Download Female Intake Form

Acupuncture Intake Form
PATIENT INFORMATION (ADULT FEMALE)
ALL INFORMATION IS CONFIDENTIAL and is useful in determining the best treatment plan for you.
Name: _________________________________________
Date of birth: ______________________
Age: __________ Gender (please circle): M or F
Occupation: _______________________
Street Address_________________________________
Home Phone: ______________________
City, State, Zip: ________________________________
Cell Phone: _______________________
E-mail: ______________________________________
Work Phone: ______________________
Place of Birth:_______________________
 single 
City Rural  Suburb  Town Other
married  divorced  separated widowed  partnership living with same sex relationship
Emergency Contact: ___________________________
Relationship to you: ________________
Address: ____________________________________
Home phone: _____________________
Cell Phone: _________________________________
Work phone: ______________________
How did you hear of us? May we thank someone for referring you? ___________________________
Have you ever received acupuncture? __________ If yes, where? ___________________________
For what conditions? _________________________________________________________________
What are you seeking treatment for today?_______________________________________________
Please indicate if any of the following pertain to you:
(Marking “yes” does not make you ineligible for treatment, however, it may restrict some of the treatment
modalities used)
 Hepatitis (A,B,C,) HIV  High Blood Pressure  Seizures
DENTAL HISTORY
Number of cavities: ____________ Number/type of filling: ________________________________
Dental surgeries (including root canal): ________________________________________________
______________________________________________________________________
HEALTH HISTORY
What are your most important health concerns? Please list in order of importance:
1.______________________________________________________
2. _____________________________________________________
3. _____________________________________________________
Date of Onset: ____________
Date of Onset: ____________
Date of Onset: ____________
Date of last physical exam: _____________ Physician: ________________ Physician’s phone: _____________
Please list any hospitalization and/or surgeries (not including those related to childbirth):
Hospitalization/surgery
Date
Reason
Please list any injuries and/or accidents:
Accident/injury
Date
Relation to health
Please list all prescription and over-the-counter medications you are currently taking:
Name
Dosage Reason for taking
Date began taking
Please list all vitamins, minerals & supplements you are currently taking (include energy drinks, etc):
Name
Dosage Reason for taking
Date began taking
Please indicate if you are taking any of the following:
 blood thinners (warfarin, Coumadin, etc.)  diet pills (diuretics, appetite suppressants, etc.)
 pain relievers (Tylenol, aspirin, etc.)  cortisone or other steroids  thyroid medication
 tranquilizers/sedatives  sleeping aids  laxatives  antacids (Tums, etc)
Approximately how many courses of antibiotics have you taken over the past 10 years? _______________
Please review the following symptoms and mark an X in the appropriate column.
Leave blank if you do not experience the symptom.
Occasional Frequent
Occasional
cough
spontaneous sweating
nasal congestion/runny nose
post-nasal drip
enlarged lymph glands
sinus congestion or infection
skin rashes or hives
asthma or wheezing
bleeding gums
shortness of breath
catch colds easily
allergies
eczema or psoriasis
acne or boils
ringworm or fungus
dry nose, throat or skin
decreased sense of smell
hoarse or sore throat or voice
low appetite
loose stool or diarrhea
acid reflux/heartburn
blood in the stool
fatigue after eating
obsession in work or relations
constipation
hemorrhoids
feelings of claustrophobia
excessive appetite
gas or bloating after food
nausea or vomiting
insomnia
tongue or mouth sores
sadness
mental restlessness
chest pain
palpitations
anxiety
vivid dreams or nightmares
excessive sweating
laughing for no reason
irritability
bitter taste in the mouth
muscle spasms or twitching
neck/shoulder tension
hearing impairment
difficulty digesting oily foods
difficulty making decisions
ringing in the ears
low back pain
sore, cold or weak knees
hair loss
urinary incontinence or urgency
dizziness/fainting
floaters in field of vision
decreased sex drive
frequent urination
cold hands and feet
body feels heavy
poor concentration
sticky taste/feeling in mouth
hot hands and feet
afternoon fevers
flushed cheeks
headaches
foggy headed
night sweats
edema or ankle swelling
cloudy urine
heat or cold intolerance
excessive thirst
change in weight
nose bleeds
ear aches or infections
bruise easily
muscle weakness
numbness/tingling
pain on urination
athlete’s foot
Frequent
Do you have a bowel movement every day? yes no Number of bowel movements per day? _____
Are your BMs
Well formed Soft  Ribbon-like Loose Contains undigested food Bad smelling Burning
upon defecation Burning/heaviness in rectum  Incomplete BMs
LIFESTYLE HISTORY
Height ________ Weight: _________ Do you exercise? _________ How many times a week? _____________
What type of exercise? ________________________________________________________________________
Do you drink coffee/black tea? __________
# 8 oz cups per day/week? _______
Do you drink soda? ________ Is it caffeinated? _________ # 12 oz glasses per day/week? ________
How much water do you drink per day? ___________________________________________________
Please describe your typical diet:
Breakfast: ___________________________________________________________________________________
Lunch: ______________________________________________________________________________________
Dinner: _____________________________________________________________________________________
Snacks: _____________________________________________________________________________________
# meals per day: ________ Do you eat at regular times each day? ____________________________________
# snacks per day: _______ How often do you eat out (or order in)? ____________________________________
Are you vegetarian, vegan, kosher? Are there other restrictions to your diet?__________________________
___________________________________________________________________________________________
Do you experience any gas, burping, bloating acid reflux or other digestive symptoms after eating any foods?
