Dr. Karen Bilton, Ph.D.
(Acupuncturist, Chinese Herbalist, Physiotherapist)
Suite 106, 24-30 Springfield Ave,
Potts Point, NSW 2011
ABN: 14 682 591 327
www.lotushealingarts.com
0416 458 477
PATIENT INFORMATION
Name
Date
Home Address
City
State NSW
Post code
E-mail Address
Mobile Phone
Occupation
Business Address
City
State NSW
Place of Birth
Sex
male;
Phone
Post code
Phone
Date of Birth
female;
Age
Marital Status
In Case of Emergency Notify
Single,
Height
Married,
Weight
Life Partner,
Divorced,
Widowed
Phone
How did you hear of this office?
Have you ever before tried acupuncture or Chinese herbal medicine?
CHIEF COMPLAINT
What are the main health problems for which you are seeking treatment?
Please rate the extent to which your current complaint affects your daily life (1 = minor; 10 = major)
Please rate your commitment to resolving this problem (1 = minor; 10 = major)
What other forms of treatment have you sought?
PAST MEDICAL HISTORY (check all which apply)
Allergies
Cancer
Diabetes
Hepatitis
High Blood Pressure
Heart Disease
Seizures
Rheumatic Fever
Surgeries
Sexually Transmitted Diseases
Thyroid Disease
Hospitalizations
Vaccinations
Childhood Illnesses
Accidents
Significant Trauma
Medications
Other (please specify)
FAMILY MEDICAL HISTORY (check all which apply and specify which blood relative)
Cancer
High Blood Pressure
Hepatitis (A, B, C)
Rheumatic Fever
Infectious Disease
Diabetes (type 1 or 2)
Heart Disease
Seizures
Emotional Disorder
Tuberculosis
Autoimmune Disease
Endocrine Disorder
Other (please specify)
If deceased age of demise
Father
Mother
LIFESTYLE (please indicate the use and frequency of the following)
Coffee
Caffeinated Beverages
Black Tea
Alcohol
Substance use (specify)
Addictions (specify)
Sibling/s
Tobacco
If stopped use of any of above indicate how long and frequency of use
Exercise (specify type)
MEDICATIONS and SUPPLEMENTS
Please list any medications and/or supplements you are currently taking
PREVIOUS HOSPITALIZATIONS
Please specify (date and procedure)
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Dr. Karen Bilton, Ph.D.
(Acupuncturist, Chinese Herbalist, Physiotherapist)
Suite 106, 24-30 Springfield Ave,
Potts Point, NSW 2011
ABN: 14 682 591 327
www.lotushealingarts.com
0416 458 477
GENERAL HEALTH and REVIEW OF SYSTEMS
Please indicate any of the following repeated symptoms experienced in the last 5 years.
General Symptoms
Skin
Urogenital
Headache – migraine
Thirst
Fainting
Poor sleep – insomnia
Fatigue
Abnormal sweating
Loss of weight
Fever
Chills – feels cold
Cold hands and feet
Hot hands and feet
Skin eruptions
Clammy skin
Dryness
Bruises easily
Rashes
Sensitive skin
Hives
Itchy skin
Jaundice
Changes in moles
Gastrointestinal
Respiratory
Neurological
Forgetfulness
Confusion
Poor memory
Dizziness
Convulsions
Paralysis
Tremors
Numbness
Eyes, Ears, Nose and Throat
Failing vision
Near sighted
Eye pain
Cross eyed
Eye inflammation
Glaucoma
Deafness
Loss of hearing
Ear discharge
Ringing in ears
Nose bleeds
Nasal obstruction
Nasal drainage
Loss of smell
Sinusitis
Allergies
Sore throat
Hoarseness
Difficulty speech
Difficulty swallowing
Change in tastes
Dental decay
Gum problems
Asthma
Frequent colds
Frequent urination
Scanty urination
Painful urination
Blood in urine
Cloudy urine
Difficult to hold urine
Stress incontinence
Kidney/bladder infections
Kidney stones
Chronic cough
Productive cough
Chest pain
Difficulty breathing
Wheezing
Cardiovascular
Irregular heart beat
High blood pressure
Low blood pressure
Chest pain
Heart trouble
Hardening of arteries
Swelling of ankles
Poor circulation
Varicose veins
Muscles and Joints
Neck Pain
Back Pain
Hip Pain
Knee Pain
Foot/Ankle/Leg Pain
Hand/Wrist/Arm Pain
Shoulder Pain
Sciatica
Pins and needles
Swollen joints
Hot joints
Arthritis
Sore muscles
Weak muscles
Hernia
Pain while walking
Bad posture
TMJ
Poor appetite
Excessive hunger
Belching
Heart burn, acid reflux
Gas
Nausea or vomiting
Stomach pain or distention
Constipation
Diarrhea, Colitis
Blood in stool
Hemorrhoids
Female
Painful menstrual periods
Excessive flow
Irregular cycle
Abnormal bleeding
Vaginal discharge or pain
Breast pain
Breast lumps
Menopausal symptoms
Reduced sex drive
Male
Genital pain
Reduced sex drive
Premature ejaculation
Impotence
Nocturnal seminal emission
Psychological
Depression
Anxiety – nervousness
Panic attacks
Nightmares
Difficulty concentrating
Treatment – counseling, therapy
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