Intake Form - nuyu acupuncture

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nuyu
acupuncture
Confidential Health Intake Form
Thank you for taking the time to complete the following information, which better helps us to assess your health needs. All information is
confidential. We are happy to answer any questions that you may have.
Client’s Name: _____________________________________ Marital Status: ________________________ Date:______/______/______
Date of Birth: _______/_______/_______
Age: _______
Gender:
M/F/T
Height: ______ Weight: ______
Address: _____________________________________________ City: _____________________ ST: ________ Zip: _______________
Home Phone _______________________ Cell Phone ______________________________ Work Phone _________________________
Email________________________________________________ How did you hear about us? __________________________________
Occupation: _____________________ Hobbies: __________________________________ Employer: ___________________________
Emergency Contact: ______________________________________ Phone Number: _________________________________________
Have you ever had acupuncture before? Y / N What was the result? ______________________________________________________
What are your main health concerns? 1.___________________________________________________________________________
2.__________________________________________________ 4. _______________________________________________________
3.__________________________________________________ 5. _______________________________________________________
Which of these health concerns has been diagnosed by a Medical Doctor (MD) ______________________________________________
Please list any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Major life events injuries, surgeries and birth or labor trauma: (please include dates): _________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Significant Family Health History: _________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
What are your treatment goals/expectations? ._________________________________________________________________________
______________________________________________________________________________________________________________
Is there any chance you are pregnant? Y/ N
Describe your menstruation cycle. (Length of flow and cycle, color of blood, etc.)____________________________________________
______________________________________________________________________________________________________________
Do you have any infectious diseases? Y/ N (if yes which ones) _________________________________________________________
______________________________________________________________________________________________________________
Please circle any symptom you experience now and underline any that you have experienced in the past
Mental- Emotional:
mood swings
nervousness/anxiety
obsessive thinking
poor memory
Insomnia
sadness
anger
Energy and Immunity:
fatigue
night sweats
lack of sweating
Respiratory:
Tuberculosis
difficulty breathing
slow wound healing
826 E Main St.
chronic infections
unusual sweating (palms, soles, elsewhere)
Emphysema
shortness of breath
mydocuments\business2\ClinicForms\NewPatient-Form-v10-KY.doc
worry
persistent cough
Pleurisy
Depression
mental fogginess
Chronic Fatigue Syndrome
frequently catch colds
Pneumonia
Asthma
other respiratory problems:_____________________________________________
502.418.2121
©Copyright: Frederick William Ehmann 2013—2014.
Louisville KY 40206
All rights reserved. – Licensed to nuyu acupuncture LLC.
nuyu
acupuncture
Confidential Health Intake Form
Date:
Client’s Name:
Head, Eye, Ear, Nose, and Throat:
impaired vision eye pain/strain
glaucoma
glasses/contacts
tearing/dryness
impaired hearing
ear ringing
earaches
ear infection
headaches
nose bleeds
frequent sore throats
teeth grinding
Hay Fever
TMD/jaw problems
Strep Throat
sore throat
itchy throat
sensation of something stuck in your throat
sinus problems
excessive thirst
List allergies:___________________________________________________________________________________________________
Cardiovascular:
Heart Disease
palpitations/fluttering
Gastrointestinal:
acid reflux
stroke
Ulcers
Irritable Bowl Syndrome
Kidney Stones
swelling of ankles
High Blood Pressure/ Low BP
heart murmurs
Rheumatic Fever
Varicose Veins
changes in appetite
Gall Bladder Disease
Genito-Urinary Tract:
chest pain
Liver Disease
blood in stools
Kidney Disease
Incontinence
nausea/vomiting
Hepatitis
polyps
painful urination
GI pain
constipation
diarrhea
Pancreatitis
poor appetite
sweet cravings
frequent urination
blood in urine
Urination at Night
difficult urination
Female Reproductive/Breasts:
irregular cycles
breast lumps/tenderness
nipple discharge
premenstrual problems
bleeding between cycles
difficulty conceiving
painful periods
heavy or light flow
vaginal discharge
menopausal symptoms
emotional reactions
Endometriosis
pregnancies
Births
Male Reproductive
sexual difficulties
prostrate problems
testicular pain/swelling
muscle spasms/cramps
arm pain
vasectomy
belching
Hemorrhoids
frequent UTI
low libido
passing gas
dizziness
Hysterectomy
how many___?
penile discharge
infertility or abnormal testing
Musculoskeletal:
neck/shoulder pain
upper back pain
mid back pain
low back pain
leg pain
joint pain (if so, where?):_______________________________________
Neurologic:
vertigo/dizziness
paralysis
numbness/tingling
loss of balance
seizures/epilepsy
Endocrine:
Hypothyroid
Hyperthyroid
Diabetes
feeling Hot or Cold
Obesity
Other hormone imbalances__________________________________________________________________________
Hypoglycemia
Hashimoto’s Disease
Autoimmune and Inflammatory Conditions:
swollen glands
Chronic Fatigue
Rheumatic Arthritis
Plantar Fasciitis Staphylococci infections Uveitis
Iritis
Fibromyalgia
Crohn’s Disease
Other: Anemia
Cancer
rashes
Eczema/Hives
Fungal infections
Shingles
bruise easily
other________________________________________________________
Lifestyle:
regular exercise
alcohol
recreational drugs
tobacco
stress
caffeine
cold hands/feet
occupational hazards
Psoriasis
spiritual practice/community
how often do you eat sugar?___________________________________________
How often do you drink water?____________________________________ How much per day? ________________________________
What do you eat? How many fruits and Vegetables do you eat on a daily basis? _____________________________________________
Breakfast:__________________________________________ Lunch:_____________________________________________________
Dinner:____________________________________________ Snacks:_____________________________________________________
Is there anything else we should know?
________________________________________________________________________
______________________________________________________________________________________________________________
Signature:
Date:______/______/______
Initial Here: ________ to receive our newsletter, special offers, a FREE allergy treatment, and Referral Rewards!
826 E Main St.
mydocuments\business2\ClinicForms\NewPatient-Form-v10-KY.doc
502.418.2121
©Copyright: Frederick William Ehmann 2013—2014.
Louisville KY 40206
All rights reserved. – Licensed to nuyu acupuncture LLC.
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