Chandra Hood M



Ancient Peony Acupuncture —Confidential Intake FormDate:Patient InformationName: Gender: Age: Date of Birth: Home Address: Home Phone:Cell:Work Phone:Email:Emergency Contact:Relationship to Patient:Emergency Contact Phone number:Primary Care Physician (PCP):PCP Phone: Date of last medical examination:Occupation:Experience with AcupunctureHave you received acupuncture treatment before? YES NO If yes, for what conditions and what was the outcome?Description of Major ComplaintsWhat are your main complaints?Primary Complaint: Secondary Complaint: Please describe your goals, hopes and expectation for your acupuncture treatment PRIMARY COMPLAINT: Briefly explain history of your Primary Complaint, i.e. how long have you had this condition; was the onset SUDDEN or GRADUAL; was there a significant event that lead to this condition? Have you seen a physician for your Primary Complaint? If yes, when and what diagnosis did you receive?Other Care: what other therapies are you doing/ have you done to manage your Primary Complaint, e.g. physical therapy, medication, chiropractic, etc.? Did these/ are these other therapies helping? SECONDARY COMPLAINT: Briefly explain history of your Secondary Complaint, i.e. how long have you had this condition; was the onset SUDDEN or GRADUAL; was there a significant event that lead to this condition? Have you seen a physician for your Secondary Complaint? If yes, when and what diagnosis did you receive?Other Care: what other therapies are you doing/ have you done to manage your Secondary Complaint, e.g. physical therapy, medication, chiropractic, etc.? Did these/ are these other therapies helping? On the diagram, please shade in the areas where you feel symptoms associated with your complaints. PLEASE NUMBER THE COMPLAINTS (Primary Complaint = #1; Secondary Complaint = #2): Medications, Supplements and herbsPlease list all medications, (prescriptions and over-the-counter drugs) supplements and/or herbs you are CURRENTLY taking: Medications, supplements, or herbs: Indication/For treatment of:1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 9. 9. 10. 10. LIST ANY ALLERGIES (to medications, supplements, herbs): Personal Medical HistoryBirth: Describe anything significant/traumatic about your birth:Vaccination History: Any unusual reaction? Any unusual vaccination?Childhood Illnesses (0-12 years): Any surgery, accidents & /or major illnesses? Please list in chronological order and indicate duration of illnesses.Age: Age: Age: Adolescence Illnesses (13-17 years): Any surgery, accidents & /or major illnesses? Please list in chronological order and indicate duration of illnesses.Age: Age: Age: Adulthood Illnesses (18 – 35 years): Any surgery, accidents & /or major illnesses? Please list in chronological order and indicate duration of illnesses.Age: Age: Age: Adulthood Illnesses (36 & up): Any surgery, accidents & /or major illnesses? Please list in chronological order and indicate duration of illnesses.Age: Age: Age: Age: Family Medical HistoryPlease note all major illnesses in your close family, e.g. diabetes, heart disease, hypertension, neurological disorders, psychological