Sarasota Family Acupuncture: Intake Form



PERSONAL INFORMATION:Name ___________________________________________ Date ________________________Address ______________________________ City _______________ State _____ Zip _________Phone _________________________ Email _________________________________________Occupation ____________________________ Employer ________________________________In Case Of Emergency, whom should we notify? ________________________ Phone ______________How did you hear about our office? ___________________________________________________Primary Care Physician _____________________________ Urologist _______________________Have you been given a medical diagnosis for your condition? __________________________________Marital Status: Single Married Separated Divorced Widowed PartneredPartner’s Name ______________________ Partner’s Age _____ Occupation ___________________Is your Partner under the care of our clinic? Yes No Years Trying to Conceive? __________Do you have any biological children? Yes No How many? ________ Age(s) _________Major Health Concerns/ Symptoms1. __________________________________2. _________________________________3. _________________________________4. _________________________________MEDICAL INFORMATION:Have you had a semen analysis? Yes No If Yes, when was the most recent analysis? _____________DateSemenVolumepHSperm ConcentrationTotal Sperm NumberTotal MotilityVitalitySperm MorphologyAbnormal Leukocytes/ Viscosity/ Liquefaction: ___________________________________________Have you had any of the following Exams or Procedures?Exam/ ProcedureYesNoNotesSperm Chromatin Structure Assay (SCSA)Sperm Aspiration (MESA/ TESA/ PESA)Anti-Sperm Antibodies (ASA)VasectomyVasectomy ReversalProstate ExamIVF with ICSIHistory of sexually transmitted disease(s) (STD): __________________________________________Genetic or chromosomal abnormalities/ translocations: _____________________________________ ____________________________________________________________________________Current supplements and/ or medications: __________________________________________________________________________________________________________________________Do you exercise regularly? Yes No If yes, what form of exercise? __________________________Do you have any of the following symptoms, either currently or in the past?SymptomYesNoNotesIrritable Bowel Syndrome (IBS) or Crohn’sSwelling of the testicles/ scrotumSensation of heat in the testiclesDifficulty ejaculatingRetrograde EjaculationErectile Dysfunction (ED)Testicular/ Scrotal itchingDifficulty urinatingTesticular PainCloudy UrinationHypospadiasHypertensionProstatitisImpotenceVaricoceleEpididymitisHerniaMedical Conditions & History: Please check any conditions you have or have had in the past. Heart Disease Asthma Mental Illness Kidney Disease Meningitis Epilepsy Paralysis Lung Disease Gonorrhea Allergies Stroke Pneumonia Measles HIV High Fever Cancer Chlamydia Liver Disease High Cholesterol Glaucoma Vein Condition Tuberculosis Mumps Chicken Pox Polio Hepatitis Migraines Kidney Disease Rheumatic Fever Thyroid Disorder Emphysema Bleeding/ Hemorrhage Nervous Disorder Auto Immune Disease Hypertension DiabetesBody Temperature (Kidney Function)Cold Hands Cold Feet Sweaty Palms Sweaty Feet Hot body temperature Cold body temperature Afternoon flushing Hot flashes Profuse sweating Lack of perspiration Perspire easily Night sweating Strong thirst Lack of thirst Night time urinationEnergy & Stamina (Lung & Kidney System) Easily fatigued Shortness of breath Lethargy Sweating Prone to Illness Wheezing AllergiesFrequent Colds/ Sinus Blood Function (Liver, Heart & Spleen System) Dizziness Poor Night Vision Floaters in eyes Tingling in extremities Poor Memory Difficulty Concentrating Itchy or Dry Eyes Tinnitus Fainting Blurry Vision Weak or Brittle NailsHeart Function Heart Palpitations Anxiety Mental Restlessness Chest Pain Hemophilia Manic Moods Restless Dreams Insomnia Arrhythmia Rapid Heart Beat Forgetfulness Hallucinations Depression High Blood Pressure Heart Murmur Tongue Ulcers Speech Impediment Severe Shyness Low Blood Pressure Mitral Valve ProlapseLung Function Persistent Cough Nosebleeds Sinus Congestion Chronic Allergies Nasal Dryness Sore Throats Dry or Flaky Skin Sneezing Wheezing Headaches Difficulty Breathing Cigarette SmokingSpleen Function Low or Weak Appetite Abrupt Weight Gain Abrupt Weight Loss Abdominal Bloating Gas Strong Food Cravings Gurgling in Intestines Fatigue After Meal Bruise Easily Hemorrhoids Hypoglycemia IndigestionStomach Function Stomachache Acid Reflux Ravenous