Intakeformpage1kl.doc.docx - Thrive Acupuncture of Utah



Patient HistoryThrive Acupuncture of UtahName:___________Date:________________Age: ___ Birthdate:______ Sex: Phone:_______________________________________Address: ______________________________________________________________________________Occupation: ______________________Years:___________Who referred you to this office? ______________________Main Reason for This Visit:__________________Known Diagnoses or Health Problems:Personal Health Goals:______________________________Previous/Present Doctor:_________________Past Medical History (Please list or describe): Year/Date Year/DateOperations or surgery: Head Injury:_________________ Hospitalizations:_________________ _________________ _________________Accidents: Serious Illnesses:_________________ _________________ _________________Broken Bones: Other:______________________Medications, Allergies, and SensitivitiesPlease list any medications or drugs, and any foods or other substances to which you are allergic:_________________________________________List all medications you are taking (including over theList any vitamin, herb, or counter meds and birth control pills – past or current): supplements you are taking: Name:Frequency: dailyName: Frequency: Health HabitsCheck yes or no and circle day or week:Tobacco smoking? Yes? No packs per day/weektype of tobaccoCoffee? Yes? No cups per day/week? Reg? DecafTea? Yes? No cups per day/week? Reg? HerbalAlcohol? Yes? No per day/week? Wine? Beer? LiquorSoft drinks? Yes? No drinks per day/week? Regular? DietArtificial Sweeteners? Yes? No packs per day/weekGlasses water/fluid per day plain water juice other What exercises/activities do you do and how often? How many hours of sleep do you get per night?Is it restful?_____________Do you have an adequate energy level?_____________________Mark the stress level in your life (0 is the least, 10 is the most): How much does stress affect you (0 is the least, 10 is the most)?What are the major stresses in your life presently?How many hours per week do you work? How many hours per week do you have for free time?___________Favorite pastime/recreational activity: Have you ever had any of the following? Please indicate “C” for current and “P” for past:GENERAL___Fever, chills, sweats ___ Snoring___ Burning or painful urination___ Night sweats___ Sore throats___ Blood in urine___ Fatigue___ Hoarseness___ Straining to urinate___ Nervousness/anxiety___ Tooth & gum problems___ Hernia___ Irritability___ Loss of taste___ Sexually transmitted disease___ Depression___ Sores in mouth___ Kidney stones___ Generally feel “run down”___ Sore tongue___ Kidney infections___ Sexual abuse (optional)RESPIRATORYFEMALE___ Emotional abuse (optional)___ Frequent “colds”___ Last menstrual period_9/4_date___ Loss of weight___ Difficulty breathing___ Currently pregnantSKIN___ Chronic or frequent cough___ Age periods started___ Non-healing sore___ Asthma or wheezing___ Duration of flow ___ days___ Hives, rash___ Emphysema___ Days in cycle _______ days___ Eczema, psoriasis___ Spitting up blood___ Pelvic pain or infection___ Frequent infection or boils___ Pleurisy (pain with breathing)___ Excess discharge___ Abnormal pigmentations, moles___ Pneumonia___ Excess discharge___ Warts___ Coughing up sputum___ PMS___ Herpes:CARDIOVASCULAR___ Menstrual cramping___ lips___ High blood pressure___ Irregular cycle___ genital___ Palpitation, irregular heart beat ___ Number of pregnancies___ zoster (shingles)___ Rheumatic fever___ Number of children___ Skin cancer or melanoma___ Chest pain or angina___ Number of ectopic pregnancies___ Brittle or weak nails___ Shortness of breath with walking___ Number of miscarriages___ Infected nails___ Shortness of breath lying down___ Number of abortionsENDOCRINE___ Difficulty walking two blocks___ DES exposure___ Diabetes___ Heart trouble___ Uterine fibroids___ Thyroid disease___ Heart attack___ Hysterectomy___ Heat or cold intolerance___ Heart murmur___ Date of menopause _________ Dry skin___ Awakening in the night smothering__ Hot flashes___ Change in hair growth or texture___ Swelling of hands, feet, or ankles___ Menopausal bleeding___ Excessive thirst or urination___ Need more than one pillow to sleep__ Breast pain___ Sexual problems___ Pain in calves with walking relieved by rest__ Breast lumps___ Hormone therapy___ Varicose veins___ Nipple discharge or bleeding___ Low or high sex driveHEMATOLOGIC___ Abnormal PAP smear___ Radiation to neck or face area___ Excessive bleeding/bruisingMALE___ Low blood sugar___ Anemia___ Testicular pain/swellingHEAD-EYES-EARS-NOSE-THROAT___ Phlebitis/blood clots in veins___ Urinary frequency or burning ___ Headache___ Are you slow to heal after___ Difficulty in starting stream of urine___ sinus (allergy)cuts or bruising?