Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download INTAKE FORM Name (Last) (First) Phone
Document related concepts
Gastroenteritis wikipedia , lookup
Neonatal infection wikipedia , lookup
Infection control wikipedia , lookup
Traveler's diarrhea wikipedia , lookup
Schistosomiasis wikipedia , lookup
Common cold wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Transcript
INTAKE FORM Name (Last) (First) Phone Number Sex Male Female Date of Birth Today's date Home Address State City Zip Code EMERGENCY CONTACT Name Phone Relationship Referred by Seeking treatment for what health concerns Onset date Has any treatment helped this (these) condition(s)? Please list. What do you find makes it worse? Have you ever had acupuncture before? Yes No Please list any pharmaceutical drugs or herbs that you are currently taking. Please list any surgeries, accidents or injuries that you have had (month/ year) Please check all that apply: GENERAL: Chills Fever Aversion to cold Low energy/fatigue Recent weight loss Night sweats Recent weight gain Spontaneous sweating Aversion to heat Susceptible to colds/flu How many times per year? EYES/EARS: Floaters Blurry vision Glaucoma Pain behind eyes Infection Earache Dry eyes Inflamed eyes /redness Ringing in ears Discharge from ear Tearing Cataract Other HEADACHE: Headaches Migraines Which region (forehead, sides, etc.) Sharp headache Dull headache Tight band headache Headache with nausea Other RESPIRATORY: Asthma Difficulty breathing Difficulty exhaling Able to bring it up? Phlegm in lungs Color if any Sensation of something stuck in thoat Current history of pneumonia Loss of sense of smell Tightness in chest Coughing up blood Hay fever/allergies Yes No Hoarseness Sinus congestion Loss of voice Nasal mucus Pneumonia Color if any Other CARDIOVASCULAR: Chest pain/angina Palpitations High blood pressure Hypochondriac pain (pain under ribs) History of heart attack, heart failure Low blood pressure Cold hands or feet Poor circulation Irregular heartbeat Ankle swelling Other GASTROINTESTINAL: Difficulty swallowing Burning sensating Bloating Belching Blood in stool Irritable bowel syndrom Gout Acid regurgitation/heartburn Gas Black stool Abdominal distension Undigested food in stool Hemorroids No appetite Constipation Candida/yeast infections Insatiable appetite Thirst Is thirst quenched by drinking? Yes Diarrhea No Nausea Prefer hot/cold drinks Other URO-GENITAL: Urination: Profuse amount Burning sensation Genital pain/swelling Urgent/bladder control problem Urine with blood Genital sores Scanty amount Current urinary tract infection Impotence Seminal emissions Cloudy urine History of urinary tract infections Low sexual energy Other PAIN Soreness Dull Better with cold Sharp Inflamed or swollen Better with heat Radiates to where? Worse in damp weather Result of an accident If so, what type of accident? Frequent urination Repetitive stress injury NEUROLOGICAL: Sensation of numbness Tingling sensation Sensation of pins and needles Location for any of these symptoms: Tremmors Drowsiness Dizziness Fainting Vertigo Paralysis Stroke Siezure Loss of balance Other SKIN/HAIR: Acne Eczema/psoriasis Oily skin Bruise easily Dark circles/bags under eyes Sores/lumps Specific areas Brittle nails Dry hair Hair loss EMOTIONAL: Anxiety Anger Depression Trouble going to sleep Difficulty concentrating Interrupted sleep Fear Nightmares Irritable Insomnia If so, what time do you wake up? Other WOMEN: Age at onset of menses Blood quality: Length of cycle (ex., every 28 days) Dark purple Premenstrual tension Bright red Hysterectomy Clots Scanty Heavy Constipation or diarrhea before or during menses Feeling of fatigue before or during menses Painful periods Pale/pink Number of pregnancies Fibroids C-section History of yeast infections/candida Ovarian cysts Breast tenderness Endometriosis Breast lumps Sores on genitlia Abnormal PAP smear Other Uterine prolapse
