Patient Intake | One Body Acupuncture

Date*

PATIENT INFORMATION First Name*

PATIENT INFORMATION Last name

GENDER

Female

Male

PATIENT INFORMATION Address*

PATIENT INFORMATION City*

PATIENT INFORMATION State

PATIENT INFORMATION Zip Code*

PATIENT INFORMATION Your email*

PATIENT INFORMATION Occupation*

PATIENT INFORMATION Company Name

PATIENT INFORMATION Primary physician

PATIENT INFORMATION Physician phone number

PATIENT INFORMATION How did you hear about us*

CONTACT INFORMATION home phone

CONTACT INFORMATION work phone

CONTACT INFORMATION other phone

CONTACT INFORMATION Another person we may contact if needed: name

CONTACT INFORMATION Another person we may contact if needed: Relationship

CONTACT INFORMATION Another person we may contact if needed: Home phone

CONTACT INFORMATION Another person we may contact if needed: Work phone

INSURANCE Patient Subscriber ID

INSURANCE Patient Group Number

INSURANCE Relationship to Insured

Self

Spouse

Child

Other

INSURANCE Company Name

INSURANCE Company Phone

INSURANCE Claim Number if an accident

INSURANCE Claim date of accident or injury

Health History What is your primary concerns for coming in for treatment

Health History What is your secondary concern for coming in for treatment

Health History What is your third concern for coming in for treatment

For your primary concern: What is your Pain Level (0-10) Zero being no pain and 10 being maximum pain

For your secondary concern: What is your Pain Level (0-10) Zero being no pain and 10 being maximum pain

For your third concern: What is your Pain Level (0-10) Zero being no pain and 10 being maximum pain

Onset of Primary concern

Onset of Secondary concern

Onset of Third concern

Cause of Primary Concern/Injury and % of time present

Cause of Secondary Concern/Injury and % of time present

Cause of Third Concern/Injury and % of time present

How is your sleep

How is your digestion

Height

Weight

Hand Dominance

List medications or food supplements you are taking

List serious illnesses, accidents, or surgeries.

Check illnesses that have occurred in blood relatives.

Diabetes

Cancer

High blood pressure

Heart disease

Stroke

Kidney disease

Check symptoms you have or have had in the last year

Tremors

Cramps

Swollen joints

Multiple choiceCheck symptoms you have or have had in the last year

Depression

Difficulty in focusing

Dizziness

Easily Startled

Excessive worry

Excessive anger

Excessive fear

Frustration

Insomnia

Mental Fogginess

Anxiety/Nervousness

Fatigue

Frequent Sighing

Headaches - Top of head

Loss of sleep / poor sleep

Loss of weight

Gain of weight

Nervousness / irritability

Overwhelmed by life

Feel achy/heavy

Vivid Dreams/nightmares

Check conditions you have or have had in the past

Aids

Allergies

Anemia

Bleeding disorders

Breast lump

Cancer

Diabetes

Hepatitis

How long has it been since you have had a complete medical exam?

Arm

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Hips

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scar

Back

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Legs

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Feet

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Neck

Pain

weakness

numbess

tenderness

swelling

sharp and stabbing

dull and achy

scars

Hands

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Shoulder

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

Knees

pain

weakness

numbness

tenderness

swelling

sharp and stabbling

dull and achy

scars

Other

pain

weakness

numbness

tenderness

swelling

sharp and stabbling

dull and achy

scars

Head

pain

weakness

numbness

tenderness

swelling

sharp and stabbing

dull and achy

scars

HEALTH HISTORY EYES/EAR/NOSE/THROAT/RESPIRATORY

Asthma/wheezing

Blurred or failing vision

Difficulty breathing

Earache

Eye Pain

Frequent Colds

Hay fever

Easily catch colds

Dry eyes

Crave warm foods/drinks

Low resistance to cold/flu

Hoarseness

Gum trouble

Nose bleeds

Loss of Vision

Loss of hearing

Persistent cough

Ringing in ears hi

Ringing in ears low

Sinus problems

Prolonged illness recovery

Constant phlegm chest/throat

HEALTH HISTORY GASTROINTESTINAL

Belching, gas or bloating

Colon Trouble

Constipation

Diarrhea

Difficulty swallowing

Distention of abdomen

Excessive hunger

Bitter/metallic taste in mouth

Alternate Constipation/diarrhea

Gall bladder trouble

Hemorrhoids (piles)

Indigestion

Nausea

Pain over stomach

Poor appetite

Vomiting

Dry or hard stool

Diarrhea w/undigested food

Gas and Bloating

HEALTH HISTORY SKIN AND ENERGETICS

Boils

Bruises easily

Itching/rash

Sensitive skin

Night Sweats

Sweats easily

Sore won’t Heal

Dry skin

Pale Complexion

Dry skin, nails, hair

Feel Cold, chilly

Cold Feet

Edema/swelling

Heat in hands, feet and chest

Crave cold food and drinks

Tend to overwork

Low sexual appetite

Infertility

Water Retention

HEALTH HISTORY GENITO/URINARY

Blood/Pus in urine

Frequent urination

Inability to control urine

Urinary tract infections

Kidney infection / stones

Lowered libido

Gallstones

Urinary difficulty

HEALTH HISTORY CARDIOVASCULAR

Chest Pain

Hardening of arteries

High or low blood pressure

Pain over heart

Varicose veins

Palpitations

Poor circulation

Previous heart attack

Rapid / irregular heart bea

Swelling of ankles

Brittle nails and hair

HEALTH HISTORY FOR WOMEN ONLY

Bleeding between periods

Clots in menses

Excessive menstrual flow

Extreme menstrual pain

Irregular cycle

Could you be pregnant

Menopausal symptoms

PMS

Previous miscarriage

Scanty menstrual flow

Hot Flashes

HEALTH HISTORY FOR MEN ONLY

Erection difficulties

Penis discharge

Prostrate trouble

Which type(s) of treatment have been helpful to your conditions(s)

