Mary Pat Finley, Licensed Acupuncturist
Balance Health + Wellness Registration and History
Patient Name
Male/Female
Date of Birth
Email
Cell Phone
___________________
Work
Home
Address
Apartment
City
____State
Single
Married
Significant Other/Partner
Zip Code
Widowed
Separated
Employer/Occupation
Divorced
________________________________
Employer Address
City
____State
Zip Code
If Minor (under 18) or Under Care of Responsible Party:
Name of Responsible and
Relationship:
Address (if different from above)
City
____State
Cell Phone
Zip Code
Work
Home
Emergency Contact
Name
Phone
Primary Doctor
Phone
How Did You Hear About Balance?
Please initial the following:
I hereby authorize the office of Balance Health + Wellness to contact me via phone or email.
I understand that I am financially responsible for all charges whether or not paid by insurance.
Please review our cancellation policy:
The providers at Balance Health + Wellness require 24 hour notification for cancelled appointments. Patients who do
cancel appointments within 24 hours will be charged the full appointment fee.
Signature
Print Name
Date
We sincerely thank you for your visit and invite you to enjoy all of the services offered at Balance Health + Wellness
including acupuncture, biofeedback, chiropractic, massage, naturopathic medicine, physical therapy and Pilates.
1
Health History
Primary Reason for your visit:
Health Concerns: Please list in order of importance. Rate severity (1 is low, 10 is high) and success (1 is no success, 10 is very successful).
Concern
Severity
Past/Present Treatments
Success Level
(1-10)
(1-10)
Medications/Supplements
Please list all medications and vitamins/supplements you are currently taking:
Current
Name
Past
Strength
Dosage
Reason
Duration
(Within last six months, circle any that apply)
Pain Relievers
Antacids
Antibiotics
Appetite control
Birth control
Blood pressure
Hormones
Insulin
Laxatives
Sedatives
Sleeping
Steroids
Are you experiencing any pain? Yes/No If yes, please illustrate in the picture
Do you have any known drug or food allergies?
Please list previous medical diagnosis:
_
Please list past surgeries, accidents or permanent disabilities:
Do you exercise?
Yes/No
What kind/frequency/duration?
Do you drink alcohol? Yes/No
# of drinks / week?
Do you smoke?
# of packs / week?
Yes/No
Do you drink caffeine? Yes/No
# of cups / day?
Do you smoke?
# of packs per week?
Yes/No
2
Thyroid
Tranquilizers
Supplement
Mary Pat Finley, Licensed Acupuncturist
Balance Health + Wellness Registration and History
WOMEN ONLY
Are you pregnant now?
Yes
No
Trying to get pregnant?
Yes
No
Planning a pregnancy?
Yes
No
Age Period Started
Flow (number of days)
Date of last period
Date of menopause
Length of Cycle
On hormone replacement?
History of post-menopausal bleeding or spotting?
Birth control method?
Number of live births?
Number of still births?
Abortions?
Last delivery?
Any complications with deliveries?
Are you sexually active?
Yes
No
History of multiple partners?
Yes
No
History of same sex partners?
Yes
No
Are you able to enjoy sex?
Yes
No
Miscarriages?
Do you have, or have you had, any of the following (circle all that apply):
vaginal infections
yeast infections
urinary tract infections (bladder)
genital herpes
genital burning
chlamydia
other sexually transmitted infection
pelvic inflammatory disease
missed periods
irregular periods
bleeding between periods
heavy bleeding with period
menstrual pain
cramping
premenstrual syndrome
ovarian cycsts
infertility
breast lumps
pain during or after sex
other (describe)
MEN ONLY
Do you have, or have you had any of the following (circle all that apply):
Testicular pain
scrotal changes
sores on penis
Unable to get erection (past or present)
discharge from penis
ejaculation of semen during sleep
burning or painful ejaculation
Premature ejaculation
unable to ejaculate
burning or painful urination
Problem passing urine
blood in urine
split or interrupted stream of urine
Genital herpes
history of other sexually transmitted infection
Are you sexually active?
Yes
No
History of multiple partners?
Yes
No
History of same sex partners?
Yes
No
Birth control method?
3
problem holding urine
prostatitis
Symptom List:
Please circle the following symptoms if you experience them on more than a rare occasion.
Group I
Group II
Group III
hearing loss
dizziness
lower back ache
knee pain
sinus congestion
swelling
darkness under the eyes
can’t stand cold
hair thinning or loss
premature aging
frequent urination
kidney stones
perspire easily
weakness of legs/knees
rapid weight change
loose or aching teeth
reduced sexual energy
thyroid problems
headaches
ringing in ears
poor eyesight
eye infections
dry or burning eyes
eczema
shingles
cold sores
convulsions
muscle spasms
irritability/anger
constipation
hemorrhoids
hepatitis
ulcer
vomiting
gallstones
indecision
pain below ribs
insomnia
skin rashes
cysts or tumors
ear infections
sore throat
lymphatic swelling
hot palms and soles
heart palpitations
can’t stand heat
bitter taste in mouth
gum problems
nose bleed
facial redness
itching or burning skin
thirst
vivid dreaming
night sweats
Group IV
Group V
Group VI
Indigestion/nausea
passing gas frequently
food allergy
ulcer
diarrhea/constipation sinus
anemia
bad breath
sores in mouth
heartburn
weak appetite
abdominal bloating
cramping
low/high body weight
blood in stool
vomiting
bronchitis
fatigue all day
asthma
wake up tired
cough
tired in afternoon
difficulty breathing
tired in evening
congestion
joint pain
nasal infection
bursitis
swelling in face
tendonitis
respiratory infections sciatic pain
cold hands and feet
4