Emmajean Rombach, LAc., Dipl. OM, MsTCM, MsBio

413.551.9199

Please answer questions as completely as possible. The information you provide helps the acupuncturist understand your physical, mental, and emotional condition more completely in order to attain your health goal. All information is confidential. Thank you for your time!

PATIENT INFORMATION
NAME: ______DATE: ____/____/______
MALE FEMALE Date of Birth: ____/____/______Age: ____ Marital Status: Single Married Separated Divorced
Street Address: ______City: ______State: _____ Zip: ______
Telephone Home: ______Cell: ______Work: ______
Place of Employment: ______Occupation: ______
Email: ______
I give my permission to be contacted by phone or email for appointment reminders: YES NO
I would like to be added to the mailing list for coupons, announcements and to receive the monthly newsletter: YES NO
Emergency Contact Name: ______Phone Number: ______
Primary Health Provider Name: ______Phone Number: ______
How did you hear about us? ______

Chief Complaint: ______

When/How did this condition occur? ______

How does this affect your life? ______

What other treatments have you tried? ______

What makes the condition better? ______

What makes the condition worse? ______

Other Complaints:

2. ______3. ______

On a scale of 1-10, rate your commitment to getting rid of the problem(s) and feeling better ______

What are your goals for your acupuncture visits? ______

Have you had acupuncture before? ______

Do you have any concerns about having acupuncture? ______

PERSONAL HEALTH HISTORY

Please list any medical conditions and surgeries along with year diagnosed:

Year Condition/Surgery

______

______

______

______

Please list all prescription medications you use, including those that you may only use occasionally. Remember inhalers, eye drops, nose sprays. Attach additional sheet if necessary.

Medication/ Dosage Reason How Long Last Dose

______

______

______

______

______

Please list all vitamin and herbal supplements that you take:

Supplement/Dosage Reason How Long Last Dose

______

______

______

______

______

Please list any allergies to food, drugs, or medications or other environmental allergens: ______

______

Please list any occupational concerns (stress, computer work, chemical contact, heavy lifting, etc. ) ______

______

PAIN/MUSCULO-SKELETAL (Please mark problem areas on diagram):

Please check any of the following conditions that you currently have, or have had in the past:

Stomach Disorder ______Hiatal Hernia ______Heartburn/Acid Reflux ______Stomach Stapled ______

Heart Disease ______High Blood Pressure ______Stroke ______High Cholesterol ______

Cancer: Where? ______Diabetes ______Thyroid Disorder: Describe ______

Circle any organs that you have had removed: GALLBLADDER UTERUS OVARIES APPENDIX

THYROID TONSILS/ADENOIDS KIDNEY

Have you had or do you have a contagious illness that may require special procedures to protect our staff and others? (NOTE: circling will not necessarily prevent you from receiving acupuncture treatments)

HEPATITIS AIDS/HIV HERPES TUBERCULOSIS VENEREAL DISEASE

FAMILY HISTORY – Please Check all that apply

Diabetes Heart Issues Kidney Disease Stroke Cancer Thyroid Issues
Mother ______
Father ______
Sibling ______

HABITS:

____ Tobacco Use (How many daily) ____ Recreational Drugs ____ Alcohol Consumption (How much)

____ Soda Consumption ____ Caffeine (Coffee, Tea) ____ Stress Scale (1-10)

What are your main interests and hobbies? ______

Do you exercise? YES NO What type of activity and how frequently? ______

______

Do you sleep well? YES NO How many Hours? ______Awake Rested? YES NO

ENERGY LEVEL (Circle): LOW 1 2 3 4 5 6 7 8 9 10 HIGH Consistent throughout day? YES NO

DIET

Do you eat three meals per day? YES NO What times do you eat? ______

Do you have food cravings? ______Intolerances? ______

Please list foods typically eaten at the following meal times:

Breakfast ______

Lunch ______

Dinner ______

Snacks ______

Do you feel satisfied after you eat? YES NO Do you have an appetite in the morning? YES NO

How much water do you drink per day? ______

Describe your thirst: STRONG NORMAL NOT THIRSTY

Do you drink your fluids: HOT COLD/ICED ROOM TEMPERATURE

BODY TEMPERATURE – please check any that apply

____ Normal ____ Cold Entire Body ____ Cold Extremities

____ Hot all day ____ Hot only in Afternoon ____ Hot only at Night

____ Spontaneous Sweating ____ Hot Flush/Night Sweating ____ No/Minimal Sweating

MEN ONLY: - Please check any applicable condition

___ Impotence ___ Weak Erection ___ Premature Ejaculation ___ Testicular Pain/Lump

___ Low Sex Drive ___ Penile Discharge ___ Prostate Problems

WOMEN ONLY:

Age at First Period: ______Could you be pregnant now? YES NO

Number of pregnancies: ______Births: ______

Are you in menopause? YES NO Post-Menopausal Bleeding? YES NO

When did your last period end? ______# of days in monthly cycle? _____ # of days of flow ______

Describe menstrual flow: HEAVY MODERATE LIGHT CLOTS

Color of menstrual flow: DARK RED/PURPLE BRIGHT RED SLIGHTLY REDDISH BROWN

Birth Control Use: NONE PILLS SPERMICIDES IUD BARRIERS OTHER______

How long have you taken birth control pills? ______

Do you suffer from Cramping? NONE MILD MODERATE SEVERE

BEFORE PERIOD DURING PERIOD AFTER PERIOD

PreMenstrual Syndrome: (Please Circle) FLUID RETENTION CRAVINGS FATIGUE

FLUCTUATING EMOTIONS DEPRESSION BREAST TENDERNESS

Do you suffer from any of the following: (Please circle)

BLEEDING BETWEEN PERIODS INFERTILITY OVARIAN CYSTS HOT FLASHES

PELVIC INFLAMMATORY DISEASE ENDOMETRIOSIS MASTITIS YEAST INFECTIONS

CURRENT CONDITION CHECKLIST

NAME: ______DATE: ______

PLEASE CHECK EACH SYMPTOM YOU CURRENTLY EXPERIENCE. Leave Blank if Not Applicable.

RESPIRATORY / CARDIOVASCULAR / GASTROINTESTINAL
____ Difficulty breathing when
lying down / ____ Heart Palpitations / ____ Nausea/Vomiting
____ Shortness of breath / ____ Chest Pains / ____ Acid Regurgitation
____ Tight Chest / ____ High Blood Pressure / ____ Belching/Gas
____ Asthma/Wheezing / ____ Blood Clots / ____ Hiccup
____ Dry Cough / ____ Low Blood Pressure / ____ Bloating/Distension
____ Wet Cough / ____ Fainting / ____ Bad Breath
____ Phlegm (Thick/Thin?) / ____ Difficulty breathing / ____ Diarrhea/Loose stools
____ Coughing up Blood / ____ Tachycardia / ____ Constipation
____ Pneumonia / ____ Irregular Heartbeat / ____ Bloody stools
____ Snoring / ____ Bruise Easily / ____ Mucus in stools
____ Difficulty digesting oily foods
____ Hemorrhoids/Itching Anus
MUSCULOSKELETAL / SKIN/HAIR / ____ Intestinal Pain/Cramps
____ Neck/Shoulder Pain / ____ Rashes/Hives / ____ Rectal Pain/Burning
____ Back Pain / ____ Ulcerations/Boils / ____ Peculiar Taste in mouth
____ Knee Pain / ____ Eczema
____ Joint Pain/Arthritis / ____ Psoriasis / HEAD/EYES/EARS/NOSE/THROAT
____ Muscle spasms/Twitches / ____ Acne / ____ Glasses/Contacts
____ Bone Loss/Osteoporosis / ____ Hair Loss / ____ Red/Dry/Itchy Eyes
____ Muscle Cramps / ____ Itching, Dry / ____ Poor Vision
____ Limited Use/Range of Motion / ____ Dandruff / ____ Blurred Vision
____ Change in Hair/Skin texture / ____ Night Blindness
____ Fungal infections / ____ Myopia/Presbyopia
GENITOURINARY / ____ Glaucoma/Cataracts
____ Pain on Urination / ____ Teeth Problems
____ Frequent Urination / NEUROPSYCHOLOGICAL / ____ Teeth Grinding/Clenching
____ Urgent Urination / ____ Seizures / ____ TMJ
____ Blood in Urine / ____ Numbness/Tingling / ____ Gum Problems
____ Unable to hold Urine / ____ Tics/Tremors / ____ Sores on lips/tongue
____ Incomplete Urination / ____ Poor Memory / ____ Dry Mouth
____ Wake to Urinate / ____ Lack of Concentration / ____ Sinus Problems/Infections
____ BedWetting / ____ Depression / ____ Excessive Phlegm
____ Reduced Urine flow/Volume / ____ Anxiety / ____ Recurrent Sore Throat
____ Increased Libido / ____ Irritability / ____ Swollen Glands
____ Decreased Libido / ____ Easily Stressed / ____ Nosebleeds
____ Kidney Stones / ____ Mood swings / ____ Ringing in Ears (High/Low?)
____ Urinary tract infections / ____ Seeing a Therapist / ____ Poor Hearing
____ Frequent Earaches
____ Headache/Migraines
____ Concussion

I have reviewed the information indicated on this questionnaire and attest that it is accurate to the best of my knowledge. I understand that this information will be used to determine appropriate and healthful treatment. If there is a change in medical status, I will inform the practitioner.

Signature: ______Date: ______