Thank You for Taking the Time to Fill out This Intake Form. Please Bring It with You To

Dear Patient,

Thank you for taking the time to fill out this intake form. Please bring it with you to your first visit so we can review it together. Since Chinese Medicine is holistic, the more I know about the whole of you, the better we can treat the part that brought you here.

Life in Balance Acupuncture is located at 534 NW Fourth Street, about one and a half blocks north of Harrison Boulevard, between Tyler and Polk Avenues, on the west side of the street. The entrance and parking are at the back of the building.

Please dress in loose clothing and do have something to eat a few hours before your visit. Your first visit will last about 90 minutes and costs $135 (follow-up visits are $90). You are responsible for full payment at the time of service. Should you need to reschedule this visit, please call (541) 757-4868 at least 24 hours in advance to avoid being charged (for Monday appointments, we need to hear from you by Friday at 3pm).

Thank you for the opportunity to work with you on your journey towards optimal health and wellness.

Sincerely,

Brodie Welch, L.Ac.

Treatment Schedule

Day, Date, Time

2013 Oct 3

2013 Oct 3

Patient Information

Page 1 of 6

Family History

Name ______Date ___/___/_____

Phone numbers:

Home (____)______Cell (____)______Work (____)______

Preferred phone for messages (circle one) Home Cell Work

Address ______City______State___Zip______

Email ______Would you like to receive our e-newsletter? Y N

Age: _____ Sex: _____ Height: _____ Weight _____Date of Birth ___/___/____

Relationship Status ______Occupation ______

Emergency contact ______Emergency contact #______

Primary Care Physician ______Doctor’s phone ______

Whom may we thank for this referral? ______

Have you ever had acupuncture before? Yes c No c

Please list your top three health concerns you would like to be free of, in order of importance. (These may be physical, emotional, or spiritual issues.)

1)______

How long has this been a concern? ______How did it begin? ______

2)______

How long has this been a concern? ______How did it begin? ______

3) ______

How long has this been a concern? ______How did it begin? ______

How do these conditions affect your life?______

______

______

Have you been treated for this by anyone else? Yes c No c

What kinds of treatments have you had? ______

Name of practitioner(s) ______

Have these treatments helped? Yes c Somewhat c Not much c Not at all c

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 2 of 7

Health History

Please write “C” in the box next to conditions you currently have and “P” in the box next to conditions you have had in the past.

c Alcoholism c Hepatitis (Type ___) c Liver or Gallbladder problem

c Allergies c Herpes c Multiple Sclerosis c Tuberculosis

c Anemia c High blood pressure c Obesity c Ulcer

c Asthma c HIV / AIDS c Pancreatitis c Varicose Veins

c Cancer c Kidney Disease c Pneumonia c Other:

c Diabetes c Lupus c Polio ______

c Epilepsy c Malaria c Stroke ______

c Heart Disease c Mental illness c Thyroid problem ______

What conditions run in your family? ______

Do you have a pacemaker? Yes c No c

Known or suspected allergens: ______

How was your health as a child? Excellent c Good c Average c Poor c

Did you feel safe and nurtured as a child? Always c Usually c At times c Never c

Please list any surgeries, hospitalizations, and accidents with their dates:

______

______

Pain

On the pictures below, please indicate all areas of pain, numbness, or discomfort:

Is the sensation: dull c achy c comes and goes c moves around c

c sharp c stabbing c constant c burning c radiating to: ______

How painful is it, on a scale of 0 (none) to 10 (excruciating)? ______

What helps the pain? Movement c Pressure c Rest c Heat c Ice c

Nothing c Drugs c Other c ______

What aggravates the pain? Movement c Pressure c Rest c Heat c Ice c

Nothing c Other specific activity c ______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 2 of 6

Health Inventory

Please put a check mark (ü) by the symptoms you have now.

Place an X by any symptoms that you have noticed in the past 3 months.

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 3 of 6

Women Only

c allergies (respiratory)

c persistent cough

c shortness of breath

c wheezing

c frequent colds/ flu

c nosebleeds

c sore throat

c grief, sadness

c tiredness

c nasal congestion

c abdominal fullness

c abdominal pain

c bloating

c belching

c bruising easily

c eating disorder

c dizziness with standing up

c gas

c hemorrhoids

c cold hands and feet

c heavy feeling in head

c heavy feeling in limbs

c nausea

c prolapsed organs

c low appetite

c loose stools

c diarrhea

c constipation

c dry stools

c sticky stools

c headaches

c incomplete bowel movements

c soreness near ribs

c migraines

c irritability

c feeling of a lump in throat

c difficulty swallowing

c high blood pressure

c breast tenderness

c incomplete urination

c dry mouth or throat

c bitter taste in mouth

c red or sore eyes

c anger

c rapid hungering

c burning sensation in chest or throat

c heartburn

c bad breath

c mouth / tongue sores

c bleeding gums

c hot flashes

c night sweats

c dizziness

c ringing in ears

c thirst

c excessive libido

c frequent urination

c incontinence

c get up more than once a night to urinate

c cold feet (only)

