Download New Patient Intake Form - Healing Touch Acupuncture

Healing Touch Acupuncture
New Patient Intake & Financial Policy Form
Date_________________
Name ___________________________ Date of Birth __________ Age _______
Address_____________________________________________________
City___________________ State ____________Zip____________
Home Phone ______________Work Phone _____________Cell___________
Email address_____________________ □M □ F
Marital Status_________
Emergency Contact (Name & Number)____________________________
Employer__________________Occupation_____________Hours/wk______
Work Address_________________________________________________
Referred by?___________________May we thank them for the referral?_____
Primary Care Physician______________________Phone________________
Are you under a physician’s care now? □YES □NO Reason________________
Is this visit related to a work or motor vehicle injury? □YES □NO
Injury Date____________
Have you had acupuncture before?
□YES □NO
Chinese Herbs?
□YES □NO
Insurance Information: (please fill out if you have acupuncture coverage)
Insurance Co. Name________________________Policy #_______________
Insurance Co. Address___________________________________________
City ________________State ________________Zip____________
Phone_________________________________
Subscriber’s Name___________________ Relationship to Subscriber:_______
Address __________________________________Phone_______________
Subcriber’s Date of Birth ___________Policy #________Group # __________
Deductible Amount? __________Date Met? __________ Co-Pay Amount _____
Second Insurance Co. Name _________________Policy#_______________
Address __________________________________Phone_______________
I hereby assign to Chérri Gallison, LAc LPC any medical benefits for services
rendered by her to which I am entitled. I authorize the release of any medical or other
information necessary to process claims for those services. I understand I am
responsible for any charges not covered by insurance. I agree to pay for services on the
day received unless other arrangements are made. I understand that appointments
missed or cancelled more than twice with less than 24 hours notice will incur full
charges. I understand and agree to this financial policy:
Signature _________________________________ Date _______________
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Medical History Form
Date_________________
Name_______________________________
Reason for visit today?___________________________________________
How long have you had this condition?______________Is it getting worse?____
Does it bother your:
□Sleep □Work □Other (what?)____________________
What was the initial cause?________________________________________
What makes it better?________________________________________
What makes it worse?________________________________________
Family Medical History:
□Allergies
□Cancer
□Seizures
□Arteriosclerosis
□Diabetes
□Stroke
□Asthma
□Alcoholism
□Heart Disease □High Blood Pressure
□Substance Abuse
Is there anything else about your family history I should know?______________
Patient Health Information
Ht.__________ Wt.__________
Blood Pressure_________
□Yes □No
□No
Do you have any reason to believe you are pregnant?
Do you have any chronic infectious diseases?
□Yes
What prescription or over the counter medications do you take CURRENTLY?
What vitamins/herbs/supplements do you take CURRENTLY?
□
□
Do you have food or drug allergies or sensitivities?
Yes
No
(Please List)______________________________________________
Your Medical History: (check if you had or currently have any of these conditions)
□AIDS/HIV
□Alcoholism
□Allergies
□Appendicitis
□Epilepsy
□Goiter
□Gout
□Heart Disease
□Pleurisy
□Major Traumas
□Pneumonia
(car, fall, etc. – list:)
□Polio
_______________
□Rheumatic Fever _______________
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□Arteriosclerosis□Hepatitis
□Scarlet Fever □Tuberculosis
□Asthma
□Herpes
□Stroke
□Typhoid Fever
□Birth Trauma □High Blood Pressure □Surgery (list) □Ulcers
□Cancer
□Measles
______________□Venereal Disease
□Chicken Pox □Multiple Sclerosis ______________□Whooping Cough
□Diabetes
□Mumps
______________□Other (specify)
□Emphysema □Pacemaker
□Thyroid Disorders _______________
Your Diet & Lifestyle Issues:
□Low □Normal □High
□Coffee □Artificial Sweeteners □Soft Drinks □Sugar □Salty Foods
Thirst for water? □Low □High
Strongly like my water? □Cold □Hot □Tepid
Appetite?
Please describe your typical diet, including any foods that you do or do not eat:
Do you feel this is a good diet for you?
□Yes □No
If No, in what ways would you like to change your diet?___________________
Do you use tobacco (what form/how much)?____________________________
Do you drink alcohol (what form/how much)?___________________________
Exercise (what form/how much)?____________________________________
Sleep Habits ___________________________________________
Are you sexually active?
