This Is Totally Confidential and Is Used Only for Me to Determine the Best Plan of Treatment

New Patient Intake Form

This is totally confidential and is used only for me to determine the best plan of treatment for you. Please fill it out as completely as you can by typing in the blanks and hitting the Tab key to advance through the fields. Thanks!

Personal Information

Name: / Age: / Today’s Date:
Emergency Contact Name: / Emergency Contact Phone:
Have you had acupuncture before?
Yes No / If yes, what were you treated for?

How often and how much of the following do you consume?

Water: / Coffee / Sodas:
Alcohol: / Tobacco / Iced Tea
(black or green):
Artificial Sweeteners: / Sugar:

Please list any prescription or over-the-counter meds you take currently. Include herbs and supplements too. Please attach a separate sheet if you need more room or just bring a list in with you for your appointment.

Medications/Herbs/Supplements / Reason

Your Health History

What is the main health problem for which you are seeking treatment?
How long have you had this condition? / How did it start?
What other forms of treatment have you tried?
What makes it better? / What makes it worse?
Are there any other problems you’d like to tackle?

Please check any conditions you’ve had in the past. We’ll get to current stuff on another page.

Addiction (drugs, food, smoking) / COPD / High Cholesterol / Tonsillitis
AIDS / Diabetes / Hypertension / Tuberculosis
Alcoholism / Digestive Disorders / HIV positive / Typhoid Fever
Anemia / Eating disorders / Malaria / Ulcers
Appendicitis / Elevated liver
enzymes / Measles / Venereal Disease
Arteriosclerosis / Emotional Imbalance / Mononucleosis / Low blood pressure
Arthritis / Emphysema / Multiple Sclerosis / Hysterectomy
Asthma / Epilepsy / Mumps / Kidney problems
Bladder disease / Fibromyalgia / Nephritis / Depression
Breast lumps / Food, chemical or
drug poisoning / Neuralgia / Mental disorders
Breathing problems / Gall stones / Paralysis / Suicidal thoughts
Bulemia / German measles / Polio or meningitis
Bursitis / Glaucoma / Prostate problems
Cancer / Goiter / Rheumatism
Candida / Gout / Scarlet fever
Chicken pox / Heart disease / Small pox
Chronic fatigue / Hernia / Stroke
Colitis/bowel disease / Hepatitis / Thyroid problems
Surgeries:
Significant Traumas (Accidents, disasters, death of loved ones):
Allergies:
What kind of regular exercise do you do?
Do you have any kind of occupational stress? If so, please describe:

Your Family Medical History

Please check all that apply

Diabetes / Cancer / Breast Cancer / High blood
pressure / Low blood
pressure
Asthma / Allergies / Alcoholism
or addictions / Hysterectomy / Prostate
problems
Heart Disease / Kidney
disorders / Stroke / Depression,
emotional
disorders / Suicide

Your Symptoms and Current Medical Status

Please place a checkmark next to any symptom or conditions you have now or experience frequently.

Loose stools or diarrhea / Indigestion / Nausea or vomiting / Acid reflux
Belching / Varicose veins / Anemia / Bruise easily
Lack of appetite / Diabetes or hypoglycemia / HIV positive
or AIDS / Sweat easily
Feeling of reten-
tion of food in
stomach / Prolapsed organs / Eating disorder / Suicidal feelings
Tendency to become obsessive in work or relationships
Insomnia. Time? / Heart palpitations / Restlessness
Nightmares or
sleep disturbed by
dreams / Anxiety attacks / Easily startled / Chest pain
Racing of heart / Irregular heartbeat / Arthritis / Poor vision
Headaches/migraines. Where are they usually and when do you get them?
High/low blood pressure / Cataracts / Spots before eyes
(floaters) / Ringing in ears
Dizziness / Gallstones / Shingles / Herpes
Eczema / Shoulder or neck tension / Sciatica / Impatience
Difficult bowel
movements / Hemorrhoids / Hepatitis / Soft or brittle
nails
Depression / Fullness behind the ribs / Indecisiveness / Easily angered
Cough / Bronchitis / Sadness / Shallow
breathing
Sinus congestion,
frequent infections / Asthma / Sore throat / Shortness of
breath
Weak voice / Constipation / Recent use of
antibiotics / Emphysema
Nasal discharge: Clear White Yellow Green Bloody Thick Thin/watery
Skin problems:
Hearing loss / Low back pain / Weak or sore knees / Edema or
swelling
Hair loss / Prostate disorders / Impotence / Urinary disorders
Osteoporosis / Teeth/gum problems / Reduced sexual
energy / Fearfulness
Spontaneous
sweating / No energy to speak / Lack of strength
Dislike of physical
movement / General physical
weakness / General fatigue
Blurred vision / Dry, brittle hair / Poor memory / Skin rashes
Numbness (where):
Aversion to cold / Cold hands and feet / Easily chilled
Frequent clear
urination / Lack of thirst / Desire for hot
drinks / Desire for cold
drinks
Frequently thirsty / Hot hands and feet / Night sweats
Low-grade
afternoon fever / Dry throat / Red, flushed cheeks
Other:

Pain Patients

After you complete this form, print it out and shade or circle the areas where you feel pain.If you prefer to submit electronically we can complete this step when you come to the clinic.

