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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Sarah Johnson L. Ac. Austin, TX 78704 Patient Intake Form Please take time to completely fill out this form. It will help me in providing you with a careful evaluation of your health. If you have any questions, please feel free to ask. All information is confidential. Personal Information: Name:_______________________________ D.O.B.__________ Age:________ Today’s Date:________ Address:_________________________________________ City:________________________________ State:______ Zip:__________ Primary Phone:___________________ Alt. Phone:___________________ Email:____________________________________ Occupation:_________________________________ Emergency Contact Person:_____________________________ Number:__________________________ Primary Care Provider:_________________________________ Number:_________________________ How did you hear about us? ________________________________ Marital Status: Single Married Separated Divorced Widowed Partnered Partner’s Name:________________________ Partner’s Age:_______ Occupation:__________________ Have you ever been treated by Oriental medicine before? Yes No Medical Information: Main Complaint (including diagnosis, duration, other forms of treatment): Additional Complaints/Concerns (list in order of significance): Significant Traumas/Surgeries: Medications, Herbs, Supplements: Allergies (environmental, food, chemical, or drug): Diet & Exercise: Meals per day:____ Caffeinated Beverages (per day or week):____ Alcohol (per day or week):_____ Are you on any type of special or restricted diet? Do you smoke? Yes No If so, how many cigarettes (per day or week)? Do you use any recreational drugs? Yes No If so, what type and how often?___________________ Do you exercise regularly? Yes No No. of days per week:_____ Length of workout:_____ Type of Activity:___________________________ Family Medical History Please check any condition that applies to your immediate family. Write “F” for father, “M” for mother, “S” for sister, “B” for brother, “GM” for grandmother, and “GF” for grandfather next to the box you checked. Diabetes ________ Heart Disease ________ Allergies ________ Cancer ________ Stroke ________ Asthma ________ High Blood Pressure ________ Seizures ________ Other _______________________________________ Personal Medical History Please check any current or previous conditions . Diabetes Heart Disease Asthma Injury/Trauma Kidney Disease Meningitis Epilepsy Nerve Damage Chronic Pain Ulcers Paralysis Lung Disease STD/STI Liver Disease High Cholesterol Glaucoma Chemical Dependency Auto Immune Disease Hypo/Hyperglycemia Anemia Tuberculosis Shingles Hepatitis Migraines Skin Disorder Rheumatic Fever Thyroid Disorder Vein Disorders Infertility Emphysema COPD Beeding/Hemorrhage Nervous Disorder Mental Illness Hypertension Acid Reflux Disease Crohn’s Disease Seizures Please check any of the symptoms you have experienced in the last 3 months: Body Temperature (Kidney Organ System) Cold Hands Cold Feet Sweaty Palms Sweaty Feet Hot Body Temperature Cold Body Temperature Afternoon Flushing Night Time Urination Profuse Perspiration Lack of Perspiration Night Sweating Perspire Easily Strong Thirst Hot Flashes Energy and Stamina (Lung and Kidney System) Easily Fatigued Lethargy Shortness of Breath Sweating Prone to Illness Frequent Colds Wheezing Allergies Blood Function (Liver, Heart, Spleen System) Dizziness Poor Night Vision Floaters Tingling in Extremities Poor Memory Difficulty Concentrating Itchy or Dryness Blurred Vision Tinnitus Fainting Weak or Brittle Nails Heart Function Heart Palpitations Anxiety Mental Restlessness Chest Pain Hemophilia Manic Moods Restless Dreams Insomnia Arrhythmia Rapid Heart Beat Forgetfulness Hallucinations Depression High Blood Pressure Mitral Valve Prolapse Tongue Ulcers Speech Impediment Severe Shyness Low Blood Pressure Heart Murmur Lung Function Persistent Cough Nosebleeds Sinus Congestion Wheezing Phlegm Production Sneezing Chronic Allergies Difficulty Breathing Dry or Flaky Skin Nasal Dryness Sore Throat Cystic Fibrosis Spleen Function Low/Weak Appetite Abdominal Bloating Strong Food Cravings Abrupt Weight Gain Gas Gurgling in Intestines Abrupt Weight Loss Bruise Easily Fatigue After a Meal Hemorrhoids Hypoglycemia Indigestion Stomach Function Stomach Ache Acid Reflux Ravenous Appetite