Acupuncture Intake
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Today’s Date: ____/____/____ KAM Acupuncture Health History Questionnaire All of your answers will be held confidential. Name: ____________________________________________ DOB: ____/____/____ Age: ______ Gender: ______ Height: ______ Weight: ______ Occupation: _______________________________________ Marital Status: Never Married Married Widowed Divorced/Separated Address: ___________________________________________________________________________________ Home Phone: ______________________ Cell Phone: ______________________ Email Address: ____________________________________________________________ Emergency Contact: _________________________Phone:______________ Relation to You :_______________ Referred by: ____________________________________________________ Have you ever been treated by acupuncture or Oriental medicine before: Yes No Describe your main complaint, including location and when, how and why it began. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ How frequently does this problem bother you? _____________________________________________________ When it does bother you, how long does the episode last? ___________________________________________ Anything make it better? (Circle best answer) Anything make it worse? (Circle best answer) Hot Cold Damp Touch/Pressure Hot Cold Stress Damp Touch/Pressure Scale at its best: ___/10 (Best=0, Worst=10) Wind Drugs Wind Stress Movement Other: _____________________ Movement Drugs Dull Achy Rest (Sitting/Lying) Other: _____________________ Scale at its worst: ___/10 If pain is involved, what is the quality? (Circle best answer) Rest (Sitting/Lying) Scale currently: ___/10 Sharp/Stabbing Burning Throbbing Other: _____________________ If pain is involved, does the pain: Move around Stay in one place Have you been diagnosed for this problem? If so, what? ___________________________________ What kinds of treatments have you tried? Massage Physical Therapy Western Medicine Chiropractic Reiki Acupuncture Herbs Homeopathy Other: __________________________________________ Secondary complaints you’d like help with: ________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list any medications/vitamins/supplements/herbs you are currently taking (past 6 months): Medication Dosage Reason for taking __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list any allergies (drugs/food/chemicals/environmental/metals): __________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list any hospitalizations/surgeries (including dates): ___________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please list any significant trauma (falls/auto accidents): ______________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Are there any areas of your life that you find stressful? _______________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Do you have a regular exercise program? No Yes If yes, please describe: _________________________ __________________________________________________________________________________________ Do you follow any type of special diet (vegetarian/vegan/medical-related/other)? No Yes If yes, what type of diet? _________________________________________________________ Please describe your average daily diet: Morning: ___________________________________________________________________________________ Afternoon: _________________________________________________________________________________ Evening: ___________________________________________________________________________________ How many 8-oz. glasses of water do you drink per day? _____________________________________________ How many cups of caffeinated coffee, tea, or cola do you drink per week? _______________________________ How many alcoholic beverages do you drink per week? ______________________________________________ Do you smoke? No Yes If yes, how many cigarettes or cigars per day? ___________________________ Please describe any use of drugs for non‐ medical purposes: __________________________________________ __________________________________________________________________________________________ Frequency of colds/flu: (# per month/year/season): _________________________________________________ Past Personal Medical History of Significant Illnesses: Cancer Stroke Rheumatic Fever Heart disease Allergies High Blood Pressure Thyroid disease Autoimmune Disease Asthma Venereal disease Candida Seizures HIV Alcoholism Diabetes Hepatitis EBV Mental Illness Other: ______________________________ Family Medical History of Significant Illnesses: Cancer Stroke Rheumatic Fever Heart disease Thyroid disease Autoimmune Disease Asthma Allergies High Blood Pressure Venereal disease Alcoholism