How would you characterize your pain?

Dull or
achy / Sharp or
stabbing / Burning / Tingling / Numbness / Electrical
shock

Gynecological Information

Any possibility you are pregnant? / Yes / No / Birth control:

Number of:

Pregnancies: / Births: / Miscarriages: / Abortions: / C-Sections:

PAP

Date of last PAP: / Pap results:
Vaginal sores?

Menstrual flow (skip it if you’re in menopause and no longer bleeding):

Heavy / Light / Clots / Painful
Color of Menses: / # Days between periods:
Length of period: / Date of last period:
Age of 1st period: / Spotting between periods:

PMS

Breast soreness / Bloating / Moodiness / Irritability
Cramps / Other: ____

Perimenopause

Skipped or
irregular periods / Hot flashes / Moodiness / Vaginal dryness
Age at menopause: / Hysterectomy age/reason:
Vaginal Discharge (describe):
Breast lumps
or cysts: / Endometriosis
(when):
Other:

Final Bits

Favorite season: / Least favorite season:
How would you describe your overall emotional state?
Anything else you’d like to discuss:

For Your Information

Please read following:

1. I only use sterile, disposable needles.
2. Occasionally acupuncture can leave a small hematoma (bruise under the skin). This is not a cause for concern as it will go away in a few days. Gentle pressure applied at the site will stop any small amount of bleeding that is occurring under the skin.
3. If I recommend herbs for you, I am recommending them for you and not for anyone else. Please don’t give your herbal prescriptions to anyone else!
4. After receiving acupuncture treatment you might feel a little lightheaded (and sometimes euphoric). Please feel free to have a seat, drink a little water and relax to let yourself come back to normal. In a few minutes you will feel relaxed and clear headed.
5. You may be asked to see a physician or chiropractor for your condition if needed. Please do so if it is within your means. I will only ask this of you when I believe it to be necessary.
6. All fees are payable prior to your treatment.

Informed Consent to Treatment

I, the undersigned, hereby request and consent to treatment by acupuncture and/or other procedures within the scope of the practice of acupuncture. Methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, guasha, herbal therapy, bodywork, Reiki and medical Qigong.

I am hereby informed that the aforementioned treatment methods are all generally safe but that there may be some side effects or risks, as follows:

Acupuncture may potentially cause temporary bruising, swelling, bleeding, numbness and tingling, or soreness at the site of needling. Unlikely risks of acupuncture include lung puncture (pneumothorax), nerve damage, organ puncture, and infection - although I use only sterile, disposable needles and maintains a clean and safe environment.

Potential risks of moxibustion include blistering, burns, and scarring. Common side effect of cupping and gua sha are temporary bruising and redness lasting a few days.

The herbal and nutritional supplements (which may be from plant, animal, or mineral sources) recommended to me are generally safe in the traditionally recommended doses. Possible side effects of herbs include nausea, gas, stomache ache, diarrhea, and headache. Unusual side effects of herbs include vomiting, rashes, hives, and tingling of the tongue. I understand I must stop taking any herbs and notify my acupuncturist if I experience any discomfort or adverse reaction.

I will notify the acupuncturist should I become pregnant or if I am in the process of trying to get pregnant as certain acupuncture points and herbs are contraindicated during pregnancy and could induce miscarriage.

I understand that I can discuss risks and benefits further before signing if I so choose, although I do not expect my practitioner to be able to anticipate and explain all possible risks and complications of treatment. I rely on my practitioner to exercise her judgment in my best interest during the course of treatment, based upon the facts then known.

I fully understand that there is no implied or stated guarantee of success or effectiveness of a specific treatment or series of treatments.

I understand that my practitioner will keep all of my records confidential.

In signing this form, I acknowledge any inherent risks, and give my consent for treatment; healthcareoperations received, incurred or carried out by my practitioner.

______

Signature of Person being treatedDate

Camelot Acupuncture

Patient Intake Form – Page 1 of 7