disorders, blood disorders, cancer, high cholesterol, etc.MotherFatherSiblingsMaternal GrandparentsPaternal GrandparentsSymptom Overview BY System Please check all symptoms that you are CURRENTLY experiencing AND/OR experience FREQUENTLY. A = Acute (under 3 months)C = Chronic (over 3 months—experience at some point most days)F = Experience frequently (on & off) Musculoskeletal FORMCHECKBOX ACFJoint clicking FORMCHECKBOX ACFLimitation of movement FORMCHECKBOX ACFStiffness FORMCHECKBOX ACFSpasms or cramps FORMCHECKBOX ACFSwelling FORMCHECKBOX ACFWeakness FORMCHECKBOX ACFPain: Full body FORMCHECKBOX ACFPain: Facial (e.g. jaw) FORMCHECKBOX ACFPain: Neck FORMCHECKBOX ACFPain: Upper Back FORMCHECKBOX ACFPain: Mid Back FORMCHECKBOX ACFPain: Low Back FORMCHECKBOX ACFPain: Shoulder FORMCHECKBOX ACFPain: Elbow FORMCHECKBOX ACFPain: Wrist FORMCHECKBOX ACFPain: Hand FORMCHECKBOX ACFPain: Hip FORMCHECKBOX ACFPain: Knee FORMCHECKBOX ACFPain: Ankle FORMCHECKBOX ACFPain: Foot FORMCHECKBOX ACFOTHER (Please list)Eyes, Ears, Nose & Throat FORMCHECKBOX ACFLoss of vision FORMCHECKBOX ACFEye pain FORMCHECKBOX ACFTearing or eye dryness FORMCHECKBOX ACFEye discharge FORMCHECKBOX ACFEye redness FORMCHECKBOX ACFEar discharge FORMCHECKBOX ACFEar itching FORMCHECKBOX ACFEar pain &/or infections FORMCHECKBOX ACFLoss of hearing FORMCHECKBOX ACFRinging or buzzing in ears FORMCHECKBOX ACFProblems with balance (vertigo) FORMCHECKBOX ACFOlfaction (sense of smell) impaired FORMCHECKBOX ACFNose obstruction (stuffiness) FORMCHECKBOX ACFNose bleeds FORMCHECKBOX ACFSinus pain, pressure &/or infections FORMCHECKBOX ACFOTHER (Please list)Respiratory FORMCHECKBOX ACFChest pain &/or tightness FORMCHECKBOX ACFBluish discoloration of skin FORMCHECKBOX ACFCough FORMCHECKBOX ACFCoughing up blood (hemoptysis) FORMCHECKBOX ACFShortness of breath (dypsnea) FORMCHECKBOX ACFSore throat FORMCHECKBOX ACFSputum production FORMCHECKBOX ACFVoice changes FORMCHECKBOX ACFWheezing FORMCHECKBOX ACFOTHER (Please list)Cardiovascular FORMCHECKBOX ACFChanges in skin temperature & color FORMCHECKBOX ACFChest pain &/or pressure FORMCHECKBOX ACFEdema FORMCHECKBOX ACFFainting (syncope) FORMCHECKBOX ACFFatigue FORMCHECKBOX ACFPalpitations FORMCHECKBOX ACFSkin ulceration FORMCHECKBOX ACFSwelling of the ankles &/or legs FORMCHECKBOX ACFOTHER (Please list)Digestive FORMCHECKBOX ACFAbdominal distention/bloating FORMCHECKBOX ACFAbdominal mass FORMCHECKBOX ACFAbdominal pain FORMCHECKBOX ACFAcid regurgitation &/or Heartburn FORMCHECKBOX ACFAlternating constipation/diarrhea FORMCHECKBOX ACFRectal bleeding FORMCHECKBOX ACFConstipation FORMCHECKBOX ACFDiarrhea FORMCHECKBOX ACFGas FORMCHECKBOX ACFEating disorder FORMCHECKBOX ACFIndigestion FORMCHECKBOX ACFJaundice (yellow tint to skin &/or eyes) FORMCHECKBOX ACFNausea FORMCHECKBOX ACFVomiting FORMCHECKBOX ACFOTHER (Please list))Urogenital FORMCHECKBOX ACFDifficulty with urine flow FORMCHECKBOX ACFIncontinence FORMCHECKBOX ACFPainful urination (dysurea) FORMCHECKBOX ACFRashes FORMCHECKBOX ACFRed urine FORMCHECKBOX ACFUrinary tract infection (UTI) FORMCHECKBOX ACFOTHER (Please list)Neurological FORMCHECKBOX ACF Changes in consciousness FORMCHECKBOX