Mental Illness Diabetes Seizures HIV Hepatitis Arthritis Other: _________________________ Hot/Cold: Do you have a tendency to feel: Are only your hands and feet cold: Hotter than others No Yes Colder than others If yes, is it your: hands Neither feet both (Circle best answer) Any abnormal sweating? No Yes If yes, is it: constant nightsweating menopausal hot flashes (Circle best answer) Skin/Hair: (Check all that apply) Rashes Ulcerations Dandruff Hair Loss Hives Itching Eczema Pimples Moles Any other changes in hair or skin? (texture/color/premature graying/sudden hair loss) ______________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Head, Eyes, Ears, Nose, and Throat: Headaches (where appropriate, circle best answer) Duration:_________________ Location: (Forehead / Temples / Behind Eyes / Top of Head / Back / Sinus ) Other: _______________________ Frequency: _____ X per: day / week / month How long do they last?____________________________ How severe is the pain on a scale of 0-10: ___/ 10 (Best=0, Worst=10) Pain at its best: ___ /10 Pain at its worst: ___/10 Currently: ___ /10 Is it (Better/ Worse / Neither) when you apply pressure to the headache? Is it worse with (Improper Eating/ in the Morning/ in the Evening/ Bright Lights / Noise)? Do they come at a certain time of day? If so, when? ____________________________________________ Do they come (Before / After / During ) your period? What is the Quality of the Pain? Dull Achy Sharp stabbing Throbbing Pressure Whole Head Feels Heavy Eyes Dry Itchy Watery Red Burning Painful Cataracts Ears Any ringing in ears? No Yes If yes, what is the pitch? _________________________________ Nose Any nasal issues? _______________________________________________________________________ Throat Recurrent Sore Throats Dry Itchy Other Lip sores Tongue sores Other: _______________________________________________ Cardiovascular: (Circle all that apply) Concussions Eye Strain Migraines Seeing Spots Poor Hearing Cold Hands/Feet Swelling of Hands Palpitations Swelling of Feet Blurry Vision Glasses /Contacts Teeth Problems Jaw Clicks Low Blood Pressure Poor Vision Color Blindness Grinding Teeth Facial Pain High Blood Pressure Fainting Night Blindness Earaches Sinus Problems Clots Dizziness Nose Bleeds Bleeding Gums Phlebitis Difficulty in Breathing Varicose Veins Irregular Heartbeat Vascular Spiders Chest Pain or Pain down the Arm Respiratory: (Circle all that apply) Shortness of Breath Pain with a deep breath Cough Coughing Blood Bronchitis Pneumonia Difficulty in breathing when lying down Production of phlegm (what color?________________) Appetite: Asthma Other: ___________________________ Blood How is your appetite?_________________________________________________________________________ Do you have any unusual taste in your mouth: No Yes If so, what? ___________________________ Do you have a sensation of feeling “weighed down” or heaviness in your body? Have you gained or lost weight in the last 6-12 months? No No Yes Yes If so, how much? I’ve Gained / Lost ________ lbs. Do you have a tendency to crave any of the following flavors: (Circle all that apply) Sweets Sour Bitter Spicy Greasy Fried Salty Thirst: How much water do you drink per day?_________________________ Other liquids & amounts? _____________________________________________________________________ Are you frequently thirsty? No Yes Do you have thirst with little desire to drink? No Yes Do you prefer (Hot / Cold) beverages? Gastrointestinal: (Circle all that apply) Indigestion eating Belching Gas Rectal Pain Ulcer Diarrhea Bad Breath Vomiting Eating Disorders Constipation Nausea Abdominal Pain or Cramps Bloating after Recurrent/Chronic Antibiotic Use Chronic Use of Laxatives/Stool Softeners Hemorrhoids (Are they currently bleeding? No Yes) Black/Bloody Stools Parasite history Any other stomach or intestinal problems? ______________________________________________ How often do you move your bowels? _________ times per (Day / Week) What is the consistency of your stools? Loose-Diarrhea / Hard-Constipated / Watery / Formed / Thin Genitourinary: (Circle all that apply) Pain on Urination Urgency to Urinate Unable to hold urine Blood in Urine Prostate Problems Decrease in Flow Poor Sex Drive Difficulty Urinating Do you wake up at night to urinate? Genital Sores No Frequent Urination Kidney Stones Erection Difficulty Yes If so, how often? ____ times per night Any particular color to your urine? ___________________ Do you take vitamins? _______________ Sleep: How many hours do you sleep? ____ per night Trouble falling asleep? No Yes If so, why? Bedtime? ______ PM Trouble staying asleep/wake-ups during the night? Urinate Restless Other: ________________ How many times do you wake per night? ________ Is there a specific time you usually wake up during the night? ________ Do you feel well-rested in the AM? Energy Level: (0=Low, 10=High) Wake-up? ______ AM No Yes No Yes How is your overall Energy Level: _____/10 How is your energy level after exercise? Better Same How is your energy level after meals? Better Worse Same Worse How is your energy level after a bowel movement? Better Same Do you have Fatigue... In the Afternoon? In the morning? After work? No Yes No Yes Worse No Yes When weather is (Damp / Hot / Cold) Musculo-skeletal: (Circle all that apply) Neck Pain Muscle Pains Hand/Wrist Pain Knee Pain Shoulder Pain Back Pain Hip Pain Muscle Weakness Foot/Ankle Pain Other joint/ bone problem?