Name First Date Of Birth MM slash DD slash YYYY Have you had acupuncture before? Yes No If “yes”, for what condition? What are your main concerns:What are your main concerns: What are your main concerns:2 What are your main concerns:2 What current treatments are you receiving for your concerns?Circle quality of pain: Throbbing shooting stabbing Sharp hot burning aching Heavy Cramping How long have you had this pain: 3 months or less 12 – 24 months 3 – 6 months more than 24 months How often does this pain occur? continuously 1 or 2 times a day several times a day Several days a week Less than 4 times a month pt Physical therapy Chiropractic Massage Therapy Other None Untitled Location of pain: (on the diagram below please circle areas of pain or mark X for numbness/tingling) Is this pain a result of: Cancer Treatment Following An Operation No Obvious Cause Untitled Are you currently under Chemotherapy or Radiation Treatment: Yes No Clinician / Group treating you: For the following sections, please check off all symptoms that you are experiencing now or within the past 6 months: nausea vomiting belching heartburn bad breath bleeding gums ulcers excessive appetite change in appetite frequent colds sinus infection cough cough with blood production of phlegm hay fever or allergies frequent urination urgency to urinate pain on urination urine / bowel incontinence weak urine stream blood in urine kidney stones low back pain sore / weak knees crave salty foods often feel afraid endometriosis fibroids/ovarian cysts dry eyes red eyes eye inflammation blurred vision poor night vision floaters (spots in visual field) visual changes glasses / contact lenses cataracts crave sour foods high blood pressure low blood pressure palpitations irregular heart beat fevers frequent or strong thirst tend to feel warmer than others night sweats sweat easily prefer cold food and drink Arthritis irritable bowel syndrome gas abdominal bloating abdominal pain decreased appetite indigestion low energy / fatigue crave sweets decreased ability to taste or smell sweet taste in mouth often feel pensive / over thinking Edema Asthma bronchitis pneumonia chronic obstructive pulmonary disease often feel sad crave pungent foods frequent urinary tract infections frequent vaginal infections pelvic inflammatory disease abnormal PAP smear irregular periods premenstrual syndrome painful menstrual periods abnormal bleeding menopause symptoms breast lumps infertility decreased hearing ear infections Insomnia excessive / vivid dreams grinding teeth depression anxiety / stress Irritability treated for emotional / psychological problems indecisiveness often feel angry chest pain or pressure jaw, neck, shoulder or arm pain nausea swollen hands or feet chills cold hands / feet tend to feel colder than others cold sweats prefer warm food and drink menstrual cramps immune compromised diarrhea constipation blood in stools / black stools pus in stools hemorrhoids anal fissures rectal pain nose bleeds recurring sore throat difficulty swallowing laryngitis / hoarse voice dry skin itching acne rashes hives eczema psoriasis impotence premature ejaculation testicular lumps prostatitis genital itching / pain genital lesions / discharges decreased libido ear ringing – low pitch ear ringing – high pitch fibrocystic breast migraine dizziness fainting seizures localized weakness numbness or tingling of limbs Tremors poor coordination paralysis aversion to wind tendonitis gallstones blood clotting disorders phlebitis poor memory crave bitter foods excessive joy headache neck stiffness concussion enlarged lymph glands auto immune disease(s): Family History – please complete for each family member by placing an X in the appropriate box:Diabetes Self Mother Father Sister Brother Spouse Child Cancer/Tumor, Type: Self Mother Father Sister Brother Spouse Child Seizures Self Mother Father Sister Brother Spouse Child High Blood Pressure Self Mother Father Sister Brother Spouse Child Drug use /(substance abuse) Self Mother Father Sister Brother Spouse Child Alcohol abuse Self Mother Father Sister Brother Spouse Child Heart Disease Self Mother Father Sister Brother Spouse Child Stroke Self Mother Father Sister Brother Spouse Child Depression / Mental Illness Self Mother Father Sister Brother Spouse Child Age at Death Self Mother Father Sister Brother Spouse Child Allergies – please list any known allergies (ex. food, hay fever, pollen, drugs, medication, etc.): Sleep What time do you typically go to sleep? Hours : Minutes AM PM AM/PM What time do you typically wake up? Hours : Minutes AM PM AM/PM Is it difficult to stay asleep? Yes No Do you wake feeling rested? Yes No Stress Level (1=no stress, 10=high stress): Major Hospitalizations – please list any hospitalizations (within 1 year) or surgeries: Year Operation or Illness Name of Hospital City and State Year Operation or Illness Name of Hospital City and State Other past or current infections (MRSA/ C-Diff, etc.)? Total Pregnancies Living Ectopic Miscarriages Induced Abortions Western Drugs – please list all current prescribed medications (Sutter patients please skip to the Herbs & Supplements section, your Western Medications will be verified during your appointment)Drug NameDosageFrequency Add RemoveHerbs & Supplements – please list all current herbs & supplementsNameBrandStrengthFrequency Add RemoveDiet – please describe any restricted diet you follow now or have in the past: Please describe what you eat in a typical day: Breakfast Morning Snack Lunch Afternoon Snack Dinner Evening Snack How is your dental health? Good / fair / poor When was your last visit to the dentist? Do you exercise? Yes No Untitled Gym Walking Running Cycling Yoga Other Times Per Week Hours : Minutes AM PM AM/PM Untitled Do you have any spiritual practices? If so, please describe: What are your goals for your health? What are the top 3 priorities in your life? To be completed by Acupuncturist: T: P: LU/LI: HT/SI: SP/ST: LV/GB: PC/SJ: KI/UB: Assessment: OM Dx: OM Tx Principles: Treatment Plan Right: Left: Midline: Tx Methods and Reasoning: Acupuncture pts, Moxa, Cupping, Myofascial Release, Herbal Formula (dosage, administration), Supplements, Dietary & Lifestyle, lab/imaging, referrals # In # Out Follow up: Weekly For: Total Number Of Visits Consent to Receive Acupuncture Acupuncture is a healing art that stimulates specific points on the body to treat diseases or relieve pain. Stimulation may be produced by needles, heat, digital pressure and electrical currents, etc., but most frequently in the form of needling. In rare incidents, patient may experience certain side effects or reactions including fainting, bleedings, pneumothorax, puncturing of viscera, broken needles and other hazards associated with the treatment procedures. Although acupuncture is known to be safe it may have potential side effects. I have read the above regarding the potential side effects of acupuncture treatment, and I understand that no guarantee of results has been made. I consent to such treatment and release Innovative Body Healing, LLC and its practitioners from any and all claims of damages for any injury which may result from the treatment. SignatureDate MM slash DD slash YYYY Practitioner Name & Credentials Date Reviewed: For office use only: Date of service: MM slash DD slash YYYY Name: First MRN # :