ACF Confusion FORMCHECKBOX ACF Difficulty concentrating FORMCHECKBOX ACF Dizziness FORMCHECKBOX ACF Dysphasia (impaired ability to speak) FORMCHECKBOX ACF Gait disturbance FORMCHECKBOX ACF Headache FORMCHECKBOX ACF Numbness and/or tingling FORMCHECKBOX ACF Loss of consciousness FORMCHECKBOX ACF Paralysis FORMCHECKBOX ACF Post shingles pain FORMCHECKBOX ACF Problems coordinating movements FORMCHECKBOX ACF Severe forgetfulness FORMCHECKBOX ACF Tremor FORMCHECKBOX ACF Visual disturbance FORMCHECKBOX ACF Weakness FORMCHECKBOX ACF OTHER (Please list)Integumentary (Skin) FORMCHECKBOX ACF Changes in hair FORMCHECKBOX ACF Changes in nails FORMCHECKBOX ACF Changes in skin color FORMCHECKBOX ACF Itching (prurites) FORMCHECKBOX ACF Never sweat FORMCHECKBOX ACF Rash and/or skin lesion FORMCHECKBOX ACF Unusual sweating FORMCHECKBOX ACF Wounds that will NOT heal FORMCHECKBOX ACF OTHER (Please list)Psychological FORMCHECKBOX ACF Feelings of grief FORMCHECKBOX ACF Feeling of sadness FORMCHECKBOX ACF Feeling fearful/anxious/nervous FORMCHECKBOX ACF Difficulty managing anger FORMCHECKBOX ACF Feeling manic FORMCHECKBOX ACF Feeling worried or overly pensive FORMCHECKBOX ACF Feelings of panic FORMCHECKBOX ACF Feeling overwhelmed FORMCHECKBOX ACF Extreme mood swings FORMCHECKBOX ACF Extreme lack of emotion FORMCHECKBOX ACF OTHER (Please list)Sleep FORMCHECKBOX ACF Difficulty falling asleep FORMCHECKBOX ACF Dream disturbed sleep FORMCHECKBOX ACF Wake up & cannot fall back asleep FORMCHECKBOX ACFOTHER (Please list)Miscellaneous FORMCHECKBOX ACFExtremely low energy/fatigue FORMCHECKBOX ACFOTHER (Please list)FOR WOMEN ONLY FORMCHECKBOX ACFAbnormal vaginal bleeding FORMCHECKBOX ACFChanges in hair distribution FORMCHECKBOX ACFFertility concerns FORMCHECKBOX ACFIrregular menstruation FORMCHECKBOX ACFMenopausal symptoms FORMCHECKBOX ACFNo menses FORMCHECKBOX ACFPain with menses (dysmenorrhea) FORMCHECKBOX ACFPain during or after sexual relations FORMCHECKBOX ACFPelvic pain FORMCHECKBOX ACFPremenstrual symptoms FORMCHECKBOX ACFSexual dysfunction FORMCHECKBOX ACFUnusual discharge FORMCHECKBOX ACFOTHER (Please list)Are you pregnant OR trying to become pregnant? YES NO Have you ever been pregnant? YES NO If yes, how many pregnancies: # Births # Miscarriages # Abortions FOR MEN ONLY FORMCHECKBOX ACFFertility concerns FORMCHECKBOX ACFProstate problems FORMCHECKBOX ACFSexual dysfunction FORMCHECKBOX ACFUnusual discharge FORMCHECKBOX ACFOTHER (Please list)VII.MEDICAL DISEASES/CONDITIONS. Please check all that apply AND indicate (by circling) if it is current or if you had the problem in the past, but is now resolved.C = Current conditionP = Past condition, but is now resolved. FORMCHECKBOX CPAIDS/HIV FORMCHECKBOX CPAlcoholism &/or substance addiction FORMCHECKBOX CPAllergies (If yes, pls indicate diagnosis & history) FORMCHECKBOX CPAnemia FORMCHECKBOX CPAsthma FORMCHECKBOX CPBell’s Palsy FORMCHECKBOX CPBlood clotting disorder (If yes, pls indicate diagnosis & history) FORMCHECKBOX CPBipolar disorder FORMCHECKBOX CPCancer (If yes, pls indicate diagnosis & history) FORMCHECKBOX CPChron’s Disease &/or colitis FORMCHECKBOX CPChronic Fatigue Syndrome (CFIDS) FORMCHECKBOX CPDepression (Major) FORMCHECKBOX CPDiabetes FORMCHECKBOX CPEczema FORMCHECKBOX CPEndometriosis FORMCHECKBOX CPFibroids FORMCHECKBOX CPInfertility FORMCHECKBOX CPLung disease, e.g. COPD (If yes, pls indicatediagnosis & history) FORMCHECKBOX CPFibromyalgia FORMCHECKBOX CPGallstones FORMCHECKBOX CPHeart disease (If yes, pls indicate diagnosis &history) FORMCHECKBOX CPHepatitis A / B / C FORMCHECKBOX CPHernia FORMCHECKBOX CPHerpes FORMCHECKBOX CPHypertension FORMCHECKBOX CPHypoglycemia FORMCHECKBOX CPIrritable Bowel Syndrome (IBS) FORMCHECKBOX CPJoint Replacement (If yes, pls indicatediagnosis & history) FORMCHECKBOX CPKidney Stones and/or Disease (If yes, plsindicate diagnosis & history) FORMCHECKBOX CPLupus FORMCHECKBOX CPLyme Disease FORMCHECKBOX CPLymph node removal FORMCHECKBOX CPMitral valve prolapse FORMCHECKBOX CPMood Disorder FORMCHECKBOX CPMononucleosus FORMCHECKBOX CPMultiple Sclerosis FORMCHECKBOX CPOrgan removal or transplant (If yes, plsindicate diagnosis & history) FORMCHECKBOX CPOsteoarthritis FORMCHECKBOX CPOsteoporosis FORMCHECKBOX CPPacemaker (heart or stomach) FORMCHECKBOX CPParkinson’s Disease FORMCHECKBOX CPPelvic Inflammatory Disease FORMCHECKBOX CPPolio FORMCHECKBOX CPPsoriasis FORMCHECKBOX CPPTSD (Post-Traumatic Stress Disorder) FORMCHECKBOX CPReflux esophagistis (GERD) FORMCHECKBOX CPRheumatic fever FORMCHECKBOX CPRheumatoid arthritis FORMCHECKBOX CPScarlet Fever FORMCHECKBOX CPSchizophrenia FORMCHECKBOX CPScoliosis FORMCHECKBOX CPSeizures and /or epilepsy FORMCHECKBOX CPShingles FORMCHECKBOX CPSleep Disorder FORMCHECKBOX CPStroke FORMCHECKBOX CPSchizophrenia FORMCHECKBOX CPThyroid disease (If yes, pls indicate diagnosis& history) FORMCHECKBOX CPUlcer FORMCHECKBOX CPTrigeminal Neuralgia FORMCHECKBOX CPTuberculosis FORMCHECKBOX CPVascular disease (e.g. phlebitis) (If yes, plsindicate diagnosis & history) FORMCHECKBOX CPOTHER (pls list)Lifestyle Information Stress, Energy Level & SleepDo you think that stress, including recent major life changes, is contributing to your main complaints and/or negatively impacting any other aspect of your physical or mental health? If yes, briefly describe:Do you have any problems with your energy level? If yes, please briefly describe:Do you have any problems with sleep? If yes, please briefly describe: Do you have any problems with your sexual drive? If yes, please briefly describe:Smoking, Alcohol & DrugsDo you smoke tobacco? YES NO If yes, do you believe that this is a problem for you?Do you drink alcohol? YES NO If yes, do you believe that this is a problem for you?Do you use recreational drugs and/or prescription medications that your physician does not know about? YES NO Do you believe that this is a problem for you?Diet and NutritionIf applicable, briefly describe any problems you think you have with your eating habits and appetite. Do you believe that your diet has any impact on your complaints? YES NOAre you concerned about your weight and/or appetite (under or overweight, too much or too little appetite)? YES NOAnything else you wish to bring to my attention: ................
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