New Patient Health History (Male) Confidential

New Patient Health History (Male) Confidential SLO Family Acupuncture 2066 Chorro St  San Luis Obispo, CA 93401 (805) 242-6852  www.slofamilyacupuncture.com

Name ______Date ______

Address______City/State/Zip ______

Phone: H) ______W) ______C) ______

Email ______Occupation______

Emergency Contact: Name ______Phone ______

Whom may we thank for your referral? ______

Sex: Male Female Height ______Weight ______Date of Birth ______Age ____

Relationship: Married Committed Relationship Divorced Widowed Single

Please take a moment to answer the following questions:

Have you had acupuncture before? Yes No When/With Whom? ______

What are your particular goals for this acupuncture session? ______

______

Additional Health Concerns: ______

______

How would you describe your current state of health? ______

What makes you feel better? ______

What makes you feel worse? ______

When do you last remember feeling really great? ______

Are you currently under the care of any of the following medical professionals?

Medical Doctor Chiropractor Personal Trainer  Nutritionist  Acupuncturist  Massage Therapist  Psychiatrist  Naturopath  Physical Therapist

Who is your Primary Care Doctor? ______New Patient Health History (Male) Confidential

Please mark on the figures below where you are experiencing any discomfort, pain, or tension.

Please check any that apply:

Musculoskeletal System Stones Sinusitis Arthritis UTI Frequent Cold/ Flu Artificial Joints Bursitis Immune System Joint Pain Cancer Integumentary System (Skin) Muscular Dystrophy Fibromyalgia Burns Osteoporosis Diabetes Dermatitis Plantar Fascitis Tendonitis Edema Eczema Whiplash HIV/AIDS Fungal Infections Impetigo Carpal Tunnel Lupus Scars Syndrome Lymphoma Rash Chronic Fatigue Syndrome Digestive System Circulatory System Acid Reflux Nervous System Alzheimer’sAtherosclerosis Thrombosis Diarrhea Headaches Heart Attack Constipation Migraines Stroke Ulcers Multiple Sclerosis Parkinson’sVaricose Veins Food Allergies Disease Seizures Poor Circulation Gall Stones Sleep Disorders Shingles High Blood Pressure Hepatitis Spinal Cord Injury Low Blood Pressure Recent change in appetite Respiratory System Emotional System Asthma Depression Urinary System Allergies Anxiety Frequent Urination Kidney Bronchitis Grief New Patient Health History (Male) Confidential Anger Other ______

Date of last prostate check up ______PSA results ______Manual prostate exam results ______Lab results ______Frequency of urinations: daytime______nighttime______Pain with urination? ______Color of urine: clear murky dark yellow other ______Any odor? ______Please circle any that apply: Dribbling urination Retention of urine Decreased libido Impotence Premature ejaculation Testicular pain Delayed stream Incontinence Rectal dysfunction Back pain Other ______STD/STI’s: Gonorrhea Syphilis AIDS Herpes Chlamydia Date(s) ______

Please list any accidents, surgeries, or hospitalizations (include approx date) ______

Please list any medications, vitamins, and herbs, with dosages, that you are currently taking and the reason why you are taking them: ______

Do you have any known allergies? ______

Please indicate frequency of the following:

Water ______Coffee ______Soda ______Tobacco ______Alcohol ______Drugs ______Exercise: Type ______How often? ______

Family History of Disease:  Cancer  Stroke  Heart Disease  Emotional Disorders  Diabetes  Seizures  High Blood Pressure  Other: ______ Unknown

Thank you for taking the time to complete this intake form. I look forward to working with you. New Patient Health History (Male) Confidential –Carla Nerelli, L.Ac