Marguerite Shinouda, L



Marguerite Shinouda, L.Ac.

NYS License #867

8 Nepale Drive 437 New Paltz Road New Paltz, NY 12561 Highland, NY 12528 T: (845) 532-4005 F: (845) 255-8046

Today's Date:_________

Name: _____________________ Date of Birth:__________________

Address: ___________________ Home Phone: __________________

_______________________________ Daytime/Mobil Phone:___________

Emergency Contact: _________ Email Address: _________________

Insurance Info(if Applicable): Member #________________Claim #_________________

Member name and birthday if different from patient:________________________________________

Date of Accident:____________ Insurance Company’s phone number:_________________________

Referring Doctor’s name and phone #:____________________________________________________

How did you hear about our practice?____________________________

Main Concern: Secondary Concerns:

______________________________ ____________________________________

______________________________ ____________________________________

What Makes it Better? What Makes it Worse?

(rest/stretching, hot/cold, seasons morning/evening, foods?)

_______________________________ ____________________________________

Other Current Treatments: Medications:

_______________________________ ____________________________________

_______________________________ ____________________________________

Allergies: Supplements:

________________________________ ____________________________________

_______________________________ ____________________________________

1 Medical History

Major Accidents and Month/Year of Occurrence: _____________________

______________________________________________________________________

Surgeries and Month/Year of Occurrence: __________________________

______________________________________________________________________

Major Illnesses and Month/Year of Occurrence: ______________________

______________________________________________________________________

Family Tendencies (diabetes, heart disease, cancer, high blood pressure):

______________________________________________________________________

Frequent Exposures (cold & damp, chemicals, x-rays, etc): ___________________

______________________________________________________________________

Habits and Cravings (smoking, alcohol, sweets, etc)__________________________

______________________________________________________________________

Frequency and Type of Exercise:_______________________________________

______________________________________________________________________

Patient Intake Form

Please check all symptoms you have experienced within the last six months. If they do not apply, leave them blank. If you experience them frequently, check them twice. Some symptoms may be listed more than once, check them each time they occur.

Section 1: Bi Section3: Xue Section 5: Yin

My condition feels better… ___Pale face & nails ___Feverish in the afternoon

___with cold ___Blurry vision ___Night sweats

___with heat ___Palpitations ___Dry mouth

___with rest ___Numbness ___Dry throat

___with exercise ___Scanty menses ___Feverish palms & soles

___without pressure ___Short menstrual cycles ___Irritable

___with pressure ___Dizzy, lightheaded ___Insomnia

___in the morning ___Flushed cheeks

___through the day ___Localized sharp pain

___Lump, mass, or cyst Section 6: Jing

Section 2: Qi ___Painful menses ___Premature greying

___Easily fatigued ___Irregular menses ___Hair loss

___Shortness of breath ___Dark red spots ___Tooth loss

___Spontaneous sweating ___Infertility

___Dizziness(Lightheaded) ___Feverish ___Impotence

___Hard to project voice ___Irritable ___No sex drive

___Bleeding ___Memory loss

___Intermittent dull pain ___Red, painful skin eruptions

___Bloating/Fullness ___Heavy menses Section 7: JinYe

___Sighing ___Hoarse voice

___Stuck feeling in throat Section 4: Yang ___Dry mouth

___Repeated throat clearing ___Feverish ___Dry skin

___Pre-menstrual irritability ___Sweat easily ___Dull, dry hair

___Thirst ___Thirst

___Cough ___Constipation ___Dry stools

___Asthma ___Red Face ___Scanty urine

___Nausea ___Sore throat or mouth ___Dry eyes and nose

___Vomiting ___Dark, scanty urine

___Belching ___Irritable Section 8: Feng

___Hiccups ___Preference for cold drinks ___Sneezing

___Preference for no blankets ___Clear runny nose

___Hemorrhoids ___Prefer cold air ___Aversion to drafts

___Organ Prolapse(sinking) ___Head and body aches

___Chronic diarrhea ___Cold body ___Nasal congestion

___Bearing down sensation ___Cold limbs ___Chills & fever

___Low sex drive

___Chronically tired ___Spasms

___Desire to sleep a lot ___Tremors

___Retaining water ___Dizziness, vertigo

___Preference for warm drinks ___Stroke

___Always sleep with a blanket ___Bells palsy

___Prefer warm air ___Convulsions

Section 9: Shi Section 14: Pi Section 19: Wei

___Heavy feeling ___Low appetite ___Stomach ulcer

___Bloating & Swelling ___Diarrhea ___Stomach pain

___Nausea ___Abdominal bloating ___Acid regurgitation

___No thirst ___Nausea ___Nausea

___Milky discharge ___Bleed easily ___Vomiting

___Loose stools ___Bruise easily ___Swollen, painful gums

___Weight gain ___Organ prolapse ___Bad breath

___Frequent worrying ___Always hungry

Section 10: Tan

___Fullness in chest Section 15: Shen Section 20: UB

___Coughing up mucus ___Painful low back ___Painful, burning urination

___ Frequently clearing throat ___Weak low back ___Bladder stones

___Decreased appetite ___Painful knees ___Kidney stones

___Wheezing ___Weak knees ___Cloudy urine

___Dizziness ___Poor vision ___Bloody urine

___Poor hearing

Section11: Fei ___Incontinence

___Coughing ___Nocturnal emission

___Asthma ___Frequent urination

___Shortness of breath ___Sexual dysfunction

___Chest fullness ___Hair loss

___Chest pain ___Bone weakening

___Wake up between 3-5 am ___Infertility

___Sadness & Grief ___Poor memory

___Frequently fearful

Section 12: Xin

___Palpitations Section 16: LI

___Anxiety ___Constipation

___Insomnia ___Burning Anus, Rectum

___Vivid dreaming ___Hemorrhoids

___Chest pain

___Left arm pain Section 17: SI

___Tongue sores or ulcers ___Abdominal pain

___Hysteria ___Burning urination

___Forgetfullness ___Bearing down sensation in groin

Section 13: Gan Section 18: Dan

___Pain in ribs ___Right side trunk pain

___Pain in sides of trunk ___Jaundiced skin

___Frequent anger ___Bitter taste in mouth

___Frequent depression ___Alternating chills & fever

___Migraine headache ___Nausea

___Vertigo ___Vomiting bitter fluids

___Ringing in ears ___Easily frightened

___Red or painful eyes ___Indecisive

___Poor vision ___Insomnia

___Poor nail growth

Painful areas: Mark with xx's

Numb, tingling areas: Mark with oo's

Pulse: _____________________________________________

Tongue: ____________________________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download