Appetite Bad Breath Bleeding Gums Heartburn Stomach Ulcer Belching Hiccups Nausea Vomiting Mouth UlcersBowel Function & Elimination (Intestinal Function) Loose Stool Diarrhea Incomplete Stools Constipation Blood in Stools Mucus in Stools IBS or Colitis Small, dry, hard stools Less than 1 BM/ Day Crohn’s Disease Eating DisorderAccumulated Dampness Mental Fogginess Mental Sluggishness Poor Mental Focus Heaviness in Head Heaviness in Limbs Heaviness in Whole Body Swollen Hands Swollen Feet Joint Stiffness/ Ache Symptoms worsen in rainy weather Edema in Legs Edema in Abdomen Chest CongestionLiver & Gallbladder Function Chest Pain Chest Tightness All Over Body Tension Muscle Spasms Seizures Alternating Diarrhea & Constipation Irritability Easy to Anger Easily Frustrated Convulsions Numbness/ Tingling Lump in Throat Easily Overwhelmed Depression Pain in Ribcage Chronic Neck Tension Shoulder Tension Ringing in Ears Skin Rashes Acne Headaches Migraines GallstonesEyes (Liver Function) Itchy Eyes Dry Eyes Watery Eyes Grittiness in Eyes Poor Night Vision Red & Irritated Eyes Bloodshot Eyes Seeing Spots Near Sighted Far Sighted Astigmatism GlaucomaKidney Function Frequent Cavities Broken/ Loose Teeth Weak Bones Ringing in Ears Weak Knees Knee Soreness Low Back Pain Prostate Problems Cold Lower Back Cold Hips/ Buttocks Cold Knees Incontinence Hair Loss Early Graying of Hair Hearing Loss Quick to Fear/ FrightUrinary Bladder Function Normal Color Dark Yellow Clear Color Reddish Color Cloudy Strong Odor Dribbling Difficulty Initiating the Stream of Urination Small Amount Large Amount Very Frequent Weak Stream Night-time Urination UTI/ Pain or burning HesitancyLibido Function Normal Pain with Ejaculation High Sex Drive Fatigue Following Sexual Activity Diminished Sex Drive Infertility Diabetic Erectile Dysfunction Erectile DysfunctionFERTILITY STRESS MANAGEMENTManaging stress effectively is an essential component of healthy reproduction. The more effectively stress is managed, the more your body and mind become relaxed, receptive and fertile.Is your job stressful? Yes No In what area(s) of your life do you feel the most stressed? Circle ALL that apply: Fertility Process - Job/ CareerPartner/ Spouse Relationship - Parents/ Family - Financial - Friends - Other(s) __________________How would you rate your current stress level? (1 being the least, 10 being the highest) 1 2 3 4 5 6 7 8 9 10MEDICAL EVALUATION:I was evaluated by a Physician, OB/GYN, or Reproductive Endocrinologist for the condition(s) being treated within the last 12 months. Yes NoPermission to maintain medical privacy and share medical information.All of the information that you provide is strictly confidential. It is our policy never to disclose any personal or medical information about any patients under our care without first obtaining your express permission to do so. Many of our patients are under the care of an OB/GYN, a Reproductive Endocrinologist, or a Fertility Specialist. In an effort to maximize your clinical results, we may want to contact your Doctor(s) and send them periodic updates about your case and your progress. Do you grant your permission for us to discuss the details of your case with your OB/GYN, Reproductive Endocrinologist, and/ or Fertility Specialist? Yes No________________________________________________ ________________________ Patient Signature DateInformed Consent to Eastern Medical HealthcareI hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or the patient named below, for whom I am legally responsible) by the acupuncturist(s) employed by Sarasota Family Acupuncture.I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs.I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (phnumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment.I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in some doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant.By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.I also understand that Sarasota Family Acupuncture requires a minimum of 24 hour notice for an appointment change or cancellation. A $35.oo service fee will be charged for any missed appointments._____________________________ ____________________________ ______________ Patient’s Name (Printed)Patient’s SignatureDateIf under 18 years old:________________________________ ____________________________________Print Name of Patient’s Representative Relationship or Authority of Patient’s Rep_________________________________ _____________________Signature of Patient’s Rep Date ................
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