THETIS MASSAGE THERAPY



Acupuncture Intake FormPlease complete this questionnaire carefully. The information you provide will assist in creating a complete health profile for you. All of your answers are strictly confidential. If you have any questions, please ask.Name (Last, First): Gender:DOB:Age:Relationship status: FORMCHECKBOX Single FORMCHECKBOX Common Law FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX Widowed FORMCHECKBOX OtherFull Address: Phone:Cell:Email Address:BC Care Card Number: Extended Medical Insurer: Occupation: Family/Referring Doctor:Doctor’s Phone: Emergency Contact:Relationship to You:Emergency Contact Phone:How did you hear about us?Have you had Acupuncture before?PERSONAL HEALTH HISTORYChildhood Illness: Measles Mumps Rubella Chickenpox Rheumatic Fever PolioMedical History: FORMCHECKBOX Asthma FORMCHECKBOX High / Low Blood Pressure FORMCHECKBOX Kidney Disease FORMCHECKBOX Arthritis FORMCHECKBOX Pacemaker FORMCHECKBOX Liver / Gall Bladder Disease FORMCHECKBOX Broken Bones FORMCHECKBOX Heart Disease FORMCHECKBOX Seizures FORMCHECKBOX Cancer FORMCHECKBOX Bleeding Disorder FORMCHECKBOX Stroke FORMCHECKBOX Colitis FORMCHECKBOX Hepatitis ____ FORMCHECKBOX Substance Abuse FORMCHECKBOX Diabetes FORMCHECKBOX Herpes / Shingles FORMCHECKBOX Thyroid Imbalance FORMCHECKBOX Gastritis FORMCHECKBOX High Cholesterol FORMCHECKBOX Tuberculosis FORMCHECKBOX Gout FORMCHECKBOX HIV / AIDS FORMCHECKBOX Bleeding DisorderCHIEF COMPLAINTSPlease indicate your chief concerns for your health:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you tried any other treatments or therapies for the above concerns and were they effective? Please explain.Have you been given a specific diagnosis by a health professional for the above? When? Surgeries / Trauma / Accidents (ex. car accident)YearPlease Explain: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medications / Pain Killers / Supplements / Vitamins / MineralsNameStrengthFrequency Taken FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AllergiesDrug / Environment / FoodReaction You Have/Had FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HEALTH HABITSDietAre you dieting or avoiding certain foods? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain:Do you have any problems with eating or appetite? Please explain.Caffeine FORMCHECKBOX None FORMCHECKBOX Coffee FORMCHECKBOX Tea FORMCHECKBOX Cola / Energy Drinks / Energy Pills# of cups/cans per day? Daily ActivityWhat do you do for daily exercise/activity (ex. walk the dog, running, ski, etc.)?AlcoholDo you drink alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, what kind? ___________________________________ How many drinks per week? _________________TobaccoDo you use tobacco or have used in the past? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Cigarettes – pks./day _____________________ FORMCHECKBOX Chew - #/day ______________ FORMCHECKBOX Pipe - #/day ____________ FORMCHECKBOX Cigars - #/day _____________ FORMCHECKBOX # of Years ___________ FORMCHECKBOX Or Year Quit __________DrugsDo you currently use recreational or street drugs? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever given yourself street drugs with a needle? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been treated for substance abuse? FORMCHECKBOX Yes FORMCHECKBOX NoAre you concerned with any of your answers to the above questions? FORMCHECKBOX Yes FORMCHECKBOX NoFAMILY HEALTH HISTORYAgeSignificant Health Problems (heart disease, cancer, Mental Illness, arthritis, etc.)FatherMotherGrandparent(M / F)Grandparent(M / F)Sibling (M / F)Sibling(M / F)MENTAL HEALTHIs stress a major problem for you? FORMCHECKBOX Yes FORMCHECKBOX NoPlease rate your stress level on a scale of 0 to 10 (0 = no stress; 10 = extreme stress) __________________Do you feel depressed or anxious? FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer panic attacks or heart palpitations when stressed? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever attempted suicide or intentionally hurt yourself? When? _________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever seriously thought about hurting yourself or anyone else? FORMCHECKBOX Yes FORMCHECKBOX NoHave you ever been to a counselor or therapist? FORMCHECKBOX Yes FORMCHECKBOX NoNeuro-Psychological (select all that apply) FORMCHECKBOX Seizures FORMCHECKBOX Lack of Concentration FORMCHECKBOX Poor Memory / Forgetfulness FORMCHECKBOX Tremors / Tics FORMCHECKBOX Depression FORMCHECKBOX Learning Disability FORMCHECKBOX Concussion History FORMCHECKBOX Seasonal Affective Disorder FORMCHECKBOX ADHD FORMCHECKBOX Numbness / Tingling FORMCHECKBOX Irritable / Bad Temper FORMCHECKBOX Bell’s Palsy / Trigeminal Neuralgia FORMCHECKBOX Lack of Coordination FORMCHECKBOX Mood Swings FORMCHECKBOX Other: FORMCHECKBOX Loss of Balance FORMCHECKBOX Abuse Survivor / PTSDsleepHow many hours of sleep do you get a night on average? ______________________Do you have trouble falling asleep? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have trouble staying asleep? FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel rested upon waking? FORMCHECKBOX Yes FORMCHECKBOX NoDo you feel tired during the day? FORMCHECKBOX Yes FORMCHECKBOX NoDo you suffer from nightmares or frequent dreaming while asleep? FORMCHECKBOX Yes FORMCHECKBOX Noreproductive health (as applicable)Age of first menses: _________ Menses every ______________ days Length of Menses: ________________Please circle ALL that apply with regards to your menses:Menstrual Flow: Heavy / Light / Irregular / Spotting / Clotted / With Mucous / Other: _____________________________________Color of Menstruate: Bright Red / Dark Red / Pale Red / Brown / Purple / Black / Other: ___________________________________PMS: Bloating / Headaches / Breast Tenderness / Abdominal Cramping / Upset Stomach / Food Cravings / Mood Swings / Discharge Do you experience pain before / during / or after your menses?Other (please explain):Number of Pregnancies: Live Births: Abortions: Miscarriages:Are you pregnant or breastfeeding? FORMCHECKBOX Yes FORMCHECKBOX NoHave you had a D&C, hysterectomy, or Cesarean? FORMCHECKBOX Yes FORMCHECKBOX NoAny hot flashes or sweating at night? FORMCHECKBOX Yes FORMCHECKBOX NoAny problems with vaginal discharge or vaginal dryness? FORMCHECKBOX Yes FORMCHECKBOX NoExperienced any recent breast tenderness, lumps, or nipple discharge? FORMCHECKBOX Yes FORMCHECKBOX NoPlease select all that apply. FORMCHECKBOX Pre Menopause FORMCHECKBOX Menopause FORMCHECKBOX Post Menopause FORMCHECKBOX Endometriosis FORMCHECKBOX PCOS FORMCHECKBOX Frequent Yeast Infections FORMCHECKBOX Fertility Problems FORMCHECKBOX Other:Do you experience any loss of interest in sex? FORMCHECKBOX Yes FORMCHECKBOX NoDo you or have you ever had a sexually transmitted infection? FORMCHECKBOX Yes FORMCHECKBOX NoAny difficulty with erection or ejaculation? FORMCHECKBOX Yes FORMCHECKBOX NoAny testicle pain or swelling? FORMCHECKBOX Yes FORMCHECKBOX NoAny problems with prostatitis? FORMCHECKBOX Yes FORMCHECKBOX NoDate of last prostate exam? ________________________________________________oTHER PROBLEMSCheck if you currently have, or have had, any symptoms in the following areas to a significant degree.General Health FORMCHECKBOX Sudden Changes in Energy Levels FORMCHECKBOX Muscle Weakness FORMCHECKBOX Poor or No Appetite FORMCHECKBOX Fatigue / Low Energy FORMCHECKBOX Sweat Easily FORMCHECKBOX Changes in Appetite FORMCHECKBOX Cravings _______________________ FORMCHECKBOX Night Sweats FORMCHECKBOX Body Generally Warm / Cold FORMCHECKBOX Weight Loss / Gain FORMCHECKBOX Easy to Bruise FORMCHECKBOX Poor Balance FORMCHECKBOX Frequent Colds and Flus FORMCHECKBOX Bleeding Disorder FORMCHECKBOX Hearing Loss Skin, Hair, & Nails FORMCHECKBOX Acne / Pimples FORMCHECKBOX Itchy Skin FORMCHECKBOX Moles / Skin