Date: ___________________________
Last name:
Birth date:
Address:
First name:
Check preferred contact #:
Phone (home):
☐
City:
Phone (work):
☐
Province:
Phone (cell):
☐
Postal Code:
Referred by:
Would you like to receive clinic
newsletter/promotions?:
Occupation:
Email:
Yes
☐
No
☐
Reason for visit:
Have you had acupuncture before:
Yes ☐
No ☐
Family Physician name:
Family Physician phone:
Western medical diagnosis (if applicable):
Other medical treatment received:
Physiotherapy ☐ Naturopathy ☐ Chiropractic ☐ Massage ☐ Other ☐
Please list any prescription medication or over the counter drugs currently taking:
1.
2.
3.
4.
5.
6.
Please list herbal medicine and other supplements currently taking:
1.
2.
3.
4.
5.
6.
Please list any allergies (food, drug, environmental, etc.):
1.
2.
3.
4.
Kristin Greenacre, R.Ac GREENACRE ACUPUNCTURE
400 Pleasant Park Road, Ottawa, ON K1H 5N1 Tel: 613-240-9092
www.greenacreacupuncture.com
Please indicate any of the following conditions that apply to you or an
immediate family member:
Heart
conditions
Diabetes
Stroke
Low blood pressure
Kidney disorder
High blood
pressure
Neurological
condition
Cancer
Respiratory
conditions
HIV/AIDS
Sprain/strain/fracture
Osteoporosis
Headaches/migraines
Jaw pain
Arthritis
Dizziness/fainting
Contagious illness
Skin conditions
Digestive problems
Hemophiliac
Wear a pacemaker
Lung condition
Epilepsy
Possibility of
pregnancy
Upcoming surgeries
Deep vein thrombosis
Spinal or head injury
Hepatitis
Do you use the following? If so, how often?
Cigarettes ☐
Alcohol
☐
Drugs
☐
Coffee
☐
Pop
☐
Do you participate in the following activities? If so, how often?
Yoga ☐
Running ☐
Fitness class ☐
Gym ☐
Biking ☐
Swimming ☐
Walking ☐
Other ☐
In the space below, please describe areas of pain/concern:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Check the sensations/pain characteristics:
Sharp
☐
Severe ☐
Burning
Stabbing
☐
☐
Moving
Shooting
☐
☐
Tingling
Throbbing
☐
☐
What relieves the pain (ice, rest, activity, massage, heat…)?
What aggravates the pain (weather, heat, cold, rest, activity…)?
Kristin Greenacre, R.Ac GREENACRE ACUPUNCTURE
400 Pleasant Park Road, Ottawa, ON K1H 5N1 Tel: 613-240-9092
www.greenacreacupuncture.com
Dull
☐
Numbness ☐
Date last menstruation began:
Is your menstrual cycle:
Regular
☐
Irregular
☐
Menstrual cycle length (i.e.: 28 days):
How many days do you bleed in total:
How old were you when you had your first menstruation:
How old were you when you went through menopause:
Describe:
Your flow:
Heavy ☐
Light ☐
Average
☐ Other
___________________
Consistency of blood:
Watery ☐
Thick ☐ Average ☐ Other
________
Color of blood: Pink ☐ Red ☐ Bright red ☐ Dark red ☐ Purple ☐ Brown
☐
Blood clots present: Yes ☐
No ☐ If yes, when: Start ☐ Mid ☐ End
☐
Yes ☐
Do you experience menstrual pain?
No ☐
If yes, when? Before menses ☐ During ☐ Specify which days ____ After
☐
What relieves the pain?
Character of pain? Stabbing ☐ Cramping ☐ Dull ☐ Heavy ☐ On/Off
☐
Check the PMS symptoms that apply:
Breast tenderness ☐ Cramps ☐ Acne ☐ Change in bowel ☐
Nausea ☐
Bloating ☐ Headaches ☐ Moodiness ☐ Fatigue ☐
Night sweats ☐
Sleep disturbances ☐ Weepiness ☐ Other
_____________
How many times have you been pregnant?
How many times have you given birth?
Have you had any miscarriages?
Yes ☐
No ☐
If yes, how many, at how many weeks pregnant, and in what year?
How many times have you had a D & C performed?
How many abortions have you had?
In what year?
Were there any complications that occurred during these pregnancies?
