ACUPUNCTURE REGISTRATION & HISTORY
Patient Information
□ Married
Date _________________
Occupation_______________________________________
Patient Name_____________________________________
Last
First
□ Single
□ Other
Employer/School__________________________________
MI
Whom may we thank for your referral?
Address_________________________________________
_______________________________________________
City _________________________________
State ______________ Zip ______________
IN CASE OF EMERGENCY, CONTACT
E-mail __________________________________________
Name__________________________________________
Home Phone (_____)___________________
Phone__________________________________
Mobile Phone (______)_____________________
Communication Preference (circle one)
Work Phone (______)_____________________
Phone:
Gender □ M □ F
Can we contact you via email:
Age __________
Cell
Home
Appointment reminder:
Birthdate _________________________
Yes
Email
No
Home
Cell
Do Not Contact
Patient Condition
Major symptoms (in order of importance) __________________________________________________________________________________
When did your symptoms appear? ____________________________________________
What would you most like to achieve with acupuncture? _______________________________________________________________________
Are you open to Chinese herbs?
□ yes
□ maybe
□ no
If yes, by what method?
□ pill
□ tincture
What treatments have you already received for your condition?
□ medication
□ surgery
□ physical therapy
□ massage
□ acupuncture
□ chiropractic
□ herbs
□ other
Name and address of other doctor(s) who have treated you for your condition ____________________________________________
Date of last: Physical Exam ____________
Are you pregnant?
□ yes
Blood Test ____________
□ no due date ________________________________
Family History
Indicate if you or immediate family have had the following:
□ Alcoholism
□ Anemia
□ Arthritis
□ Asthma
□ Autoimmune
□ Bleeding Disorders
□ Cancer
□ Chronic Fatigue
□ Diabetes
□ Drug Abuse
□ Epilepsy
□ Gallstones
□ Heart Disease
□ Hepatitis
□ High Blood Pressure
□ High Cholesterol
□ Stroke
□ Kidney/Bladder Trouble □ Thyroid Problems
□ Mental Illness
□ Ulcers
□ Multiple Sclerosis
□ Osteoporosis
Heath History
EXERCISE
WORK ACTIVITY
HABITS
□ none
□ moderate
□ daily
□ vigorous
□ sitting
□ standing
□ light labor
□ heavy labor
□ smoking
□ alcohol
□ caffeine
□ high stress
Injuries/Surgeries/Major Illnesses
Description
packs/day______________
drinks/week ____________
cups/day_______________
reason ________________
Date
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Medications
Allergies
Vitamins/Herbs/Minerals
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Energy & Immunity
□ Frequent sore throat
Dietary restrictions (list)
□ Allergies
□ Glaucoma
_________________
Female Health
□ Anemia
□ Loss of voice
_________________
Age of 1st menses ______
□ Catch colds easily
□ Nosebleeds
_________________
Date of last menses_____
□ Fatigue (chronic)
□ Poor night vision
□ Thyroid problems
□ Post-nasal drip
Neurological
Length of cycle_____ days
□ Tinnitus
□ Numbness/Tingling
□ Heavy flow
□ Swollen glands
□ Paralysis
□ Light flow
□ Poor memory
□ Irregular cycle
Mind & Emotions
□ Anxiety/Excessive worry
Duration of flow____ days
□ Depression/Sadness
Skin
□ Seizures
□ Bleeding between periods
□ Insomnia
□ Acne
□ Tics
□ Clots in menstrual blood
□ Irritability
□ Brittle nails
□ Tremors
□ Ovulation pain
□ Mood swings
□ Changes in moles/lumps
□ Vertigo/Dizziness
PMS:
□ Vivid dreams
□ Cysts
□ Irritability
□ Dry hair or hair loss
Musculoskeletal
□ Crying easily
Respiratory
□ Dry, itchy skin
□ Arthritis
□ Breast tenderness
□ Asthma
□ Easy bruising
□ Fibromyalgia
□ Headaches
□ Cough
□ Eczema
□ Headaches/migraines
□ Low back pain
□ Difficulty breathing
□ Excessive sweating
□ Joint pain
□ Menstrual cramps
□ Shortness of breath
□ Hives
□ Muscle cramps
□ Sinus infections
□ Night sweats
□ Muscle spasms
Current form of contraception
□ Spontaneous sweating
□ Rashes
□ Swelling
_____________________
□ Wheezing
□ Psoriasis
□ Tendonitis
For how long __________
□ Weak muscles
# of children born_______
Cardiovascular
Gastro-intestinal
□ Chest pain
□ Abdominal pain
Kidney/Urinary
# of abortions__________
□ Cold hands & feet
□ Bad breath
□ Burning
□ Pregnancy complications
□ Low blood pressure
□ Belching
□ Edema/Swelling
□ Palpitations
□ Bloating
□ Frequent/Urgent urination
Would you like to conceive
in the future?
□ yes
□ no
□ Rapid heart beat
□ Constipation
□ Incontinence
□ Diarrhea
□ Kidney stones
Ears, Nose, Throat &
□ Excessive hunger
□ Painful urination
□ STD________________
Eyes
□ Gas
□ Prone to UTI’s
□ Abnormal PAP smear
□ Bad taste in mouth
□ Heartburn/Acid reflux
□ Bleeding gums/Mouth sores
□ Hemorrhoids
Male Health
□ Decreased libido
□ Blurry vision
□ Hiccups
□ Decreased libido
□ Endometriosis
□ Cataracts
□ Lack of appetite
□ Discharge from penis
□ Frequent yeast infections
□ Dry mouth
□ Laxative use
□ Genital itching
□ Hot flashes
□ Eye Dryness
□ Mucus/Blood in stool
□ Groin pain
□ Ovarian cysts
□ Excessive phlegm
□ Nausea/Vomiting
□ Impotence
□ PCOS
□ Excessive thirst
□ Sudden weight change
□ Premature ejaculation
□ Unusual vaginal discharge
□ Fainting
□ Ulcers
□ Prostatitis
□ Uterine fibroids
□ STD________________
□ Vaginal dryness
□ Floaters or spots
# of miscarriages_______
□ Breast lumps