Discoloration FORMCHECKBOX Dandruff / Dry Scalp FORMCHECKBOX Rashes / Hives FORMCHECKBOX Sensitive Skin FORMCHECKBOX Dry / Brittle Nails FORMCHECKBOX Eczema / Psoriasis FORMCHECKBOX Skin Ulcers FORMCHECKBOX Hair Loss FORMCHECKBOX Rosacea FORMCHECKBOX Warts FORMCHECKBOX Frequent Fungal Infections FORMCHECKBOX Other:head, ears, eyes, nose, & throat FORMCHECKBOX Headaches FORMCHECKBOX Cataracts FORMCHECKBOX Nose Bleeds FORMCHECKBOX Migraines FORMCHECKBOX Taste / Smell Problems FORMCHECKBOX Sinus Problems FORMCHECKBOX Concussions FORMCHECKBOX Poor Hearing FORMCHECKBOX TMJ Pain / Joint Problems FORMCHECKBOX Dizziness FORMCHECKBOX Ear Aches FORMCHECKBOX Facial Pain FORMCHECKBOX Blurry Vision FORMCHECKBOX Ear Ringing / Tinnitus FORMCHECKBOX Toothaches FORMCHECKBOX Floaters in Vision FORMCHECKBOX Difficulty Swallowing FORMCHECKBOX Recurrent Sore Throat FORMCHECKBOX Eye Strain / Eye Pain FORMCHECKBOX Thirst FORMCHECKBOX Lip / Mouth Sores FORMCHECKBOX Night Blindness FORMCHECKBOX Dry Mouth / Throat FORMCHECKBOX Other:cardiovascular FORMCHECKBOX High / Low Blood Pressure FORMCHECKBOX Stroke FORMCHECKBOX Cold Hands / Feet FORMCHECKBOX Chest Pain / Angina FORMCHECKBOX TIA History FORMCHECKBOX Swelling of Hands / Feet FORMCHECKBOX Irregular Heartbeat FORMCHECKBOX Pacemaker FORMCHECKBOX Fainting / Lightheaded FORMCHECKBOX Palpitations FORMCHECKBOX Blood Clots FORMCHECKBOX Shortness of Breath FORMCHECKBOX Heart Attack FORMCHECKBOX Spider Veins / Varicose Veins FORMCHECKBOX Other:respiratory FORMCHECKBOX Asthma FORMCHECKBOX COPD FORMCHECKBOX Easily Winded FORMCHECKBOX Bronchitis FORMCHECKBOX Emphysema FORMCHECKBOX Phlegm / Expectoration FORMCHECKBOX Cough FORMCHECKBOX Difficult / Painful Breathing FORMCHECKBOX Other Lung Condition: FORMCHECKBOX Cough with Blood FORMCHECKBOX Tight Sensation in ChestGastrointestinal FORMCHECKBOX Nausea FORMCHECKBOX Acid Reflux / Heartburn FORMCHECKBOX Rectal Pain FORMCHECKBOX Vomiting FORMCHECKBOX Constipation FORMCHECKBOX Blood in Stool FORMCHECKBOX Stomach Ulcers FORMCHECKBOX Diarrhea / Loose Stools FORMCHECKBOX Black Stools FORMCHECKBOX Bad Breath FORMCHECKBOX Abdominal Bloating / Gas FORMCHECKBOX Hemorrhoids FORMCHECKBOX Belching / Hiccups FORMCHECKBOX Abdominal Pain / Cramping FORMCHECKBOX Other: FORMCHECKBOX Indigestion FORMCHECKBOX Chronic Laxative UseHow many bowel movements do you have per day? ___________________ Per week? ____________________________Urology FORMCHECKBOX Nighttime Urination FORMCHECKBOX Incontinence FORMCHECKBOX Blood in Urine FORMCHECKBOX Frequent Urination FORMCHECKBOX Retention of Urine FORMCHECKBOX Copious Amount of Urine FORMCHECKBOX Painful / Burning Urination FORMCHECKBOX Difficult Urination FORMCHECKBOX Frequent Urinary Tract Infections FORMCHECKBOX Difficulty Emptying Bladder FORMCHECKBOX Urgency to Urinate FORMCHECKBOX Kidney Stones - When? ___________ FORMCHECKBOX Loss of Force of Urination FORMCHECKBOX Dribbling after Urination FORMCHECKBOX Other:Joint & Muscle conditions FORMCHECKBOX Neck Pain FORMCHECKBOX Carpal Tunnel FORMCHECKBOX Arthritis - Type: _________________ FORMCHECKBOX Shoulder Pain FORMCHECKBOX Back Pain – Upper / Mid / Lower FORMCHECKBOX Bursitis FORMCHECKBOX Elbow Pain FORMCHECKBOX Hip Pain FORMCHECKBOX Hypermobility FORMCHECKBOX Golfers’ / Tennis Elbow FORMCHECKBOX Knee Pain FORMCHECKBOX Sciatica FORMCHECKBOX Hand / Wrist Pain FORMCHECKBOX Foot / Ankle Pain FORMCHECKBOX Muscle CrampsAreas of concernPlease mark the painful areas on the diagrams below and record the type of discomfort you experience (i.e. numbness, tingling, stabbing, sharp, aching, throbbing, etc.). Rate the discomfort on a scale of 0 to 10 (0 = no pain; 10 = excruciating pain).Do changes in the weather make your problem areas better or worse?Does applying heat or cold make your problem area better or worse?What do you to try to alleviate your symptoms and does it help? ................
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