Acupuncture Registration
Name:______
Have you had acupuncture before? Yes or No
If yes, what for and how long ago? ______
______
Why Have you come for acupuncture treatment? ______
______
How long has this been affecting you? ______
How are you currently treating this ailment (medications, heating pad, therapy, etc.) ______
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DIETARY
How often do you eat?______Tea Intake:______
Dietary Restrictions:______Coffee Intake:______
______Water Consumption:______
Supplements:______Recreational Drugs: Yes or No
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How often do you exercise and what type?______
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DIGESTION Please circle all which apply to you:
Food Cravings:______
Burping/belching Abnormal Tastes:______
Bloating
Stomach Pain
Stools Urine
Diarrhea/soft stools How often do you urinate?______
Constipation Mucus/blood/clouding/frothy urine
Blood/mucus in stool
Gas/flatulence
How often do you have a bowel movement per day/week?______
MOUTH/EARS/NOSE/THROAT
Near sighted or far sighted Loss of vision Dry eyes Itchy eyes Blurry eyes Glaucoma Floaters in eyes Mouth ulcers/sores Dry lips Toothaches Gums bleed easily Sensation of something stuck in throat Dry/scratchy throat Cough Bloody nose
Sinus problems Sighing
SENSATION
Sweats easily
Night sweats
Fatigue
Do you tend to be cold/hot?______
Do you get a fever in the late afternoon (tidal fever)?______
SLEEP
When do you go to sleep?______Wake up?______
Wake up during the night
Trouble falling asleep
Insomnia
Dreams/Nightmares
Nap
Wake up feeling rested?______
GYNECOLOGY (Female) ANDROLOGY (Male)
Onset of menstruation:______Impotence
Regular/irregular Early ejaculation/leakage
Color Pain (in scrotum, etc.)
Clots STDs______
Pain during/before/after ______
PMS – Cramps/bloating/mood changes/cravings/breast tenderness
Do you use contraception? If so which types?______
Currently Pregnant (if you are or have come seeking fertility assistance, please request pregnancy forms)
Abortions
Vaginal discharge
Menopause
STDs______
Please give a brief description of how you are emotionally feeling today (angry, sad, depressed, frustrated, stressed, happy, anxious, etc.)?______
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How do you relax?______
What is your favorite hobby?______
How would you describe yourself in one word?______
Any other information you would like to share?______
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