____________________________________________________________________________________________
Do you use tobacco? ________ How many times per day/week? _____________________________________
Have you used tobacco in the past? ________ When did you stop? __________________________________
Do you drink alcoholic beverages? _________ How many drinks do you have per day/week? _____________
Do you use recreational drugs? ____________ How many times per day/week/month/year? ______________
Have you been treated for drug/alcohol addiction? ________________________________________________
#hours you sleep per night: _____________ Time you go to bed: ___________ Wake up: ______________
Do you sleep well? ____________________ Do you awake feeling rested? ___________________________
What is your average stress level (1 is lowest, 10 is highest)? (please circle) 1 2 3 4 5 6 7 8 9 10
What is your average energy level (1 is lowest, 10 is highest)? (please circle) 1 2 3 4 5 6 7 8 9 10
At what time of day is your energy typically at its best? _________________ At its worst? ________________
How do you feel about the following areas of your life?
great
good
fair
significant other
family relations
friendships
living arrangements
self image
sex
work
vacations/time off
exercise
spirituality
poor
bad
How much change are you willing to/able to make at this time to improve your health? (Please circle)
Minimal
Some
Complete
FAMILY HISTORY
Father’s current age: _______ Please circle: good health poor health deceased (cause & age) ___________
Mother’s current age: _______ Please circle: good health poor health deceased (cause & age) ___________
Please indicate whether you or any family member has, or has ever had any of the following conditions:
Disorder/Illness
Which family member
Date
Frequency (if applicable)
(include yourself; give
important details)
Alcoholism/addictions
Allergies/asthma
Alzheimer’s disease
Anemia
Arthritis
Autoimmune disorders
Bell’s Palsy
Birth defects
Bleeding disorders
Blood clots
Cancer (specify type)
COPD
Crohn’s disease
Depression/anxiety
Diabetes
Epilepsy
Fibromalygia
Gallbladder problems
Glaucoma
Heart disease
Heart murmurs
Hepatitis
High cholesterol
High blood pressure
HIV/AIDS
Infectious disease
Infertility
Irritable bowel
Kidney disease
Kidney stones
Mental illness
Osteoporosis
Pacemaker/defibrillator
Polycystic Ovary
Restless Leg
Shingles
Stroke
Thyroid dysfunction
Tuberculosis
Ulcers
Urinary tract infections
Yeast infections
Have you had any procedures related to any of these diagnoses? yes no
If yes, what?______________________________________________________________
If you circled cancer, please describe the type of cancer and the course of treatment:
___________________________________________________________________________________________
FOR WOMEN
Are you still menstruating? ____________ Age menses began: __________ Date of last period: ____________
Are you now pregnant? ___________
Date of your last ob/gyn exam: ___________
# of live births: ____ Total # of pregnancies: ______ #of miscarriages: _______ # of terminations: ______
Pregnancy Year
Length of
Hours Type of Sex Weight Complications
Meds during
pregnancy of
delivery
labor/delivery
labor
?
First
Second
Third
Fourth
Are you sexually active? ____________________________ STDs?____________________________________
What birth control do you currently use? _______________________ How long have you used it? _________
What other types of birth control have you used in the past? ________________________________________
Do you experience any sexual difficulties? (please describe) _________________________________________
Do you experience any of the following?
Occasional Frequent
Occasional Frequent
Endometriosis
Fibrocystic breasts
Ovarian cysts
Breast cancer
Uterine fibroids
Breast lumps
Abnormal pap smear
Nipple discharge
Yeast infections
Vaginal discharge/odor
Urinary tract infections
Herpes
Pain/itching of genitalia
HPV (human papilloma virus)
Genital lesions/discharge
Hysterectomy
PID (pelvic inflammatory
Uterine prolapse
disease
# of days between periods: ______ # of days you bleed: _____ Do you bleed between periods? _____
Do you bleed  heavy  moderate  light  very little
Have your periods changed since they started? yes no
When?_______________________Why? ___________________________________________________
What color is your menstrual blood (check all that apply)
 Pale pink/red Red  Bright Red  Dark red  Dark red/brown  Black  Dark purple
# of pads/tampons used: ___ day 1 ___ day 2 ___ day 3 ___ day 4 ___ day 5 ___ day 6+
On your heaviest day, which do you use? (please circle )  Regular
Super
Super plus
How often do you change your pad/tampon?
