Nature Body Care Acupuncture Spring Hill Dr., Spring Hill, FL Office: Fax:
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1 13017 Spring Hill Dr., Spring Hill, FL NAME DATE I. Goals: What would you most like to achieve through your work at the NBC Acupuncture Center? II. Major Symptoms: Please list in order of importance what symptoms are of concern to you. (most concerning to least, along with the duration of the symptom) Use the following illustration to indicate painful or distressed areas: Are you experiencing pain/discomfort in any area of your body? Y / N If yes, using the models to the left, please indicate the location of the discomfort by using the symbol that best describes the feeling: X X X P P P D D D N N N Sharp/stabbing Pins & Needles Dull/Aching Numbness For Women: 1. Are you pregnant now? [ ]Yes [ ]No [ ]Unsure 2. Indicate number of occurrences: Live Births Pregnancies Miscarriages Abortions 3. Age: First period Menopause (if applicable) 4. Date: Last Pap Smear / Last Mammogram / 5. Any History of an Abnormal Pap Smear? [ ] Yes [ ] No If so, what / when?
2 13017 Spring Hill Dr., Spring Hill, FL 6. Is your menses cycle regular? [ ] Yes [ ] No a) Average number of days of flow b) The flow is: [ ] Normal [ ] Heavy [ ] Light c) The color is: [ ] Normal [ ] Dark [ ] Purple [ ] Light Brown [ ] Brown 7. Do you have the following menstruation related signs/symptoms? [ ] Difficulty with Orgasm [ ] Cramps [ ] PMS [ ] Heavy Vaginal discharge between periods [ ] Pain with Intercourse [ ] Nausea [ ] Bleeding between Periods [ ] Blood Clots [ ] Breast Distention [ ] Vaginal Discharge For Men: 1. Do you have any bothersome urinary symptoms? [ ] Yes [ ] No Describe: 2. Check all that apply: [ ] Erectile dysfunction [ ] Difficulty with orgasm [ ] Pain or swelling of the testicles [ ] Impotence/erectile [ ] Premature ejaculation [ ] Feeling of coldness or dysfunction numbness in genitalia [ ] Pain/Subtly of testicles [ ] Frequent need to urinate at night 3. Do you get up at night to urinate? [ ] Yes [ ] No How often? 4. To what extent do these conditions interfere with your daily activities (work, sleep, socializing, sex, etc.)? 5. Have you sought Medical intervention for these problems? If so, when? 6. What treatments have you tried for these problems and how successful have they been? III. Medical History Please check all that apply Date Diagnosed Date Diagnosed Diabetes / / High Cholesterol / / High Blood Pressure / / High Blood Pressure / / Thyroid Disease / / Seizures / / Cancer / / Hepatitis / / HIV / / Others / / IV. Surgical History
3 V. Family History Please check all that apply and state how you are related to the family member with that condition. Condition Mother Father Sibling Maternal Grandparent Heart disease Cancer Hypertension Stroke Asthma Allergies Migraines Depression Other mental illness Substance abuse Osteoporosis Diabetes Glaucoma Paternal Grandparent VI. Medications / Supplements Medications you are currently taking (please include prescription medicine, supplement, herbal supplements and over the counter medicines you take on a regular basis, along with dosages and brands if known) Allergies (to medications, chemicals or foods): VIII. Nutrition 1. Do you follow a special diet? [ ] Yes [ ] No If yes, how would you describe the diet? (ie Vegetarian, Vegan, Low Carb, etc.) 2. What do you eat on a typical day? a) Breakfast b) Lunch c) Dinner d) Snacks e) Foods you tend to crave: f) Foods you dislike:
4 IX. Social History 1. How much per day do you use of the following? a) Coffee, tea, soft drinks: b) Alcohol: c) Cigarettes, cigars, other tobacco: d) Other drugs: 2. Have you ever had a problem with alcohol or alcoholism? [ ] Yes [ ] No 3. Have you ever had a problem with dependency on other drugs? [ ] Yes [ ] No 4. If yes which and when? 5. Do you have a known history of any exposure to toxic substances? [ ] Yes [ ] No 6. If so, please list which and when you first noticed symptoms? 7. In the past year, how many days have been significantly affected by your health? 8. How many days did you feel generally poor? 9. How many times were you in the hospital? 10. Please describe your current exercise regimen: Hours per week: Activities: [ ] No Exercise 11. How many hours of sleep do you usually get per night during the week? 12. Do you awake feeling rested? [ ] Yes [ ] No Do you feel you sleep well at night? [ ] Yes [ ] No 13. Who would you describe as your source of primary social support? (relationship to you) X. Other Information Please list and briefly describe the most significant events in your life: Have you been treated for emotional issues? [ ] Yes [ ] No Have you ever considered or attempted suicide? [ ] Yes [ ] No Do you have any other neurological or psychological problem? [ ] Yes [ ] No Please provide us with any other information that you think is relevant for us to know:
5 HEALTH: CHECK ALL THAT APPLY GENERAL CARDIOVASCULAR FEMALE Past Current Condition Past Current Condition Past Current Condition [ ] [ ] Poor appetite [ ] [ ] High blood pressure [ ] [ ] Frequent urinary tract infections [ ] [ ] Excessive appetite [ ] [ ] Low blood pressure [ ] [ ] Frequent vaginal infections [ ] [ ] Insomnia [ ] [ ] Blood clots [ ] [ ] Pain / itching of genitalia [ ] [ ] Fatigue [ ] [ ] Palpitations [ ] [ ] Genital lesions / discharge [ ] [ ] Fevers [ ] [ ] Phlebitis [ ] [ ] Pelvic inflammatory disease [ ] [ ] Night sweats [ ] [ ] Chest pain [ ] [ ] Abnormal pap smear [ ] [ ] Sweat easily [ ] [ ] Irregular heart beat [ ] [ ] Irregular menstrual periods [ ] [ ] Chills [ ] [ ] Cold hands / feet [ ] [ ] Painful menstrual periods [ ] [ ] Localized weakness [ ] [ ] Fainting [ ] [ ] Premenstrual syndrome [ ] [ ] Poor coordination [ ] [ ] Difficult breathing [ ] [ ] Abnormal bleeding [ ] [ ] Bleed or bruise easily [ ] [ ] Swelling of hands / feet [ ] [ ] Menopausal syndrome [ ] [ ] Catch cold easily [ ] [ ] Other: [ ] [ ] Breast lumps [ ] [ ] Change in appetite [ ] [ ] Hot flashes [ ] [ ] Strong thirst RESPIRATORY [ ] [ ] Menopausal syndrome [ ] [ ] Other: Past Current Condition [ ] [ ] Other: [ ] [ ] Asthma SKIN & HAIR [ ] [ ] Bronchitis NEUROLOGICAL Past Current Condition [ ] [ ] Frequent colds Past Current Condition [ ] [ ] Rashes [ ] [ ] Chronic obstructive [ ] [ ] Seizures [ ] [ ] Hives [ ] [ ] Pulmonary disease [ ] [ ] Tremors [ ] [ ] Itching [ ] [ ] Pneumonia [ ] [ ] Numbness/tingling of limbs [ ] [ ] Eczema [ ] [ ] Cough [ ] [ ] Concussion [ ] [ ] Pimples [ ] [ ] Coughing blood [ ] [ ] Pain [ ] [ ] Dryness [ ] [ ] Production of phlegm [ ] [ ] Paralysis [ ] [ ] Tumors, lumps [ ] [ ] Other: [ ] [ ] Other: HECK & NECK GASTRO-INTESTINAL PSYCHOLOGICAL Past Current Condition Past Current Condition Past Current Condition [ ] [ ] Dizziness [ ] [ ] Nausea [ ] [ ] Depression [ ] [ ] Fainting [ ] [ ] Vomiting [ ] [ ] Anxiety / stress [ ] [ ] Neck stiffness [ ] [ ] Diarrhea [ ] [ ] Irritability [ ] [ ] Enlarged lymph glands [ ] [ ] Belching [ ] [ ] Treated for emotional or [ ] [ ] Headaches [ ] [ ] Blood in stools/black [ ] [ ] Psychological problems [ ] [ ] Concussions [ ] [ ] Stools [ ] [ ] Other: [ ] [ ] Other: [ ] [ ] Bad breath [ ] [ ] Rectal pain INFECTION SCREENING EARS [ ] [ ] Hemorrhoids Past Current Condition Past Current Condition [ ] [ ] Constipation [ ] [ ] HIV [ ] [ ] Infection [ ] [ ] Pain or cramps [ ] [ ] TB [ ] [ ] Ringing [ ] [ ] Indigestion [ ] [ ] Hepatitis [ ] [ ] Decreased hearing [ ] [ ] Gall bladder disorder [ ] [ ] Gonorrhea [ ] [ ] Other: [ ] [ ] Gas [ ] [ ] Chlamydia [ ] [ ] Other: [ ] [ ] Syphilis EYES [ ] [ ] Genital warts Past Current Condition GENITO-URINARY [ ] [ ] Herpes: oral [ ] [ ] Blurred vision Past Current Condition [ ] [ ] Herpes: genital [ ] [ ] Visual changes [ ] [ ] Kidney stones [ ] [ ] Poor night vision [ ] [ ] Pain or urination MUSCULAR-SKELETAL [ ] [ ] Spots [ ] [ ] Frequent urination Past Current Condition [ ] [ ] Cataracts [ ] [ ] Blood in urine [ ] [ ] Stiff neck / shoulders [ ] [ ] Glasses / contacts [ ] [ ] Urgency to urinate [ ] [ ] Low back pain [ ] [ ] Eye inflammation [ ] [ ] Unable to hold urine [ ] [ ] Back pain [ ] [ ] Other: [ ] [ ] Other: [ ] [ ] Muscle spasm, twitching, cramps [ ] [ ] Sore, cold or weak knees NOSE, THROAT, MOUTH MALE [ ] [ ] Joint pain Past Current Condition Past Current Condition [ ] [ ] Nose bleeds [ ] [ ] Pain / itching genitalia [ ] [ ] Sinus infections [ ] [ ] Genital lesions/ discharge [ ] [ ] Hay fever or allergies [ ] [ ] Impotence [ ] [ ] Recurring sore throats [ ] [ ] Weak urinary stream [ ] [ ] Grinding teeth [ ] [ ] Lumps in testicles [ ] [ ] Difficulty swallowing [ ] [ ] Other:
I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture?
NAME DATE I. Goals: What would you most like to achieve through your work at Twelve Pathways Acupuncture? 1. 2. 3. 4. 5. II. Major Symptoms: Please list in order of importance what symptoms are of concern
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