___ Discharge from penis___ tension___ Difficulty with bleeding excessively___ Frequent night urination___ migraineafter tooth extraction or surgery___ Prostate pain/swelling___ Head feels “heavy”___ Mononucleosis___ Undescended testicle___ Loss of memoryGASTROINTESTINAL___ Impotence___ Light-headedness or “spaciness”___ Painful bowel movementLOCOMOTOR-MUSCULOSKELETAL___ Light bothers eyes___ Vomiting blood or food___ Joint swelling___ Eye disease or injury___ Heartburn/indigestion___ Arthritis or joint pain___ Blurry vision___ Food sticks in throat___ Weakness of muscles or joints___ Double vision___ Difficulty swallowing___ Back pain (see next page)___ Loss of vision___ Diarrhea or loose stools___ Difficulty walking___ Glaucoma, cataracts___ Ulcer (stomach or duodenal)___ Leg cramps___ Loss of balance___ Gallbladder disease or stones___ Leg ulcers___ Dizziness or vertigo___ Liver trouble/hepatitis MENTAL EMOTIONAL/NEUROLOGIC___ Loss of hearing___ Bloody or black stools___ Fainting spells___ Ear disease___ Constipation___ Epilepsy/Seizures___ Impaired hearing___ “Nervous” stomach___ Stroke or mini-stroke___ Ringing/buzzing in ears___ Nausea and/or vomiting___ Paralysis___ Ear pain___ Bloating in stomach after eating___ Weakness of an arm or leg___ Discharge from ear___ Bloating or gas in lower abdomen___ Insomnia or trouble sleeping___ Runny nose or nasal discharge___ Thin or ribbon like stoolsTendency towards:___ Nosebleeds___ Hard or difficult bowel movements___ Sadness/grief/depression___ Chronic sinus troubleGENITOURINARY___ Anger/irritability___ Frequent urination___ Anxiety/fear___ Involuntary loss of urine___ Mental overactivityNECKLOW BACKHIPS, LEGS, AND FEET___ Pain___ Low back pain___ Pain in buttocks (R/L)___ Neck pain with movement___ upper lumbar___ pain in hip joint (R/L)___ forward___ lower lumbar___ pain down leg (R/L) ___ backward___ Sacroiliac pain___ Pain down both legs___ turning to the left___ Low back pain is worse when___ Knee pain (R/L)___ turning to the right___ working___ Leg cramps (R/L)___ bending to the left___ lifting___ Cramps in feet (R/L)___ bending to the right___ stooping___ Pins & needles in legs (R/L)___ Pinched nerve in neck___ standing___ Numbness of leg (R/L)___ Neck feels out of place___ sitting___ Numbness of feet (R/L)___ Muscle spasms in neck___ bending___ Numbness of toes (R/L)___ Grinding sounds in neck___ coughing___ Feet feel cold (R/L)___ Popping sounds in neck___ lying down (sleeping)___ Swollen ankles (R/L)___ Arthritis in neck___ walking___ Swollen feet (R/L)___ Swollen glands___ other___ Pain relieved withTHERAPEUTIC TECHNIQUESSHOULDERS___ ice___ Acupuncture___ Pain in shoulder joint (R/L)___ heat___ Herbal Medicine___Pain across shoulders___movement___ Homeopathy/Bach Flower___ Bursitis (R/L)___ physical therapy___ Nutrition___ Arthritis (R/L)___ topical analgesics___ Rolfing/Structural___ Can’t raise arm___ medications integration___ above shoulder level___ other___ Massage___ over head___ Slipped disk___ Chiropractic___ Can’t put arm behind back___ Low back feels out of place___ Psychotherapy (Optional)(as if putting on a bra)___ Muscle Spasms___ Visualization/Guided ___ Tension in shouldersimagery___ Pinched nerve in shoulder (R/L)___ Biofeedback___ Muscle spasms in shoulders___ Movement Therapy___ Physical TherapyARMS AND HANDS___ Reiki___ Pain in upper arm (R/L)___ Craniosacral Therapy___ Pain in elbow (R/L)___ Therapeutic Exercise___ Movement aggravates pain___ Other ______________ Pain in forearm (R/L)___ Pain in hands (R/L)___ Pain in fingers (R/L)___ Feeling of pins & needles in arms (R/L)___ Feeling of pins & needles in fingers (R/L)___ Numbness in arms (R/L)___ Numbness in fingers (R/L)___ Fingers go to sleep (R/L)___ Hands cold (R/L)___ Swollen joints in fingers (R/L)___ Arthritis in fingers (R/L)___ Loss of grip strength (R/L)MID-BACK & CHEST___ Mid-back pain___ Pain between shoulder blades___ Sharp stabbing pain___ Dull ache___ Pain from front to back___ Muscle spasms in mid back___ Pain in kidney area___ Chest pain___ Shortness of breath___ Pain around ribs ................
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