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JANET N. LURIE, L.AC 5512 NE 109TH CT. SUITE B VANCOUVER, WA 98662 360-910-8004 PATIENT INTAKE FORM Name: __________________________________________________Date ______________________ (First) (Middle) (Last) Street Address _____________________________________________________________________ City ____________________State ___________________________ Zip Code _________________ Home Telephone _____________________ Work ________________________________________ E-Mail _____________________________________________________________________________ Age:_______Date of Birth ________________________Female:___________Male ____________ Marital Status ________________________Occupation _________________________________ Emergency Contact ____________________________Telephone__________________________ Relationship of this person to you___________________________________________________ Referred By ____________________________________How did you hear about us _________ Family Physician ___________________________________________________________________ Insurance Carrier ______________________________Policy Number _____________________ Have you tried Acupuncture or Chinese Herbal Medicine before? _____________________ Results ____________________________________________________________________________ HEALTH HISTORY QUESTIONAIRE What is your primary concern, condition, injury or illness? __________________________ How long has it bothered you? ______________________________________________________ Describe what caused it or how it started ___________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How does this condition affect work, sleep, appetite, etc.? ___________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Have you received treatment for this condition? _When? _____________________________ From whom? _______________________________________________________________________ What was the diagnosis? ___________________________________________________________ What were the results of the treatment? _____________________________________________ Has the condition gotten: Better ________________Worse_________Same _______________ SYSTEMS REVIEW Please circle: Code P = previous condition Y = present condition N = never had Depression Easily stressed Fatigue Numbness or tingling Acne/Boils Headaches Jaw/TMJ Glasses/contacts Tearing/dryness Impaired hearing Cough Asthma Shortness of breath Chest pain Heart Disease High/Low Blood Pressure Heartburn Constipation Blood in stool Pain in urination Frequency at night Frequent infections Sleep soundly Wake in the night Trouble falling asleep Physically or mentally restless Arthritis Easy bruising or bleeding Varicose veins Weakness Age of first menses_____________ Length of cycle_____________days Duration of cycle___________days Painful menses Heavy or excess flow PMS Endometriosis Breast tenderness/pain Hernia Impotence YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN Anxiety or nervousness Diabetes Seizure Rashes Itching Migraines Floaters in eyes Blurriness Glaucoma Ringing in ears Phlegm Bronchitis Difficulty breathing Palpitations/Flutters Swelling in ankles Fainting Nausea/Vomiting Diarrhea Gall bladder disease Urinary frequency Inability to hold urine Kidney stone Dream excessively Trouble returning to sleep YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN Wake too early Joint pain/stiffness Muscle spasms/stiffness Anemia YPN YPN YPN YPN FEMALE REPRODUCTION Are cycles regular Difficulty conceiving Abnormal PAP YPN Clotting YPN Discharge YPN Birth control YPN Ovarian cysts YPN Spotting MALE REPRODUCTION YPN Testicular masses/pain YPN Prostate Disease YPN YPN YPN YPN YPN YPN YPN YPN YPN YPN 2 HEALTH HISTORY From whom are you currently receiving health care? ___________________ What is your chief complaint? ________________________________________ What, if any, contagious diseases do you have at this time? __________ What childhood illnesses have you had? _______________________________ What hospitalizations have you had? __________________________________ What allergies to drugs or foods do you have? ________________________ What current medications do you take? ________________________________ FAMILY HISTORY Father Møther Brothers Sisters Spouse Child(ren) Age (if living) _______ ______ ___ ______ ______ __________________ Health (G or P _______ ______ ___ ______ ______ __________________ List any chronic conditions in your family _______ ___________________ LIFESTYLE Do you exercise? Y N If yes, what kind? _________________________ How do you describe your body temperature?(circle one) Cool, cold, neutral, warm, hot In what part of your body do you hold your tension? _________________ Do you take vitamins or other supplements? ___________________________ If there is any additional information you would llke to add, use the back of this sheet. ACUPUNCTURE CONSENT FORM Acupuncture is performed by the insertion of needles through the skin, and/or by the application of heat to the skin at certain points on or near the surface of the body in an attempt to treat pain, disease, or other dysfunctions. Adverse side effects may result. These could include, but are not limited to local bruising, minor bleeding, fainting , temporary pain or discomfort, and temporary aggravation of symptoms existing prior to acupuncture treatment. Acupuncturists may recommend treatment with substances from the Oriental Material Medica. Adverse side effects may result from taking these substances. These include, but are not limited to , changes in bowel habits, temporary abdominal pain or discomfort , and the possible temporary aggravation of symptoms existing prior to herbal treatment. If you experience any problems which you can associate with these substances, stop taking them and call your practitioner Signature____________________________________________________________ __ 3 4