Kristin Greenacre, R.Ac GREENACRE ACUPUNCTURE
400 Pleasant Park Road, Ottawa, ON K1H 5N1 Tel: 613-240-9092
www.greenacreacupuncture.com
Have you ever been diagnosed with:
STD
Yes ☐
No ☐
If yes, list:
Pelvic Inflammatory disease
Yes ☐
Yes ☐
No ☐
Uterine fibroids
Polyps
Yes ☐
No ☐
No ☐
Pelvic adhesions
Yes ☐
No ☐
Prolapsed uterus
Yes ☐
No ☐
Unique shape of uterus
Endometriosis
Yes ☐
Yes ☐
No ☐
No ☐
Yes ☐
PCOS (polycystic ovarian syndrome)
No ☐
Date of last pap smear: ____________/_______________/________________
Have you ever had an abnormal pap smear?
Yes ☐
Do you get yeast infections regularly?
Do you get bladder infections regularly?
If yes, what color?
White ☐
If yes, what consistency?
Yellow ☐
Have you ever had an IUD?
No ☐
Green ☐
Pink ☐
Thick ☐
Yes ☐
No ☐
When did you stop?
Yes ☐
No ☐
Red ☐
Sticky ☐
No ☐
Yes ☐
Have you taken oral contraceptives?
If yes, for how long?
No ☐
No ☐
Watery/Thin ☐
If yes, does it have a foul odor?
No ☐
Yes ☐
Yes ☐
Do you have vaginal discharge?
Yes ☐
Kristin Greenacre, R.Ac GREENACRE ACUPUNCTURE
400 Pleasant Park Road, Ottawa, ON K1H 5N1 Tel: 613-240-9092
www.greenacreacupuncture.com
Check each symptom that you currently have, leave it blank if not applicable:
Gan
____ Irritability/Impatience
____ Depression
____ Stress
____ Emotional eating
____ Unfulfilled desires
____ Visual problems/
floaters
____ Blurred vision
____ Poor night vision
____ Red/dry/itchy eyes
____ Headaches/migraines
____ Dizziness
____ Feeling lump in throat
____ Muscle twitching/
spasm
____ Neck/shoulder
tension
____ Brittle nails
____ Sighing
____Sensation of pain
under rib cage
____ PMS
____ Genital itch/pain/rash
Xin
____ Palpitations
____Chest pain/tightness
____ Insomnia/sleep
problems
____Restlessness/easily
agitated
____ Vivid dreams
____ Lack of joy
____Forgetfulness
____ Aversion to heat
____ Bitter taste in mouth
____ Tongue/mouth ulcers/
cankers
Shen
____ Frequent urination
____ Bladder infection
____ Lack of bladder
control
____ Wake to urinate
____ Feel cold easily
____ Cold hands/feet
____ Night sweats
____ Hot flushing
____ Low sex drive
____ High sex drive
____ Loss of head hair
____ Hearing problems
____ Crave salty food
___ Fearful
____ Poor long term
memory
____ Ankle swelling
____ Tinnitus
Fei
____ Dry cough
____ Cough with
phlegm
____ Nasal
discharge/drip
____ Sinus infection/
congestion
____Itchy/painful throat
____ Dry mouth/nose/
throat
____ Skin rashes/hives
____ Snoring
____ Greif/sadness
____ Shortness of breath
____ Allergies
____ Asthma
____ Weak immune
system
____ Alternate chills/
fever
Pi
____ Heaviness in head/
body
____ Fatigue after eating
____ Difficult getting up in
the morning
____ Water retention
____ Muscular weakness/
tiredness
____ Bruise easily
____ Unusual bleeding
(nose, stool)
____ Bad breath
____ Poor appetite
____Increased appetite
____ Crave sweets
____ Poor digestion
____ Nausea/vomiting
____ Bloating/gas
____ Hemorrhoids
____ Constipation
____ Loose stool
____ Alternate
constipation/ loose stool
____Abdominal pain
____ Intestinal pain/
cramping
____Heartburn
____ Over thinking
____ Overweight
____ Foggy mind
____ Yeast infection
____ Aversion to cold
____ Cold nose
____ Increased thirst
____ Prefer warm drinks
____ Prefer cold drinks
____ Sweat easily
On a scale of 1-10, how would you rate your daily energy level (10 being best):
Kristin Greenacre, R.Ac GREENACRE ACUPUNCTURE
400 Pleasant Park Road, Ottawa, ON K1H 5N1 Tel: 613-240-9092
www.greenacreacupuncture.com