Bad Breath Bleeding Gums Heartburn Stomach Ulcer Belching Hiccups Nausea Vomiting Mouth Ulcers Bowel Function and Elimination (Intestinal Function) Loose Stools Diarrhea Incomplete Stools Constipation Blood in Stools Mucous in Stools IBS or Colitis Small, Hard, Dry Stools Less than 1 BM/Day Chron’s Disease Eating Disorder Accumulated Dampness Mental Fogginess Swollen Hands Poor Mental Focus Mental Sluggishness Swollen Feet Joint Stiffness/Ache Chest Congestion Heaviness of head, limbs, or whole body Edema in Legs Edema in Abdomen Liver and Gallbladder Function Chest Pain Chest Tightness Body Tension Muscle Spasms Muscle Cramps Seizures Teeth Clenching Irritability Easy to Anger Easily Frustrated Convulsions Numbness/Tingling Chronic Neck Tension Difficulties with Stress Depression Skin Rashes Pain in Ribcage Acne Heaviness in Ribcage Headaches Lump in Throat Migraines Shoulder Tension Gall Stones Ringing in Ears Eye Pain/Dryness Alternating Diarrhea and Constipation Eyes (Liver Function) Itchy Eyes Dry Eyes Watery Eyes Grittiness Poor Night Vision Red and Irritated Bloodshot Seeing Spots Near Sighted Far Sighted Astigmatism Glaucoma Cold Lower Back Cold Hips/Buttocks Cold Knees Incontinence Hair Loss Early Graying Hearing Loss Quick to Fright Kidney and Bladder Function Frequent Cavities Broken/Loose Teeth Weak Bones Ringing in Ears Weak Knees Knee Soreness Low Back Pain Prostate Problems Urinary Function Normal Color Reddish Color Dark Yellow Cloudy Clear Color Strong Odor Difficulty Initiating the Stream of Urine Small Amount Large Amount Frequent Urination Night Time Urination Dribbling UTI/Pain/Burning Weak Stream Burning Sensation Female Reproductive Function Age of First Period______ Length of Cycle______ Duration of Bleeding______ Day of Ovulation______ Date of Last PAP______ Date of Last Period______ Number of Pregnancies______ Vaginal Births______ Cesarean Births______ Ectopic Pregnancies______ Miscarriages______ Abortions______ Failed IUIs______ Failed IVFs______ Menstrual Cycle My periods are: Like Clockwork Somewhat Regular Erratic If your cycle is erratic: Shortest # of cycle days______ Longest # of cycle days______ PMS: Irritability Food Cravings Spotting Before Period Headache/Migraine Constipation Low Back Pain Bloating Dizziness Breast Soreness Fatigue Heavy Bleeding Scanty Bleeding Dark Colored Blood Watery or Pink Blood Pain is Sharp Pain is Dull Pain Improves with Rest Normal Bleeding Interrupted Flow Clotting Painful Periods Pain Improves with Heat Pain Improves with Exercise During Ovulation Cervical Mucus is clear, stretchy, and abundant. Yes No Previous Diagnostic Assessments Amenorrhea Anovulation Anti-sperm Antibodies Autoimmune Oopharitis Elevated FSH Levels Endometriosis Fallopian Tube Blockage Habitual Miscarraige Hyperprolictinemia Anovulation Luteal Phase Defect Menorrhagia Ovarian Cyst Ovarian Hyperstimulation Syndrome Pelvic Inflammatory Disease (PID) Polycystic Ovarian Syndrome (PCOS) Premature Menopause Premature Ovarian Failure (POF) Resistant Ovarian Syndrome Unexplained Infertility Uterine Fibroids Uterine Septum Previous Gynecological Surgeries Dilation and Curettage (D&C) Falloposcopy Hysterosalpingogram (HSG) Hysteroscopy Hysterectomy Laparoscopy (endometriosis) Laparoscopy (ovarian cysts) Laparoscopy (uterine fibroids) Mastectomy/Lumpectomy Myomectomy Tuboplasty Other: ______________________________________ Male Reproductive Function Testicular Swelling Sensation of Heat in Testicles Testicular Pain Scrotal Itching Retrograde Ejaculation Prostititis Difficulty Ejaculating Difficulty Urinating Erectile Dysfunction Vasectomy Vasectomy Reversal Epididymitis Impotence Infertility Vericocele Hernia History of Sexually Transmitted Disease (STD): Medical Evaluation: I have been evaluated by a medical physician for the condition being treated in the past 12 months. Yes No Permission to Maintain Medical Privacy and Share Medical Information: All of the information that you provide is strictly confidential. It is our policy never to disclose any personal or medical information about any patient under our care without first obtaining your express permission to do so. In an effort to maximize your clinical results, we may want to contact your Doctor(s), and send them periodic updates about your case and your progress. Do you grant your permission for us to discuss the details of your case with your Medical Doctor? Yes No