Download Generations New Patient Intake

Generations Acupuncture New Patient Intake
Important: Complete this document as thoroughly as possible. Some of the questions that follow may seem unrelated to
your condition, but they may play a major role in diagnosis and treatment. All information is strictly confidential.
General Patient Information:
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
City, State, Zip code: ________________________________________________________________________________
Home phone: (_______)_________________________ Age: _____________ Date of birth: ______/______/______
Occupation: ________________________________________ Employer: ______________________________________
Hours worked per week: ____________Is your health complaint related to work?
☐ Yes ☐ No
Family physician name and phone number: _________________________________________________________________
How may we contact you? ☐ By phone call ☐ By text ☐ By email
Cell phone:
(_______)_________________________
Email address: _____________________________________________________________________________________
Would you like to be on our email list? ☐ Yes ☐ No
How did you hear about us? ___________________________________________________________________________
Guardian (if under 18): ______________________________________ Relationship to child: _________________________
Person to notify in an emergency: ____________________________________ Relationship: ________________________
Phone number for person above: (_______)_________________________
What is your reason for getting treatment? In order of significance to you:
1.
_________________________________________________________________________________________
2.
_________________________________________________________________________________________
3.
_________________________________________________________________________________________
How do these conditions impair your daily activities?
________________________________________________________________________________________________
Patient Medical History
Injuries: __________________________________________________________________________________________
Surgeries: ________________________________________________________________________________________
Past and/or current Illnesses: _________________________________________________________________________
Current Medications: ________________________________________________________________________________
Current Supplements: _______________________________________________________________________________
Are you currently taking pain medication or blood thinners? (Including Aspirin) ☐ Yes ☐ No
How is your sleep? _________________________________________________________________________________
How is your digestion? ______________________________________________________________________________
Check symptoms you have had in the last year or have now:
☐ Depression
☐ Difficulty focusing
☐ Headaches or migraines
☐ Easily startled
☐ Excess worry or fear
☐ Anxiety
☐ Fatigue
☐ Excess anger or irritability
☐ Insomnia or poor sleep quality
☐ Rapid weight loss or gain
☐ Feeling overwhelmed
☐ Dizziness
Musculoskeletal: Check if there is pain, weakness, and/or numbness
☐ Neck
☐ Wrist/hand
☐ Leg
☐ Shoulder
☐ Back
☐ Knee
☐ Elbow
☐ Hip
☐ Ankle/foot
☐ Eye pain
☐ Hearing loss
☐ Problems with teeth and gums
☐ Blurred or failing vision
☐ Ringing in ears
☐ Asthma/wheezing
☐ Glaucoma
☐ Enlarged glands
☐ Difficulty breathing
☐ Dry eyes
☐ Frequent colds
☐ Chronic cough
☐ Excessive tearing
☐ Hay fever
☐ Chronic hiccups
☐ Earache
☐ Frequent bleeding from nose
☐ Frequent ear infections
☐ Sinus problems
Eyes/Ears/Nose/Throat/Respiration:
Gastrointestinal:
☐ Belching, excess gas
☐ Excess hunger
☐ Poor appetite
☐ Bloating
☐ Gall bladder problems
☐ Increased appetite
☐ Constipation
☐ Reflux
☐ Hemorrhoids
☐ Diarrhea
☐ Stomach pain
☐ Nausea
☐ Vomiting
Cardiovascular:
☐ Chest pain
☐ Poor circulation
☐ Irregular or rapid heart beat
☐ High or low blood pressure
☐ Heart attack
☐ Swelling of ankles
☐ Acne
☐ Itching/rash
☐ Night sweating
☐ Bruise easily
☐ Sensitive skin
☐ Spontaneous sweating
☐ Dry skin
☐ Sore that won’t heal
Skin:
Urinary:
☐ Bladder or urinary tract infection
☐ Frequent urination
☐ Inability to control urine
☐ Blood or pus in urine
☐ Unable to empty bladder
☐ Kidney infection/stones
☐ Infertility
☐ Excess or scanty menstrual flow
Reproductive:
☐ Lowered libido
☐ Erection difficulties
☐ Bleeding between periods
☐ Previous miscarriage #_________
☐ Penis discharge
☐ PMS: _______________________
☐ Pregnancies to term #_________
☐ Prostrate problems
☐ Severe menstrual pain
Could you be pregnant? ________
The information on this form is correct to the best of my knowledge.
Signature: _____________________________________________________________ Date: _____________