ICE

MOVEMENT

Rehab Exercise

HEAT

REST

PAIN MEDICATION

SUPPLEMENTS

SLEEP

Massage

CHINESE HERB

Other

Are you unable to carry on any activities you previously engaged due to your condition(s)/complaint (s)

Yes

No

If Yes activities ( 1 of 3):

If Yes activities ( 2 of 3):

If Yes activities ( 3 of 3):

List 3 activities or applicable functional outcome goals based on your current condition(s)/complaints (1 of 3).

Functional outcome goal/activity (2 of 3)

Functional outcome goal/activity (3 of 3)

HEALTH HISTORY BRIEFLY DESCRIBE WHAT CAUSED YOUR SYMPTOMS IN YOUR OWN WORDS. TELL ME HOW AND WHEN YOUR CONDITION PRESENTED

I - T (1 of 8) : Do you have recent blood work results

Yes

No

If Yes, any abnormal findings: Yes

If Yes, any abnormal findings: No

I - T (2 of 8) Are you taking Levothyroxine

Yes

No

I - T (3 of 8) Do you feel fatigue?

Yes

No

I - T (4 of 8) Do you feel temperature?

Cold

Hot

Alternating Hot and Cold

I - T (5 of 8) Do you have constipation?

Yes

No

I - T (6 of 8) Is Obesity a challenge for you?

Yes

No

I - T (7 of 8) Does your Blood Pressure run less than 120/80?

Yes

No

I - T (8 of 8) Do you feel exhausted?

Yes

No

II - A (1 of 2) Do you have slow or non-healing injuries or wounds?

Yes

No

II - A (1 of 2) Do you feel depressed?

Yes

No

III - St (1 of 11) Do you eat regularly?

Yes

No

III - St (2 of 11) Do you take supplements?

Yes

No

III - St (3 of 11) Are you concerned with autoimmune issues?

Yes

No

III - St (4 of 11) Is your bowel movement solid and well formed?

Yes

No

III - St (5 of 11) Number of bowel movements per day?

III - St (6 of 11)How often do you eat?

III - St (7 of 11) Color and frequency of urine?

III - St (8 of 11) Do you sweat easily?

Yes

No

III - St (9 of 11) Do you have a desire for food or drink?

Yes

No

III - St (10 of 11) Desired drink temperature?

Room Temperature

Hot

Cold

III - St (11 of 11) Do you have slow or non-healing injuries?

Yes

No

IV - I /T (1 of 5) Have you been chronically sick?

Yes

No

IV - I /T (2 of 5) Have you been diagnosed with an Autoimmune Disease?

Yes

No

IV - I /T (3 of 5) Do you have pain & inflammation?

Yes

No

IV - I /T (4 of 5) Have you been diagnosed with Heart Disease?

Option 1

Option 2

IV - I /T (5 of 5) Have you been diagnosed with Diabetes?

Yes

No

V - S (1 of 1) Do you have scars?

Yes

No

VI - D (1 of 5) Do you have mercury amalgam fillings?

Yes

No

VI - D (2 of 5) Do you have root canal treated teeth?

Yes

No

VI - D (3 of 5) Do you have wisdom tooth extractions?

Yes

No

VI - D (4 of 5) Do you have impacted teeth?

Yes

No

VI - D (5 of 5) Do you have trouble breathing?

Yes

No

VII - E (1 of 9) Do you have ear ringing?

Yes

No

VII - E (2 of 9) Do you have dizziness?

Yes

No

VII - E (3 of 9) Do you crave a specific flavor?

Yes

No

VII - E (4 of 9) If you crave a specific flavor, which flavor?

Sweet

Bitter

Sour

Salty

Pungent

VII - E (5 of 9) If you crave a specific food, what food?

VII - E (6 of 9) Do you have troubling falling asleep?

Yes

No

VII - E (7 of 9) Do you have troubling falling asleep

Yes

No

VII - E (8 of 9) What are your emotions today?

Joy

Grief

Worry

Anxiety

Irritability

Fear

Anger

Stress

VII - E (9 of 9) How many hours do you sleep?

GOALS for Your Care: People see an Acupuncturist for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

I want the Doctor to select the type of care appropriate for my condition.

Relief care: Symptomatic relief of pain or discomfort.

Corrective care: Correcting and relieving the cause of the problem as well as the symptom.

Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with Acupuncture care

AUTHORIZATION: I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of Acupuncture. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my checkbox as a signed statement of authorization with my signature provided in office for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

I agree with this statement of authorization

Patient Intake Form

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