___________________ Neuro-psychological: (Circle all that apply) Dizziness Lack of Coordination Easily susceptible to stress Areas of Numbness Loss of Balance Depression Poor Memory Bad Temper Anxiety Concussion Seizures Other:____________________________ Emotional State: What is your general state of emotion? Circle the most appropriate emotion(s). Happiness Sadness Worry Stress Anger Irritability Obsession Pensiveness Fear Other: ______________________ Stress In the past year, have you experienced any significant loss? (death of loved one or pet, job loss, miscarriage, divorce or separation, etc.)? No Yes In general, do you feel actively supported by your family and friends? No Yes How is your overall stress level? (0=Low, 10=High): ___/10 Anger Are you comfortable expressing anger? No Yes How do you handle anger? (Circle all that apply) Repressed expression Sudden outburts ***Men may skip this section*** Irritability Rib/side pain Other: _____________ Reproductive and Gynecological: Age of first period ____ Average length of period ____days First date of last period ______________ Length of your cycle ____days Last PAP date ______________ # of pregnancies ____ # of births ____ # of premature births ____ # of miscarriages ____ Circle all that apply: Painful/Irregular Excess Facial Hair Periods Absence of period Pale Watery Menses Menopause (Age)____ Vaginal Dryness Vaginal sores: History of STDs? No Yes If so, what?_________________________________ Was treatment given? Y / N Do you use birth control now? No Yes If so, what type/how long? _______________________ Have you ever taken the birth control pill or been on Estrogen replacement therapy? No Yes If so, for how long? ___________________________________ Have you had problems with fertility?_____________________________________________________________ Are you currently sexually active? Vaginal discharge: No No Yes Yes If so, color/quantity/odor? __________________________________________ How often does this occur?_________________________________________ Please describe your period in detail, including the specific color of the blood (i.e. bright red, dark red, purple, brown or pale); the quantity of sanitary products you use per day; and whether you experience clots, including size (i.e. pea, dime, nickel, quarter), color and number: ______________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have there been any notable changes in your cycle in the past 6-12 months? No Yes If so, what?_______________________________________________________________ PMS/Mood Changes: (Circle all that apply) Irritable Moody Weepy Depressed Other:__________________________ When in your cycle do you get these symptoms? (Before Period / During Period / After Period ) Breasts: (Circle all that apply) Masses (Soft & Gummy / Hard & Rocklike) Fibrocystic Breasts Tenderness Swelling Cysts Other: ___________________ Pain: (Circle all that apply) If you have pain, when does it come in the cycle: ( Before Period / During Period / After Period ) Quality of Pain ( sharp & stabbing / dull & achy) Pain location: _______________________________________ Duration of Pain: ____________________________________________________________________________ How severe is the pain on a scale of 0-10 (Best=0, Worst=10): When pain is at its best? ____/10 When pain is at its worst? ____/10 Currently? ____/10 What makes the pain Better? (Circle all that apply) Heat Stress Cold Damp Wind Rest Sitting Lying Movement Touch/Pressure Drugs Lying Movement Touch/Pressure Drugs Other:______________________ What makes the pain Worse? (Circle all that apply) Heat Stress Cold Damp Wind Rest Sitting Other:______________________ Section below for acupuncturist use only. General observations: ________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Tongue: ___________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Pulse: ___________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Diagnosis: _________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Treatment Plan (including adjuncts):
