Happy Valley Wellness and Acupuncture New Patient Intake Form General Information Name Birthdate Age Address City State M F Zip Phone Numbers (mark the best number to contact you with an *) OK to leave a message? Y N Home Cell Email Work OK to email information? Y N Marital Status Number of children Education level Occupation Age of children Hours per week Employer How did you hear about this practice? Emergency Contact Name/Relationship Phone Health Care Providers Primary Care/Family Doctor Specialist (s) May I contact these providers to ensure coordination of care if needed? Y N Have you or anyone you know had previous acupuncture experiences? Y N Social History How many times per day do you use the following: Cigarettes Coffee Tea Soda Alcohol Recreational drugs Do you exercise? Y N Type/Frequency: Past Medical History Check any condition that you currently have, have ever been treated for, or were ever diagnosed with: Alcohol abuse Allergies Anxiety Arthritis Asthma Atrial fibrillation/irregular heartbeat Bleeding/clotting disorder Cancer (type if applicable) Celiac disease/gluten sensitivity Congestive heart failure/CHF COPD Depression Diabetes Depression Other Fibromyalgia Herniated disc Headaches/Migraines Heart attack/Myocardial infarction Hepatitis/Liver disease High blood pressure/hypertension High cholesterol/hyperlipidemia HIV/AIDS Immune disorder Joint replacement Kidney disease/disorder Low blood pressure/hypotension Lyme disease Lymph node removal Mental illness Multiple Sclerosis Pacemaker Parkinson’s Sciatica Seizures Sinus infections Skin disorder Stroke Substance abuse Thyroid disease TIA Ulcers List any surgeries or hospitalizations you have experienced with the approximate year: List any medications or supplements you are currently taking: Family History List any physical, medical, or mental illnesses and current age or age of death: Mother: Father: Siblings: Children: Grandparents: Current Symptoms Please check any symptoms you currently experience on a regular basis: General: Poor appetite Poor coordination Poor balance Unable to fall asleep Tremors Bruise/bleed easily Unable to stay asleep Overeating Sweat easily/heavily Fatigue Localized weakness Chills Weight loss Excess thirst Sudden drop in energy Weight gain Fever Catch colds easily Other (please specify) Skin/Hair/Nails: Rashes Eczema Itching Psoriasis Dandruff Hair loss Redness Hives Other (please specify) Acne Soft/brittle nails Head, Eyes, Ears, Nose, Throat: Dizziness Poor hearing Eye pain Earaches Blurred vision Headaches Floaters Migraines Spots in eyes Recurrent sore throats Night blindness Sores on lips/tongue Ringing in ears Dry mouth/throat Other (please specify) Bleeding gums Nosebleeds Facial pain Jaw clicking/pain Tooth pain Lightheadedness Cardiovascular/Respiratory: Dizziness Low blood pressure High blood pressure Irregular blood pressure Irregular heart beat Fainting Cold hands/feet Other (please specify) Chest pain Blood clots Difficulty breathing Palpitations Cough Asthma/COPD Bronchitis Pneumonia Phlegm Pain with deep breaths Shortness of breath Congestion Difficulty breathing when lying Swelling in hands/feet Urinary/Genital: Pain with urination Frequent urination Unable to hold urine Waking at night to urinate Other (please specify) Kidney stones Blood in urine Urgency to urinate Unable to hold urine Impotence Decrease in urine flow Sores on genitals Gastrointestinal: Nausea Abdominal pain/cramps Vomiting Indigestion Constipation Heartburn/reflux Diarrhea Food retention Gas Lack of appetite Bloating Excess appetite Belching Rectal pain Other (please specify) Musculoskeletal: Neck pain Foot/ankle pain Back pain Shoulder pain Knee pain Hip pain Muscle pain Hand/wrist pain Other (please specify) Autoimmune/Inflammatory: Hashimoto’s disease Systemic Lupus Erythematosus Atopic dermatitis Neurodermatitis Alopecia (baldness) Other (please specify) Black stools Blood in stools Hemorrhoids Bad breath Sensitive abdomen Chronic laxative use Sciatica Muscle weakness Rheumatism Colitis Crohn’s Allergies Food allergies Cellulitis Sinus issues Vulvitis Celiac disease Female/Gynecological: Painful menses Irregular menses Vaginal dryness Vaginal discharge/odor Ovarian cysts Other (please specify) Breast lumps/swelling Fibroids Endometriosis Hot flashes Urinary tract infections Male Reproductive issues: Testicular pain Decreased sex drive Infertility issues Other (please specify) Painful urination Penile discharge Inability to maintain/achieve erections Do you have any scars? Y N Location: Infertility issues PMS Sexually transmitted diseases Decreased sex drive Lifestyle: How many hours of sleep do you get per night? Do you feel rested in the morning? Y N On a scale of 1-10, how much stress do you have? On a scale of 1-10, how much energy do you have? Do you enjoy hobbies? Please list: How many hours do you work per week? Do you enjoy your job? Y N What kind of goals do you have for your health? Circle the most important goal: What do you hope to achieve with acupuncture?