New Patient Intake Form – Cumming Acupuncture

Patient's Name *

First

Last

Street Address *

Apt #

City *

State *

Date of Birth *

Zip Code *

Sex *

Male
Female

Height

Weight

Email *

Phone # *

First

Middle

Last

Can we leave a message, if you’re not available?

Y
N

Occupation:

Y
N

Marital Status:

EMERGENCY CONTACT:

Name

Relationship

Single Line Text

Phone #

How did you hear about us?

HEALTH HISTORY

On a scale of ‘1 to 10’, please rate the intensity of your chief complaint (0 – no discomfort, 10 = extreme discomfort)

On AVERAGE your complaint is

At WORST your complaint is

Frequency

Please check the box that best represents how frequent you feel your chief complaint(s)

Duration

When you are feeling your symptom, how long you your symptoms last?

(copy)

mins
hours
days
constant

What Aggravates or Alleviates your Chief Complaints?

First

Last

How are your health problems interfering with the following areas of your life?

Work

Family

Hobbies

Life

How have you taken care of your health in the past?

How did the previous methods work for you?

ARE YOU HERE VISITING US, BECAUSE YOU (please choose one):

1. Just want to get some relief from your symptoms, and them you’ll manage the rest with medications(s)
2. Want to Find and Correct the Root Cause of your Health problem(s), it possible, and Re-train your body to heal itself so that you can be less dependent on medications
3. Other

If you were to sit down and discuss your life 3 years from now and look back at today, what would have to happen for you to be happy with your progress?

(please take your time and don’t sell yourself short)

What potential barriers do you foresee that would prevent you from achieving your Health goals?

Rate on a scale of 1-10 (1 being lowest, 10 being highest)

How important is it for you to resolve your health concerns?

Are you prepared to make the appropriate lifestyle changes that may be necessary in order to achieve your goals?

Are you pregnant?

Yes
No

If yes, how far along?

Do you exercise:

Never
Daily
Weekly
Monthly

Explain

Do your work activities mostly involve:

Sitting (time:)
standing (time:)
Light labor
Heavy labor

What is your daily intake of the following:

Caffeine
Alcohol
Nicotine/tobacco

Illicit Drugs

Yes
No

Comments

Imaging & Tests

X-ray (s)

MRI (s)

CT (CAT Scan (s)

Ultrasound (s)

Cholesterol

Blood Sugar

Mammogram

PAP Smear

Blood Tests (Which)

Nerve Conduction

Please check to indicate if you have ever had any of the following:

Please list ALL health care providers (family, physicians, surgeons, specialists, chiropractors, etc.) currently treating you:

List ALL disorders you are CURRENTLY being treated for (include the dates of when you were diagnosed)

List ALL disorders you have had, or have been diagnosed with (include the dates of when you were diagnosed):

List ALL types of Surgeries you have had in the past (includes dates):

List ALL Accidents and/or hospitalizations you have had in the past (include dates):

List ALL Allergies (Food, Medications, Pollen, etc.):

List ALL Medicines (prescriptions & over-the-counter) you are CURRENTLY taking (include duration of use & Dosage):

List ALL Nutritional supplements, Herbs, or Vitamins, you are currently taking:

List all Medical conditions of your immediate family:

MOTHER

Age if living

If deceased, cause of death

Cancer (s)

Diabetes

Heart Disease

Stroke

Autoimmune Disorders

Mental Illness

Other

FATHER

Age if living

If deceased, cause of death

Cancer (s)

Diabetes

Heart Disease

Stroke

Autoimmune Disorders

Mental Illness

Other

BROTHERS

Age if living

If deceased, cause of death

Cancer (s)

Diabetes

Heart Disease

Stroke

Autoimmune Disorders

Mental Illness

Other

SISTERS

Age if living

If deceased, cause of death

Cancer (s)

Diabetes

Heart Disease

Stroke

Autoimmune Disorders

Mental Illness

Other

We find that when all of your healthcare providers are up to date with your treatment progress, it makes it easier for all of us to better help you improve your health. Is it okay if we contact the above healthcare providers to update them on the treatments you are receiving here?

Yes
No

IMPORTANT: Complete these documents as thoroughly as possible, please be honest with yourself. Some of the questions that follow may seem unrelated to your condition, BUT they may play a major role in diagnosis and treatment. All information is strictly confidential.

PAIN SENSATION

PAIN LOCATION

DIGESTION

BOWELS

Watery stool w/ undigested food
Borborygmus (rumbling noise in intestines)
Constipated / Difficult defecation
Frequent Bowel movements but in small quantity
Diarrhea w/ Foul Smell or spasms
Anus Burning, swelling, itching & pain
Diarrhea / Loose Stool
Constipated w/ dry stools

CARDIOVASCULAR

Palpitations / Heart Fluttering
Chest Pain
Edema / Fluid Retention in Lower Limbs

MENTAL ACUITY

Mental Confusion
Poor Memory
Lack of Concentration
Foggy Brain

PERSPIRATION

Absence of sweating
Frequent & Spontaneous Sweating
Night Sweats

IMMUNE SYSTEM / ENERGY

Frequent Common Colds / Infections
Fatigue, Low Energy
Low Libido

ORAL & UPPER RESPIRATORY HEALTH

RESPIRATORY SYSTEM

EMOTIONAL HEALTH

BODY TEMPERATURE

Cold hands & feet / Cold Body temp sensation
Hot flashes / Heat in hands, feet, chest / Hot Body temp sensation
Chills w/ low grade fever
Fever w/ sweating

EYE HEALTH

Blurred Vision / Decrease in vision / Night Blindness
Dry Eyes
Eyes are Red. Swollen, painful
Floaters

SKIN, HAIR, NAILS

URIUNATION

Frequent & Excessive clear urination
Scanty, dark, difficult urination, painful urination
Urinary Incontinence, dribbling after urination
Frequent, Urgent, painful urination
Sudden interruption to urine stream
Urine is dark, yellow, cloudy
Stones / Sand in urine
Blood in urine

SLEEP QUALITY

Waking at 2 or 3 am w/ difficulty falling back to sleep
Difficulty falling asleep
Dream disturbed sleep. Excessive dreaming, wake Frequently
Easily Awakened
Inability to stay asleep

NERVE HEALTH

MALE ORGAN

Premature Ejaculation / Involuntary discharge of Semen w/o Orgasm
Impotence (Inability to achieve erection)
Testicular pain w/ swelling & Burning sensation
Eczema in Scrotum

FEMALE ORGAN