□Yes □No
Method of contraception?__________________________________
What are the major stressors in your life?______________________________
What gives you pleasure?__________________________________________
Hobbies/Interests?_________________________________
Do you have a spiritual or faith practice (please explain) ?_________________
____________________________________________________________
What emotions predominant in your life?
____________________________________________________________
Have you experienced any major traumas (please explain)?
____________________________________________________________
Is there anything else I should know about you?
___________________________________________________________
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Body System Review – Please check any areas of concern, whether current, past, or occasional.
Current Past Occasional
GENERAL:
Current Past Occasional
Feeling hot or cold
Cold hands or feet
Fatigue
Low energy
Anemia
Slow wound healing
Chronic infections
Allergies
Difficulty sleeping
Unexplained fever
Headaches
Frequent colds
Alcohol or substance abuse
CARDIOVASCULAR:
Heart disease
Stroke
Chest pain
High blood pressure
Low blood pressure
Heart palpitations
Irregular heartbeat
Heart murmur
Rheumatic fever
Varicose veins
Ankle swelling
Water retention/edema
MUSCULO-SKELETAL:
Lower back pain
Upper back pain
Neck pain
Shoulder pain
Arm/wrist/hand pain
Leg/foot pain
Joint pain/stiffness
Arthritis
Muscle spasms/cramps
RESPIRATORY:
Shortness of breath
Difficulty breathing
Lung congestion
Persistent cough
Asthma/wheezing
Chronic bronchitis
Influenza
Pneumonia
Pleurisy
Emphysema
Tuberculosis
NERVOUS SYSTEM;
Numbness/tingling
Paralysis/atrophy
Dizziness/Vertigo
Fainting
Seizures/Epilepsy
Tics
Forgetfulness/Poor memory
Depression
Irritability
Easily stress
Anxiety/Nervousness
Mood swings
Abuse survivor
Considered/attempted
suicide
Seeing a therapist
GASTROINTESTIONAL:
Poor appetite
Excessive appetite
Changes in appetite
Weight gain or loss
Excessive thirst
Belching
Gas/bloating
Indigestion
Acid
regurgitation/heartburn
Nausea/vomiting
Abdominal cramps/pain
Hemorrhoids
Hiccups
Bad breath
Peculiar tastes
Diarrhea
ENDOCRINE:
Hypo/hyper thyroid
Low blood sugar
Diabetes I or II
Unusual day sweats
Night sweats
Current Past Occasional
Current Past Occasional
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Frequent stools
Constipation
Slow/infrequent stools
Laxative use
Undigested food in stool
Mucous in stool
Black or bloody stool
Itchy or burning anus
Colitis/Irritable bowel
Intestinal pain or cramping
Rectal pain
Appendicitis
Gall bladder problems
Liver trouble
EENT:
Vision problems/changes
Eye pain or strain
Red, itchy eyes
Floaters (spots) in vision
Poor night vision
Glaucoma
Tearing/dryness
Glasses/contacts
Hearing problems
Earaches/discharge
Ear ringing/tinnitus
Sinus problems
Phlegm
Nose bleeds
Frequent sore throats
Enlarged thyroid
Hay fever
Teeth grinding
Jaw pain/clicking
Dental problems
Headaches
Migraines
Concussion
SKIN & HAIR:
Frequent bruising
Itching
Dryness
Rashes
Acne
Eczema
Psoriasis
Herpes
Hives
Shingles
Ulcerations
Fungal infections
Hair loss
GENITO-URINARY:
Freq. urinary tract infections
Painful urination
Excessive urination
Changes in steam
Leakage of urine
Bed wetting
Blood in urine
Sexually transmitted disease
Kidney stones
Kidney disease
MEN’S HEALTH:
Sexual difficulties
Prostate problems
Testicular pain/swelling
Discharge from penis
Changes in sexual desire or
function
Fertility issues
WOMEN’S HEALTH:
PMS
Menstrual irregularity
Menstrual cramping
Changes in menstrual cycle
Bleeding between cycles
Vaginal pain/infections
Vaginal discharge
Frequent yeast infections
Pain with intercourse
Breast pain/lumps
Nipple discharge
Menopause symptoms
Hot flashes
Menopause
Changes in sexual desire or
function
Sexual difficulties
Fertility issues
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