose q Watery q Incomplete q Hard and Dry
q Strong Smell q With mucous q With blood q Other
Describe:
_____________________________________________________________________
_____________________________________________________________________________
Body Weight:
q Normal q Overweight q Underweight
If overweight:
How many pounds would you like to lose? _____
How many years ago did you first start to gain weight? _____
Are you following a weight control program at this time? _____
Describe: _____________________________________________________________________
_____________________________________________________________________________
Drinking:
q Normal q Abnormal
q Thirsty q Dry Mouth q Drink a lot q Dry mouth but no desire to drink
q Not thirsty but drink a lot anyway
Describe: _____________________________________________________________________
_____________________________________________________________________________
Urination:
q Normal q Abnormal
q Frequent q Urgent q Burning q Painful q Cloudy q Dark Color
q Foul smell q Bloody q Difficult q Retention
Number of times per day_____ Number of times per night_____ Other____________
Describe: _____________________________________________________________________
_____________________________________________________________________________
Lifestyle:
q Alcohol q Tobacco q Marijuana q Drugs q Occupational Hazards
Regular exercise: Type____________ Frequency___________
Type____________ Frequency___________
Menstrual History
Age at which Menses Began _____
Age at which it stopped _____
Are your periods painful? q Yes q No
How many days does the pain last? _____
How many days do you normally bleed? _____
How heavy is the bleeding? qLight qNormal q Heavy
What color is the blood? qLight red qRed qDark Red
qBrown qBlack
Is there clotting? qYes qNo
Do you have premenstrual tension? qYes qNo
Does your face break out before or during your period? qYes qNo
Do your breasts become tender premenstrually? qYes qNo
Do you retain water during your period? qYes qNo
Do you bleed or spot between periods? qYes qNo
Are your menstrual cycles spaced irregularly? qYes qNo
How many days are there from one period to the next? _______
Date of last menstrual period _______________
Number Years
How many pregnancies have you had? ______ ______________
How many children do you have? ______ ______________
How many abortions have you had? ______ ______________
How many miscarriages have you had? ______ ______________
How many times has a D&C been performed? ______ __________
Complications? __________________________________________
Have you ever had an abnormal pap smear? qYes qNo
Have you ever had a cervical biopsy, operation,
cauterization or conization? qYes qNo
Have you ever had a venereal disease? qYes qNo
Do you get yeast infections regularly? qYes qNo
Have you ever been
diagnosed with a chlamydial infection? qYes qNo
Do you have chronic vaginal discharge? qYes qNo
Do you have any sores on your genitalia? qYes qNo
Have you ever had pelvic inflammatory disease? qYes qNo
Were you treated for it? qYes qNo
How?
______________________________________________
_______________________________________________________
Date of last Pap smear __________________________
Have you ever been diagnosed
with uterine fibroids or polyps? qYes qNo
Have you ever been diagnosed with endometriosis? qYes qNo
Have you been diagnosed with pelvic adhesions? qYes qNo
Have you been diagnosed
with any pelvic abnormalities? qYes qNo
Have you taken any medications other than contraceptives
for gynecological conditions?
Medicine Reason How long
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
_____________________ ____________________ __________
Have your cycles changed since they began? qYes qNo
How? __________________________________________________
Do you ovulate on your own? qYes qNo
On what day of your cycle? ___________________________
Do your breasts get tender at/during ovulation? qYes qNo
Do you get premenstrual low back pain? qYes qNo
Do your bowel movements become loose at the beginning of your period? qYes qNo
5
Fertility History
How long have you been trying to conceive?_________________
Is there a history of infertility in your family? qYes qNo
Describe: _________________________________________
Have you had fertility treatments? qYes qNo
If yes, when and where? ______________________
By whom? _________________________________
What types? _______________________________
Have you taken medication to help you ovulate? qYes qNo
When? _________________ How long? ______________
Have your fallopian tubes been evaluated medically? qYes qNo
What were the results? ______________________________
Have you had any tubal operations? qYes qNo
Have you had any hormone laboratory tests performed? qYes qNo
What
were the results? _____________________________
Do you have a single partner
with whom you have been trying to conceive? qYes qNo
How long have you been married or living together?________
Has he had a fertility workup? qYes qNo
What were the results? ______________________________
Is your partner supportive of your wish to conceive? qYes qNo
Have you taken oral contraceptives? qYes qNo
When?__________________ How long?__________________
Have you ever had an IUD? qYes qNo
When? __________________ How long?__________________
Have you ever taken DepoProvera? qYes qNo
When? __________________ How long? _________________
Have you had a diagnosis relating to infertility? qYes qNo
What
was it? ________________________________________
How is your sexual energy? qLow qNormal qHigh
Are you experiencing any sexual problems? qYes qNo
Does your partner experience any
sexual dysfunction? qYes qNo
Do you douche regularly? qYes qNo
With what? _____________________________
Do you use vaginal lubricants? qYes qNo
Are you more than 20% over your ideal body weight? qYes qNo
Are you more than 20% below your ideal body weight? qYes qNo
Do you have a stressful occupation? qYes qNo
Do you exercise regularly? qYes qNo
Do you have excessive facial hair? qYes qNo
Do you have excessively oily skin? qYes qNo
Have you experienced excessive loss of head hair? qYes qNo
Have you noticed discharge from your nipples? qYes qNo
Was your mother exposed to diethylstilbestrol
(DES) when she was pregnant with you? qYes qNo
Have you been exposed to any
known environmental toxins or hormones? qYes qNo
Are you presently taking steroids? qYes qNo