Let’s work together.Interested in working together? Fill out some info and we will be in touch shortly! We can't wait to hear from you! Name * First Name Last Name Email * Phone (###) ### #### Sex Female Male Date of birth * MM DD YYYY Age SS Occupation Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * Emergency Contact Number * Country (###) ### #### Marital Status Single Long-term relationship Married Divorced Widowed Number of children Physician Name Chiropractor Name Do you have health insurance? Yes No Name of Insurance Company Does your insurance cover acupunture? Yes No Have you been treated by acupuncture before? Yes No If other or referral, please specify Main Problems: What would you like us to help you with? When did this problem begin? What are the precipitating factors? Have you been given a diagnosis? If so, what? To what extent does this problem interfere with your daily activities (work, sleep, sex etc)? What makes this problem worse? What makes this problem better? Is there anyone in your family with similar problems? Remarks and additional information Past medical history Cancer Diabetes Hepatitis Thyroid Disease Seizures Fibromialgia Arthritis Tuberculosis Hypertension Emotional Imbalance Anemia Breathing Problems Heart Disease Digestive Disorders HIV/ AIDS Positive Veneral Disease Other Please specify month/ year when diagnosis was established, and specify 'other' Have you had any surgeries? If so, what and when? Have you ever had any hospitalizations? If so, what and when? Have you ever experienced any significant physical trauma (auto accidents, sports injuries etc)? If so, what and when? Please list any allergies Family medical history Cancer Diabetes Hepatitis Hypertension Heart Disease Stroke Asthma Alcoholism Miscarriage Other Please specify family medical history e.g. family member, specify disease/ condition. Medicines taken within the last 2 months including vitamins, OTC drugs, herbs etc and their dosages. Work location Indoors Outdoors *Bonus* - I experience occupational stress (chemical, physical, psychological) Height Weight now Weight one year ago Maximum weight including when you weighed this Do you smoke? Yes No If 'Yes', what do you smoke, how many per day and since when? Do you use any drugs for non-medical purposes? If so, what? What are your exercising habits? How many hours do you sleep in general? When do you usually go to bed? Hour Minute Second AM PM How many cups of coffee do you drink per day? How many cups of soda do you drink per day? How many cups of tea do you drink per day? How many cups of water do you drink per day? What is your average number of alcoholic drinks per week? What alcoholic beverages do you usually drink? Are you a vegetarian? Yes No Yes, but not strict Checkbox Option 1 Option 2 Do you eat a lot of spicy food? Yes No Please describe your average daily diet Please specify morning, afternoon, evening and snacks Any other remarks or information regarding diet? What are the areas of the body that are distressed or painful? Please check any symptoms/ conditions you have experienced in the last 3 months Poor appetite Poor sleeping Fatigue Fevers Chills Night sweats Swaet easily Tremors Cravings Change in appetite Poor balance Bleed or bruise easily Lacalized weakness Weight loss Weight gain Peculiar tastes Desire hot food Desire cold food Strong thirst (hot or cold drinks) Sudden energy drops What time of day do you experience these symptoms? What is your favorite time of year? What is your least favorite time of year? Skin and hair: Which of these symptoms have you experienced in the past 3 months? Rashes Ulcerations Hives Itching Eczema Pimples Dandruff Dry skin Recent moles Loss of hair Purpura Change in hair or skin textures Other Musculoskeletal: Which of these symptoms have you experienced in the past 3 months? Joint disorders Weakness muscles Pain/ soreness in muscles Tremors Difficulty walking Cold hands/ feet Swelling of hands/ feet Back pain Spinal curvature Hernia Numbness Tingling Paralysis Neck tightness Neck pain Shoulder pain Hand/ wrist pain Hip pain Knee pain Sprain of joint Other Head, eyes, ears, nose and throat: Which of these symptoms have you experienced in the past 3 months? Dizziness Concussions Migraines Glasses/ lens Eye strain Eye pain Color blindness Night blindness Poor vision Cataracts Blurry vision Earaches Ringing in ears Poor hearing Spots in front of eyes Sinus problems Nose bleeding Sore throat Grinding teeth Teeth problems Facial pain Jaw clicks Sores on lips/ tongues Difficulty swallowing Other Cardiovascular: Which of these symptoms have you experienced in the past 3 months? High blood pressure Low blood pressure Chest pain Palpitations Fainting Phlebitis Irregular heartbeat Rapid hearbeat Varicose veins Other Respiratory: Which of these symptoms have you experienced in the past 3 months? Cough Coughing blood Wheezing Difficulty in breathing Bronchitis Pneumonia Chest pain Production of phlegm Neuro-psychological: Which of these symptoms have you experienced in the past 3 months? Loss of balance Lack of coordination Concussion Depression Anxiety Stress Bad temper Bi-polar Genito-urinary: Which of these symptoms have you experienced in the past 3 months? Pain with urination Frequent urination Blood in urine Urge to urinate Kidney stones Unable to hold urine Dribbling Pause of flow Frequent urinary tract infection Pain in genital Itching of genital Other If you answered 'other' in any of the above, please explain Please include the category. Gastrointestinal: Which of the following symptoms have you experienced in the past 3 months? Nausea Vomiting Diarrhea Constipation Gas Belching Black stools Blood in stools Indigestion Bad breath Rectal pain Hemorrhoids Abdominal pain/ cramps Gallbladder problems Parasites Chronic laxative use Describe your recent stools Frequency, color, odor, texture/ form Women's Health: Which of the following symptoms have you experienced in the past 3 months? Frequent vaginal infections Pelvic infections Endemetriosis Vaginal/ genital discharge Fibroids Ovarian cysts Irregular periods Clots Pain/ cramps prior or during periods Breast tenderness Breast lumps Fertility problems Hot flashes Moodiness related to periods Number of pregnancies Number of births Number of miscarriages Number of premature births Number of cesareans Number of difficult delivery births Please supply details about your period, including date of your last period (first day), age of first menses, duration of periods and amount of cycle days. What birth control, if any, do you use? Please give details of type and how long you have been on this birth control. Men's Health: Which of the following symptoms have you experienced in the past 3 months? Prostate problems Discharge Impotence Frequent seminal emission Fertility problems Ejaculation problems Painful/ swollen testicles Other If you selected 'other', please give more details. I understand the above information and guarantee this form was completed correctly and to the best of my knowledge I am an adult patient and I agree I am the parent or guardian of a patient and I agree I am the legal carer of the patient and I agree Thank you!