 Every hour or less  Every two hours  Every 4 hours  I don’t really need to change my pad or
tampon, but I do for hygiene Other:_______________________________________________________
Are your periods painful?  before period  during period  after period
Is the pain  mild  moderate  severe
Is the pain located in:  low abdomen  low back  thighs  other
Is the quality of the pain  cramping  stabbing  aching  dull  burning  constant comes and goes
Do you pass clots? (please circle) yes
no
What color are the clots?
 Bright Red  Dark red  Brownish  Black Dark purple Mucus
How big are the clots on average?
 Small stringy  Small and spotty  The size of a dime  The size of an egg yolk  The size of your fist
Do you experience pain with the passing of your clots? (please circle) yes no n/a
Do you feel better after passing clots? (please circle) yes no n/a
Other symptoms related to your period:
Occasional Frequent
Discharge
Headaches
Nausea
Constipation
Diarrhea
Cravings
Occasional
Frequent
Swollen or painful breasts
Mood swings
Increased appetite
Decreased appetite
insomnia
Is there anything else you would like us to know?
OVULATION
On what cycle day do you ovulate?_________
Do you use an ovulation predictor kit to determine ovulation? ________________________________
Do you chart your Basal Body Temperature? yes no
Do you experience any symptoms at ovulation?
 Breast tenderness  Sharp pain  Cramping
 Bowel movement changes
 Irritability/rage
Do you get cervical mucus at ovulation? yes no
For how many days?_________
Describe the quality/quantity of your cervical mucus:
 None, I never notice any even with internal exam  Scant, I only notice it with internal exam
 Moderate, I notice some on my underwear and when I urinate
 Profuse, I notice large amounts in my underwear and when I urinate
 Creamy, thick  Like rubber cement  Egg white stretchy  Watery  Other
Do you notice cervical mucus at other times during your cycle? yes no
If yes, when?_______________________For how many days?____________________
What is the quality of that mucus?___________________________________________
FERTILITY INFORMATION
How long have you been trying to get pregnant?____________
Has a physician diagnosed a difficulty with fertility due to:
 Female factor  Male factor  Unexplained
Other_________________________________________
Who is your Ob-Gyne, or Reproductive Endocrinologist?
Have you had any testing relating to your fertility?
Hormone levels:
ESTRADIOL_____FSH______LH______ ESTROGEN______PROGESTERONE_____
Other blood tests: _________________________________________________________
Laparascopy:______________________________________________________________
HSG(test to determine state of fallopian tubes):______________________________
Ultrasound:________________________________________________________________
Any uterine abnormalities?__________________________________________________
Have you taken any medication relating to your fertility?_______________________
Number of IVF procedures?___________ Number of IUIs___________________
What are your treatment goals relating to your fertility?
How would you describe the emotions most closely related to your journey towards
pregnancy?
INFORMED CONSENT
This is to inform you that Acupuncturists are not licensed to practice medicine in the state of Illinois; an
Acupuncturist is not making a medical diagnosis of your medical condition; if you want to obtain a medical
diagnosis, contact a licensed Medical Doctor.
I understand that acupuncture involves placing sterilized, one-time use, disposable needles through the skin,
which can produce a mild, but temporary discomfort, at the acupuncture site. It can occasionally cause slight
bleeding and rarely leaves a bruise. Other possible risks from acupuncture include dizziness and fainting or
light-headedness. I will report to my Acupuncturist if I feel any of the aforementioned symptoms during or
after an acupuncture treatment. Extremely rare risk of acupuncture includes nerve damage, organ puncture
and infection.
My Acupuncturist may use liniments (herbal ointments), gua sha (muscle scraping technique), cupping
(myofacial release), moxa (heat therapy), and electro-stimulation and Chinese herbs, as appropriate to
treatment.
By signing below, I show that:
 I have read and understand the possible risks and complications involved in treatment. I have had the
opportunity to discuss this consent form with my Licensed Acupuncturist. I understand I can request
more information at any time, if desired.
 I consent to receiving treatment that involves the above procedures.
 I understand that I have the right to refuse or discontinue treatment at any time.
Patient or Guardian’s Signature__________________________Date_________
Practitioner’s Signature_________________________________Date_________