c feeling cold

c low libido

c low back pain

c swollen ankles

c thinning hair

c dry, brittle nails

c dry hair or scalp

c dry skin

c dry eyes

c floating spots in vision

c decreased night vision

c muscle spasms/ tics

c difficulty staying asleep

c difficulty falling asleep

c dream-disturbed sleep

c anxiety, nervousness

c panic attacks

c lassitude, depression

c heart pounding/ racing

c memory problems

c difficulty concentrating

c chest pain

c dark yellow urine

c skin rash or sores

c yellow/green phelgm

c burning feeling with defecation

c loose stools that are very dark, yellowish or foul smelling

c difficult, painful or burning urination

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 3 of 6

Women Only

Are you pregnant? Yes c # of months ______No c Maybe c Trying c

Date of last period ______Age of first period ______Age of menopause ___

# of days you bleed ____ From 1st day of period until 1st day of the next is ___ days

Number of pregnancies ____ Births ____ Abortions ____ Miscarriages _____

Do you take birth control pills, shots, implants? Yes c No c Past use? Yes c No c

Date you stopped taking birth control pills/ shots/ implants: ______

Have you had a hysterectomy? Yes c No c Partial c Complete c

Please check all that apply:

Color of menstrual blood: Pale red c Bright red c Maroon c Purple c Brown c

c Cramps, which: occur before the bleeding c occur after bleeding begins c

dull c sharp c stabbing c better w/ heat c better w/ pressure c

c Clots with period? Approximate size? ______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 4 of 6

Women Only

c Abnormal PAP smear

c Back pain with period

c Bleeding between periods

c Breast lumps (type?) ______

c Breast tenderness

c Fibrocystic breasts

c Nipple discharge

c Endometriosis

c Uterine fibroids

c Ovarian cysts

c Irregular timing of period

c Heavy bleeding

c Scanty bleeding

c Headaches with period

c Cycle-related mood swings

c Tubal ligation

c Low libido

c Vaginal discharge

c Vaginal dryness

c Vaginal itching

c Other: ______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 4 of 6

Women Only

Men Only

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 4 of 6

Women Only

☐ Prostate cancer

☐ Swelling of prostate

☐ Testicular pain, swelling or redness

☐ Pain with intercourse

☐ Vasectomy; Date ______

☐ Impotence

☐ Pre-mature ejaculation

☐ Nocturnal emissions

☐ Low libido

☐ Other ______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 4 of 6

Women Only

Outlook

In general, how do you feel about the following areas of your life in the past month?

Yourself Great c Good c Fair c Bad c Comments ______

Family Great c Good c Fair c Bad c Comments ______

Job Great c Good c Fair c Bad c N/A c Comments ______

Significant Other Great c Good c Fair c Bad c N/A c Comments______

Spiritual/ Philosophical Great c Good c Fair c Bad c N/A c Comments______

______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 4 of 6

Diet and Lifestyle

How often do you. . . / 3 x/day
or more / Once a day / 3-4 x per week / Weekly / Monthly / Rarely
Cook from scratch
Eat organic food
Eat whole grains
Overeat
Eat within 3 hours of sleeping
Eat refined sugar
Eat white flour products (bread, baked goods, pasta)
Eat something artificial
Eat fried foods
Consume dairy products
Drink iced liquids
Drink soda
Drink coffee
Drink tea
Eat non-organic meat / dairy
Eat raw food
Skip meals

What do you typically eat? ______

How much water do you drink in a typical day? ______

Do you drink alcohol? Yes c No c How much?______How often?______

Past use? Yes c No c Date stopped?______

Do you smoke/use tobacco? Yes c No c How much?______How often?______

Past use? Yes c No c Date stopped?______

Do you use recreational drugs? Yes c No c What kind(s)? ______

Past use? Yes c No c How much?______How often?______

Foods or tastes you crave? ______When?______

How stressful do you feel your life is, on scale of 0-10, 10 being high? ______Comments ______

How well do you feel you handle stress? Great c Well c Fair c Not well c

Hours of sleep you average per night? ______hours

How often do you exercise? ______What kind(s)? ______

Medications / Supplements / Reason for Taking / Dose / Frequency

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 5 of 6

Cancellation Policy, Payment Policy and Signature

You are responsible for full payment of your account in the form of cash, check, or credit at the time of service. (Any insurance reimbursement that may be possible is between you and your insurance company.)

Should you need to reschedule or cancel a visit, please call (541) 757-4868 at least 24 hours in advance to avoid being charged for the appointment (for Monday appointments, we need to hear from you by Friday at 3pm).

Please sign below to acknowledge your acceptance of these policies and to certify that all the information provided is true to the best of your knowledge. Thank you.

Signature: ______Date: ______

Parent/ Guardian signature (if applicable) ______

Life in Balance Acupuncture [ 534 NW Fourth Street, Corvallis, OR 97330 [ 541.757.4868

Page 6 of 6