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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: _____________