<p>Acupuncture Intake Form</p><p>Name Age Birth Date Address City Postal Code Phone (home) (cell) OK to leave a message? Y/N Email address Occupation Employer Marital Status: Single / Married / Com Law / Divorced / Separated Number of Children Emergency Contact Relation Phone How did you find out about me? </p><p>Your Current Health What is your main reason for coming in today? List in order of importance other health problems that are troubling you. 1 Since when? 2 Since when? 3 Since when? 4 Since when? 5 Since when? What kind of conventional treatment have you received for any of the above?</p><p>Please rate the state of your health? Excellent Good Average Fair Poor Score you current level of energy from 1 – 10 (10 being the highest) One year ago what would you rate your energy out of 10? What is your current weight? 1 year ago? Ideal weight Height What did you have yesterday for? Breakfast: Lunch: Supper: 1 | P a g e Snacks including drinks: Amount of Water: How much water on average do you drink? </p><p>Which of the following do you currently use? Alcohol /week Tobacco /week Coffee/tea /week Cortisones /week Laxatives /week Sedatives /week Antacids /week Recreational drugs (which ones) /week</p><p>Medications (please give name, dose and amount of time on med) Med Dose since when? Med Dose since when? Med Dose since when? Med Dose since when? Med Dose since when? Med Dose since when? </p><p>Supplements/Vitamins/Herbs Name/brand Name/brand Name/brand Name/brand Name/brand Name/brand </p><p>List the most significant /stressful events in your life. Event Date Event Date Event Date Event Date Event Date </p><p>Do you feel that any of these are impacting your life /health/ happiness? Yes/No Are you currently working with a professional counselor, psychologist, social worker, pastor or therapist? Yes / No 2 | P a g e Have you in the past? Yes / No When? What are your main interests or hobbies? What is the greatest source of stress in your life? You live with? Spouse___partner_____parents_____friends_____children____Alone Are you currently in a happy supportive relationship? Very Mostly Somewhat Not Do you like your work? Y/N Do you take vacation? Y/N</p><p>Ailments Past and Present Mark an N if you have the ailment now and/or mark a P if you have had it in the past.</p><p>Allergies Weight Problems Cancer Headaches Asthma Gallstones Epilepsy Alopecia Eczema Gout Migraine Varicose Veins Psoriasis Arthritis Pneumonia Broken Bones Ear Infection Thyroid Problems Diabetes Numbness Strep Throat Anemia Malaria Tingling Hay Fever High Blood Pressure Tuberculosis Cold Hands Measles Rheumatic Fever Small Pox Cold Feet Mumps Fainting Polio Visual Problems Chicken Pox Poor Memory Parasites Warts Whooping Cough Balance Problems Gas/Bloating Mono Diphtheria Speech Problems Hemorrhoids Depression Scarlet Fever Ringing in ears Herpes Anxiety Sinusitis Jaundice Venereal Disease Sexual Abuse Canker Hepatitis Syphilis Emotional Abuse Acne Alcoholism Gonorrhea Rape Tonsillitis Stroke Miscarriage Child Abuse</p><p>What do you feel is your weakest organ system and why? Are there any of these you feel you have never been well since? Do you have any allergies to any drugs, herbs, foods, animals or other? Yes / No</p><p>Digestion Do you (burp have gas feel uncomfortable) after eating Yes/No How often do you experience this problem? Always / Sometimes / Never How long have you had this problem? How often do you have bowel movements? Is there (blood mucus undigested foods black stools)? 3 | P a g e Are your stools (formed or loose )? Any diarrhea? Ever have alternating constipation and diarrhea? Yes / No How often? </p><p>More Health History Do you exercise? Y/N If yes how often? Do you have a religious or spiritual practice? Yes / No On a scale of 1- 10 how would you rate the quality of your sleep? (10 being great) Are you usually cool warm hot average (Circle one). How many times per year do you get a cold or a flu? Have you ever been hospitalized? Yes / No What For? Have you had surgery? What For? When was the last time you were on an antibiotic? What For? </p><p>Female Age of first menses? If periods have stopped at what age did they stop? Are your cycles regular? Y/N Periods begin every days and lasts days Are your periods Heavy Medium Light What color is the blood? Are there any clots? Y/N Any cramps with your period? Yes / No Do you have any spotting or bleeding between periods? Every month? Y/N Do you have premenstrual symptoms? Y/N Water retention Breast tenderness Irritability Depression Bloating Crying Acne Mood swings Sleep Problems Food Cravings Headaches Anger Other: </p><p>Number of pregnancies Number of abortions Number of miscarriages Number of live births Any problems getting pregnant? Do you get regular PAP smears? YES/ NO Any abnormal PAP’s YES/NO Do you do regular self breast exams? Y/N Have you noticed any breast lumps? Y/N</p><p>Male Any problems with impotency? (Getting or maintaining an erection) YES/NO Any prostate problems? Y/N Have had your prostate examined? Y/N When? </p><p>Kidney and Bladder How often do you get up in the night to urinate? Has this increased recently? Y/N Have you ever had a bladder infections? Y/N How Many? How was it treated? Do you experience a burning sensation during /after urinating? Past Present Now Your urine is …..bright yellow dark yellow cloudy pale or clear strong odor Do you have difficulty stopping or starting urination? Yes/No Do you sweat? (profusely moderate little very little) 4 | P a g e Informed Consent- Jenna Roze des Ordons, R. Ac</p><p>I hereby request and consent to the performance of Acupuncture treatments and other Traditional Chinese Medicine procedures on me (or on the patient named below, for which I am legally responsible) by Jenna Roze des Ordons, R. Ac. I understand that methods or treatments may include, but are not limited to, Acupuncture, moxibustion, cupping, massage, gua sha, herbal medicine, nutritional counselling, non-insertive acu point stimulation, and/or magnets. Acupuncture is a traditional method of treatment and when combined with TCM, is a complete system of medicine. I have been informed that Acupuncture is a safe and enjoyable method of treatment. However, occasionally there may be bruising, tingling, light bleeding and or pain at the needle insertion site. Some people may experience nausea or fainting. There have been very rare instances reported of infection, pneumothorax and scarring. Bruising after cupping or gua sha is normal. I wish to rely on the Acupuncturist to exercise judgment during the course of the procedure, which is in my best interests. ______initials I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its consent, and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. ______initials I agree to pay all charges incurred for services rendered. I agree to pay a $25 fee for any missed or forgotten appointments without 24‐ hour notice of cancellation. ______initials By signing below, I agree to the above‐ named procedures.</p><p>Patients Full Name (printed) </p><p>______Signature Date</p><p>Thank you for taking the time to fill out this questionnaire. I assure you it will help me to improve your health.</p><p>5 | P a g e</p>