Acupuncture New Patient Information

437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822

ACUPUNCTURE NEW PATIENT INFORMATION

Please complete this document as thoroughly as possible. Some of the questions that follow may seem unrelated to your condition, but may play a major role in assessment and treatment. All information shared is confidential. PERSONAL INFORMATION

Patient Name: Last______Date______First______Middle______Gender M / F If patient is a minor, parent/guardian name ______Age______Date of Birth ______Address______City______State______Zip______Phone: Home______Cell______Email address______Emergency contact______Phone______Relationship______

EMPLOYMENT INFORMATION

___Full-time ___Part-time ___Self-employed ___Unemployed ___Retired ___Student Occupation______

BILLING & INSURANCE Payment is due in full at the time services are rendered. Fees are for initial visit and for return visits (additional fees may apply for specialty treatments and other services). MISSED APPOINTMENT POLICY To change or cancel appointments, please provide 24 hours’ notice to avoid incurring a cancelation fee.

CONFIDENTIALITY Your patient records and information will be kept confidential and shared only when necessary to provide care and service, by your authorization, or when required or permitted by law. The office is HIPPA compliant.

HEALTH HISTORY

Acupuncture New Patient Registration (REV 11/18/16) Page 1 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822 Please describe your main health concern(s) ______When/how did the condition(s) occur? Give dates if possible ______What treatments have you been using for the relief of the condition(s) ______To what extent does this problem interfere with your daily activities (work, sleep, sex, ect.) ______Have you had an acupuncture treatment before? Y / N If so, for what reason? ______Are you presently being treated for any (other) medical condition? Y / N Please describe ______

Please list all major illnesses/ injuries/ surgeries /hospitalizations Year Illness/ Injury/Surgery/Hospitalization Hospital Name City and State

MEDICATIONS Mark an “X” next to any medication you are now taking or have taken in the past 3 months Aspirin/Tylenol/Advil/Motrin (Ibuprophen/Acetaminophen/NSAIDs) Allergy/Antihistamines Cold Medication Pain Medications Antacids Diabetic Medication (Insulin) Psychiatric Medication Antibiotics/Antifungal Diet Pills Sleeping Pills/Tranquilizers Antidepressants Fiber/Laxatives Thyroid Medication Blood Pressure Medication Heart Medication Ulcer Medication Blood Thinners Cholesterol Medication Oral Contraceptives Hormones Other ______

Please list all other medications, you use. Include those you only use occasionally. Remember inhalers, eye drops, nose sprays, and topical creams, etc. ______Vitamins/Supplements/Herbs/Homeopathic remedies: (please list) ______

ALLERGIES Please list any allergies you have to medications, foods or other substances______

______

HABITS Please mark any habits that apply to you now or in the past.

Acupuncture New Patient Registration (REV 11/18/16) Page 2 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822 Age Habits Yes No Amount Started Age Quit ______day/wk/m Coffee/Caffeinated Drinks o ______day/wk/m Tobacco o ______day/wk/m Alcohol o ______day/wk/m Marijuana o ______day/wk/m Other Drugs o

Please list any self-destructive lifestyle habits (e.g. smoking, lack of exercise, insufficient sleep, addictions, poor diet, etc.) ______

DIET Please describe the type of foods you eat regularly

Breakfast ______

Morning Snack ______

Lunch ______

Afternoon Snack ______

Dinner ______

Evening Snack ______Are you on a restricted diet? Y / N Please describe ______Do you eat when you are worried, stressed, rushed, or not hungry? Y / N Are you tired /lethargic after meals? Y / N

EXERCISE Do you follow a regular exercise program? Y / N Please describe ______

______

SLEEP / ENERGY Do you sleep well? Y / N Please describe ______How many hours per night do you sleep? ______Do you wake rested? Y / N Describe your energy level on a scale of 1-10 (highest) ______Time of day when energy is highest ______Time of day when energy is lowest ______

Acupuncture New Patient Registration (REV 11/18/16) Page 3 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822

FAMILY MEDICAL HISTORY Complete for each family member by marking an “X” in the appropriate box Brothe Self Mother Father Sister r Spouse Child Allergies Asthma/Wheezing Blood Disorder/Anemia Diabetes Cancer or Tumors Seizures High Blood Pressure Heart Disease Stroke Kidney/Bladder Disorder Stomach/Intestinal Disorder Liver Disorder Immune Disorder Drug/Alcohol Use or Abuse Tuberculosis thyroid Disorder Depression/Mental Illness Other Age at Death

SYMPTOM CHECKLIST Mark any conditions that you are experiencing or those that you have had in the past

GENERAL Past Current Past Current ______Fatigue ______Changes in energy level ______Thirst ______Recent changes in weight ______Poor appetite ______Excessive hunger ______Fever ______Chills ______Sweats easily ______Night sweating ______Edema ______Insomnia ______Poor sleep ______Sleep too much ______Frequent dreams/nightmares ______Difficulty getting up in the morning ______Poor memory ______Confusion/forgetfulness ______Difficulty concentrating ______Localized weakness ______Poor coordination ______Congenital abnormalities ______Surgical implants ______High cholesterol levels

Acupuncture New Patient Registration (REV 11/18/16) Page 4 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822 ______Jaundice ______Other ______

HEAD/EYES/EARS Past Current Past Current ______Dizziness ______Fainting ______Neck stiffness ______Enlarged lymph glands ______Headaches/migraines ______Concussions ______Blurred vision ______Visual Changes ______Poor night vision ______Floaters (spots in visual field) ______Eye inflammation/styes ______Eye dryness ______Eye redness/itching ______Eye pain/strain ______Cataracts ______Glaucoma ______Corrective lenses ______Frequent ear infections ______Ringing: ___hi ___low pitch ______Hearing diminished/loss ______Other ______

SKIN/HAIR Past Current Past Current ______Changes in skin/hair ______Dandruff ______Hair loss/thinning ______Hives ______Rashes ______Itching ______Eczema ______Psoriasis ______Shingles ______Dryness/roughness/scaling skin ______Pimples/acne ______Tumors/lumps ______Changes in lumps/moles ______Ulcerations ______Sores that don’t heal ______Bruise/bleed easily ______Other ______

NOSE/THROAT/MOUTH Past Current Past Current ______Frequent nose bleeds ______Sinus problems ______Snoring ______Dry nose/throat ______Changes in smell ______Allergies/hay fever ______Sore throat ______Hoarseness ______Changes in taste ______Changes in taste ______Metallic/bitter taste in mouth ______Bad breath ______Difficulty swallowing ______Grinding/clenching teeth ______Tooth problems ______Bleeding gums ______Sore/red or cracked tongue ______Oral ulcers/Canker sores ______Facial pain ______Jaw clicks (TMJ) ______Other ______

RESPIRATORY Past Current Past Current ______Asthma/wheezing ______Frequent colds ______Cough ______Bronchitis ______Coughing blood ______Production of phlegm ______Difficulty breathing ______General shortness of breath ______Short of breath with exertion ______Pneumonia ______COPD ______Other ______

CARDIOVASCULAR Past Current Past Current ______Cardiac Pacemaker ______High blood pressure ______Low blood pressure ______Heart disease

CARDIOVASCULAR (cont’d) ______Blood clots ______Stroke ______Palpitations ______Irregular heart beat ______Chest pain/pressure/tightness ______Jaw/neck/shoulder/arm pain ______Poor circulation ______Cold hands/feet ______Swelling of hands/feet ______Leg pain when walking ______Phlebitis ______Varicose veins/spider veins ______Other ______

NEUROLOGICAL Past Current Past Current ______Seizures ______Tremors ______Epilepsy or convulsions ______Numbness or tingling of limbs ______Paralysis ______Pain ______Neuralgia (nerve pain) ______Other ______

GASTRO-INTESTINAL Past Current Past Current ______Nausea ______Vomiting ______Pain or cramping ______Indigestion/heartburn/acid reflux ______Esophageal pain ______Ulcers ______Belching/gas ______Stomachache ______Abdominal bloating ______Irritable bowel syndrome ______Colitis ______Crohn’s disease ______Celiac disease ______Pancreatitis ______Gall bladder disorder ______Parasites ______Recent change in bowel habits ______Diarrhea ______Constipation ______Dry, hard stools ______Soft, difficult, sticky stools ______Irregularly or poorly formed stools ______Blood or mucus in stools ______Bowel incontinence ______Hemorrhoids/rectal pain ______Chronic laxative use ______Other ______

URINARY Past Current Past Current ______Kidney disease ______Kidney stones ______Frequent urine __day __night ______Urinary tract/bladder infections ______Painful/burning urination ______Blood in urine ______Weak urinary stream ______Urgency to urinate ______Change in bladder habits ______Unable to hold urine ______Urine has foul odor ______Abnormal color urine ______Other ______

PSYCHOLOGICAL/EMOTIONAL Past Current Past Current ______Treated for phych/emotions ______Depression ______Anxiety ______Anorexia/Bulimia

Acupuncture New Patient Registration (REV 11/18/16) Page 6 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822 ______Stress/mental tension ______Irritability ______Agitation ______Nervousness ______Mood swings ______Indecisiveness ______Worrying/excess thinking ______Anger ______Sadness/grief ______Frequently crying ______Fear ______Easily startled/frightened

PSYCHOLOGICAL/EMOTIONAL (cont’d) ______Thoughts of suicide ______Other ______

INFECTION HISTORY Past Current Past Current ______HIV/AIDS ______Tuberculosis (TB) ______Hepatitis ______Sexually transmitted disease history ______Gonorrhea ______Chlamydia ______Syphilis ______Genital warts ______Herpes genital/oral ______Chicken pox ______Meningitis ______Other ______

MALE Past Current Past Current ______Genital itching/pain ______Genital lesions/discharge ______Impotence ______Infertility (e.g., abnormal sperm) ______Premature ejaculation ______Prostate problems ______Testicular lumps ______Other ______

FEMALE Past Current Past Current ______Frequent vaginal infections ______Discomfort/dryness/itching at genitals ______Genital lesions ______Vaginal discharge ______Fertility issues ______Pelvic inflammation disease (PID) ______Endometriosis ______Fibroids ______Ovarian cycts ______Abnormal PAP smear ______Irregular periods ______Pain prior to or with menses ______Premenstrual syndrome (PMS) ______Emotional changes with menses ______Abnormal bleeding ______Menopausal symptoms (hot flashes, etc) ______Breast lumps ______Painful or swollen breasts ______Discharge from breasts ______Other ______

Age at onset of menses ______Date of most recent period (first day of) ______

Date of last PAP exam ______How many days is menstrual your cycle ______

How many days does your period usually last ______Age at menopause ______

Regularity: ____regular ____irregular ____ varies between early and late ____early by ___days ____usually late by ___days

Flow: ____light ____spotting ____moderate ____heavy ____even ____uneven

Consistency: ____thin____thick ____clots present

Color: ____pale pink ____light red ____bright red ____dark/deep red ____purplish ____brown

Number of: pregnancies____ deliveries____ miscarriages____ ectopic ____ induced abortions____

What form of birth control do you use, how long? ______Do you have reason to believe that you may be pregnant? Y / N How far along are you? ______

PLEASE INDICATE ANY PAINFUL OR DISTRESSED AREAS BY MARKING THE AREA BELOW WITH AN “X”

MUSCULOSKELETAL Past Current Past Current ______Joint disorder ______Head ______Hand ______Thigh ______Spinal curvature ______Jaw ______Fingers ______Knee ______Painful/sore/stiff muscles ______Neck ______Chest ______Calf ______Tendonitis ______Throat ______Rib/flank ______Shin ______Fibromyalgia ______Shoulder ______Abdomen ______Ankle ______Muscle weakness ______Upper arm ______Upper back ______Foot ______Muscle spasms/cramps ______Elbow ______Mid-back ______Heel ______Difficulty walking ______Forearm ______Low back ______Toes ______Hernia ______Wrist

Acupuncture New Patient Registration (REV 11/18/16) Page 8 of 9 437 NE Main St Estacada, OR 97023 (503) 630-4037 17500 Strauss Ave Sandy, OR 97055 (503) 668-5822 ______Hip ______Other______

I have read and understand the above information and have completed this form correctly to the best of my knowledge. Patient’s signature______Date______

Authorized Representative, relationship to patient______Thank you for taking the time to complete this form.

Acupuncture New Patient Registration (REV 11/18/16) Page 9 of 9